eMedicine Specialties > Radiology > Cardiac

Ventricular Septal Defect: Imaging

Author: Vibhuti N Singh, MD, MPH, FACC, FSCAI, Director, Suncoast Cardiovascular Center; Chair, Cardiology Division and Cath Labs, Department of Medicine, Bayfront Medical Center; Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine
Coauthor(s): Rakesh K Sharma, MBBS, FACC, FACP, Interventional Cardiologist, The Heart and Vascular Institute of Florida; Hanumanth K Reddy, MD, FACC, Clinical Professor of Medicine, St Louis University Medical School; Associate Chief, Department of Cardiovascular Services, Three Rivers Healthcare; Navin C Nanda, MD, FACC, Director, Heart Station and Echocardiography Laboratories, Professor, Department of Internal Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham
Contributor Information and Disclosures

Updated: Aug 19, 2008

Radiography

Findings

The chest radiograph reflects the magnitude of the shunt as well as the degree of pulmonary hypertension. A shunt of moderate size causes signs of left atrial, right ventricular, and LV dilation, with some pulmonary overcirculation. Over time, a large shunt produces pulmonary hypertension in association with enlarged central pulmonary arteries, peripheral pruning, and Eisenmenger physiology. With these developments, the enlarged cardiac chamber may normalize.

Degree of Confidence

The findings are nonspecific for ventricular septal defect.

Computed Tomography

Findings

CT scans may show cardiomegaly, left atrial enlargement, and vascular engorgement.8

Magnetic Resonance Imaging

Findings

MRI has multiple capabilities in the evaluation of congenital heart disease. Morphologic information is provided by ECG-gated spin-echo and cine MRI. Ventricular volumes, mass, and function may be assessed by using cine MRI. The volumes of shunts, valvular function, and pressure gradients across valves and conduits may be estimated by use of velocity-encoded cine MRI (velocity-flow mapping). Echocardiography and Doppler techniques are now used for many of these purposes; the current clinical role of MRI is to supplement the information acquired by means of echocardiography.

Reports from several centers indicate the effectiveness of MRI for the evaluation of both children and adults with congenital heart disease. In several studies in which the results of MRI were corroborated with those of angiography and/or 2D echocardiography, an accurate anatomic diagnosis of anomalies was achieved with MRI in more than 90% of patients.

MRI has also shown substantial utility in the anatomic and functional evaluation of congenital heart disease after palliative and total correction. The visceroatrial situs, the type of ventricular loop, and the relationship of the great vessels may be identified in all patients in whom studies encompassing the entire heart are performed. The diagnostic accuracy of MRI exceeds 90% for abnormalities of arterioventricular connections; for great vessel anomalies, such as coarctation and vascular rings; for ventricular and atrial septal defects; and for abnormalities of venous connections.9,10,11,12,13

Degree of Confidence

In several studies in which the results of MRI were corroborated with those of angiography and/or 2D echocardiography, accurate anatomic diagnosis of anomalies was achieved by use of MRI in more than 90% of patients.

Information provided by MRI may also be obtained by means of echocardiography, the equipment for which is more portable. Consequently, the current clinical role of MRI is to supplement the information acquired with echocardiography.

False Positives/Negatives

False-positive and false-negative results are uncommon regarding ventricular septal defect.

Ultrasonography

Findings

Doppler color-flow and 2D mapping may be used to identify the type of defect in the ventricular septum. Perimembranous VSDs are observed as septal dropout in the area adjacent to the septal leaflet of the tricuspid valve and below the right border of the aortic annulus (see Image 1).

The subaortic or anterior malalignment type of VSD appears just below the posterior semilunar valve cusps, entirely superior to the tricuspid valve. Subpulmonary VSD appears as echo dropout within the outflow septum and extending to the pulmonary annulus. One or two of the aortic cusps may be seen to be protruding through the defect into the right ventricular outflow tract. The inlet AV septal-type of VSD extends from the fibrous annulus of the tricuspid valve into the muscular septum; it is often entirely beneath the septal tricuspid leaflet.

Muscular defects may appear anywhere throughout the ventricular septum. They may be either large and single or small and multiple.

The anatomic localization of all VSDs is facilitated by coupling 2D images with a Doppler system and by superimposing a color-coded direction and velocity of blood flow on the real-time images.14,15,16,17,18,19,20,21,22

Degree of Confidence

The degree of confidence is high.

False Positives/Negatives

False-positive and false-negative results are rare.

Angiography

Findings

Cardiac catheterization and angiography

The hemodynamics of a ventricular septal defect may be demonstrated by means of cardiac catheterization.

Indications

Catheterization is usually performed only under the following conditions: uncertainty remains regarding the size of the shunt following a comprehensive clinical evaluation; laboratory data do not fit well with the clinical findings; or pulmonary vascular disease is suspected.

Oximetry demonstrates an increase in oxygen content in the right ventricle, because with some defects, blood is ejected almost directly into the pulmonary artery (a phenomenon known as streaming). This increase is occasionally apparent only when pulmonary arterial blood is sampled.

Small, restrictive VSDs are associated with normal right-sided heart pressures and pulmonary vascular resistance. Large, nonrestrictive VSDs are associated with equal or near-equal pulmonary and systemic systolic pressures. Pulmonary blood flow may be 2-4 times greater than systemic blood flow. In patients with large, nonrestrictive VSDs who have hyperdynamic pulmonary hypertension, the pulmonary vascular resistance is only minimally elevated (pulmonary vascular resistance is equal to the pressure divided by the flow).

If Eisenmenger syndrome is present, pulmonary artery systolic and diastolic pressures are elevated, the degree of left-to-right shunting is minimal, and desaturation of blood in the LV is encountered. The size, location, and number of ventricular defects are demonstrated by left ventriculography. Contrast medium passes across the defect or defects to opacify the right ventricle and the pulmonary artery.

Degree of Confidence

The degree of confidence is high for ventricular septal defect.

False Positives/Negatives

False-positive and false-negative results are rare regarding ventricular septal defect.

More on Ventricular Septal Defect

Overview: Ventricular Septal Defect
Imaging: Ventricular Septal Defect
Follow-up: Ventricular Septal Defect
Multimedia: Ventricular Septal Defect
References
Further Reading
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References

  1. Alabdulgader AA. Congenital heart disease in 740 subjects: epidemiological aspects. Ann Trop Paediatr. 2001;21(2):111-8. [Medline].

  2. Chadha SL, Singh N, Shukla DK. Epidemiological study of congenital heart disease. Indian J Pediatr. 2001;68(6):507-10. [Medline].

  3. Mehta AV, Goenka S, Chidambaram B, Hamati F. Natural history of isolated ventricular septal defect in the first five years of life. Tenn Med. 2000;93(4):136-8. [Medline].

  4. Moodie DS. Diagnosis and management of congenital heart disease in the adult. Cardiol Rev. 2001;9(5):276-81. [Medline].

  5. Mukharji J, Sullivan L. Ventricular septal defect in the 9th decade. Mo Med. Sep 2001;98(9):468-9. [Medline].

  6. Perello Roso A, Osa Saez A, Garcia Casco MP, et al. Bacterial endocarditis in an adult with ventricular septal defect. An Med Interna. 2001;18(7):396-7. [Medline].

  7. Tomita H, Arakaki Y, Yagihara T, Echigo S. Incidence of spontaneous closure of outlet ventricular septal defect. Jpn Circ J. 2001;65(5):364-6. [Medline].

  8. Berthaux XA, Brenot P, Angel C, et al. Multirow detector computed tomography assessment of intraseptal dissection and ventricular pseudoaneurysm in postinfarction ventricular septal defect. Circulation. 2001;104(4):497-8. [Medline].

  9. Stauder NI, Miller S, Scheule AM, et al. MRI diagnosis of a previously undiagnosed large trabecular ventricular septal defect in an adult after multiple catheterizations and angiocardiograms. Br J Radiol. 2001;74(879):280-2. [Medline].

  10. Manganaro L, Savelli S, Di Maurizio M, Perrone A, Francioso A, La Barbera L, et al. Assessment of congenital heart disease (CHD): Is there a role for fetal magnetic resonance imaging (MRI)?. Eur J Radiol. Jul 17 2008;[Medline].

  11. Mooij CF, de Wit CJ, Graham DA, Powell AJ, Geva T. Reproducibility of MRI measurements of right ventricular size and function in patients with normal and dilated ventricles. J Magn Reson Imaging. Jul 2008;28(1):67-73. [Medline].

  12. Durongpisitkul K, Saiviroonporn P, Soongswang J, Laohaprasitiporn D, Chanthong P, Nana A. Pre-operative evaluation with magnetic resonance imaging in tetralogy of fallot and pulmonary atresia with ventricular septal defect. J Med Assoc Thai. Mar 2008;91(3):350-5. [Medline].

  13. Weber C, Weber M, Ekinci O, Neumann T, Deetjen A, Rolf A, et al. Atrial septal defects type II: noninvasive evaluation of patients before implantation of an Amplatzer Septal Occluder and on follow-up by magnetic resonance imaging compared with TEE and invasive measurement. Eur Radiol. Jun 21 2008;[Medline].

  14. Attenhofer Jost CH, Turina J, Mayer K, et al. Echocardiography in the evaluation of systolic murmurs of unknown cause. Am J Med. 2000;108(8):614-20. [Medline].

  15. D'Cruz IA, Calderon E, Shearin S. Acquired ventricular septal defect following stab wound color flow Doppler diagnosis. Echocardiography. Jul 1997;14(4):409-10. [Medline].

  16. Fujiwara M, Sase M, Kondou O, Furukawa S. Congenital aneurysm of the muscular interventricular septum in a fraternal case diagnosed by fetal echocardiography. Pediatr Cardiol. 2001;22(4):353-6. [Medline].

  17. Ishii M, Hashino K, Eto G, et al. Quantitative assessment of severity of ventricular septal defect by three-dimensional reconstruction of color Doppler-imaged vena contracta and flow convergence region. Circulation. 2001;103(5):664-9. [Medline].

  18. Miller-Hance WC, Silverman NH. Transesophageal echocardiography (TEE) in congenital heart disease with focus on the adult. Cardiol Clin. 2000;18(4):861-92. [Medline].

  19. Parro A Jr, Carlos Da Silveira L, Francischetti A, et al. Echocardiographic features of ventricular septal rupture with right ventricular aneurysm after acute myocardial infarction. Echocardiography. 1996;13(3):303-8. [Medline].

  20. Sittiwangkul R, Ma RY, McCrindle BW, et al. Echocardiographic assessment of obstructive lesions in atrioventricular septal defects. J Am Coll Cardiol. 2001;38(1):253-61. [Medline].

  21. Smallhorn JF. Cross-sectional echocardiographic assessment of atrioventricular septal defect: basic morphology and preoperative risk factors. Echocardiography. 2001;18(5):415-32. [Medline].

  22. Schroh AM, Laghezza LB, Domínguez PJ, Brandán V, Nento DE. [Echocardiographic Doppler evaluation of ventricular function in children with an atrial septal defect]. Rev Esp Cardiol. Jun 2008;61(6):595-601. [Medline].

  23. Bauriedel G, Redel DA, Schmitz C, et al. Transcatheter closure of a posttraumatic ventricular septal defect with an Amplatzer occluder device. Catheter Cardiovasc Interv. 2001;53(4):508-12. [Medline].

  24. Gaynor JW. Management strategies for infants with coarctation and an associated ventricular septal defect. J Thorac Cardiovasc Surg. 2001;122(3):424-6. [Medline].

  25. Okubo M, Benson LN, Nykanen D, et al. Outcomes of intraoperative device closure of muscular ventricular septal defects. Ann Thorac Surg. 2001;72(2):416-23. [Medline].

  26. Wilkinson JL. Interventional pediatric cardiology: device closures. Indian J Pediatr. 2000;67(3 Suppl):S30-6. [Medline].

  27. Miyake T, Yokoyama T, Fukuhara H. Right-to-left shunt through a ventricular septal defect during sedated sleep. Echocardiography. 1998;15(4):385-8. [Medline].

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Further Reading

Suspected congenital heart disease in the adult.
American College of Radiology - Medical Specialty Society.  1998 (revised 2007).  8 pages.  NGC:005988

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Keywords

ventricular septal defect, VSD, interventricular septal defect, heart septal defect, membranous VSD, cardiac malformation, congenital cardiac anomaly, interventricular septum, restrictive ventricular septal defect, restrictive VSD, Eisenmenger syndrome, interventricular foramen, congenital heart defect, congenital heart disease, septal defect

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Contributor Information and Disclosures

Author

Vibhuti N Singh, MD, MPH, FACC, FSCAI, Director, Suncoast Cardiovascular Center; Chair, Cardiology Division and Cath Labs, Department of Medicine, Bayfront Medical Center; Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine
Vibhuti N Singh, MD, MPH, FACC, FSCAI is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Florida Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Rakesh K Sharma, MBBS, FACC, FACP, Interventional Cardiologist, The Heart and Vascular Institute of Florida
Rakesh K Sharma, MBBS, FACC, FACP is a member of the following medical societies: American College of Cardiology, American College of International Physicians, American College of Physicians, American Heart Association, and American Medical Association
Disclosure: Nothing to disclose.

Hanumanth K Reddy, MD, FACC, Clinical Professor of Medicine, St Louis University Medical School; Associate Chief, Department of Cardiovascular Services, Three Rivers Healthcare
Disclosure: Nothing to disclose.

Navin C Nanda, MD, FACC, Director, Heart Station and Echocardiography Laboratories, Professor, Department of Internal Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham
Disclosure: Nothing to disclose.

Medical Editor

Justin D Pearlman, MD, PhD, ME, MA, Director of Dartmouth Advanced Imaging Center, Professor of Medicine, Professor of Radiology, Adjunct Professor, Thayer Bioengineering and Computer Science, Dartmouth-Hitchcock Medical Center
Justin D Pearlman, MD, PhD, ME, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

John D Newell, Jr, MD, FACR, FCCP, FASER, Co-Director of Thoracic Imaging, UCDHSC; Director of Lung Imaging Center, Professor of Radiology and Professor of Medicine, Department of Radiology, University of Colorado Health Sciences Center, National Jewish Medical and Research Center; Univ. Colorado Hospital
John D Newell, Jr, MD, FACR, FCCP, FASER is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, American Thoracic Society, Association of University Radiologists, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Siemens Medical Grant/research funds Consulting; Forevision Technologies Ownership interest Consulting; Vida Corporation Ownership interest Board membership; TeraRecon Grant/research funds Consulting; eMedicine Honoraria Consulting

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Clinical Assistant Professor of Radiology, University of Washington Medical School
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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