Atrial septal defect physical examination: Difference between revisions
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==Auscultation== | ==Auscultation== | ||
'''First heart sound, S1''' | *'''First heart sound, S1''' | ||
** Best heard at apex | ** Best heard at apex | ||
** Can be split. The reason behind the split is that the large volume of diastolic blood flow from right atrium to right ventricle causing forceful contraction of the tricuspid leaflets | ** Can be split. The reason behind the split is that the large volume of diastolic blood flow from right atrium to right ventricle causing forceful contraction of the tricuspid leaflets | ||
'''Second heart sound S2''' | *'''Second heart sound S2''' | ||
** '''Fixed splitting of the second sound (S2)'''. Commonly seen in individuals with large left-to-right and absence of pulmonary hypertension. | ** '''Fixed splitting of the second sound (S2)'''. Commonly seen in individuals with large left-to-right and absence of pulmonary hypertension. | ||
** Best heard at second intercostal space. | ** Best heard at second intercostal space. | ||
Revision as of 14:51, 22 August 2011
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Atrial Septal Defect Microchapters | |
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Treatment | |
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Surgery | |
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Atrial septal defect physical examination On the Web | |
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American Roentgen Ray Society Images of Atrial septal defect physical examination | |
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Risk calculators and risk factors for Atrial septal defect physical examination | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [[2]]; Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [[4]]
Overview
Upon physical examination, a patient with an atrial septal defect may present with a crescendo-decrescendo systolic ejection murmur and widely fixed split S2.
Physical examination
The physical findings in an adult with an ASD depends on:
- The degree of left-to-right intracardiac shunt
- Size of defect
- Associated anomalies
General physical examination
- Cyanosis and clubbing in case Eisenmenger's develops.
- Underdevelopment/below-average size for age.
Cardiovascular examination
- Precordial inspection
- Precordial bulge- The left-to-right shunting of blood causes right atrial enlargement that can present as a precordial bulge. The precordial bulge can cause a counter development of Harrison's groove that are horizontal depressions along the sixth and seventh costal cartilages at the lower margin of the thorax where the diaphragm attaches to the ribs.
- Precordial palpation
- Right ventricular impulse or heave - An increased left-to-right atrial shunt can cause a hyperdynamic right ventricular impulse or heave. The heave can be best palpated at left sternal border or the subxiphoid area.
- Pulmonary artery pulsations- Pulsatile, enlarged pulmonary artery pulsation can be felt at the second left intercostal space. These are more prononuced in patients with large left-to-right shunts. Patients with obstruction to right ventricular outflow have a less dynamic right ventricular impulse and may present with more of a tapping or thrusting quality.
- In large left-to-right shunt or the presence of a pulmonic stenosis a thrill can be palpated.
Auscultation
- First heart sound, S1
- Best heard at apex
- Can be split. The reason behind the split is that the large volume of diastolic blood flow from right atrium to right ventricle causing forceful contraction of the tricuspid leaflets
- Second heart sound S2
- Fixed splitting of the second sound (S2). Commonly seen in individuals with large left-to-right and absence of pulmonary hypertension.
- Best heard at second intercostal space.
- It should be evaluated with the patient sitting or standing.
In unaffected individuals, there are respiratory variations in the splitting of the second heart sound (S2). During respiratory inspiration, the negative intrathoracic pressure causes increased blood return into the right side of the heart. The increased blood volume in the right ventricle causes the pulmonic valve to stay open longer during ventricular systole. This causes a normal delay in the P2 component of S2. During expiration, the positive intrathoracic pressure causes decreased blood return to the right side of the heart. The reduced volume in the right ventricle allows the pulmonic valve to close earlier at the end of ventricular systole, causing P2 to occur earlier. In individuals with an atrial septal defect, there is a fixed splitting of S2. Fixed splitting occurs as a result of the extra blood return during inspiration equalized by the intraseptal communication between the left and right atrium allowed by the defect. The reason for a fixed splitting second heart sound is that: Normally the pulmonary component of S2 occurs after the aortic component A2 (due to difference in compliance and resistance in the two sides). This separation ("splitting") of S2 increases with inspiration. Fixed splitting of S2 is rare with ASDs in newborns as they have little left-to right shunts.
<youtube v=5tBk1XuEyuM/>
Murmurs
In individuals with an atrial septal defect, there is a fixed splitting of S2. Fixed splitting occurs as a result of the extra blood return during inspiration equalized by the intraseptal communication between the left and right atrium allowed by the defect.
During auscultation of the heart, a clinician may find evidence of abnormal heart sounds produced by a cardiac murmur. Atrial septal defect, being a condition that directly influences the hemodynamics between the right and left ventricle, has multiple types of associated murmurs such as:
- Crescendo-decrescendo systolic ejection murmur.
- Heard best at 2nd intercostal space at upper left sternal border.
- Occur due to increased right ventricular stroke volume across pulmonary outflow tract
- Rumbling middiastolic murmur
- In large left-to-right shunts
- Low-to-medium frequency
- Heard best at the lower left sternal border because of increased flow across the tricuspid valve.
- Ostium primum defect+cleft of the mitral valve can have an apical murmur of mitral regurgitation.
- In ostium secundum defects, it is the mitral valve prolapse where the holosystolic murmur of the mitral regurgitation emitting to the axilla is audible
- Pulmonic regurgitation
- Low-pitched diastolic murmur
- caused by pulmonary artery dilatation
- Patients with pulmonary arterial hypertension and right ventricular hypertrophy- S4 may be present, narrow S2 splitting with accentuated pulmonic component, and murmur of pulmonic regurgitation may be audible.
Extrcardiac features
- Deformed carpal bones
- Deformed thumbs
- Holt-Oram syndrome
- Deformed radial bones