Ventricular septal defect physical examination

Associate Editor-In-Chief: Priyamvada Singh, MBBS; Keri Shafer, M.D. [mailto:kshafer@bidmc.harvard.edu]; Leida Perez, M.D.

Overview
The physical examination findings of a ventricular septal defect depend upon the size of the defect, the location of the defect, the magnitude and directionality of the intracardiac shunt, and the age of the patient (the duration of the VSD).

Small VSD

 * The patient may be without signs or symptoms of a VSD.
 * A systolic thrill may be palpable along the left sternal border.
 * A loud holosystolic murmur (harsher quality than that of mitral regurgitation) may be 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

 * A forceful left ventricular impulse or heave may be present.
 * A systolic thrill along left sternal border may be present.
 * A split and accentuated pulmonic component of the second heart sound may be present.
 * A third heart sound (S3)(suggests increased flow across the mitral valve)
 * Harsh holosystolic murmur at the 3rd to 4th intercostal space to left side of sternum is characteristic of a VSD murmur.
 * A rumbling mid-diastolic murmur at cardiac apex suggests increased flow across the mitral valve.
 * A midsystolic ejection murmur may be present due to increased flow across the pulmonary valve.

Large-Sized VSD with Pulmonary Obstructive Disease

 * The features are similar to those seen in a medium-sized VSD.
 * In the first 2 years of life, the patient may have signs of left sided volume overload. After the age of 2 years, the patient have exhibit signs and symptoms of progressive pulmonary vascular obstructive disease (pulmonary hypertension. As a consequence, poor growth may be present and the left anterior thorax may bulge outward.
 * The JVP may be elevated due to right ventricular failure.
 * In the first two years of life there may be a prominent LV impulse or heave, but with the development of pulmonary hypertension, this LV prominence is diminished and cyanosis may be present which worsens with effort and with time.

Small VSD

 * The patient may be asymptomatic with no signs or symptoms.
 * A Holosystolic murmur may be present which is best heard at left sternal border in the 3rd and 4th intercostal space.

Moderate VSD

 * A displaced cardiac apex may be present.
 * A harsh holosystolic murmur at 3rd to 4th intercostal space along the left sternal border may be present.
 * The presence of a rumbling mid-diastolic murmur at cardiac apex suggests an increase flow across the mitral valve.
 * A midsystolic ejection murmur due to increased flow across the pulmonary valve may be present.

Large VSD
A large VSD may progress to Eisenmenger's syndrome. Physical examination may reveal the following:


 * Central cyanosis and clubbing may be present suggesting hypoxemia.
 * The JVP may be elevated or normal. A prominent v wave may be seen if tricuspid regurgitation is present.
 * Arrythmias such as atrial fibrillation, atrial flutter, and/or ventricular tachycardia may be present.
 * Peripheral edema may be observed in the presence of right sided heart failure.
 * Pulmonary hypertension may be present signified by the presence of a right ventricular heave, a palpable, loud P2, and a right sided S4.
 * Pulmonary regurgitationmay be present as evidenced by a 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) 

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 