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cardio.achd-vsd.chronic.v1

Adult ventricular septal defect (chronic ACHD)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Adult VSD — closure for Qp:Qs ≥1.5 + LV overload (acceptable PVR) or prior IE; distinct AR-driven surgical trigger (cusp prolapse, outlet/perimembranous); severe PAH/Eisenmenger = closure CONTRAINDICATED; small restrictive = IE-awareness + surveillance only. Manifest points at existing sibling cardio.valvular_disease.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (closure/AR-surgery/PAH axis + workups + calculators + panels), test_files, 4-PMID evidence object, chronic phases all present. PAH drug RxCUIs RxNav-validated 2026-05-16 (macitentan 1442132, tadalafil 358263, selexipag 1729002); furosemide reused; closure/surgery/IE-prophylaxis non_pharm; SNOMED deferred. 9 trigger/special-pop branches: Eisenmenger-no-closure (not-to-miss), significant-shunt closure, VSD-associated-AR, IE-history, developing-PAH, small-restrictive, pregnancy, residual-VSD, CKD.

Entry points (5)

  • symptom
    Harsh holosystolic murmur (LLSB) ± thrill
    holosystolic_murmur
  • imaging
    Echo: VSD with LV volume overload / left-to-right shunt
    echo_vsd_lv_overload
  • symptom
    New/progressive AR (aortic cusp prolapse — outlet/perimembranous)
    new_aortic_regurgitation
  • history
    History of VSD-related infective endocarditis
    vsd_endocarditis
  • history
    Known VSD — surveillance / closure evaluation
    known_vsd

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Adult surveillance + intervention timing
  • vsd_type_sizerequired
    imaging • used at FRAME
    Perimembranous/muscular/inlet/outlet + restrictive vs non-restrictive — modality + AR risk
  • qp_qsrequired
    imaging • used at RISK_STRATIFICATION
    Qp:Qs ≥1.5 + LV overload = closure indication (if PVR acceptable)
  • lv_volume_overloadrequired
    imaging • used at INITIAL_WORKUP
    LV dilatation supports hemodynamic significance
  • pulmonary_vascular_resistancerequired
    imaging • used at RISK_STRATIFICATION
    Severe PAH/Eisenmenger = closure CONTRAINDICATED
  • aortic_regurgitation_grade
    imaging • used at BRANCHING_WORKUP
    Progressive AR from cusp prolapse = surgery trigger (even small shunt)
  • ie_history
    history • used at CONTEXT
    Prior IE = closure indication + prophylaxis
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    Symptomatic significant VSD strengthens closure indication
  • creatininerequired
    lab • used at TREATMENT
    Contrast for TEE/RHC; drug dosing
  • pregnancy_status
    demographic • used at CONTEXT
    Well-tolerated if small/no PAH; Eisenmenger contraindicated

12-phase flow (12)

  1. 1FRAME
    Define VSD type/size + shunt + PVR + AR involvement
    inputs: vsd_type_size
    advance: VSD type + physiology framed
  2. 2ENTRY
    Holosystolic murmur, LV overload, new AR, IE history, known VSD
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Type, prior repair, IE history, PAH risk, pregnancy
    inputs: ie_history, pregnancy_status
    advance: context complete
  4. 4RED_FLAGS
    Eisenmenger physiology, active IE, decompensation
    inputs: pulmonary_vascular_resistance
    actions: cardiogenic_shock
    advance: no red flags or routed to PAH/IE/acute pathway
  5. 5INITIAL_WORKUP
    TTE (VSD size/shunt, LV overload, AR), ECG
    inputs: lv_volume_overload
    actions: panel.cardiac
    advance: shunt + LV overload + AR documented
  6. 6BRANCHING_WORKUP
    TEE (type/Qp:Qs/AR-cusp), RHC for PVR if PAH suspected, aortic-cusp assessment
    inputs: qp_qs, pulmonary_vascular_resistance, aortic_regurgitation_grade
    actions: preop_cardiac
    advance: type + Qp:Qs + PVR + AR resolved
  7. 7DIFFERENTIAL
    Restrictive vs moderate-large; AR-associated; Eisenmenger; double-chambered RV
    inputs: vsd_type_size, pulmonary_vascular_resistance
    advance: phenotype + closability assigned
  8. 8RISK_STRATIFICATION
    Qp:Qs ≥1.5 + LV overload + acceptable PVR → closure; progressive AR / prior IE → surgery; severe PAH → no closure
    inputs: qp_qs, pulmonary_vascular_resistance, aortic_regurgitation_grade, nyha_class
    advance: intervention decision assigned
  9. 9TREATMENT
    Surgical/transcatheter closure if indicated; AR-driven surgery; PAH therapy + no-closure if Eisenmenger; IE prophylaxis where indicated
    inputs: creatinine, vsd_type_size
    advance: closure/AR-surgery/PAH plan documented
  10. 10DISPOSITION
    ACHD centre + structural/PAH referral
    inputs: nyha_class
    actions: preop_cardiac
    advance: referral plan set
  11. 11MONITORING
    Residual VSD/device, AR progression, PAH
    inputs: pulmonary_vascular_resistance, aortic_regurgitation_grade
    actions: panel.cardiac
    advance: surveillance cadence documented
  12. 12FOLLOWUP
    Lifelong ACHD; pregnancy + transition planning; IE education
    inputs: pregnancy_status
    advance: lifelong ACHD plan documented