Question re: shunt pressures, VSD

[mshanson]

Our daughter had her echo repeat this past Friday (12 weeks old) and they advised that her ASD has gotten smaller, but that her VSD is still approx. 6 mm. He said it has a very strong shunt of 67mmHg, which he seemed to feel meant that the hole might be getting smaller? Is it possible the strong pressure means it's getting smaller? He did say he felt that it was next to impossible that it would ever close on it's own, as it is oval shaped and starts immediately JUST below the aortic valve (thankfully no signs of valve-involvement or problems), loops up and around and ends just above (or below?) the tricuspid valve. He was a little vague on details. Is this a serious location for a VSD, where it's so close to the valves? They are recomending OHS to repair within the next 6-8 weeks.
She is currently on Lasix, Spironolactone, Digoxin for her heart. Right now her symptoms as far as breathing, sweating etc.. are very well controlled by medications, though she's still struggling to gain weight. She had an NG feeding tube inserted due to failure to thrive, and even with the tube & 27-cal formula she only gained 20 grams in the last week. I'm wondering if we are wise to wait that long? I think they're hoping she'll hit 10 lbs first (she's still only 9 lbs).
Also, they mentioned that she's not growing well in length either, has only gained 1.25" in 12 weeks. The cardiologist thought there might be something else wrong, but for several weeks she was only eating 12-14 oz per day, so would that lack of calories not cause growth problems?

[mshanson]

Does that create any complications during surgery? Any increased risk for pulmonary hypertension, valve problems etc?

[Jeffrey R Boris, M.D.]

That's good news regarding both her growth and her sclerae.  The VSD you are describing would be a perimembranous VSD with inlet muscular extension, and we do see this.

[mshanson]

Thank you for replying. Well her length is not an issue, she had her knees bent, she is actually 23" now, so has been growing fine. So nice to not have to worry about that, and her eyes are also fine. Of all things, it was what she was wearing that made them look slightly blue, but they're fine.

We did find out that the echo report states that the VSD involves her aortic root? It passes through the root, and around to the tricuspid valve. Is that common?

[Jeffrey R Boris, M.D.]

Dear MSHanson,

Overall, it sounds like there is at least a moderate-sized VSD in the perimembranous area, which is a common location for it to occur.  It is not a particularly serious location unless the valves get deformed by the flow of blood through the defect or by the surgical repair.  It is certainly possible to have what appears to be a hemodynamically restrictive defect, such as having an estimated blood pressure difference, or gradient, of 67 mmHg across the defect and still have some congestive heart failure (CHF).  I cannot say specifically whether her caloric differences were associated with her growth failure, or not.  Certainly, we do see babies get behind from a growth standpoint with CHF and inadequate calories who are not able to catch up until they have heart surgery.  However, we also see genetic and metabolic disorders that can lead to either CHF or growth failure.  If the picture is unclear at this time, it would be important to have your daughter further evaluated from a genetic standpoint.