Ventricular septal defect physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]and Leida Perez, M.D.

Associate Editor-In-Chief: Keri Shafer, M.D. [2], Priyamvada Singh, MBBS



Physical Examination [1]

Children


Small VSD:

  • Asymptomatic
  • A systolic thrill may be palpable along the left sternal border
  • Loud holosystolic murmur (harsher quality than that of MR)localized to the left lower sternal border.
  • In patients with small muscular defects, the murmur may end in mid systole because of systolic contraction of the septal musculature.


Medium-Sized VSD:

  • Forceful left ventricular impulse
  • Systolic thrill along left sternal border
  • Heart sound- split with accentuated pulmonic component , third heart sound (S3)(suggest increased flow across mitral valve)


    • Harsh holosystolic murmur at 3rd to 4th intercostal space to left side of sternum (characteristic VSD murmur)
    • Rumbling mid-diastolic murmur at cardiac apex suggesting increase flow across the mitral valve.
    • Midsystolic ejection murmur due to increased flow across pulmonary valve.


Large-Sized VSD with Pulmonary Obstructive Disease:

  • Features similar to seen in medium sized VSD.
  • In the first 2 years of age the patients have signs of left sided volume overload. After age 2 old, the patients have signs and symptoms of progressive pulmonary vascular obstructive disease. As a consequence, poor growth and left anterior thorax may bulge outward early.
  • JVD may be elevated due to RV failure.
  • In the first two years there is a prominent LV impulse, but with the development of pulmonary hypertension, this LV prominence is diminished and cyanosis is present, worsens with effort and with time.


Adults

Small VSD -

  • asymptomatic
  • Holosystolic murmur heard best at left sternal border in the 3rd and 4th intercostal space


Moderate VSD

  • Displaced cardiac apex
  • Harsh holosystolic murmur at 3rd to 4th intercostal space to left side of sternum
  • Rumbling mid-diastolic murmur at cardiac apex suggesting increase flow across the mitral valve.
  • Midsystolic ejection murmur due to increased flow across pulmonary valve.


Large VSD


Large VSD may change to Eisenmenger syndrome. Physical examination may reveal-


    • right ventricular heave
    • palpable, loud P2
    • right sided S4




<youtube v=xS3jX1FYG-M/>


In first video one can appreciate the normal heart sound. On careful listening one can appreciate the S1 and S2 (lub-dub)

<youtube v=7oKz6J0Ay_I/>


In the second video one can appreciate that the first and second heart sounds are not audible and a murmur that covers the whole systole is there. This is characteristic holosystolic murmur of ventricular septal defect



References

  1. Braunwald Zipes Libby. Heart disease: A textbook of cardiovascular medicine, 6th Edition chapter 43:W.B. Saunders ;.pp 1533

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