Acute Decompensated Heart Failure in Unrepaired VSD

Clinical Presentation and Diagnosis

Perioral cyanosis with desaturation to 91% in a patient with unrepaired VSD suggests either severe pulmonary congestion or early development of pulmonary hypertension with possible bidirectional shunting, as noted by the American Heart Association 1
Initial presentation with productive cough, coryza, and fever suggests infectious etiology, according to the European Society of Cardiology 3
Temporary response to antibiotics supports bacterial component, as stated by the European Society of Cardiology 3
Progressive weight loss over 3 weeks is unusual for uncomplicated pneumonia, as reported by the European Society of Cardiology 4
Unrepaired VSD at 4 years of age carries risk of developing pulmonary vascular disease, as indicated by the European Society of Cardiology 3

VSD patients have 6-fold increased risk of infective endocarditis compared to general population, as noted by the European Society of Cardiology 3
Fever, progressive symptoms, and weight loss could represent subacute endocarditis, according to the European Society of Cardiology 3
Respiratory symptoms could represent septic pulmonary emboli, as stated by the European Society of Cardiology 3
Echocardiographic assessment is necessary to evaluate VSD size and location, left ventricular volume overload, pulmonary artery pressure estimation, ventricular function, and rule out vegetations, as recommended by the American College of Cardiology 6
Chest radiograph is necessary to assess for cardiomegaly, pulmonary vascular markings, and pulmonary edema, as suggested by the American Heart Association 5
Blood cultures must be obtained before initiating antibiotics in any VSD patient with fever and systemic symptoms, as emphasized by the European Society of Cardiology 3
Supplemental oxygen should be provided to maintain saturations >92%, as recommended by the American Heart Association 5
Diuretic therapy (furosemide) is necessary for volume management and pulmonary congestion, as stated by the American College of Cardiology 2
ACE inhibitor consideration is necessary for afterload reduction and heart failure management, as recommended by the American College of Cardiology 6