Perimembranous Ventricular Septal Defect Clinical Presentation

Updated: Dec 29, 2020
  • Author: Michael D Taylor, MD, PhD; Chief Editor: Howard S Weber, MD, FSCAI  more...
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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 congestive heart failure (CHF) at age 6-8 weeks or older, as pulmonary vascular resistance 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 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