Non-Cyanotic Heart Disease - ASD

 

Thank you for asking me to perform a cardiovascular of examine Mr. X, who presented with SOB.

 

The salient finding on examination were a ejection systolic murmur in the pulmonary area, associated with fixed splitting of the second heart sound, which I believe is consistent with an atrial septal defect.

 

I will now present my findings in full before commenting on differentials, aetiology, severity and complications.

 

The patient was comfortable at rest with normal/increased WOB.

 

On examination of the hands, there was/was no stigmata of IE, clubbing, peripheral cyanosis, or xanthomata.

 

The pulse was ____ and regular/irregular (if irregular, consistent with atrial fibrillation).

 

The blood pressure was ____.

 

On examination of the face, there was no scleral icterus, conjunctival pallor, or xanthelasma. There was no central cyanosis (unless there is Eisenmenger’s). Dentition was adequate/inadequate.

 

The JVP was not elevated at ___ cm above the sternal notch with normal waveforms/prominent A-wave/prominent V-wave.

 

The carotid pulse was normal in character.

 

On inspection of the praecordium, there were/were not scars and nil obvious deformity.

 

On palpation, the apex beat was fifth intercostal space mid-clavicular line. There was a systolic thrill at the pulmonary region. There was/was not a left parasternal heave or palpable P2 (pulmonary HTN is a late sign).

 

On auscultation, as aforementioned, there was a ejection systolic murmur loudest in the pulmonary region, without radiation, which increased on inspiration, and was associated with fixed splitting of the second heart sound.

 

On further examination, there was/was not evidence of left and right heart decompensation with sacral oedema or peripheral oedema, and vesicular breath sounds/bibasal inspiratory crackles. There was/was not a pulsatile liver, and nil gross ascites.

 

In summary, my findings are consistent with an atrial septal defect with a left to right shunt. There is/is not associated pulmonary hypertension, suggesting it is haemodynamically insignificant. There was not associated MR, TR or a VSD, suggesting this is likely an ostium secundum compared with primum (MR, TR, or VSD associated with primum as it is a defect in the endocardial cushion adjacent to the AV valves).

 

Other differentials include:

• PS

• Pulmonary hypertension with a pulmonary flow murmur

• AS

• MR

• TR

• VSD

 

I would proceed from here by:

• Confirming my diagnosis with an echocardiogram

 

What is the mechanism of the murmur in ASD?

• A mid-systolic pulmonary flow or ejection murmur, resulting from the increased blood flow across the pulmonic valve, is classically present with moderate to large left-to-right shunts. This murmur is loudest over the second left intercostal space and is usually not associated with a thrill. The presence of a thrill typically indicates a very large shunt or pulmonic stenosis

 

What is the indication for surgery?

• Depends on size of the shunt (flow ratio of 1.5 to 1 as per Talley)

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Non-Cyanotic Heart Disease - Other

 

Read Talley’s for:

• PDA - continuous murmur

• COA - better developed upper body, RF delay, HTN in arms only, chest collateral vessels, Midsystolic murmur, Turner’s syndrome

• VSD - there was a harsh pansystolic murmur, loudest at the left sternal edge with a palpable thrill. A differential includes VSD. There was/was not associated MR. There was no evidence of Down’s syndrome. The absence of clinical signs of pulmonary hypertension and left ventricular enlargement suggest that this a haemodynamically insignificant shunt. Unchanged on respiration.

 

What is the indication for surgery in VSD?

• Pulmonary to systemic flow ration of > 1.5 to 1

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