TABLE 7.12


Lesion Type% of CHD/Examination FindingsECG FindingsChest Radiograph Findings
Ventricular septal defect (VSD)2–5/6 holosystolic murmur, loudest at the LLSB, ± systolic thrill ± apical diastolic rumble with large shunt
With large VSD and pulmonary hypertension, S2 may be narrow
  • Small VSD: Normal
  • Medium VSD: LVH ± LAE
  • Large VSD: BVH ± LAE, pure RVH
May show cardiomegaly and increased PVMs, depending on amount of left-to-right shunting
Atrial septal defect (ASD)Wide, fixed split S2 with grade 2–3/6 SEM at the LUSB
May have mid-diastolic rumble at LLSB
  • Small ASD: Normal
  • Large ASD: RAD and mild RVH or RBBB with RSR′ in V1
May show cardiomegaly with increased PVMs if hemodynamically significant ASD
Patent ductus arteriosus (PDA)40%–60% in VLBW infants
1–4/6 continuous “machinery” murmur loudest at LUSB
Wide pulse pressure
  • Smallmoderate PDA: Normal or LVH
  • Large PDA: BVH
May have cardiomegaly and increased PVMs, depending on size of shunt (see Chapter 18 , Section IX.A, for treatment)
Atrioventricular septal defectsMost occur in Down syndrome
Hyperactive precordium with systolic thrill at LLSB and loud S2 ± grade 3–4/6 holosystolic regurgitant murmur along LLSB ± systolic murmur of MR at apex ± mid-diastolic rumble at LLSB or at apex ± gallop rhythm
Superior QRS axis RVH and LVH may be presentCardiomegaly with increased PVMs
Pulmonary stenosis (PS)Ejection click at LUSB with valvular PS—click intensity varies with respiration, decreasing with inspiration and increasing with expiration
S2 may split widely with P2 diminished in intensity
SEM (2–5/6) ± thrill at LUSB with radiation to back and sides
  • Mild PS: Normal
  • Moderate PS: RAD and RVH
  • Severe PS: RAE and RVH with strain
Normal heart size with normal to decreased PVMs
Aortic stenosis (AS)Systolic thrill at RUSB, suprasternal notch, or over carotids
Ejection click that does not vary with respiration if valvular AS
Harsh SEM (2–4/6) at second RICS or third LICS, with radiation to neck and apex ± early diastolic decrescendo murmur due to AR
Narrow pulse pressure if severe stenosis
  • Mild AS: Normal
  • Moderatesevere AS: LVH ± strain
Usually normal
Coarctation of aorta may present as:
  1. 1. Infant in CHF
  2. 2. Child with HTN
  3. 3. Child with murmur
Male/female ratio of 2 : 1
2–3/6 SEM at LUSB, radiating to left interscapular area
Bicuspid valve is often associated, so may have systolic ejection click at apex and RUSB
BP in lower extremities will be lower than in upper extremities.
Pulse oximetry discrepancy of >5% between upper and lower extremities is also suggestive of coarctation.
  • In infancy: RVH or RBBB
  • In older children: LVH
Marked cardiomegaly and pulmonary venous congestion. Rib notching from collateral circulation usually not seen in children younger than 5 years because collaterals not yet established.
AR, Aortic regurgitation; ASD, atrial septal defect; BP, blood pressure; BVH, biventricular hypertrophy; CDG, congenital disorders of glycosylation; CHD, congenital heart disease; CHF, congestive heart failure; HTN, hypertension; LAE, left atrial enlargement; LICS, left intercostal space; LLSB, left lower sternal border; LUSB, left upper sternal border; LVH, left ventricular hypertrophy; MR, mitral regurgitation; PVM, pulmonary vascular markings; RAD, right axis deviation; RAE, right atrial enlargement; RBBB, right bundle-branch block; RICS, right intercostal space; RUSB, right upper sternal border; RVH, right ventricular hypertrophy; SEM, systolic ejection murmur; VLBW, very low birth weight (i.e. <1500 g); VSD, ventricular septal defect.

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