الفهرس 
VENTRICULAR SEPTAL DEFECTOnly 14 pages are availabe for public view
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Abstract
V
entricular septal defect (VSD) is the most common congenital heart disease accounting for 40% of all congenital heart diseases. An isolated VSD accounts for more than 20% of all congenital heart diseases. Management in the infants and children depends on symptoms and severity of the shunt; children with small asymptomatic defects need no medical management and are unlikely to need any intervention. First-line treatment for moderate or large defects affecting feeding and growth is with medical treatment for heart failure and surgical or catheter -based intervention to close the VSD. Nowadays, successful trans-catheter device closure of trabecular (muscular) and perimembranous VSDs has been performed. Trabecular VSDs have proven to be more amenable to this technique with excellent closure rates and a low procedural mortality in comparison to open heart surgery that was being done for long time.
Echocardiography has been shown to be a useful diagnostic tool in estimation of left to right shunts and assessment of serial changes in shunt size and LV function. However, in patients with abnormal LV cavity geometries, 2D echocardiography may not be accurate enough. 3D echocardiographic methods provide a unique ability to determine absolute LV volumes, stroke volumes and EF without any mathematical assumptions. The accuracy of 3D echocardiography for determining LV volumes and EF has been validated with MRI as an independent gold standard.
BNP is one of the cardiac peptides, which increases in ventricular dysfunction. This substance is produced in the ventricle and released in the form of Pre-Pro BNP and finally becomes degraded enzymatically in response to myocardial stretch to Pro BNP.
Serum level of Pro BNP is increased in systolic and diastolic dysfunctions as it is increased in cases of left to right shunts such as VSD. On the other hand, echocardiographic findings are not always sufficient for determining the severity of hemodynamic abnormalities in VSD patients, by measuring the serum level of NT-Pro BNP, the severity of the shunt can be determined and morbidities such as recurrent pulmonary infections, heart failure, failure to thrive and Eisenmenger syndrome can be prevented.
We aimed in this study to correlate the serum level of NT- Pro BNP with different 2D and 3D variables reflecting the hemodynamic significance of ventricular septal defects including LV volumes, dimensions, functions and (Qp/Qs) measured by 2D echocardiogram.
Our study included 60 patients in the pediatric age group (up to18 years old) who were referred for elective echocardiogram in the congenital and structural heart disease unit cardiology department in Ain Shams University hospital. Patients with VSD were divided into three equal subgroups according to (Qp/Qs): group (1) included patients with (Qp/Qs <1.5), group (2) included patients with (Qp/Qs>1.5-2) and group (3) included patients with (Qp/Qs >2)).
The mean serum levels of Pro BNP were 84.5±12.09, 120.6±16.44, and 300.85±75.15 for those patients with Qp/Qs <1.5, 1.5<Qp/Qs<2, and QP/QS>2, respectively. There was a highly significant positive correlation between Pro BNP level and echocardiographic shunt quantification by QP_QS (p<0.001).
There was also a highly significant positive correlation between Pro BNP and echocardiographic VSD Size (r=0.8) & Mean PAP (r=0.8).
A highly significant positive correlation between Pro BNP and indexed LVEDV and indexed LVESV by 2D and 3D echocardiography was also noticed.
Also there was a highly significant negative correlation between Pro BNP and EF by m mode and a significant negative correlation with LV EF by Simpsons method and LV EF by 3D echocardiography.
In our study with ROC curve analysis a cut-off point of discriminating patients with QP/QS <1.5 from those >1.5 was 98 pg/ml that had the highest balanced sensitivity and specificity to predict significant shunt with sensitivity = 97.5 % and specificity = 90 %.
Our findings indicate that BNP levels reflect the severity of disease in patients with left and right ventricular volume overload, and that a BNP level of 98pg/ml is useful as one indicator of intervention in VSD patients. By combining the BNP measurement with echocardiography, we believe it will be possible to determine whether or not intervention should be performed in CHD patients. Monitoring BNP levels is also useful for determining the timing for such intervention especially in patients with moderate sized VSD with Qp/Qs (>1.5-2). Most importantly, monitoring BNP levels is a noninvasive technique and therefore minimizes trauma to the patient.
But, Further study with a larger number of patients is needed specially to study the moderate group (Qp/Qs>1.5-2) that had borderline Pro BNP with longer follow up to assess if Qp/Qs, LV volumes, function & Pro BNP will be improved in response to medical treatment or intervention will be needed