Ventricular Septal Defect (VSD): Recognize the Symptoms, Causes, and Right Treatment Options

Does your baby often seem weak while breastfeeding, break out in cold sweats, or struggle to gain weight? Be careful: these complaints may be a sign of Ventricular Septal Defect (VSD), a congenital heart defect that often goes unnoticed. Have it confirmed through a doctor’s examination. The good news is that with early detection and proper treatment, children can grow up healthy like other children.

VSD is one of the most common congenital heart abnormalities, or congenital heart diseases, in the world, including in Indonesia. According to data from the Indonesian Ministry of Health (Kemenkes) and the Indonesian Pediatric Society (IDAI), about 20 to 30% of all congenital heart disease cases in children are VSD. This means that out of every 100,000 live births, 283 babies may have it. Unfortunately, many cases are diagnosed late because the symptoms are often vague.

VSD can be “silent”, showing no clear symptoms, especially when the hole in the heart’s septum is still small. Parents may assume that signs such as a baby tiring quickly, frequent respiratory infections, or difficulty breastfeeding are normal. In fact, these may be signals that the heart is working harder than it should. Without a thorough heart examination (such as echocardiography), VSD can go unnoticed until it causes serious complications later in life.

01 / Heart Disease

What Is Ventricular Septal Defect (VSD)?

Ventricular Septal Defect (VSD) is a congenital heart defect characterized by a hole in the wall (septum) that separates the two lower chambers of the heart, the right and left ventricles. This hole allows oxygen-rich blood from the left ventricle to flow back into the right ventricle and then to the lungs, instead of going directly to the rest of the body. As a result, the heart works harder and blood pressure in the lungs can rise.

VSD is one of the most common congenital heart defects. It occurs as the fetal heart develops during pregnancy, when the wall between the ventricles does not form completely, leaving one or more holes.

How VSD Differs From Other Congenital Heart Defects

Congenital heart defects come in many types, and it is important to understand the differences between VSD and other conditions:

Type of defect	Main difference from VSD
Atrial Septal Defect (ASD)	The hole is in the wall between the upper chambers (atria), not the lower chambers. Symptoms are usually milder and may only be felt in adulthood.
Patent Ductus Arteriosus (PDA)	A blood vessel that should close after birth stays open, causing abnormal blood flow between the aorta and the pulmonary artery.
Tetralogy of Fallot (ToF)	A combination of 4 heart defects, including a large VSD plus narrowing of the pulmonary artery. Babies are often blue (cyanosis) from birth.
Pulmonary Stenosis	Narrowing of the pulmonary valve, not a hole in the heart’s septum. It makes the right side of the heart work extra hard.

Classification of VSD by Size and Location of the Defect

VSD is grouped by the size of the hole and its location in the heart’s septum:

A. By Size

Type	Hole size	Impact on the heart
Small VSD	<5 mm	Often causes no symptoms and may close on its own.
Moderate VSD	5 to 10 mm	Babies may tire quickly while breastfeeding; risk of recurrent lung infections.
Large VSD	>10 mm	A lot of blood leaks through, the heart enlarges, and there is a risk of heart failure if not operated on.

B. By Location

• Perimembranous (subaortic), 70 to 80% of cases: Located in the upper part of the ventricular septum near the aortic valve; this is the most common type of VSD.
• Muscular (trabecular), 5 to 20% of cases: Located in the muscular part of the ventricular septum; there may be one or several holes.
• Inlet, 5 to 8% of cases: Located near the atrioventricular valves; often associated with other defects such as atrioventricular septal defect.
• Outlet (supracristal), 5 to 7%: Located near the ventricular outflow tract; more common in Asian populations and can cause complications in the aortic valve.

02 / Heart Disease

Causes and Risk Factors of VSD

Ventricular Septal Defect (VSD) is a congenital heart defect that develops while the fetus is still in the womb. Although its exact cause is not yet fully understood, several factors have been identified as main causes and as risk factors that increase the likelihood of VSD.

1. Main Cause: Abnormal Heart Development in the Fetus

VSD occurs because of disrupted formation of the heart’s septum during the first 6 to 8 weeks of pregnancy. As the fetus develops, the septum should close completely to separate the left and right ventricles. In VSD, however, this process is not completed, leaving a hole.

Why does this happen?

• Incomplete division of heart cells: Genetic or environmental factors can disrupt the signals that guide tissue formation.
• Abnormal fetal blood flow: This affects the pressure inside the heart, so the septum does not close tightly.

2. Risk Factors That Increase the Likelihood of VSD

Several factors that may increase the risk of a baby being born with VSD include:

• Family history of congenital heart disease: If a parent or sibling has a congenital heart defect, the child’s risk of VSD is 2 to 4 times higher (American College of Cardiology, 2023). What you can do: Genetic counseling before pregnancy, especially if there is a strong family history.
• Exposure to infections or certain medications during pregnancy: Infections such as rubella (German measles) in the first trimester of pregnancy can increase the risk of heart defects in the fetus. In addition, the use of certain medications, such as anti-seizure drugs (for example, sodium valproate and phenytoin), has also been linked to an increased risk of VSD.
• Genetic syndromes (for example, Down Syndrome): Babies with genetic syndromes such as Down syndrome have a higher risk of VSD. About 45% of children with Down syndrome have a congenital heart defect, including VSD. Other syndromes: Turner Syndrome, DiGeorge Syndrome.

The importance of early screening:

• A fetal heart ultrasound (fetal echocardiogram) can detect VSD from weeks 18 to 22 of pregnancy.
• If a VSD is detected, the medical team can prepare a delivery plan and treatment right after birth.

03 / Heart Disease

VSD Symptoms to Watch Out For

Ventricular Septal Defect (VSD) can cause symptoms that vary depending on the size of the hole and the patient’s age. It is important for parents and adults to recognize the signs that may appear so they can seek medical help promptly.

1. In Babies and Children

Symptoms of VSD in babies and children often appear within the first few weeks after birth, especially if the hole in the ventricular septum is fairly large. Some signs to watch out for include:

• Difficulty breastfeeding or eating: The baby may tire quickly while breastfeeding, stop feeding before being full, or sweat while feeding.
• Slow growth: The baby’s weight does not increase in line with the normal growth chart, or the baby even loses weight.
• Fast breathing or difficulty breathing: The baby breathes faster than usual, looks short of breath, or uses extra muscles to breathe.
• Frequent respiratory infections: The baby is more prone to infections such as colds or pneumonia.
• Pale or bluish skin: Especially on the lips, tongue, or nails, which indicates a lack of oxygen in the blood.
• Fast heart rate: The heart beats faster than normal, even when the baby is resting.

These symptoms show that the baby’s heart and lungs are working harder than usual. If you notice these signs in your child, consult a doctor promptly.

2. In Adults (If Not Diagnosed in Childhood)

Some people with a small VSD may have no symptoms until adulthood. However, if VSD is not diagnosed or treated in childhood, symptoms can appear over time, especially if complications develop. Signs to watch for include:

• Shortness of breath: Especially during activity or exercise.
• Fatigue: Feeling tired or weak easily, even after light activity.
• Irregular heartbeat: Feeling palpitations or a heartbeat that is irregular.
• Swelling in the legs or abdomen: Caused by fluid buildup due to reduced heart function.
• Bluish skin: Especially on the lips and nails, indicating low oxygen levels in the blood.

If you experience these symptoms, it is important to consult a doctor promptly for further evaluation. Early detection and treatment can prevent serious complications later on.

Important fact:

• Patients with a VSD >10 mm who do not undergo surgery have a higher risk of sudden death.

04 / Heart Disease

How Is VSD Diagnosed?

Diagnosing Ventricular Septal Defect (VSD) requires a thorough approach that involves a physical examination and various supporting tests. Early detection is very important for determining the right treatment and preventing complications later on.

1. Physical Examination by a Cardiologist

The first step in detecting VSD usually begins with a physical examination by a doctor. One characteristic sign that may be found is a heart murmur, a whooshing sound heard as blood flows through the hole in the ventricular septum. This murmur is usually heard during an examination with a stethoscope and can give an early clue that a VSD is present.

2. Supporting Tests

To confirm the diagnosis and assess the severity of VSD, the doctor will recommend several supporting tests:

• Echocardiography (heart ultrasound): This is the main test for diagnosing VSD. Using sound waves, echocardiography produces moving images of the heart, allowing the doctor to see the size, location, and blood flow through the hole in the ventricular septum. This test has high sensitivity for detecting VSD.
• Electrocardiogram (ECG): This test records the heart’s electrical activity and can show heart enlargement or rhythm disturbances related to VSD.
• Chest X-ray: Used to see the size and shape of the heart and the condition of the lungs. In VSD, an X-ray may show an enlarged heart or increased blood flow to the lungs.

3. When Is Cardiac Catheterization Needed?

Cardiac catheterization is an invasive procedure that involves inserting a catheter into a blood vessel to reach the heart. This test is usually done if non-invasive tests do not provide enough information or if further assessment of pressure and blood flow inside the heart is needed. Besides diagnosis, catheterization can also be used to perform corrective procedures in some VSD cases.

4. Prenatal Diagnosis (Detection Before Birth)

VSD can be detected while the baby is still in the womb through fetal echocardiography, which is usually performed between 18 and 24 weeks of pregnancy. This test allows the doctor to see the structure and function of the fetal heart in detail, helping to plan treatment after birth. This early detection is very important, especially if there is a family history of congenital heart defects or other risk factors.

Note:

• Many large VSDs can be detected before birth.

With a combination of a physical examination and the right supporting tests, VSD can be diagnosed accurately, allowing effective treatment and reducing the risk of complications in the future.

05 / Heart Disease

Possible Complications If VSD Is Not Treated

If Ventricular Septal Defect (VSD) is not treated properly, it can trigger various serious complications that affect quality of life and can even be life-threatening. Here are four main complications to watch out for:

1. Pulmonary Hypertension (High Blood Pressure in the Lungs)

Pulmonary hypertension is a condition in which blood pressure in the pulmonary arteries rises significantly. In an unrepaired VSD, blood from the left ventricle (which is oxygen-rich) flows into the right ventricle, causing excess blood flow to the lungs. As a result, the blood vessels in the lungs become stiff and narrow, increasing the pressure inside them. If left untreated, this condition can cause permanent damage to the lung blood vessels and increase the workload of the right side of the heart.

Warning signs:

• Shortness of breath that gets progressively worse
• Tiring easily, even during light activity
• Lips and nails starting to turn blue (cyanosis)

Critical facts:

• Some patients with a large untreated VSD may go on to develop pulmonary hypertension.
• Once permanent damage to the lung blood vessels has occurred, this condition cannot be completely cured.

2. Infective Endocarditis (Heart Valve Infection)

Infective endocarditis is an infection of the inner lining of the heart (endocardium), including the heart valves. People with VSD have a higher risk of this infection because abnormal blood flow can damage heart tissue, making it easier for bacteria to attach and grow. Symptoms of endocarditis include fever, fatigue, muscle pain, and heart rhythm disturbances. Prevention includes maintaining good oral and dental hygiene and giving antibiotics before certain medical procedures.

Important notes:

• The risk of endocarditis in VSD patients is higher than in people without VSD.
• Some cases of endocarditis require surgery.

3. Heart Failure

Heart failure occurs when the heart is unable to pump blood effectively enough to meet the body’s needs. In a large untreated VSD, the heart works harder to pump blood, which causes the heart muscle to enlarge and weaken.

Clinical manifestations:

• In babies:
  • Difficulty breastfeeding
  • Cold sweats
  • No weight gain
• In adults:
  • Swelling in the legs and abdomen
  • Often waking at night because of shortness of breath
  • Chronic cough

Health data:

• Babies with a large VSD are at risk of heart failure within the first 6 months if left untreated.

4. Eisenmenger Syndrome

Eisenmenger syndrome is a late complication of an unrepaired VSD. It occurs when blood flow through the VSD reverses direction, from left-to-right to right-to-left, because of high pressure in the pulmonary artery. As a result, oxygen-poor blood flows throughout the body, causing cyanosis (bluish skin), fatigue, shortness of breath, and an increased risk of serious complications such as stroke and heart failure. Eisenmenger syndrome is a life-threatening condition that requires specialized medical care.

Characteristic signs:

• Permanently bluish skin color
• Drumstick-shaped fingertips (clubbing fingers)
• Coughing up blood
• Recurrent fainting

Special warning:

• This condition is irreversible (it cannot be reversed)
• In advanced stages, a heart-lung transplant may be one of the options
• Life expectancy may be reduced

06 / Heart Disease

VSD Treatment and Management Options

Here is a complete explanation of the treatment and management options for Ventricular Septal Defect (VSD), tailored to the size of the defect and the patient’s condition:

1. Small VSD (May Close on Its Own)

Most small VSDs do not require specific medical procedures because they are very likely to close spontaneously as the child grows.

However, in some cases, symptoms such as shortness of breath, fatigue, or slow growth may appear. To manage these symptoms, the doctor may prescribe:

• Diuretics: Help reduce excess fluid in the body, which reduces the heart’s workload.
• ACE inhibitors: Lower blood pressure and reduce the heart’s workload by widening the blood vessels.
• Cardiac glycosides (for example, digoxin): Increase the strength of heart contractions and help control the heart rate.

In addition to medication, regular monitoring by a pediatric cardiologist is very important to ensure optimal development and to detect changes in the condition early.

2. Moderate to Large VSD (Requires Intervention)

Moderate to large VSDs can cause excessive blood flow to the lungs, increasing the risk of serious complications such as pulmonary hypertension and heart failure. Therefore, medical intervention is needed, which may include:

1. Open-heart surgery: This procedure involves:
   • General anesthesia.
   • An incision in the chest to access the heart.
   • Use of a heart-lung machine during the operation.
   • Closing the VSD hole with a patch or stitches.
2. Transcatheter VSD closure (minimally invasive): For some types of VSD, especially those in certain locations and in patients with suitable anatomy, closure using a catheter can be an alternative. The advantages of this method include a recovery time that is generally faster than with open surgery. However, not all patients are eligible for this procedure; a thorough evaluation by the medical team is needed. This procedure involves:
   • Inserting a catheter through a blood vessel in the groin.
   • Guiding the catheter to the heart to place a closure device over the VSD hole.

3. The Right Timing for Intervention in Children

Choosing the timing of intervention is very important to prevent long-term complications. In general, intervention is recommended at:

• Age 6 to 12 months: For babies with a large VSD or significant symptoms.
• Before 18 months of age: To prevent permanent pulmonary hypertension from developing.

Decisions about the timing of intervention should be based on a thorough evaluation by a pediatric cardiologist, taking into account the size of the VSD, clinical symptoms, and the results of supporting tests.

It is important to consult a pediatric cardiologist regularly to monitor the VSD and determine the most suitable treatment strategy. With timely treatment and appropriate methods, the prognosis for children with VSD is very good, allowing them to grow and develop normally.

07 / Heart Disease

Living With VSD: What Should Parents and Patients Know?

Living with Ventricular Septal Defect (VSD) can be a challenging journey, but with proper treatment, children can grow and develop optimally. Here is important information for parents and patients:

1. Growth and Development of Children With VSD

Children with a small VSD generally do not have problems with growth and development. However, with larger VSDs, symptoms such as tiring while breastfeeding, rapid breathing, and slow weight gain can occur. In such cases, medical interventions such as high-calorie nutrition or surgery may be needed to support optimal growth.

Facts to know:

• Children with a small VSD that has closed on its own generally develop normally like other children
• For VSDs that have been surgically repaired:
  • Most children can reach age-appropriate developmental milestones.
  • Extra monitoring is needed for body weight (risk of failure to thrive) and motor development (because they often tire easily).

Tips for parents:

1. Record your child’s development in the KMS book (Indonesia’s child growth monitoring card) or health record book
2. Provide play-based stimulation suited to your child’s age
3. Have regular consultations with a pediatrician and a cardiologist

2. Physical Activity and Sports: Allowed or Not?

Physical activity is very important for children’s health, including children with VSD. Children with a small VSD without complications can usually take part in all types of sports. However, for those with a moderate to large VSD or with pulmonary hypertension, physical activity may need to be limited. After a VSD closure procedure, children can generally return to sports after 3 to 6 months, depending on their individual condition.

General guidelines:

VSD condition	Recommended activities	What to avoid
Small VSD (already closed)	All competitive sports	–
VSD after surgery	Light to moderate exercise (swimming, cycling)	Heavy physical contact within 6 months after surgery
Large VSD not yet operated on	Light daily activities	Competitive sports

Special attention:

• Children with pulmonary hypertension need strict activity restrictions.
• Have a treadmill test or stress echocardiography before starting a regular exercise program.

3. Nutrition and Regular Monitoring

Children with VSD, especially those with symptoms, may need a higher calorie intake to support their growth. Regular monitoring of weight and growth is very important. In some cases, nutritional supplements or special formula may be recommended to make sure energy needs are met.

Ideal diet:

• Babies: Exclusive breastfeeding plus high-calorie formula if needed
• Children:
  • Small but frequent meals (5 to 6 times a day)
  • High in protein (meat, fish, eggs)
  • Limit salt to avoid fluid retention
• Monitoring schedule:
  • Small VSD: heart ultrasound once a year
  • VSD after surgery:
    • 1 month after surgery
    • 3 months
    • 6 months
    • After that, once a year

Self-monitoring checklist:

• Resting heart rate (normal for children: 70 to 120 beats per minute)
• Color of the lips and nails (watch for a bluish tint)
• Appetite and body weight

4. Long-Term Prognosis

With proper treatment, the prognosis for children with VSD is very good. Most children who receive treatment or a VSD closure procedure can lead normal, healthy lives. However, long-term monitoring by a cardiologist is still needed to detect and manage possible complications in the future.

It is important for parents and patients to maintain good communication with the medical team, follow the routine check-up schedule, and make sure the child gets appropriate nutrition and physical activity. With the right support, children with VSD can grow and develop optimally.

08 / Heart Disease

VSD and Pregnancy: What Should You Watch For?

Pregnancy in women with a history of Ventricular Septal Defect (VSD) requires special attention to ensure the safety of both mother and baby. Here is important information to know:

1. Pregnancy Risks for Women With VSD

Women with a small VSD and no serious complications can generally go through pregnancy with minimal risk. However, with a larger VSD or with complications such as pulmonary hypertension, pregnancy risks increase significantly. Possible complications include heart failure, arrhythmia, stroke, and even maternal death. The fetus is also at risk of prematurity, low birth weight, or even fetal death.

2. Preventing the Transmission of Defects to the Fetus

Although not all VSD cases can be prevented, several steps can reduce the risk of congenital heart defects in the fetus:

• Regular prenatal check-ups: Having regular pregnancy check-ups helps detect and manage problems early.
• Taking folic acid: Taking a multivitamin containing 400 micrograms of folic acid every day can reduce the risk of birth defects, including heart defects.
• Avoid unhealthy habits: Avoiding smoking, alcohol, and exposure to harmful substances during pregnancy is important to prevent defects in the fetus.
• Vaccination: Getting vaccinated, for example with the rubella vaccine before pregnancy, can prevent infections that could cause heart defects in the fetus.

3. Close Monitoring During Pregnancy

For women with VSD, pregnancy should be closely monitored by a multidisciplinary medical team made up of an obstetrician, a cardiologist, and other specialists. The steps usually taken include:

• Risk stratification: Assessing the severity of the VSD and determining an appropriate care plan.
• Regular monitoring: Routine check-ups to monitor the mother’s heart condition and the baby’s development.
• Delivery planning: Determining the most suitable method and timing of delivery for mother and baby.
• Postpartum care: Providing intensive care after delivery to prevent further complications.

Ideal monitoring:

Trimester	Required tests	Frequency
First	Maternal echocardiography, early fetal ultrasound	Once a month
Second	Fetal echocardiography, BNP test	Twice a month
Third	Arrhythmia monitoring, fetal growth ultrasound	Once a week

Emergency signs to report immediately:

• Shortness of breath that worsens at rest
• Heart rate persistently >120 beats per minute
• Sudden swelling of the face and hands
• Sharply reduced fetal movement

With proper planning and monitoring, many women with VSD can go through pregnancy and give birth safely.

09 / Heart Disease

Conclusion

Finding out that someone, especially a child, has Ventricular Septal Defect (VSD) can certainly be a stressful experience for a family. However, it is important to know that VSD is a congenital heart defect that can be managed well, especially when it is recognized early and receives proper medical supervision.

With today’s advances in medical technology and multidisciplinary care, most children with VSD can grow up healthy and active and enjoy a good quality of life. In fact, many small VSDs close on their own as the child grows, without the need for surgery.

Take Proactive Steps: Detection and Check-Ups Are Real Solutions

If you have a newborn, are planning a pregnancy, or have a family history of congenital heart disease, do not delay consulting a medical professional. Early detection and regular monitoring are the wisest steps to look after your little one’s heart health.

🔍 Remember: Not all VSD symptoms are obvious from the start. That is why regular heart check-ups are strongly recommended, especially for babies and children with complaints such as difficulty breastfeeding, poor weight gain, or frequent respiratory infections.

💬 You are not alone in facing this. At Heartology Cardiovascular Hospital, cardiologists can help evaluate a VSD and determine appropriate treatment.