Heart septum in a newborn. Symptoms of IVS defects. Treatment of ventricular septal defects

A ventricular septal defect is a congenital or acquired heart defect consisting of incomplete separation of the cavities of the right and left ventricles. As a result, part of the blood from one ventricle (usually from the left, as it is stronger) enters the other and disrupts the normal functioning of the heart and blood circulation in the body.

A ventricular septal defect most often occurs in utero; in rare cases, a similar pathology develops during life. This defect can be considered in two ways:

1. Isolated, arising as independent problem, congenital or acquired origin,

2. How component some other combined defects.

During life, this defect can occur as a result of myocardial infarctionlocalized in the area of ​​the septum.

Ventricular septal defect occurs in approximately 20-25% of cases of all congenital heart defects, in one out of a thousand newborns. With the development of technologies for caring for premature newborns and seriously ill children, the frequency of the defect has been increasing in recent years.

Causes

Heart defects, including ventricular septal defects, occur in the earliest stages of heart development from 3-4 to 8-10 weeks of intrauterine life.

The main causes of violations are considered to be external and internal unfavorable factors. Several key points stand out:

• genetic predisposition, especially in families with existing heart defects or diseases
• viral infections contracted in the early stages of pregnancy, rubella, measles, influenza and herpes are especially dangerous
• drinking alcohol, smoking
• taking medications with embryotoxic effects (antibiotics, anti-epileptic drugs, some sedatives)
• the presence of diabetes mellitus with sharp fluctuations in blood glucose
• work in hazardous industries (gas stations, paint and varnish plants, chemical plants)
• stress factors

Kinds

Depending on the size of the defect in the interventricular septum, we can distinguish:

• small defect or Tolochinov-Roger disease (hole size from 1-2 mm to 1 cm),
• a large defect measuring more than half the size of the aortic orifice or more than 1 cm.

Based on the location of the hole in the septum, three types of defect are distinguished:

• membranous. The defect is located in the area upper segment interventricular septum, under the aortic valve. Usually not large sizes and can close spontaneously as the child grows.
• muscular. The defect is located in the muscular part of the septum, far enough from the valves and conduction system of the heart. Can close independently in small sizes.
• supra-ridge. Located in the area of ​​​​the border of the efferent vessels of the right and left ventricles, it usually does not close on its own.

What happens when there is vice

In the cavity of the right ventricle, the blood pressure during contraction is several times lower than in the left.

If there is a defect in the interventricular septum, blood moves from the left ventricle to the right during contraction. As a result, the pressure in it increases, and it is transmitted to the vessels of the pulmonary (pulmonary) circulation. Blood rich in oxygen also gets there, but the large circle does not receive enough blood.

Constant overload of the right ventricle leads to its failure and condition pulmonary hypertension. Gradually, the vessels of the pulmonary circulation become sclerotic (replaced by connective tissue that is inextensible and impermeable to gases) and irreversible changes in the lungs.

Symptoms of ventricular septal defect

The first manifestations of the defect can develop already in the first days or weeks of life. Especially with a large defect and pronounced discharge of blood into the right ventricle.

Manifest:

• cyanosis (blue discoloration) of the skin, limbs and face, aggravated by crying,
• loss of appetite, sluggish sucking with frequent interruptions,
• violation of weight gain, slow rate of development,
• the occurrence of shortness of breath,
• fatigue, such children sleep a lot,
• the formation of edema in the legs, feet and abdomen,
• tachycardia.

Sometimes, with small defects in the septum, signs may not appear externally, however, they are detected when listening to the heart in the form of rough murmurs.

Diagnostics

A defect can be suspected by examining the child and listening to the heart. But usually parents learn about heart defects in advance, even before the birth of the child, during screening ultrasounds during pregnancy. Large defects can be detected on ultrasound in the second or third trimester.

If a heart murmur is detected after birth, a course of examinations is prescribed:

• Ultrasound of the heart with Dopplerometry (study of blood flow),
• X-ray of the chest to determine the size of the heart and possible defects,
• Puloximetry - measurement of oxygen concentration in capillary blood.
• cardiac catheterization with contrast X-ray examination, measurement of pressure in the chambers of the heart,
• MRI of the heart to determine the structure of the heart and the size of the defect, the presence of complications.

Treatment of ventricular septal defects

Cardiologists and cardiac surgeons are involved in the diagnosis and treatment of defects.

For minor defects in the septum, a wait-and-see approach can be chosen - often the defects close on their own. If the hole does not interfere with life, health and does not interfere with blood circulation, it is actively monitored without performing surgery.

If the defect is large, the normal operation heart and blood circulation, it is necessary to decide on heart surgery.

In preparation for surgery, medications can be used that help regulate heart rhythm, stabilize blood pressure, maintain myocardial nutrition, and regulate blood clotting.

Surgery for significant ventricular septal defects is performed when the child is able to adequately tolerate anesthesia and can recover quickly.

There are several methods, these include:

• cardiac catheterization with the introduction of a catheter through the femoral vein to the cavities of the heart and the application of a patch to the defect area under the control of ultrasound and other devices. Helps well with small and muscle defects.
• surgery on open heart. It is used for a combined defect (tetralogy of Fallot) or for a significant, low-lying defect that cannot be covered with one patch. During this operation, the child is connected to a heart-lung machine.

Today, through cardiac surgery, it is possible to save the lives of those children who were previously doomed to suffering and death at an early age. After the operation, children begin to develop as normal and continue to live a normal life.

Complications and prognosis

With small defects in the heart of 1-2 mm, children can grow as usual and not show any symptoms; with more significant defects, signs of the defect may be observed, which without treatment can turn into complications.

The main ones include Eisenmenger syndrome - irreversible consequences pulmonary hypertension with vascular sclerosis and death of a child from cardiac and respiratory failure

To others serious complications include:

• formation of heart failure,
• development of inflammation of the inner lining of the heart - endocarditis,
• strokes, due to an increase in blood pressure in the pulmonary circulation and the formation of uneven blood flow with thrombus formation,
• disorders of the valvular apparatus and the formation of valvular heart defects.

Various forms of ventricular septal defect (VSD) are found in children in the first years of life.

It is extremely rare in adults.

This malformation is dangerous with a high probability of sudden death.

This aspect is the main relevance of the problem. Its timely identification allows saving the patient’s life.

What is pathology

A ventricular septal defect is called a “white” congenital heart defect (CHD) with increased blood flow. This is due to the late appearance of skin cyanosis. Such defects include primary and secondary shunts in the atrial septum (ASD).

The interventricular septum separates the right and left parts of the heart. Normally there is no message. This defect is characterized by the presence of a shunt between the ventricles. This causes characteristic symptoms.

Its dimensions range from a few mm to complete absence septa to form a single ventricular cavity. IN the latter case a ventricular septal defect in a newborn has poor prognosis and leads to death.

It is rare in adults for several reasons:

• spontaneous closure in childhood;
• surgical correction of the defect;
• high mortality rate.

Ventricular septal defect is a problem in pediatric cardiology.

Mechanisms of development of hemodynamic disorders

With congenital heart disease of the VSD type, a disruption of the normal blood flow occurs, the degree of which depends on certain conditions:

• cardiac output values;
• size of the defect;
• resistance to increased load on the vessels of the pulmonary and systemic circulation.

The mechanism of disruption of normal hemodynamics during interventricular defect goes through several stages:

1. The primary discharge of blood from the cavity of the left ventricle to the right through the hole during cardiac contraction. There is an increase in pulmonary blood flow. The consequence of this process is volume overload of the left ventricle and atrium.
2. Compensatory stage. In this case, an increase in the muscle layer of the left ventricle occurs due to increased load - hypertrophy. If the defect is small in size (up to 2 mm), then the symptoms do not manifest themselves for a long time.
3. The development of pulmonary hypertension is typical for a defect with a shunt size of more than 5–6 mm. It occurs due to a decrease in the lumen of the arteries due to their hypertrophy. Its appearance occurs in such cases in the first months of life. Pulmonary hypertension determines the severity of VSD.
4. Redirection of blood discharge from right to left. This is called Eisenmenger syndrome. Clinically this manifests itself as cyanosis skin.
5. Decompensatory stage, which is characterized by an increase in the right and left parts of the heart with the development of severe circulatory failure. It is considered a terminal form of the defect.

Reasons for development

At congenital defects heart VSD is a consequence of intrauterine development in violation of the formation of cardio-vascular system.

Factors that provoke such a defect in embryogenesis are divided into 2 groups:

1. From the mother's side:
2. the presence of congenital heart disease in close relatives;
3. past viral infections in the first half of pregnancy - measles rubella, chicken pox, enteroviral lesions, measles;
4. severe toxicosis;
5. chronic alcoholism;
6. smoking;
7. intravenous drug addiction.
8. From the fetus:
9. intrauterine growth retardation and chronic hypoxia (especially in the first trimester);
10. chromosomal diseases: Down syndrome, hypogenitalism, microcephaly;
11. cleft of the hard palate in combination with a cleft lip.

The process of formation of the cardiovascular system in the fetus is worsened by a simultaneous combination of several factors.

Classification

A ventricular septal defect may be:

• isolated;
• combined with other defects of the Fallot group, stenosis of the pulmonary artery, patent ductus arteriosus.

Based on the size of the defect, there are 3 options:

• Tolochinov-Roger disease, when the shunt is small in size 1 - 2 mm;
• restrictive ventricular septal defect, in which its size is smaller than the diameter of the aorta;
• non-restrictive – the most unfavorable. Characterized by large sizes exceeding the diameter of the aorta.

Depending on where in the interventricular septum the shunt is located, the defect is classified as follows:

1. Perimembranous makes up the majority of all defects identified. The hole is localized in the upper part of the septum.
2. Subarterial (subaortic), combined with insufficiency of the heart valve apparatus.
3. Muscular variant of ventricular septal defect. A feature of this localization is the possibility of the formation of several shunts. The partition takes on the appearance of “Swiss cheese”.
4. Supply.

Such types of division of RVDP are important for determining individual treatment tactics.

Main symptoms

With a small defect of the interventricular septum in children there is asymptomatic vice. It can be detected accidentally during a routine examination.

With medium and large shunt sizes, patients note:

• delay in physical development;
• shortness of breath;
• fatigue;
• poor tolerance to physical activity;
• chronic fatigue;
• heartbeat;
• frequent acute respiratory diseases;
• cyanosis of the skin and mucous membranes;
• hemoptysis.

The most severe defect occurs in children older than 2 months with large defect sizes. Their symptoms are pronounced and progress rapidly.

Diagnostics

Early detection of VSD includes the following steps:

• collection of complaints;
• studying the patient’s medical history, including the intrauterine period of development and pregnancy pathology;
• physical examination;
• lab tests;
• instrumental research methods.

During a general examination in patients with VSD, attention is drawn to:

• pale skin;
• cyanosis of the skin (especially the nasolabial triangle);
• deformation of fingers and nails like drumsticks and watch glasses;
• cardiac hump (chest deformation);
• systolic trembling at the lower half of the left edge of the sternum;
• increased apical impulse during heart contractions;
• Auscultation: pathological rough noises of a certain localization, signs of pulmonary hypertension, additional sounds, tachycardia or arrhythmias.

The results of laboratory studies do not reveal specific signs characteristic of VSD. Erythrocytosis (a large number of red blood cells) is often detected in general analysis blood due to prolonged hypoxia.
Additional diagnostic methods include:

1. Plain X-ray of the chest organs. The image of VSD reveals:
2. enlargement of the left chambers of the heart;
3. strengthening of the pulmonary pattern;
4. reduction of the aortic arch;
5. enlargement of the pulmonary artery.
6. ECG showing overload of the right and left parts of the heart.
7. 24-hour Holter study to detect arrhythmias.
8. Ultrasound examination, which makes it possible to diagnose the defect, its location, size and pathological blood flow, and the degree of pulmonary hypertension. It can be performed transthoracically and transesophagally. Based on the results of ultrasound, a restrictive and non-restrictive type of defect is determined. In the first case, the pressure gradient between the left and right ventricles is more than 50 mm Hg, and the diameter of the defect is less than 80% of the functional ring aortic valve. For restrictive VSD the values ​​are reversed.
9. Cardiac catheterization and angiography, clarifying adjacent defects, the condition of the vascular bed.

The diagnosis is made with a characteristic auscultation picture and visualization of the defect on ultrasound.

Therapy methods

Treatment of VSD includes the following:

• general recommendations;
• medications;
• surgical intervention.

Medicines are prescribed symptomatically for signs of heart failure, rhythm disturbances, and pulmonary hypertension. Universal remedy there is no such thing as VSD!

Surgery

Surgical treatment is carried out according to strict indications:

1. Signs of heart failure and frequent infections respiratory tract, despite adequate conservative therapy.
2. An asymptomatic variant of the course of the defect in children over 5 years of age.
3. Absence of complaints in children under 5 years of age in the presence of dilation of the cavities of the heart, insufficiency of the valve apparatus, and rhythm disturbances.

Surgery is contraindicated for high pulmonary hypertension. Surgical treatment is not performed on newborn children with a small defect (up to 3 mm), since it can close independently at the age of 1–4 years. If the defect persists, surgery in such cases is performed after 5 years. The prognosis for such children is favorable.

If the ventricular septal defect in newborns is accompanied by heart failure and is of medium or large size, then surgery indicated up to 3 months of age.

The essence of the operation itself is shunt plastic surgery. At the same time, a patch is applied and sewn with a continuous seam. Conducted under general anesthesia under conditions of artificial circulation.

After the operation, the child is observed for at least 3 years. Repeated surgical treatment is prescribed if recanalization of the VSD has occurred (departure of part of the patch).

Why you need to treat

If left untreated, VSD can lead to serious complications:

• thromboembolism;
• sudden death;
• fatal rhythm disturbances;
• infective endocarditis;
• acute left ventricular failure.

For a child during their development, death occurs in a large percentage of cases.

Interventricular septal defect must be promptly identified and treated. If you delay in seeing a doctor, the pathology leads to dire consequences.

Therefore, it is important to know what a VSD is and what the risks are.

Poor environment, unbalanced diet, low level life of the population - all this leads to various childhood pathologies. Today we will talk about heart disease. From our article you will learn what kind of disease this is and whether it is worth sounding the alarm if doctors discover it in a newborn or adult child.

What is a ventricular septal defect in the heart?

Ventricular septal defect is a pathology of the development of the heart muscle, occurring in approximately 40% of newborns. A VSD is a cavity formed in the fetal heart during its formation stage. The diameter of the cavity indicates how serious the consequences of the pathology can be. A VSD of 1-2 mm usually heals on its own during the first years of the baby’s life. Accordingly, the larger the diameter, the greater the risks. A cavity with a diameter of more than 30 mm is considered the most dangerous.

Forms and types of VSD

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CHD VSD in newborns (or older children) can be either an independent disease or part of an anamnesis as part of any pathology of the cardiovascular system. Experts classify the defect according to two parameters - size and location. Each classification contains a certain number of types and forms. By size they are distinguished:

• small (up to 1 cm);
• medium (1-2 cm);
• large (2 cm or more).

Based on the location of the defect, the following are distinguished:

Key role in efficiency VSD treatment timely and correct diagnosis plays a role. Periodic examinations by a doctor reveal pathology at an early stage and help avoid adverse consequences associated with the dynamics of the disease. The procedure for medical observation and therapeutic measures depends on the type of defect detected.

Causes and symptoms

Common factors influencing the appearance of a ventricular septal defect or VSD:

• the child has a history of frequent infectious diseases (herpes, rubella, mumps, chickenpox, etc.);
• early toxicosis during pregnancy;
• side effects from medications;
• mother's non-compliance balanced diets during pregnancy or lactation;
• vitamin deficiency;
• late pregnancy (after 40 years);
• maternal history chronic pathologies endocrine or cardiovascular systems;
• disturbance of background radiation in the place of residence of the mother or child;
• hereditary factor;
• congenital pathologies in the genome.

Symptoms of a ventricular septal defect are presented in the table:

Later, by the age of 3-4 years, with heart disease, children independently report symptoms that cause them concern, for example:

• pain in the heart area;
• shortness of breath in the absence of external factors;
• frequent cough;
• periodic nosebleeds;
• fainting.

How is pathology diagnosed?

Methods for diagnosing VSD include:

1. Auscultation. This type of medical examination detects heart murmurs. If they exceed the norm, we can talk about the likelihood of trabecular defect.
2. Ultrasound of the heart. Most often, ultrasound examination is performed in the presence of concomitant pathologies. Laboratory research absolutely safe. It gives objective assessment such important indicators as heart function, conductivity, general state.
3. Chest X-ray. X-ray irradiation is an examination method that should not be used frequently due to its harmful influence on the body. However, if necessary, diagnostics are carried out every six months or a year to monitor the degree of development of the defect.
4. Pulse oximetry. Absolutely safe research. The sensor is installed by a specialist on the patient’s finger to determine the patient’s blood oxygen saturation level.
5. Cardiac catheterization. One of the most accurate and at the same time expensive methods for diagnosing VSD. Through femur the specialist inserts a catheter with a contrast agent. Contrast darkens some areas of the photo and focuses attention on others. With the help of catheterization, the condition of the heart structures, the pressure in its chambers and, as a result, the general danger of pathology are determined. The examination is carried out using X-rays only as prescribed by a doctor.
6. Magnetic resonance imaging. The most expensive diagnostic method. It is used in rare cases when all others have failed. Provides complete information about the layer-by-layer structure of the heart muscle.

Treatment options

The treatment regimen for ventricular septal defect is influenced by many factors. These include the type of pathology, the patient’s age and even his psychological state. There are two types of therapy for VSD of the heart: conservative and surgical. Surgical intervention is usually not resorted to without serious reasons. To diagnose the need for surgery, observation is required for up to 4-5 years (except in emergency cases).

Medication

Drug therapy does not provide a 100% cure for the disease. No medicine can remove the cavity formed in the heart. The drugs are intended only to minimize the manifestation VSD symptoms(shortness of breath, pallor, nosebleeds). Besides, drug therapy reduces the risk of complications after surgery, if required.

Below is a list of medications used in the composition complex therapy for VSD:

• regulators of muscle heart rate (Digoxin and beta blockers - Inderal and Anaprilin);
• blood clotting regulators (Aspirin, Warfarin).

Operation

Surgery for VSD is necessary only in extreme cases. According to Dr. Komarovsky, the need for operations of this kind arises very rarely. However, many pediatricians recommend surgery in childhood to prevent possible exacerbations in adulthood. The advisability of surgical intervention is decided in each case individually.

During the operation, the surgeon places a special “patch” on the cavity, preventing the excessive outflow of blood from the left lobe of the heart to the right. This can be done in several ways. The choice of method depends on the urgency of the operation: elimination of the defect can be carried out both urgently and on a planned basis. Surgical interventions with a ventricular septal defect, the heart is divided into 2 types:

1. Cardiac catheterization is the most common and least traumatic method of surgery. The catheter is inserted into the defect site through the patient's femoral vein. A mesh patch is attached to the end of the boat, with the help of which the defect is closed. It is performed under local anesthesia.
2. Open surgery. It is considered a more aggressive method, requires long rehabilitation and is associated with risks of complications. In open surgery, the surgeon makes an incision into the heart and places a synthetic patch into the cavity of the interventricular septum. It is carried out under general anesthesia.

Complications and consequences for the child

Complications after surgery to close a VSD are rare. According to statistics, death during or after surgery occurs in only 1% of cases.

1-2% of operations lead to other serious complications in the form of pathologies of the cardiovascular system or strokes. Sometimes in this case there is a need for repeated surgery.

To avoid the adverse consequences of surgery, you need to protect your child from infections as much as possible. various kinds. Strengthen your child’s immunity and, if possible, protect him from contact with sick people. Separately, it should be said about the postoperative suture. Negligent treatment of it can lead to blood poisoning, so strictly follow all doctor’s recommendations.

Take your child to the doctor immediately if the following symptoms occur:

• febrile fever (body temperature from 37.5 °C);
• swelling of the suture;
• fluid in the wound;
• pain in the chest area;
• change in skin tone (blueness or pallor);
• swelling of the face;
• dyspnea;
• constant fatigue and lethargy;
• lack of activity (refusal to play);
• nausea and vomiting;
• loss of consciousness;
• dizziness and other complaints.

The health of the unborn baby is influenced by many factors. Improper intrauterine development can cause congenital defects of internal organs. One of the disorders is ventricular septal defect (VSD), which occurs in a third of cases.

Peculiarities

VSD is a congenital heart defect (CHD). As a result of the pathology, a hole is formed connecting the lower chambers of the heart: its ventricles. The level of pressure in them is different, which is why when the heart muscle contracts, some blood from the more powerful left side enters the right. As a result, its wall stretches and enlarges, and the blood flow of the pulmonary circle, for which the right ventricle is responsible, is disrupted. Due to increased pressure venous vessels become overloaded, spasms and tightness occur.

The left ventricle is responsible for blood flow in the systemic circle, so it is more powerful and has higher pressure. In case of pathological course arterial blood into the right ventricle the required level of pressure decreases. For supporting normal indicators the ventricle begins to work with greater force, which further increases the load on right side heart and leads to its enlargement.

The amount of blood in the pulmonary circle increases and the right ventricle has to increase pressure to ensure normal speed passing through the vessels. This is how the reverse process occurs - the pressure in the pulmonary circle now becomes higher and blood flows from the right ventricle to the left. Oxygen-enriched blood is diluted with venous (depleted) blood, and a lack of oxygen occurs in organs and tissues.

This condition is observed with large holes and is accompanied by disturbances in breathing and heart rhythm. Often the diagnosis is made in the first few days of the baby’s life, and doctors begin immediate treatment, prepare for surgery, and, if it is possible to avoid surgery, conduct regular monitoring.

A small VSD may not immediately appear or may not be diagnosed due to mild symptoms. Therefore, it is important to know about possible signs presence of this type of congenital heart disease in order to take timely measures and treat the child.

Blood flow in newborns

Communication between the ventricles is not always pathological deviation. In the fetus during intrauterine development, the lungs do not participate in enriching the blood with oxygen, so the heart has an open oval window (ooo), through which blood flows from the right side of the heart to the left.

In newborns, the lungs begin to work and the lungs gradually become overgrown. The window closes completely at the age of about 3 months; for some, overgrowth is not considered a pathology by the age of 2 years. With some deviations, OOO can be observed in children 5–6 years of age and older.

Normally, in newborns, the ooo is no more than 5 mm, in the absence of signs cardiovascular diseases and other pathologies, this should not cause concern. Dr. Komarovsky recommends constantly monitoring the baby’s condition and regularly visiting a pediatric cardiologist.

If the hole size is 6-10 mm, this may be a sign of VSD and surgical treatment is required.

Types of defect

The cardiac septum may contain one or more pathological holes of different diameters (for example, 2 and 6 mm) - the more there are, the more complex the degree of the disease. Their size varies from 0.5 to 30 mm. Wherein:

• A defect measuring up to 10 mm is considered small;
• Holes from 10 to 20 mm are medium;
• A defect over 20 mm is large.

According to the anatomical division of VSD in a newborn, there are three types and differ in location:

1. A hole occurs in the membranous (upper part of the heart septum) in more than 80% of cases. Defects in the shape of a circle or oval reach 3 cm; if they are small (about 2 mm), they can spontaneously close as the child grows up. In some cases, defects of 6 mm heal; whether surgery is needed is decided by the doctor, focusing on the general condition of the child and the specific course of the disease.
2. Muscular JMP in the middle part of the septum is less common (about 20%), in most cases it is round in shape, with a size of 2 - 3 mm and can close with the age of the child.
3. At the border of the ventricular efferent vessels, a supracrestal septal defect is formed - the rarest (approximately 2%), and almost never resolves on its own.

In rare cases, a combination of several types of JMP occurs. The defect can be an independent disease, or accompany other severe abnormalities in the development of the heart: a defect interatrial septum(ASD), problems with arterial blood flow, coarctation of the aorta, stenosis of the aorta and pulmonary artery.

Reasons for development

The defect forms in the fetus from 3 weeks to 2.5 months of intrauterine development. If the course of pregnancy is unfavorable, pathologies may occur in the structure of internal organs. Factors that increase the risk of VSD:

1. Heredity. Predisposition to VSD can be transmitted genetically. If any of your close relatives had defects various organs, including the heart, there is a high probability of abnormalities occurring in the child;
2. Viral diseases infectious nature(flu, rubella) that a woman suffered in the first 2.5 months of pregnancy. Herpes and measles are also dangerous;
3. Reception medicines– many of them can cause intoxication of the embryo and lead to the formation of various defects. Particularly dangerous are antibacterial, hormonal, anti-epileptic drugs and those affecting the central nervous system;
4. Bad habits of the mother - alcohol, smoking. This factor, especially at the beginning of pregnancy, increases the risk of abnormalities in the fetus several times;
5. The presence of chronic diseases in a pregnant woman - diabetes, problems of the nervous, cardiac system and the like can provoke pathologies in the baby;
6. Vitamin deficiency, deficiency of necessary nutrients and microelements, strict diets during pregnancy, the risk of birth defects increases;
7. Severe toxicosis on early stages pregnancy;
8. External factors - dangerous environmental conditions, harmful conditions labor, increased fatigue, overexertion and stress.

The presence of these factors does not always cause the occurrence serious illnesses, but increases this probability. To reduce it, you need to limit their exposure as much as possible. During Taken measures to prevent problems in fetal development are a good prevention of congenital diseases in the unborn child.

Possible complications

Defects small size(up to 2 mm) in the normal condition of the baby are not a threat to his life. Regular examination and observation by a specialist are required and can spontaneously stop over time.

Large holes cause disruption of the heart, which manifests itself in the first days of the baby’s life. Children with VSD have difficulty with colds and infectious diseases, often with complications of the lungs, pneumonia. They may develop worse than their peers and have difficulty withstanding physical activity. With age, shortness of breath occurs even at rest, and problems with internal organs appear due to oxygen starvation.

Interventricular defect can cause serious complications:

• Pulmonary hypertension - increased resistance in the pulmonary vessels, which causes right ventricular failure and the development of Eisenmenger syndrome;
• Acute cardiac dysfunction;
• Inflammation of the inner lining of the heart of an infectious nature (endocarditis);
• Thrombosis, threat of stroke;
• Malfunctions of the heart valves, the formation of valvular heart defects.

To minimize the consequences harmful to the baby’s health, timely qualified assistance is necessary.

Symptoms

The clinical manifestations of the disease are determined by the size and location of the pathological holes. Small defects of the membranous part of the cardiac septum (up to 5 mm) occur in some cases without symptoms; sometimes the first signs appear in children from 1 to 2 years of age.

In the first days after birth, the baby can hear heart murmurs caused by the flow of blood between the ventricles. Sometimes you can feel a slight vibration if you put your hand on your baby's chest. Subsequently, the noise may weaken when the child is in vertical position or experienced physical stress. This is caused by compression muscle tissue in the hole area.

Major defects can be detected in the fetus even before or immediately after birth. Due to the characteristics of blood flow during intrauterine development in newborns normal weight. After birth, the system is rebuilt to normal and the deviation begins to manifest itself.

Small defects located in the lower region of the heart septum are especially dangerous. They may not show symptoms in the first few days of the child's life, but over time, breathing and heart problems develop. If you pay close attention to your child, you can notice the symptoms of the disease in time and contact a specialist.

Signs of possible pathology that should be reported to your pediatrician:

1. Paleness of the skin, blue lips, skin around the nose, arms, legs during exertion (crying, screaming, overexertion);
2. The baby loses appetite, gets tired, often drops the breast during feeding, and slowly gains weight;
3. During physical activity and crying, babies experience shortness of breath;
4. Increased sweating;
5. A baby older than 2 months is lethargic, drowsy, and has decreased physical activity, there is a delay in development;
6. Frequent colds that are difficult to treat and develop into pneumonia.

If such signs are detected, the baby is examined to identify the causes.

Diagnostics

They can check the condition and functioning of the heart and identify the disease. following methods research:

• Electrocardiogram (ECG). Allows you to determine congestion of the cardiac ventricles, identify the presence and degree of pulmonary hypertension;
• Phonocardiography (PCG). As a result of the study, it is possible to detect heart murmurs;
• Echocardiography (EchoCG). Able to detect blood flow disturbances and help to suspect VSD;
• Ultrasonography. Helps evaluate myocardial function and pressure levels pulmonary arteries, the amount of blood discharged;
• Radiography. Chest photographs can be used to determine changes in the pulmonary pattern and an increase in the size of the heart;
• Probing of the heart. Allows you to determine the level of pressure in the arteries of the lungs and the ventricle of the heart, increased content oxygen in venous blood;
• Pulse oximetry. Helps determine the level of oxygen in the blood - a deficiency indicates disorders in the cardiovascular system;
• Cardiac catheterization. Helps assess the condition of the heart structure and determine the level of pressure in the heart ventricles.

Treatment

VSD 4 mm, sometimes up to 6 mm - small in size - in the absence of disturbances in respiratory, cardiac rhythm and normal development child allows in some cases not to use surgical treatment.

If the general clinical picture worsens or complications arise, surgery may be prescribed in 2–3 years.

Surgery is performed with the patient connected to a heart-lung machine. If the defect is less than 5 mm, it is closed with U-shaped sutures. If the hole is larger than 5 mm, it is covered with patches made of artificial or specially prepared bio-material, which is subsequently overgrown with the body’s own cells.

If it is needed surgical treatment child in the first weeks of life, but this is impossible due to some indicators of the baby’s health and condition, a temporary cuff is placed on the pulmonary artery. It helps equalize the pressure in the ventricles of the heart and alleviates the patient's condition. After a few months, the cuff is removed and surgery is performed to close the defects.

Version: MedElement Disease Directory

Ventricular septal defect (Q21.0)

Congenital diseases, Cardiology

general information

Short description

Ventricular septal defect(VSD) is the most common isolated congenital defect detected at birth. Quite often, VSD is diagnosed in adulthood.
If indicated, the defect is treated in childhood. Spontaneous closure of the defect is often observed.

Classification

There are four possible localization of the ventricular septal defect(VSD):

1. Membranous, perimembranous, conoventricular - the most common localization of the defect, found in approximately 80% of all VSDs. The defect is found in the membranous part of the interventricular septum with possible spread to the inlet, septal and outlet sections of the septum; under the aortic valve and the septal cusp of the tricuspid valve; aneurysms often develop Aneurysm - expansion of the lumen blood vessel or heart cavity due to pathological changes in their walls or developmental abnormalities
membranous section of the septum, resulting in partial or complete closure of the defect.

2. Muscular, trabecular - up to 15-20% of cases of all VSDs. Completely surrounded by muscle, can be localized in various parts of the muscular section of the interventricular septum. There may be several defects. Spontaneous closure is especially common.

3. Supracrestal, subarterial, subpulmonary, infundibular defects of the outflow tract - occur in approximately 5% of cases. The defect is localized under the semilunar valves of the cone-shaped or outlet part of the septum. Often combined with progressive aortic insufficiency due to prolapse Prolapse is a downward displacement of any organ or tissue from its normal position; The cause of such displacement is usually weakening of the tissues surrounding and supporting it.
of the aortic valve leaflets (most often the right one).

4. Defects of the afferent tract (atrioventricular canal) - the inlet section of the interventricular septum directly below the attachment point of the atrioventricular valve rings; often observed in Down syndrome.

Single septal defects are more common, but there are also cases multiple defects. VSD is also observed in combined heart defects, such as tetralogy of Fallot Tetralogy of Fallot is a congenital heart defect: a combination of stenosis of the pulmonary trunk, ventricular septal defect, displacement of the aorta to the right and secondary developing hypertrophy of the right heart.
, corrected transposition great vessels.

Etiology and pathogenesis

The formation of the heart with chambers and large vessels occurs by the end of the first trimester. The main malformations of the heart and large vessels are associated with impaired organogenesis at 3-8 weeks of fetal development.

Ventricular septal defects(VSD), like other congenital heart defects, is inherited polygenically and multifactorially in 90% of cases. In 5% of cases, congenital heart disease is part of a chromosomal abnormality (Down syndrome Down syndrome is a hereditary human disease caused by trisomy on chromosome 21 of the normal chromosome set, characterized by mental retardation and a peculiar appearance. One of the most common NCDs (incidence rate 1-2 cases per 1000 births); the likelihood of having children with Down syndrome increases with maternal age
, Sotos syndrome Sotos syndrome (cerebral gigantism syndrome) is a congenital, in most cases sporadic (there are families with an autosomal dominant type of inheritance) disease. Characterized by tall stature, large knobby skull, convex forehead, hypertelorism, high palate, anti-Mongoloid eye shape, moderate retardation mental development
, Patau syndrome Patau syndrome is a hereditary human disease chromosomal type, caused by trisomy on chromosome 13; characterized by the development of craniofacial anomalies, heart defects, finger deformities, disorders of the genitourinary system, mental retardation, etc.
), in another 5% of cases is caused by mutation of single genes .
Changes in hemodynamics depend on the following factors: location and size of the defect, degree of pulmonary hypertension, myocardial condition Myocardium (syn. cardiac muscle) - middle layer walls of the heart, formed by contractile muscle fibers and atypical fibers that make up the conduction system of the heart
right and left ventricles, pressure in the systemic and pulmonary circulation.

Intrauterine hemodynamics in VSD. In utero, the pulmonary circulation (PCC) does not function. All blood passing through the lungs is classified as big circle blood circulation (BCC). Therefore, the intrauterine hemodynamics of the fetus does not suffer. The defect can only be determined when ultrasound examination fetus

Hemodynamics of a newborn with VSD . At birth, the vessels of the ICC have a thick wall with a well-defined muscle layer, due to which a high resistance is created for the blood passing through the ICC. In this regard, there is high pressure in the ICC (75-80 mm Hg), almost corresponding to the pressure in the left ventricle and aorta, that is, in the BCC. The pressure gradient between the right and left ventricles is insignificant, there is almost no discharge of blood in any direction and, accordingly, there is no noise. Noise and slight cyanosis (mainly perioral) may occur with screaming, coughing, straining, sucking, when a right-left shunt may appear. Small defects may themselves provide resistance to blood flow, reducing the difference in gradient between the right and left ventricles.

Approximately by the second month of a child’s life, the thickness of the muscle wall, vascular resistance and pressure in the ICC decrease (up to 20-30 mmHg). The pressure in the right ventricle becomes less than in the left, which leads to blood shunting from left to right, and therefore noise.

Hemodynamics in children older than 2 months . As the pressure in the ICB and right ventricle decreases, the pressure gradient increases, and the volume of blood discharge in systole increases Systole - phase cardiac cycle, consisting of sequential contractions of the myocardium of the atria and ventricles
from the left ventricle to the right. That is, in diastole Diastole - phase of the cardiac cycle: expansion of the cavities of the heart associated with relaxation of the muscles of their walls, during which the cavities of the heart fill with blood
the right ventricle receives blood from the right atrium, and in systole - from the left ventricle. In the MCC, and then in left atrium and the left ventricle, a larger volume of blood enters. Diastolic overload of the left ventricle appears, which first leads to its hypertrophy and then to dilatation Dilatation is a persistent diffuse expansion of the lumen of a hollow organ.
.
When the left ventricle can no longer cope with such a volume of blood, blood stagnation occurs in the left atrium, and then in the pulmonary veins - venous pulmonary hypertension develops. Increased pressure in the pulmonary veins leads to increased pressure in the pulmonary arteries and the development of arterial pulmonary hypertension Pulmonary hypertension - high blood pressure blood in the vessels of the pulmonary circulation
.
Thus, the right ventricle requires more effort to “push” blood into the ICC. In addition to venous congestion in the ICC, arterial spasm (Kitaev reflex) is added, which increases the resistance in the ICC and the load, and hence the pressure in the right ventricle. Persistent spasm of the arteries first leads to their fibrosis and then to obliteration Obliteration is the occlusion of the cavity of an internal organ, canal, blood or lymph vessel.
blood vessels, making pulmonary hypertension irreversible.

High pressure in the ICC quickly leads to hypertrophy and dilatation of the right ventricle - right ventricular failure develops. As the pressure in the right ventricle increases, it first becomes the same as in the left (the noise decreases), and then a right-left shunt appears (the noise reappears).
This is how medium- and large-sized VSDs occur in the absence of treatment. Average duration Life expectancy does not exceed 25 years; most children die before the age of 1 year.

Epidemiology

Ventricular septal defect is the most common congenital heart defect, found in 32% of patients, either alone or in combination with other anomalies.
Perimembranous defects account for 61.4-80% of all cases of VSD, muscle defects - 5-20%.

The gender distribution is almost the same: girls (47-52%), boys (48-53%).

Risk factors and groups

Risk factors influencing the formation of congenital heart defects in the fetus

Family risk factors:

Presence of children with congenital heart defects (CHD);
- presence of congenital heart disease in the father or close relatives;
- hereditary diseases in family.

Maternal risk factors:
- congenital heart disease in the mother;
- diseases connective tissue in the mother (systemic lupus erythematosus Systemic lupus erythematosus (SLE) - autoimmune disease human, in which antibodies produced by the human immune system damage the DNA of healthy cells, predominantly connective tissue is damaged with the obligatory presence of a vascular component
, Sjögren's disease Sjögren's syndrome is an autoimmune systemic disorder of connective tissue, manifested by involvement of pathological process exocrine glands, mainly salivary and lacrimal, and a chronic progressive course
and etc.);
- the mother has an acute or chronic infection during pregnancy (herpes, cytomegalovirus, Epstein-Barr virus, Coxsackie virus, toxoplasmosis, rubella, chlamydia, ureaplasmosis, etc.);
- taking medications (indomethacin, ibuprofen, antihypertensives, antibiotics) in the 1st trimester of pregnancy;
- primigravidas over 38-40 years old;
- metabolic diseases (diabetes mellitus, phenylketonuria).

Fetal Fetal - relating to the fetus, characteristic of the fetus.
risk factors:
- presence of episodes of rhythm disturbance in the fetus;
- extracardiac anomalies;
- chromosomal disorders;
- malnutrition Hypotrophy is a nutritional disorder characterized by varying degrees underweight
fetus;
- non-immune hydrops fetalis;
- deviations in fetoplacental blood flow indicators;
- multiple pregnancy.

Clinical picture

Clinical diagnostic criteria

Cardiomegaly syndrome, Pulmonary hypertension syndrome, systolic murmur, parasternal hump, tachypnea-type dyspnea, symptoms of heart failure

Symptoms, course

Ventricular septal defect in the fetus

Isolated VSD in the fetus is clinically divided into 2 forms depending on its size and the amount of blood discharge:
1. Small VSD (Tolochinov-Roger disease) - located mainly in the muscular septum and are not accompanied by pronounced hemodynamic disturbances.
2. VSDs are quite large in size - located in the membranous part of the septum and lead to pronounced hemodynamic disturbances.

Clinic of Tolochinov-Roger disease. The first (sometimes the only) manifestation of the defect is a systolic murmur in the heart region, which appears mainly from the first days of a child’s life. There are no complaints, the children are growing well, the heart boundaries are within the age norm.
In the III-IV intercostal space to the left of the sternum, systolic trembling is heard in most patients. Characteristic symptom the defect is a rough, very loud systolic murmur. The murmur, as a rule, occupies the entire systole and often merges with the second sound. The maximum sound is observed in the III-IV intercostal space from the sternum. The noise is well conducted throughout the entire region of the heart, to the right behind the sternum, is heard on the back in the interscapular space, is well carried through the bones, is transmitted through the air and can be heard even if the stethoscope is raised above the heart (remote noise).

In some children, a very gentle systolic murmur is heard, which is better detected in the supine position. With physical activity, the noise decreases significantly or even disappears completely. This is explained by the fact that due to the powerful contraction of the heart muscles during exercise, the hole in the interventricular septum in children is completely closed and the blood flow through it is completed. There are no signs of heart failure in Tolochinov-Roger disease.

Pronounced VSD in children. It manifests itself acutely from the first days after birth. Children are born at term, but in 37-45% of cases moderate congenital malnutrition is observed, the cause of which is not clear.
The first symptom of defects is systolic murmur, which is heard from the neonatal period. In some cases, already in the first weeks of life, children show signs of circulatory failure in the form of shortness of breath, which appears first with restlessness, sucking, and then in a calm state.
During the first year of life, children often suffer from acute respiratory diseases, bronchitis, pneumonia. More than 2/3 of children are lagging behind in physical and psychomotor development, 30% develop grade II malnutrition.
For most children it is typical early start formation of the central cardiac hump Heart hump is a protrusion visible by eye in the precordial region in some (mainly congenital) heart defects, developing as a result of prolonged pressure of enlarged parts of the heart on the anterior wall of the chest
, the appearance of pathological pulsation over the upper region of the stomach. Systolic tremor is detected in the III-IV intercostal space to the left of the sternum. The borders of the heart are slightly expanded across and upward. Pathological accent of the 2nd tone in the 2nd intercostal space on the left at the sternum, often combined with its splitting.
In all children, a rough systolic murmur typical of VSD is heard, which occupies the entire systole, with a maximum sound in the third intercostal space to the left of the sternum. The noise is well transmitted to the right behind the sternum in the III-IV intercostal space, to the left auscular zone and to the back, often it “encircles” the chest.
In 2/3 of children, from the first months of life, pronounced signs of circulatory failure are observed: anxiety, difficulty sucking, shortness of breath, tachycardia. These signs are not always interpreted as a manifestation of heart failure and are often regarded as concomitant diseases ( acute otitis media, pneumonia).

VSD in children older than one year. The defect enters the stage of attenuation of clinical signs due to the intensive growth and anatomical development of the child’s body. At the age of 1-2 years, a phase of relative compensation begins - shortness of breath and tachycardia Tachycardia - increased heart rate (more than 100 per minute)
are missing. Children become more active, gain weight and grow better, and get sick less often concomitant diseases, many of them are catching up with their peers in their development.
An objective examination reveals in 2/3 of children a centrally located cardiac hump, systolic trembling in the III-IV intercostal space to the left of the sternum. The borders of the heart are slightly expanded across and upward. The apical impulse is of medium strength and strengthened.
On auscultation Auscultation is a method of physical diagnosis in medicine, which consists of listening to sounds produced during the functioning of organs.
There is a splitting of the second tone in the second intercostal space on the left at the sternum, its accentuation may be observed. A rough systolic murmur is heard along the left edge of the sternum with a maximum sound in the third intercostal space on the left and a large distribution area.
In some children, diastolic murmurs of relative pulmonary valve insufficiency are also heard:
- Graham-Still noise - appears as a result of increased pulmonary circulation in the pulmonary artery and with an increase in pulmonary hypertension; is heard in the 2-3 intercostal space to the left of the sternum and is well carried up to the base of the heart;

Flint noise - occurs as a result of relative mitral stenosis, appearing when large cavity left atrium, due to large arteriovenous discharge of blood through the defect; is better determined at the Botkin point Botkin's point - a section of the anterior surface chest wall in the IV intercostal space between the left sternal and parasternal lines, in which a number of auscultatory manifestations of mitral heart defects (for example, the tone of the mitral valve opening), aortic valve insufficiency (protodiastolic murmur) are most clearly heard and functional systolic murmurs are recorded
and is carried out to the apex of the heart.

Depending on the degree of hemodynamic disturbance, there is a very large variability in the clinical course of VSD in children, which requires a different therapeutic and surgical approach to such children.

Diagnostics

1.Echocardiography- is the main study to make a diagnosis. It is carried out to assess the severity of the disease, determine the location of the defect, the number and size of defects, and the degree of volume overload of the left ventricle. During the study, it is necessary to check for the presence of aortic valve insufficiency, which occurs as a result of prolapse of the right or non-coronary leaflet (especially with outflow tract defects and highly localized membranous defects). It is also very important to exclude a two-chamber right ventricle.

2. MRI MRI - magnetic resonance imaging
is carried out in cases where it is not possible to obtain sufficient data during echocardiography, especially when assessing the degree of left ventricular volume overload or quantitative assessment of the shunt.

3. Cardiac catheterization carried out with high pulmonary blood pressure(based on echocardiography results) to determine pulmonary vascular resistance.

4. Chest X-ray. Degree of cardiomegaly Cardiomegaly is a significant increase in the size of the heart due to its hypertrophy and dilatation
and the severity of the pulmonary pattern directly depends on the size of the shunt. An increase in the cardiac shadow is associated mainly with the left ventricle and left atrium, and to a lesser extent with the right ventricle. When the ratio of pulmonary and systemic blood flow is 2:1 or more, noticeable changes in the pulmonary pattern occur.
Children in the first 1.5-3 months of life with large defects are characterized by an increase in the degree of pulmonary hypervolemia Hypervolemia (plethora) - the presence of an increased volume of circulating blood in the vascular bed
in dynamics, which is associated with a physiological decrease in total pulmonary resistance and an increase in shunt from left to right.

5. ECG ECG - Electrocardiography (method of recording and studying electric fields generated during the work of the heart)
- changes reflect the degree of load on the left or right ventricle. In newborns, right ventricular dominance remains. As the discharge through the defect increases, signs of overload of the left ventricle and left atrium appear.

Differential diagnosis

Open common AV channel;
- common arterial trunk;
- departure of the great vessels from the right ventricle;
- isolated pulmonary artery stenosis;
- defect of the aortopulmonary septum;
- congenital mitral insufficiency;
- aortic stenosis.

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