TABLE 7.12: Acyanotic Congenital Heart Disease

Acyanotic Congenital Heart Disease

Lesion TypeExamination 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		Small – moderate PDA: Normal or LVH
Large PDA: BVH		May have cardiomegaly and increased PVMs, depending on size of shunt
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 present		Cardiomegaly 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
Moderate – severe AS: LVH ± strain		Usually normal
Coarctation of aorta may present as:
1. Infant in CHF
2. Child with HTN
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.

TABLE 7.12: Acyanotic Congenital Heart Disease is a sample topic from the Harriet Lane Handbook.

To view other topics, please or .

The Harriet Lane Handbook app and website provides pediatric diagnosis and treatment, pediatric management algorithms, and pediatric drug formulary from experts at Johns Hopkins University. .