 Ventricular septal defect is another example of an acyanotic heart defect. Again we have an example over here on the right side. We'll note that there's a defect in the ventricle and blood will flow down the pressure gradient from the left ventricle into the right ventricle. So this again similarly to ASD it's due to a failure of the interventricular septum to close and a really high yield concept is that a VSD is the most common overall type of congenital heart defect and if you're talking about a patient with Down syndrome it's also the most common type of congenital heart defect in a Down syndrome patient and we know that Down syndrome patients do tend to have a variety of different congenital heart defects. And what are we going to hear on physical exam for these patients? We're going to hear a harsh holo systolic murmur in the tricuspid area. Again the left ventricle is a much more high pressure chamber compared to the left atrium. So if we're comparing a VSD to ASD the volume of a VSD will generally be ladder because there's more pressure pushing the blood through the defect. And another concept you should be aware of is how to correlate the volume of the murmur with the size of the defect. So again we have an example of a relatively small defect in the in the picture right here. So you'll imagine that when the blood is flowing down the pressure gradient there's a lot of turbulence of blood flowing through this small area and that turbulence will cause a louder murmur. Whereas if we now think of another example of maybe a larger defect that encompasses more of the interventricular septum, blood will flow much more easily through that defect and will cause less turbulence and as a result will be quieter. So actually you should be aware of the fact that a quieter VSD murmur is actually a bigger VSD and a worse prognosis. So these patients again echo as the gold standard for workup. And similarly to an ASD you have deoxygenated blood flowing from the left side of the heart to the right side of the heart. So you have an increased O2 saturation in the right ventricle and pulmonary artery. Similarly to ASDs most will resolve spontaneously and they have the same indications for surgery as well.