Perimembranous Ventricular Septal Defect Clinical Presentation
- Author: Michael D Taylor, MD, PhD; Chief Editor: Stuart Berger, MD more...
History
Murmur
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.
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.
Chromosomal anomalies
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.
Physical Examination
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 heart sound
- Narrowly split second heart sound; occasional accentuated pulmonary component
- Absent third heart sound
- Palpable thrill at the mid- to lower left sternal border (very small VSDs)
- Absent diastolic murmur with small VSDs
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, the left ventricular ̶ to ̶ right ventricular pressure gradient, and the degree of left-to-right shunting. 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 second heart sound with occasional loud pulmonary component
- A loud holosystolic murmur with wide precordial radiation maximal at the left mid-sternal border
- 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
Williams LJ, Correa A, Rasmussen S. Maternal lifestyle factors and risk for ventricular septal defects. Birth Defects Res A Clin Mol Teratol. Feb 2004;70(2):59-64. [Medline].
Oberlander TF, Warburton W, Misri S, Riggs W, Aghajanian J, Hertzman C. Major congenital malformations following prenatal exposure to serotonin reuptake inhibitors and benzodiazepines using population-based health data. Birth Defects Res B Dev Reprod Toxicol. Feb 2008;83(1):68-76. [Medline].
Chen FL, Hsiung MC, Nanda N, Hsieh KS, Chou MC. Real time three-dimensional echocardiography in assessing ventricular septal defects: an echocardiographic-surgical correlative study. Echocardiography. Aug 2006;23(7):562-8. [Medline].
Chessa M, Butera G, Negura D, et al. Transcatheter closure of congenital ventricular septal defects in adult: Mid-term results and complications. Int J Cardiol. Jan 28 2008;[Medline].
Fu YC, Bass J, Amin Z, et al. Transcatheter closure of perimembranous ventricular septal defects using the new Amplatzer membranous VSD occluder: results of the U.S. phase I trial. J Am Coll Cardiol. Jan 17 2006;47(2):319-25. [Medline].
Thanopoulos BD. Catheter closure of perimembranous/membranous ventricular septal defects using the Amplatzer occluder device. Pediatr Cardiol. Jul-Aug 2005;26(4):311-4. [Medline].
Fischer G, Apostolopoulou SC, Rammos S, Schneider MB, Bjornstad PG, Kramer HH. The Amplatzer Membranous VSD Occluder and the vulnerability of the atrioventricular conduction system. Cardiol Young. Oct 2007;17(5):499-504. [Medline].
Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].
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