If a child with ventricular septal defect (VSD) improves, what are the possibilities?
1) Decrease in size of VSD – good – needs no further treatment.
2) Development of right ventricular outflow tract (RVOT) obstruction – bad – needs surgical treatment.
3) Development of pulmonary vascular disease – ugly – nothing can be done.
How do you clinically differentiate these situations?
Look for features of RVOT obstruction and pulmonary hypertension.
When the defect is decreasing in size, pansystolic murmur becomes prominent, but second sound is normal.
If RVOT obstruction develops, pulmonary component of second sound (P2) becomes softer. VSD murmur gets replaced by RVOT murmur.
If pulmonary hypertension develops, P2 becomes loud and VSD murmur decreases and disappears.
What are the causes of prominent a waves in JVP?
Basically it indicates a resistance to RV filling, which may be due to RV hypertrophy or RV inflow obstruction.
Those with RVH:
Pulmonary stenosis (not seen if associated with VSD), Pulmonary hypertension, RV cardiomyopathy
Due to RV inflow obstruction:
Tricuspid atresia, Tricuspid stenosis, tumours obstructing RV inflow
When can regression of clubbing occur in cyanotic congenital heart disease (CCHD)?
1) Following surgical correction of CCHD.
2) In severe anemia (Ref: Garson’s text book).
What are the situations of CCHD and low pulmonary blood flow with cardiomegaly on chest X-ray (CXR)?
Tetralogy of Fallot (TOF) with aortic regurgitation.
TOF with large collaterals.
Ebstein’s anomaly of tricuspid valve.
TOF with anemia and heart failure.
TOF with AV canal defects.