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

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)

• Murmur

• • 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-

• Central cyanosis, Clubbing (suggesting hypoxemia)
• JVP may be elevated or normal. A prominent 'v' wave may be seen in case a tricuspid regurgitation is present.
• Rhythm disturbances - Atrial fibrillation, atrial flutter, ventricular tachycardia
• Peripheral edema in case of right sided heart failure.

• Pulmonary hypertension-

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

• Pulmonary regurgitation- high pitched decresendo diastolic murmur (Graham Steelle murmur)

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

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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