Incidence

  • AR develops after 2 years of age and progresses slowly.
  • Incidence of AR in VSD is 5 to 8%.
  • More likely to occur in outlet VSD.
  • More likely in males with VSD.

Pathology

  • Cusps-
    • Outlet VSD- RCC or LCC may prolapse.
    • PM VSD- RCC or NCC may prolapse.
  • Mechanisms of prolapse-
    • Loss of support
    • Defective commissure
    • Prolapsed cusp gets deformed further worsening AR
  • Cusp prolapse in outlet VSD may cause RVOT obstruction.

Hemodynamics

  • The hemodynamic alterations due to AR are-
    • LV becomes more volume overloaded
    • Left to right shunt may become small
    • RVOT obstruction may occur

Clinical features

  • VSD and AR murmurs
  • LV type cardiomegaly

ECG

  • Significant LV volume overload pattern out of proportional to the shunt.

Chest X-ray

  • LV type cardiomegaly out of proportional to the increase in pulmonary vasculature.
  • Ascending aortic dilation in a case of VSD. (Usually in a VSD aorta does not become prominent)

Management

  • Once AR develops, even if VSD is not significant surgery has to be done.
  • VSD closure is done with repair or replacement of the aortic valve.