EXHIBIT 4.9

SUPPLEMENTAL INDENTURE

                        SECOND SUPPLEMENTAL INDENTURE (this “Supplemental Senior SubordinatedIndenture”), 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 liabilitycompany (“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, VanguardHealth 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 deliveredto 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 SubordinatedNotes”);

                        WHEREAS, Section 4.16 of the Senior Subordinated Indenture provides that under certaincircumstances 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 SubordinatedIndenture 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 andthe Issuers are authorized to execute and deliver this Supplemental Senior Subordinated Indenture.

                        NOW, THEREFORE, in consideration of the foregoing and for other good and valuableconsideration, 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 termsused herein without definition shall have the meanings assigned to them in the Senior Subordinated Indenture.

                        2.         AGREEMENT TO GUARANTEE.  TheNew 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 otherapplicable 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

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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.  Nopast, 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 theSenior 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 Notewaives 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 othercommunications 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.  ThisSupplemental 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 maysign 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.  TheSection headings herein are for convenience only and shall not affect the construction hereof.

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

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                        IN WITNESS WHEREOF, the parties hereto have caused this Supplemental Indenture to beduly 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

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                                                                                               U.S. BANK NATIONAL ASSOCIATION                                                                                               as Trustee

                                                                                               By:       /s/ Richard Prokosch                                                                                                              Name: Richard Prokosch                                                                                               Title:   Vice President

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