EXHIBIT 4.9





SUPPLEMENTAL INDENTURE





                        SECOND SUPPLEMENTAL INDENTURE (this “Supplemental Senior Subordinated
Indenture”), dated as of  March 28, 2005, among  VHS Acquisition Subsidiary Number 11, Inc., a Delaware corporation ( the “New Guarantor”) and a subsidiary of Vanguard Health Holding Company II, LLC, a Delaware limited liability
company (“VHS Holdco II”), Vanguard Holding Company II, Inc., a Delaware corporation and a wholly owned subsidiary of VHS Holdco II (together with VHS Holdco II, the “Issuers”), Vanguard Health Holding Company I, LLC, Vanguard
Health Systems, Inc. and U.S. Bank National Association, as trustee under the Senior Subordinated Indenture referred to below (the “Trustee”).


WITNESSETH





                        WHEREAS, the Issuers and the existing Guarantors have heretofore executed and delivered
to the Trustee an indenture (as amended, supplemented or otherwise modified, the “Senior Subordinated Indenture”), dated as of September 23, 2004 providing for the issuance of 9% Senior Subordinated Notes due 2014 (the “Senior Subordinated
Notes”);


                        WHEREAS, Section 4.16 of the Senior Subordinated Indenture provides that under certain
circumstances the New Guarantor shall execute and deliver to the Trustee a supplemental indenture pursuant to which the New Guarantor shall unconditionally guarantee all of the Issuers’ Obligations under the Senior Subordinated Notes and the Senior Subordinated
Indenture on the terms and conditions set forth herein (the “Note Guarantee”); and


                        WHEREAS, pursuant to Section 9.01 of the Senior Subordinated Indenture, the Trustee and
the Issuers are authorized to execute and deliver this Supplemental Senior Subordinated Indenture.


                        NOW, THEREFORE, in consideration of the foregoing and for other good and valuable
consideration, the receipt of which is hereby acknowledged, the New Guarantor, the Issuers and the Trustee mutually covenant and agree for the equal and ratable benefit of the Holders of the Senior Subordinated Notes as follows:


                        1.         DEFINED TERMS.  Defined terms
used herein without definition shall have the meanings assigned to them in the Senior Subordinated Indenture.


                        2.         AGREEMENT TO GUARANTEE.  The
New Guarantor hereby agree, jointly and severally with all existing Guarantors (if any), to provide an unconditional Guarantee on the terms and subject to the conditions set forth in Article 12 of the Senior Subordinated Indenture and to be bound by all other
applicable provisions of the Senior Subordinated Indenture and the Senior Subordinated Notes and to perform all of the obligations and agreements of a Guarantor under the Senior Subordinated


1


Indenture.  The Guarantee of the New Guarantor shall be subordinated to Senior Debt as provided in the Senior Subordinated Note Indenture


                        3.         NO RECOURSE AGAINST OTHERS.  No
past, present or future director, manager, officer, employee, incorporator, stockholder or member of the Issuers, any parent entity of the Issuers or any Subsidiary, as such, will have any liability for any obligations of the Issuers or the Guarantors under the
Senior Subordinated Notes, this Senior Subordinated Indenture, the Note Guarantees or for any claim based on, in respect of, or by reason of, such obligations or their creation.  Each Holder of Senior Subordinated Notes by accepting a Senior Subordinated Note
waives and releases all such liability.  The waiver and release are part of the consideration for issuance of the Senior Subordinated Notes.  The waiver may not be effective to waive liabilities under the federal securities laws.


                        4.         NOTICES.  All notices or other
communications to the New Guarantor shall be given as provided in Section 14.02 of the Senior Subordinated Indenture.


                        5.         RATIFICATION OF INDENTURE;
SUPPLEMENTAL INDENTURES PART OF INDENTURE.  Except as expressly amended hereby, the Senior Subordinated Indenture is in all respects ratified and confirmed and all the terms, conditions and provisions thereof shall remain in full force and effect.  This
Supplemental Senior Subordinated Indenture shall form a part of the Senior Subordinated Indenture for all purposes, and every holder of Senior Subordinated Notes heretofore or hereafter authenticated and delivered shall be bound hereby.


                        6.         GOVERNING LAW.  THIS INDENTURE,
THE NOTES AND THE SENIOR SUBORDINATED NOTE GUARANTEES SHALL BE GOVERNED BY, AND CONSTRUED IN ACCORDANCE WITH, THE LAWS OF THE STATE OF NEW YORK.


                        7.         COUNTERPARTS.  The parties may
sign any number of copies of this Supplemental Senior Subordinated Indenture.  Each signed copy shall be an original, but all of them together represent the same agreement.


                        8.         EFFECT OF HEADINGS.  The
Section headings herein are for convenience only and shall not affect the construction hereof.


                        9.         TRUSTEE MAKES NO
REPRESENTATION.  The Trustee makes no representation as to the validity or sufficiency of this Supplemental Indenture.


2






                        IN WITNESS WHEREOF, the parties hereto have caused this Supplemental Indenture to be
duly executed and attested, all as of the date first above written.


Dated: March 28, 2005





                                                                                               
VHS ACQUISITION SUBSIDIARY

                                                                                               
NUMBER 11, INC.





                                                                                               
By:       /s/ James H. Spalding               


                                                                                               
Name: James H. Spalding

                                                                                               
Title: Senior Vice President








                                                                                               
VANGUARD HEALTH HOLDING

                                                                                               
COMPANY II, LLC





                                                                                               
By:       /s/ James H. Spalding               


                                                                                               
Name: James H. Spalding

                                                                                               
Title: Senior Vice President








                                                                                               
VANGUARD HOLDING COMPANY II,

                                                                                               
INC.





                                                                                               
By:       /s/ James H. Spalding               


                                                                                               
Name: James H. Spalding

                                                                                               
Title: Senior Vice President








                                                                                               
VANGUARD HEALTH HOLDING

                                                                                               
COMPANY I, LLC





                                                                                               
By:       /s/ James H. Spalding               


                                                                                               
Name: James H. Spalding

                                                                                               
Title: Senior Vice President








                                                                                               
VANGUARD HEALTH SYSTEMS, INC.





                                                                                               
By:       /s/ James H. Spalding               


                                                                                               
Name: James H. Spalding

                                                                                               
Title: Senior Vice President








3


                                                                                               
U.S. BANK NATIONAL ASSOCIATION

                                                                                               
as Trustee





                                                                                               
By:       /s/ Richard Prokosch               


                                                                                               
Name: Richard Prokosch

                                                                                               
Title:   Vice President





4