Station 3.11: Ventricular septal defect

Question 1

Clinical signs

What are the clinical signs of Ventricular septal defect?

Ventricular septal defect

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

Answer 1

• Thrill at the lower left sternal edge
• Auscultation:
  
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Extra points
Consider:
* Other associated lesions: AR, PDA (10%), Fallot’s tetralogy and coarctation
* Pulmonary hypertension: loud P2 and RV heave + cyanosis and clubbing (Eisenmenger’s)
* Endocarditis

Question 2

Discussions - Causes

What are the causes of Ventricular septal defect?

Ventricular septal defect

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

Answer 2

• Congenital
• Acquired (traumatic, post‐operative or post‐MI)

Question 3

Discussions - investigation

What investigations do you prescribe for Ventricular septal defect?

Ventricular septal defect

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

Answer 3

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

Question 4

Discussions - management

What management do you prescribe for Ventricular septal defect?

Ventricular septal defect

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

Answer 4

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

Question 5

Discussions - Associations with VSD

What are the Associations with VSD with Ventricular septal defect?

Ventricular septal defect

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

Answer 5

1… Fallot’s tetralogy
* Right ventricular hypertrophy
* Overriding aorta
* VSD
* Pulmonary stenosis
Blalock–Taussig (BT) shunts
* Partially corrects the Fallot’s abnormality by anastomosing the subclavian artery to the
pulmonary artery
* Absent radial pulse and scar

Other causes of an absent radial pulse
* Acute: embolism, aortic dissection, trauma, e.g. radial artery sheath
* Chronic: atherosclerosis, coarctation, Takayasu’s arteritis (‘pulseless disease’)

2… Coarctation
A congenital narrowing of the aortic arch that is usually distal to the left subclavian artery

Question 6

Clinical signs

What are the clinical signs coarctation?

Coarctation

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

Answer 6

• Hypertension in right ± left arm (coarctation usually occurs between left common carotid and left subclavian arteries)
• Prominent upper body pulses, absent/weak femoral pulses, radiofemoral delay
• Heaving pressure loaded apex
• 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 7

Discussions - Associations

What are the clinical associations of coarctation?

Coarctation

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

Answer 7

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

Question 8

Discussions - investigations

What are the clinical investigations for coarctation?

Coarctation

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

Answer 8

• ECG: LVH and RBBB
• CXR: rib notching, double aortic knuckle (post‐stenotic dilatation)

Question 9

Discussions - management

What clinical management do you prescribe for coarctation?

Coarctation

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

Answer 9

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

Question 10

clinical signs

What clinical signs for Patent ductus arteriosus (PDA)?

Patent ductus arteriosus (PDA)

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

Answer 10

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

Question 11

Discussion - complications

What clinical complications for Patent ductus arteriosus (PDA)?

Patent ductus arteriosus (PDA)

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

Answer 11

• Eisenmenger’s syndrome (5%)
• Endocarditis

Question 12

Discussions - management

What clinical management do you prescribe for Patent ductus arteriosus (PDA)?

Patent ductus arteriosus (PDA)

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

Answer 12

• Closed surgically or percutaneously