| Observation |
- Well-appearing with normal growth and O2 saturation
- Soft (≤2/6) murmur without thrill
- No respiratory distress, hepatomegaly, or tachycardia
- Small muscular VSDs close spontaneously in ~50% by age 2
- Outpatient follow-up every 3–6 months
- No antibiotic prophylaxis required (AHA 2007 guidelines — simple VSD)
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| Echo + Cardiology Referral |
- Murmur ≥3/6, with thrill, or harsh quality
- Abnormal S2 (fixed split, single, or accentuated)
- Any diastolic murmur component
- Cardiac symptoms: poor feeding, diaphoresis, tachycardia, hepatomegaly
- Abnormal EKG (RVH, LVH, or axis deviation)
- Cardiology referral for large or symptomatic VSD
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| Medical Treatment |
- Furosemide + spironolactone for symptomatic CHF from large VSD
- Caloric supplementation (high-density formula) for failure to thrive
- ACE inhibitors reduce afterload → decrease L→R shunt magnitude
- Medical therapy NOT indicated in well-appearing infant without CHF
- Indomethacin = for PDA closure in PREMATURE infants — NOT for VSD
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| Surgical / Catheter Repair |
- Surgical patch closure for large VSD causing CHF or failure to thrive
- Catheter-based device closure for selected muscular VSDs
- Indicated when Qp:Qs >2:1 or uncontrolled symptoms
- NOT indicated for small asymptomatic VSD
- Elective repair by 6–12 months for symptomatic large VSDs
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