Dear Dr. My 4.5 months old dd has 1 moderate 5mm perimembranous outlet restrictive VSD and 2 very small apical muscular restrictive VSDs. Gradient is 50mm Hg. Marked LA dilation. She has problem in weight gain and presently on diuretics. ACE inhibitors. Further prognosis plz.
Without evaluating your daughter or her tests, I cannot say exactly what she needs. However, something doesn't seem particularly right with me with these tests. The poor weight gain and left atrial dilation suggest that she has congestive heart failure with significant recirculation of her blood through her lungs, but you say that there is a 50 mmHg gradient across the VSD (unless you mean across the apical VSDs). I would expect a very low gradient across the perimembranous defect. At this age, she very well may potentially be considered to have failed medical management and may require surgical closure of her large defect.
Thanx a lot. I got her checked from another paeds cardiologist. Her smaller ones have healed, however perimembranous moderate ones has shown regression by 1mm at least to 4mm.However there is an indication of LA dilation and LV volume overload. PG across VSD is 40 mm Hg now. Some other info are IVSD 0.4 cm, Vel A 3.13m/s.
Dear Jeffrey, If only one moderate size perimembranous VSD can effect to cause LA dilation and LV volume overload, does it mean that either the VSD is not restrictive or size is larger than moderate or maybe VSD is accompanied by another abnormality not yet identified. Thanks alot for your response. Also shouldn't the rise in PH come up as an observation under the symptoms I have just discussed. Thanks again
A moderate sized defect can still cause volume loading. That said, with the elevated gradient and a diameter of 4 mm, it may certainly be getting smaller and starting to restrict flow such that with time, the volume loading could fall. The big issue is ensuring that she is eating well without getting out of breath or getting sweaty with feeds, as she may be able to continue to close the defect down and make it more restrictive.
Dear Jeffery, being located 5000 miles away from you, I have the only option of thanking you with sincerity for taking out time to answer my queries . She has shown to improve her feed by double after closure of small VSDs. We hope to see it get better. Thanks million again.
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