Ventricular Septal Defect

Question 1

Ventricular Septal Defect presentation

Answer 1

This patient has developed sudden shortness of breath. Examine his heart.

Question 2

Clinical signs of Ventricular septal defect

Answer 2

1. Thrill at the lower left sternal edge
2. Auscultation:
   - Systolic murmur well localized at the left sternal edge with no radiation.
   - No Audible A2.
   - Loudness does not correlate with size (Maladie de Roger: loud murmur due to high-flow velocity through a small VSD).
   - If Eisenmenger’s develops the murmur often disappears as the gradient diminishes.
3. Other associated lesions: AR, PDA (10%), Fallot’s tetralogy and coarctation
4. Pulmonary hypertension: loud P2 and RV heave + cyanosis and clubbing (Eisenmenger’s)
5. Endocarditis

Question 3

Auscultation in VSD

Answer 3

1. Systolic murmur well localized at the left sternal edge with no radiation.
2. No Audible A2.
3. Loudness does not correlate with size (Maladie de Roger: loud murmur due to high-flow velocity through a small VSD).
4. If Eisenmenger’s develops the murmur often disappears as the gradient diminishes.

Question 4

Causes of VSD

Answer 4

1. Congenital
2. Acquired (traumatic, post‐operative or post‐MI)

Question 5

Investigation for VSD

Answer 5

1. ECG: conduction defect: BBB
2. CXR: pulmonary plethora
3. TTE/TOE: site, size, shunt calculation and associated lesions
4. Cardiac catheterization: consideration of closure

Question 6

Management of VSD

Answer 6

Surgical (pericardial patch) or percutaneous (Amplatzer® device) closure of haemodynamically significant defects.

Question 7

Associations with VSD

Answer 7

1. Fallot’s tetralogy
2. Coarctation
3. Patent ductus arteriosus (PDA)

Question 8

Fallot’s tetralogy

Answer 8

1. Right ventricular hypertrophy
2. Overriding aorta
3. VSD
4. Pulmonary stenosis

Question 9

Blalock–Taussig (BT) shunts

Answer 9

• Partially corrects the Fallot’s abnormality by anastomosing the subclavian artery to the pulmonary artery
• Absent radial pulse and scar

Question 10

causes of an absent radial pulse

Answer 10

• Acute:
  1. Embolism,
  2. Dissection
  2. Trauma, e.g. radial artery sheath
• Chronic: ABCT
  1. Atherosclerosis,
  2. Blalock-Taussig (BT) Shunts
  3. Coarctation,
  4. Takayasu’s arteritis (‘pulseless disease’),

Question 11

Coarctation of Aorta

Answer 11

A congenital narrowing of the aortic arch that is usually distal to the left subclavian artery.

Question 12

Clinical signs of Coarctation of Aorta

Answer 12

1. Hypertension in right ± left arm (coarctation usually occurs between left common carotid and left subclavian arteries)
2. Prominent upper body pulses, absent/weak femoral pulses, radiofemoral delay
3. Heaving pressure loaded apex
4. Auscultation:
   - Continuous murmur from the coarctation and collaterals radiating through to the back.
   - There is a loud A2.
   - There may be murmurs from associated lesions

Question 13

Auscultation in Coarctation of Aorta

Answer 13

1. Continuous murmur from the coarctation and collaterals radiating through to the back.
2. There is a loud A2.
3. There may be murmurs from associated lesions

Question 14

Associations of Coarctation of Aorta

Answer 14

1. Cardiac: VSD, bicuspid aortic valve and PDA
2. Non‐cardiac: Turner’s syndrome and Berry aneurysms

Question 15

Investigation of Coarctation of Aorta

Answer 15

1. ECG: LVH and RBBB
2. CXR: rib notching, double aortic knuckle (post stenotic dilatation)

Question 16

Management of Coarctation of Aorta

Answer 16

1. Percutaneous: endovascular aortic repair (EVAR)
2. Surgical: Dacron patch aortoplasty
3. Long‐term anti‐hypertensive therapy
4. Long‐term follow‐up/surveillance with MRA: late aneurysms and recoarctation

Question 17

Patent ductus arteriosus (PDA)

Answer 17

Continuity between the aorta and pulmonary trunk with left to right shunt
Risk factor: rubella

Question 18

Clinical signs Patent ductus arteriosus (PDA)

Answer 18

1. Collapsing pulse
2. Thrill second left inter‐space
3. Thrusting apex beat
4. Auscultation: loud continuous ‘machinery murmur’ loudest below the left clavicle in systole

Question 19

Complications of Patent ductus arteriosus (PDA)

Answer 19

1. Eisenmenger’s syndrome (5%)
2. Endocarditis

Question 20

Management of Patent ductus arteriosus (PDA)

Answer 20

Closed surgically or percutaneously