Perimembranous Ventricular Septal Defect Clinical Presentation
- Author: Michael D Taylor, MD, PhD; Chief Editor: Howard S Weber, MD, FSCAI more...
Most patients with small perimembranous ventricular septal defects (VSDs) are asymptomatic but come to medical attention because a systolic murmur is discovered. Patients with large, isolated perimembranous VSDs are typically asymptomatic in the newborn period and no murmur is typically appreciated.
Progression of symptoms
Typically, infants with large VSDs present with signs and symptoms of pulmonary overcirculation or CHF at age 6-8 weeks or older, as PVR continues to fall and the degree of left-to-right shunting increases.
Signs and symptoms include poor feeding, decreased weight gain, tachypnea, tachycardia, sweating (especially with feeding), and lethargy.
VSDs are the most common congenital heart lesion (20-30%) in infants with chromosomal anomalies or syndromes. These defects may be discovered in the first days of life when additional diagnostic evaluations are performed to exclude multiple congenital defects.
The size of the ventricular septal defect (VSD) and the degree of left-to-right shunting significantly influence findings in a typical physical examination. The following may be found with small VSDs:
Normal vital signs with normal weight gain
Quiet precordium with normal apical impulse
Normal first and second heart sounds
Absent third heart sound
Palpable thrill at the mid- to lower left sternal border
Absent diastolic murmur
A grade II-VI/VI holosystolic murmur that widely radiates throughout the precordium is present along the left sternal border. The intensity of the murmur is usually inversely proportional to the size of the defect, indicating a significant left ventricular ̶ to ̶ right ventricular pressure gradient. In general, smaller defects produce louder murmurs. Systolic murmurs from VSDs are usually holosystolic; they may occasionally sound crescendo or crescendo-decrescendo.
The following may be shown with large VSDs:
Poor growth and weight gain
Symptoms of CHF, including tachypnea, tachycardia, sweating, and pallor
Hyperdynamic precordium with or without precordial bulge due to underlying cardiomegaly.
Abnormal apical impulse with or without right ventricular tap; a thrill is uncommon
Normal first heart sound and a narrowly split or single increased second heart sound
A prominent third heart sound that produces a gallop rhythm at the apex.
A mid-diastolic flow rumble at the cardiac apex, caused by a significant (at least 2:1 ratio) left-to-right shunt with excessive flow across a normal mitral annulus
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