Imaging in

Ventricular
Septal Defect
Rizki Yuda Purnomo
21904101028
Adviser : dr. P. Tigor Yeheskiel, Sp. Rad
Background • Ventricular septal defect (VSD), most
common congenital cardiac anomaly in
children and adults

• An abnormal communication between the

right and left ventricles and shunt formation is
the main mechanism of hemodynamic
compromise in VSD.

• Many VSDs close spontaneously, if dont, large

defects can lead to complications such as
pulmonary arterial hypertension (PAH),
ventricular dysfunction and an increased risk
of arrhythmias

Dakkak, Wael and Tony I. Oliver. Ventricular Septal Defect. National

Centre for Biotechnology Information. 2020. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK470330.
Epidemiology
VSD 37% of all congenital heart disease in
children.

The incidence of VSD :

0.3% of newborns
90% may eventually close spontaneously
Incidence is significantly lower in adults

VSDs have no gender predilection

Dakkak, Wael and Tony I. Oliver. Ventricular Septal Defect. National

Centre for Biotechnology Information. 2020. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK470330.
Patophysiology
The main pathophysiologic mechanism of VSD is shunt
creation between the right and left ventricles. The
amount of blood shunted and the direction of the
shunted blood determine the hemodynamic significance
of the VSD. These factors are governed by the size,
location of the VSD and pulmonary vascular resistance.

In the setting of long-standing large left-to-right shunts,

the pulmonary vascular endothelium undergoes
irreversible changes resulting in persistent PAH. When
the pressure in the pulmonary circulation exceeds the
pressure in the systemic circulation, the shunt direction
reverses and becomes a right-to-left shunt. This is
known as Eisenmenger syndrome

Dakkak, Wael and Tony I. Oliver. Ventricular Septal Defect. National

Centre for Biotechnology Information. 2020. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK470330.
 Type 1 :  Infundibular, outlet. This VSD is located below
Classification the semilunar valves (aortic and pulmonary)
Type 2 :  Membranous. This VSD is, by far the most
common type, accounting for 80% of all defects. It is
located in the membranous septum inferior to the crista
supraventricularis. 
Type 3 : Inlet or atrioventricular canal. This VSD is located
just inferior to the inlet valves (tricuspid and mitral) within
the inlet part of the right ventricular septum.
Type 4 : Muscular, trabecular. This VSD is located in the
muscular septum, bordered by muscle usually in the
apical, central and outlet parts of the interventricular
septum.

VSD can also be classified into size. The size is described in

comparison to the diameter of the aortic annulus.
• small : less or equal to 25%
Rasuli, Bahman and Yurangga Weerakkody el al. • medium : more than 25% but less than 75%
Ventricular Septal Defect. 2020. Radiopedia. Available at :
https://radiopaedia.org/articles/ventricular-septal-defect/ • large : greater than 75%
Dakkak, Wael and Tony I. Oliver. Ventricular Septal Defect. National
Centre for Biotechnology Information. 2020. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK470330.
 Clinical Features
The presentation of unrepaired VSDs dependent on the presence of
hemodynamically significant shunt and size of the defect.
1. Small : Asimptomatic
2. Medium : moderate LV volume overload and absent to mild PAH;
they present late in childhood with mild congestive heart failure
(CHF)
3. Large : CHF early in childhood due to the severe LV overload and
severe PAH
Murmur : Pan-systolic (left lower sternal border)
Infundibular defect ( pulmonis area)
Eisenmenger syndrome: Diastolic decrescendo murmur (aortig regurgitation)
1. Cyanosis Mid-diastolic rumble (lower left sternal border in Increased LV flow)
2. Desaturation Systolic click (membranous defect)
3. Dyspnea
4. Syncope
5. Secondary arythrocytosis
6. Clubbing Rasuli, Bahman and Yurangga Weerakkody el al. Ventricular Septal Defect. 2020. Radiopedia.
Available at : https://radiopaedia.org/articles/ventricular-septal-defect/
Dakkak, Wael and Tony I. Oliver. Ventricular Septal Defect. National Centre for Biotechnology
Information. 2020. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470330.
Imaging Diagnosis
● Ultrasound
● Colour Doppler Transthoracic ● Anamnesis
Echocardiography (TTE) ● Physical Examiation
● Chest X-ray
● CT-Scan ● Electrocardiography
● MRI
● Cardiac catheterization

Rasuli, Bahman and Yurangga Weerakkody el al. Ventricular Septal Defect. 2020. Radiopedia.
Available at : https://radiopaedia.org/articles/ventricular-septal-defect/
Dakkak, Wael and Tony I. Oliver. Ventricular Septal Defect. National Centre for Biotechnology
Information. 2020. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470330.
Ultrasoound
Allows direct visualization of the septal defect; a transthoracic parasternal short axis at the
level of the aortic valve is typically the view of choice for differentiation between supracristal
and perimembranous defects

Specific features sought after include:

1. defect localization
2. direction of VSD jet
3. hemodynamic consequences
• restrictive VSD's have a more benign prognosis
• non-restrictive septal defects are larger and tend to transmit significant volume to
the right-sided circulation

Rasuli, Bahman and Yurangga Weerakkody el al. Ventricular Septal Defect. 2020. Radiopedia.
Available at : https://radiopaedia.org/articles/ventricular-septal-defect/
Colour Doppler Transthoracic Echocardiography (TTE)

• The most used technique for intracardiac shunt

evaluation is transthoracic and especially
transoesophageal echocardiography, which is by many
still considered the reference standard
• Blood flow shunt right to the left

Dakkak, Wael and Tony I. Oliver. Ventricular Septal

Defect. National Centre for Biotechnology Information.
Chest X-Ray 2020. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK470330.

• The chest radiograph Rasuli, Bahman and Yurangga Weerakkody el al.

Ventricular Septal Defect. 2020. Radiopedia.
can be normal with a Available at :
small VSD. Larger https://radiopaedia.org/articles/ventricular-septal-
defect/
VSDs may show
cardiomegaly
CT-Scan and MRI
• CT and MRI can also be used to visualize intracardiac.
• Show wentricle defect

Cardiac Catheterization
• Procedure used to diagnose and treat
certain cardiovascular conditions. During cardiac
catheterization, a long thin tube called a catheter is inserted
in an artery or vein in your groin, neck or arm and threaded
through your blood vessels to your heart.

Rasuli, Bahman and Yurangga Weerakkody el al. Ventricular Septal Defect. 2020. Radiopedia.
Available at : https://radiopaedia.org/articles/ventricular-septal-defect/
Dakkak, Wael and Tony I. Oliver. Ventricular Septal Defect. National Centre for Biotechnology
Information. 2020. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470330.
Differential ● Atrioventricular septal defect
● Atrial septal defect
Diagnose

Dakkak, Wael and Tony I. Oliver. Ventricular Septal Defect. National Centre for Biotechnology
Information. 2020. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470330.
Prognosis
The prognosis is good for patients who
have undergone VSD repair. However,
they have a higher risk of arrhythmia,
endocarditis and Congestive heart failure
in the long run in comparison to the
general population.

Dakkak, Wael and Tony I. Oliver. Ventricular Septal Defect. National Centre for Biotechnology
Information. 2020. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470330.
 Possible small

CASES membranous VSD.

Left to right
ventricular flow is
Female 25 years-old demonstrated. 
24 week pregnancy
anomaly scan. Positive first Nicolay Simon, Rodrigo A., Bharati S.,
Paul L., Christiaan Vrints, Paul M. 2015.
trimester combined test. CT Imaging Features of Atrioventricular
Shunts: What The Radiologist Must Know.
Insight Imaging. (7)p:119-129. DOI
10.1007/s13244-015-0452-7
Ultrasound
 CASES
18 year-old gravid
female at 19 weeks as
per dating ultrasound.
Large VSD

image on the left showing a large defect within the membranous

portion of the ventricular septum. The color Doppler image on the
right shows blood flow through the defect from right to left ventricle.

Nicolay Simon, Rodrigo A., Bharati S., Paul L., Christiaan Vrints, Paul M. 2015. CT Imaging Features of
Atrioventricular Shunts: What The Radiologist Must Know. Insight Imaging. (7)p:119-129. DOI
10.1007/s13244-015-0452-7
 CASES
19 year-old gravid
female at 18 weeks and 6
days as per the
ultrasound done for
Nuchal translucency.
Screening for congenital
abnormalities
unremarkable. Small
image on the right showing a small defect within the membranous
VSD. portion of the ventricular septum. The color Doppler image on the
left shows blood flow through the defect from right to left ventricle.

Nicolay Simon, Rodrigo A., Bharati S., Paul L., Christiaan Vrints, Paul M. 2015. CT Imaging Features of
Atrioventricular Shunts: What The Radiologist Must Know. Insight Imaging. (7)p:119-129. DOI
10.1007/s13244-015-0452-7
Nicolay Simon, Rodrigo A., Bharati S., Paul L., Christiaan Vrints, Paul M. 2015. CT Imaging Features of Atrioventricular
Shunts: What The Radiologist Must Know. Insight Imaging. (7)p:119-129. DOI 10.1007/s13244-015-0452-7
 Conclusion

Ventricular septal defect (VSD), most common congenital cardiac

anomaly in children and adults.
VSD classified based on localization and size.
The clinical features can be asymptomatic until murmur or PAH.
It can be diagnosted by anamnesis, physical examination, ECG
and Imaging.
 THANK
S!
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