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-
- 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.
- right ventricular heave
- palpable, loud P2
- right sided S4
- Pulmonary regurgitation- high pitched decresendo diastolic murmur (Graham Steelle murmur)
<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
- ↑ Braunwald Zipes Libby. Heart disease: A textbook of cardiovascular medicine, 6th Edition chapter 43:W.B. Saunders ;.pp 1533