Ventricular septal defect physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Priyamvada Singh, MBBS; Keri Shafer, M.D. [2]; Leida Perez, M.D.
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
- May be asymptomatic with no signs or symptoms
- 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 progress 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)
Video Examples of Physical Examination Findings
In first video one can appreciate the normal heart sound. On careful listening one can appreciate the S1 and S2 (lub-dub) <youtube v=xS3jX1FYG-M/>
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 <youtube v=7oKz6J0Ay_I/>