This document discusses the clinical approach to diagnosing congenital heart disease. It provides statistics on the incidence of CHD and notes it occurs in 6 per 1000 live births for moderate/severe forms. A clinical diagnosis of CHD requires accurate observations and logical inferences. CHD is classified based on whether cyanosis is present, pulmonary blood flow, the side of the heart affected, and whether pulmonary hypertension is present. The diagnosis involves considering the patient's history, physical exam findings, chest x-ray, and ECG.

1. CLINICAL APPROACH TO THE
DIAGNOSIS OF CONGENITAL
HEART DISEASE

2. INCIDENCE OF CHD
 6 PER 1000 LIVE BIRTHS
- FOR MODERATE AND SEVERE FORMS OF CHD.
 19 PER 1000 LIVE BIRTHS
- IF POTENTIALLY SERIOUS BICUSPID AORTIC VALVE IS
INCLUDED.
 75 PER 1000 LIVE BIRTHS
-IF VERY SMALL MUSCULAR VSDS ARE INCLUDED.

3. CLINICAL DIAGNOSIS OF CHD
 REPRESENTS THE EPITOME OF APPLIED LOGIC.
 DIAGNOSES EMERGE WITH GRATIFYING
FREQUENCY WHEN CORRECT INFERENCES
ARE DRAWN FROM ACCURATE OBSERVATIONS.
 IT IS A STIMULATING CHALENGE AND A
CONSTANT SOURCE OF SELF EDUCATION.

4. CLINICAL CLASSIFICATION OF CONGENITAL
HEART DISEASE
1.ACYANOTIC WITHOUT A SHUNT (NORMAL OR DECREASED
PULMONARY ARTERIAL BLOOD FLOW)
A.MALFORMATIONS ORIGINATING IN THE RIGHT SIDE OF THE HEART
(FROM MOST PROXIMAL TO MOST DISTAL.)
B.MALFORMATIONS ORIGINATING IN THE LEFT SIDE OF THE HEART
(FROM MOST PROXIMAL TO MOST DISTAL.)
2.ACYANOTIC WITH A SHUNT
(LEFT TO RIGHT, INCREASED PULMONARY ARTERIAL BLOOD FLOW)
SHUNT AT ATRIAL LEVEL
SHUNT AT VENTRICULAR LEVEL
SHUNT BETWEEN AORTIC ROOT AND RIGHT SIDE OF HEART
SHUNT AT AORTOPULMONARY LEVEL
SHUNT AT MORE THAN ONE LEVEL

5. CLINICAL CLASSIFICATION OF CONGENITAL
HEART DISEASE
CYANOTIC
 INCREASED PULMONARY ARTERIAL BLOOD FLOW
 NORMAL OR DECREASED PULMONARY ARTERIAL
BLOOD FLOW
 DOMINANT LEFT VENRICLE
 DOMINANT RIGHT VENTRICLE
 WITH PULMONARY HYPERTENSION
 WITHOUT PULMONARY HYPERTENSION
 NORMAL OR NEARLY NORMAL VENTRICLES.

6. DIAGNOSIS OF CHD- FIVE BASIC QUESTIONS
 IS THE PATIENT ACYANOTIC (OR) CYANOTIC?
 IS PULMONARY ARTEIAL BLOOD FLOW
INCREASED (OR) NOT ?
 DOES THE MALFORMATION ORIGINATE IN THE
LEFT (OR) RIGHT SIDE OF THE HEART ?
 WHICH IS THE DOMINANT VENTRICLE ?
 IS PULMONARY HYPERTENSION PRESENT (OR)
NOT ?

7. DIAGNOSIS OF CONGENITAL HEART DISEASE
 HISTORY
 GENERAL EXAMINATION
 EXAMINATION OF PRECORDIUM
 CHEST SKIAGRAM
 ECG

8. HISTORY

DEVELOPMENT AND WEIGHT GAIN

FEEDING DIFFICULTY, TACHYPNEA, DYSPNEA

FREQUENT RESPIRATORY INFECTIONS

CYANOSIS AND CYANOTIC SPELLS, SQUATTING

EXERCISE INTOLERANCE

CHEST PAIN, SYNCOPE, PALPITATIONS

NEUROLOGICAL SYMPTOMS

ANTENATAL HISTORY

FAMILY HISTORY

9. HISTORY- ONSET OF CYANOSIS
EARLIEST ONSET
• D-TGA
• PA,INTACT SEPTUM
• PA,VSD
• OBSTRUCTED TAPVC
• TRICUSPID ATRESIA
• EBSTEIN'S ANOMALY
LATE ONSET
• EISENMENGER
PHYSIOLOGY
• TAPVC
• EBSTEIN'S
ANOMALY
• PS, STRETCHED PFO

10. PAROXYSMAL HYPOXIC SPELL
FOUND IN
 TETROLOGY OF FALLOT
 OTHER DISEASES WITH FALLOT’S PHYSIOLOGY
 PULMONARY ATRESIA WITH VSD
COMMENST AGE
 4MONTH TO 12 MONTH OF AGE
RARE BEYOND 2YEARS OF AGE
FEAUTURES
 OCCURS USALLY IN THE MORNING, AFTER A GOOD SLEEP.
 PRECIPITATED BY FEEDING , CRYING & BLADDER AND BOWEL MOVEMENTS
 HYPERPNEA INCREASES, CYANOSIS DEEPENS. MAY DEVELOP SYNCOPE -
CONVULSION-CVA
MACHANISMS
 INFUNDIBULAR PULMONARY SPASM
 OVER REACTION OF IMMATURE RESPIRATORY CENTER.
 PARAOXYSMAL ATRIAL TACHYCARDIA.

12. SQUATTING
 AGE OF OCCURRENCE
 MACHANISMS RIGHT - LEFT SHUNT IS DECREASED DUE TO
1. DECREASED VENOUS RETURN
2. INCREASD SVR DUE TO COMPRESSION OF FEMORAL
ARTERY
 SQUATTING EQUIVALENTS
1. KNEE-CHEST POSITION
2. SITTING WITH LEGS DRAWN UNDERNEATH
3. STANDING WITH CROSSED LEGS.

13. Squatting Position

14. SYMPTOM EVALUTION FOR CHD
SYMPTOM
CONGENITAL HEART
DISEASES
EXERTIONAL ANGINA
AS, PS, PPH, ALCOPA
EXERTIONAL SYNCOPE AS, PS.
CYANOSIS WITH SYNCOPE TOF
DYSPHAGIA DOUBLE AORTIC ARCH,
ANOMALOUS ORIGIN OF RIGHT
SUBCLAVIAN ARTERY PASSING
BELOW OESOPHAGUS.
CVA IN A CYANOTIC CHILD
CYANOTIC CHD COMPLICATED BY
CEREBRAL ABSCESS, CEREBRAL
THROMBI & PARADOXICAL

15. ANTENATEL HISTORY
MATERNAL DISEASES CARDIAC MALFORMATIONS IN
THE NEW BORN
MATERNAL RUBELLA
(IN THE FIRST TRIMESTER OF PREGNANCY)
CONGENITAL RUBELLA SYNDROME
- PDA, PERIPHERAL PULMONARY
ARTERY STENOSIS, VPS, ASD.
MATERNAL LUPUS ERYTHMATOSUS CONGENITAL COMPLETE HEART BLOCK
MATERNAL DIABETUS
TGA, VSD, COMMON ATRIUM,
CARDIOMEGALY,CARDIOMYOPATHY

16. ANTENATAL HISTORY – TERATOGENIC
DRUGS
TERATOGENIC
DRUGS
CARDIAC MALFORMATIONS EXTRA CARDIAC
ABNORMALITIES
THALIDOMIDE VARIABLE -TF,VSD,ASD,TA PHOCOMELIA
LITHIUM EBSTEIN'S ANOMALY OF
TRICUSPID VALVE,
TRICUSPID ATRESIA
NONE
ISORETINOIN VSD
ALCOHOL ABUSE FOETAL ALCHOL SYNDROME
- VSD (45% OF INFANTS), PDA, ASD
MICROCEPHALY, GROWTH
AND MENTAL RETARDATION,
SMOOTH PHILTRUM, THIN
UPPERLIP
EPTOIN FOETAL HYDANTION SYNDROME
- PS, AS, COARCTATION OF AORTA,
PDA
MICROCEPHALY, GROWTH
AND MENTAL RETARDATION,
SHORT PALPABERAL
FISSURES, SMOOTH
PHILTRUM, THIN UPPERLIP

17. FOETAL ALCOHOL SYNDROME
AFFECTS 30-40% OF CHILDREN BORN
TO ALCOHOLIC MOTHER
CLINICAL FEATURES
- UNDER DEVELOPED- APPEARING
CENTRL FACE DUE TO
MAXILLARY HYPOPLASIA
- SMALL AND UPTURNED NOSE
- INDISTINCT (OR) SMOOTH PHILTRUM
- MICROGNATHIA
- THIN UPPER LIP AND VERMILON
CARDIAC ANOMALIES
- VSD
- ASD

18. Physical Examination
•
General appearance, weight and nutrition
•
Association with chromosomal syndromes
and other systemic malformations
•
Colour
•
Vital Signs
– Pulse, BP, respiration and temperature

19. GENDER PREDISPOSITION OF CHD
MALE
1. VALVULAR A.S
2. CORACTATION
OFAORTA
3. TGA
4. HYPOPLASTIC LEFT
HEART SYNDROME
5. PULMONARY AND
TRICUSPID ATRESIAS
6. TOF
FEMALE
1. ASD
2. PDA
3. EBSTENIS ANOMALY
OF TRICUSPID VALVE.

20. GENERAL EXAMINATION
GENERAL APEARANCE
1. SHORT STATURE -TURNER SYNDROME, NOONAN SYNDROME,
-ELIS–VAN CREVELD SYNDROME.
2. POORLY DEVELOPED - COARCTATION OF AORTA
LOWER EXTREMITIES
HEAD & FACE
1. HYPERTELORISM
[WIDELY SET EYES] -NOONAN SYNDROME
-TURNER SYNDROME (BCAV, COARC.AORTA)
-MULTIPLE LENTIGENES SYNDROME (P.S, HOCM)
-WILLIAM SYNDROME (SUPRA VALVULAR A.S)
2. WEBBING OF THE NECK -TURNER SYNDROME, NOONAN SYNDROME
3. LOW SET EARS - DOWN SYNDROME, WILLIAM SYNDROME,
- NOONAN SYNDROME
4. LOW POSTERIOR HAIRLINE -TURNER SYNDROME, NOONAN SYNDROME
5. TYPICAL FACIAL APPEARANCE
-MONGOLIAN FACIES -DOWN SYNDROME
- ELFIN FACIES -WILLIAM SYNDROME

21. HYPERTELORISM
 CLINICAL MEASURMENTS
1. INTERPUPILLARYDISTANCE (IPD) . 2. INNER INTERCANTHAL
DISTANCE (ICD)
3. OUTER INTERCANTHAL DISTANCE (OCD)
 RADIOLOGICAL MEASUREMENTS
1. INNER INTERORBITAL DISTANCE (IID). 2.OUTER INTERORBITAL
DISTANCE (OID)

22. HYPERTELORISM
 ORBITAL HYPERTELORISM
INCREASED OUTER CANTHAL DISTANCE (OR) OUTER INTER
ORBITEL DISTANCE.
 OCCULAR HYPERTELORISM
INCREASED IPD.
 TELECANTHUS
1. LARGE DISTANCE BETWEEN TWO MEDIAL CANTHI,
WHEN COMPARED TO INTER ORBITAL DISTANCE.
(NORMAL ADULT-30MM)
2. MUSTARDE RATIO
ICD/IPD > 0.55
3. SUSPECTED WHEN LOWER LID PUNCTA IS LATERAL TO THE
MEDIAL EDGE OF IRIS IN STRAIGHT GAZE.

23. LOW SET EAR - MEASUREMENTS
 AN IMAGINARY LINE IS DRAWN FROM THE OUTER CANTHUS TO EXTERNAL
OCCIPITAL PROTUBERANCE
(OR)
 DRAW A LINE JOINING INNER AND OUTER CANTHUS AND EXTENDING IT.
 IF THE SUPERIOR ATTACHMENT OF THE PINNA IS
-AT (OR) ABOVE THIS LINE → NORMAL
-BELOW THIS LINE → LOW SET EARS

24. LOW HAIRLINE - MEASUREMENTS
TWO CRITERIAS
 POSTERIOR HAIRLINE IS BELOW
THE
LEVEL OF 5TH
CERVICAL SPINOUS
PROCESS.
 RATIO OF
DISTANCE BETWEEN EXT OCCIPITAL
PROTUBERANCE TO POSTERIOR
HAIR LINE &
DISTANCE BETWEEN POSTERIOR
HAIRLINE TO C7 SPINOUS
PROCESS.
= > 1/6 IN MEN
> 1/4 IN WOMEN

25. SHORT NECK
BIRD’S INDEX
 RATIO BETWEEN THE HEIGHT AND DISTANCE
BETWEEN THE EXTERNAL OCCEPITAL
PROTRUBERANCES TO THE C7 SPINOUS
PROCESS.
 NORMAL RATIO – BELOW 12.8
 SHORT NECK IS WHEN THE RADIO IS > 13.6.

26. TURNER SYNDROME
Row 1 Row 2 Row 3 Row 4
0
2
4
6
8
10
12
Column 1
Column 2
Column 3
CHROMOSOMAL PATTERN - 45 XO
CLINICAL FEATURES
-PHENOTYNE- FEMALE, SHORT STATURE,WEBBED
NECK, LOW HAIR LINE,SMALL CHIN
- PROMINENT EARS (LARGE AURICLES)
- BROAD CHEST WITH WIDELY SPECED NIPPLES,
CUBITUS VALGUS, SHORT 4TH METECARPALS
AND METATARSALS, NARROW HYPER CONVEX
NAILS, PIGMENTED NEVI, ABSENT AUXILLARY
AND PUBIC HAIR (OVARIAN DYSGENESIS)
CARDIAC ANOMALIES
- COARCTATION OF AORTA (MORE COMMEN IN
TURNER WITH WEBBING OF THE NECK.)
- BICUSPID AORTIC VALVE WITH AS.

27. NOONAN SYNDROME
CLINICAL FEATURES
- PTOSIS, DOWNWARD SLANTING EYES
- HYPERTELORISM. LOW SET EARS,
- LOW POSTERIOR HAIR LINE,
- MICROGNATHIA, WEBBED NECK, FLAT
CHEST, SHORT STATURE, MENTAL
RETARDATION, HYPOSPADIASIS,SMALL
UNDESCENDED (OR) CRYPTORCHID
TESTES.
- NORMAL CHROMOSOMES.
CARDIAC ANOMALIES
- DYSPLASTIC PULMONARY VALVE STENOSIS
(60%)
- HYPERTROPHIC CARDIOMYOPATHY(20%).

28. EXAMINATION OF EYES
EYES
EXTERNAL APPEARANCE
1. PTOSIS - NOONAN SYNDROME
2. BRUSHFIELD SPOTS - DOWN SYNDROME
3. COLOBOMA OF IRIS - CAT'S EYE SYNDROME (TOF,TRICUSPID
ATRESIA, ASD & VSD)
4. PREMATURE CATARACT – CONGENITAL RUBELLA SYNDROME
INTERNAL APPERANCE
RETINA
1. TORTOUS RETINAL ARTERIES - COARCTATION OF AORTA
WITH 'U' TURNS WITHOUT
CHARACTERISTIC CHANGES
OF HYPERTENSIVE RETINOPATHY

29. CONGENITAL RUBELLA SYNDROME
DUE TO 1ST TRIMESTER MATERNAL
RUBELLA INFECTION
CLINICAL FEATURES
-CONGENITAL CATARACT
-CONGENITAL DEAFNESS
-MENTAL DEFICENCY
- MICROCEPHALY
- PROLEFERATIVE VASCULAR
LESIONS.
CARDIAC ANOMALIES
- PDA , ASD.
- PULMONARY VALVULAR AND
ARTERIAL STENOSIS.

30. EXAMINATION OF MOUTH
MOUTH
LIPS
1. ABSENT PHILTRUM - FOETAL ALCOHOL SYNDROME
2. LONG PHILTRUM - WILLIAM SYNDROME
3. BLUISH DISCOLOURATION - CYANOSIS
MUCUS MEMBRANE
1.CLUSTERS OF SMALL RUBY PATCHES - HERDITARY TELANGIECTASIA
(RENDU – OSLER- WEBER SYNDROME)
TEETH
1. MALFORMED TEETH - WILLIAM SYNDROME
2. PREMATURELY ERUPTED TEETH - ELIS VAN CREVELD SYNDROME
(PRESENT AT BIRTH + GINGIVAL
HYPERTROPHY + MULTIPLE FRENULA
TONGUE
1. LONG PROTRUDING TONGUE - DOWN SYNDROME
2. HIGH ARCHED PALATE - NOONAN SYNDROME
3. CLEFT OF SOFT PALATE - VELOCARDIOFACIAL SYNDROME (VSD)

31. WILLIAMS SYNDROME
NON FAMILIAL SUPRA VALVULAR AS
CLINICAL FEATURES
- FACE IS DIAGNOSTIC
- HEAD IS SMALL (ELF – LIKE APPERANCE)
- CHEEKS ARE FULL AND BAGGY
- MOUTH AND FOREHEAD ARE LARGE
- CURVED LIPS, PEG SHAPED, WIDELY
SPACED TEETH
- MENTAL RETARDATION
CARDIAC ABNORMALITES
- SUPRA VALVULAR AS
- PULMONARY ARTERY BRANCH STENOSIS.

32. HEREDITARY TELANGIECTASIA

33. EXAMINATION OF EXTREMITIES
A. COLOUR
1. CYANOSIS & CLUBBING - CYANOTIC CONGENITAL HEART DISEASES
2. DIFFERENTIAL CYANOSIS - PDA WITH SEVERE PHT WITH Rt to Lt SHUNT
3. REVERSED DIFFERENTIAL - D- TGA WITH PHT WITH PREDUCTAL COARCTATION OF
CYANOSIS AORTA WITH REVERSED FLOW THROUGH PDA.
B. STRUCTURE
1. POLYDACTYLY - ELIS – VAN – CREVELD SYNDROME.
- LAWRENCE MOON BIDEL SYNDROME.
-TURNER SYNDROME.
2. SYNDACTYLY - ELIS- VAN CREVELD SYNDROME.
3. FINGERIESD THUMB - HOLD- ORAM SYNDROME.
4. BROAD THUMB & TOES - RUBINSTEIN – TAYBI SYNDROME (PDA)
5. SIMIAN PALMAR CREASE - DOWN SYNDROME.
6. CUBITUS VALGUS DEFORMITY - TURNER SYNDROME.
7. ROCKER – BOTTOM FEET - TRISOMY – 18 (PDA , VSD)

35. CARDIAC DEFECTS CAUSING CENTRAL CYANOSIS
 TRANSPOSITION OF
THE GREAT ARTERIES
 TETRALOGY OF FALLOT
 TRICUSPID ATRESIA
 TRUNCUS ARTERIOSUS
 TOTAL ANOMALOUS
PULMONARY VENOUS
RETURN.
 EBSTEIN ANOMALY
 EISENMENGER
PHYSIOLOGY
 CRITICAL PULMONARY
STENOSIS (OR) ATRESIA
FUCTIONALLY SINGLE
VENTRICLE.

36. SYMMETRIC CYANOSIS

37. DIFFERENTIAL CYANOSIS

38. DOWN SYNDROME
CHROMOSOMAL ABNORMALITY-TRISOMY 21
CLINICAL FEATURES
- SHALLOW ORBITS
- EPICANTHAL FOLDS, HYPERTELORISM
- BRUSHFIELD SPOTS (SPECKLED IRIS)
- PROTRUDING TONGUE, MENTAL
RETARDATION
- LOWSET EARS, TRANSVERSE PALMAR
CREASE.
CARDIAC ABNORMALITIES
- ENDOCARDIAL CUSHION DEFECTS (2/3
OF CASES)
- VSD.

39. TRISOMY-18 SYNDROME

40. HOLT–ORAM SYNDROME
INHERITENCE: - AUTOSOMAL DOMINENT
CLINICAL FEAUTURES
- -HYPOPLASTIC THUMB WITH AN
ACCESSORY PHALANX (TRIPHALANGISM)
--THUMB MAY BE RUDIMENTARY (OR) ABSENT
--METACARPAL BONE MAY BE
SMALL (OR) ABSENT
--HYPOPLASTIC RADIUS.
CARDIAC ANOMALY
- OSTIUM SECUNDOM ASD.

41. ELLIS – VAN CREVELD SYNDROME
INHERITENCE
 AUTOSOMAL RECESSIVE
CLINICAL FEATURES
 DWARFISM WITH POLYDACTYLY OF THE
HANDS (INVARIABLE)
 POLYDACTYLY OF THE FEET (10%)
 POLYCARPALY (9 OR 10TH CARPEL BONE)
 CLINODACTYLY (BENT FINGERS)
 SYNDACTYLY (INTERDIGITAL WEBBING)
 HYPOPLASIA OF THE NAILS
 PREMATURE ERUPTION OF MALFORMED
MAXILLARY INCISORS; GINGIVAL
HYPETORPHY AND MULTIPLE FRENULA
CARDIAC ANOMALY
 COMMON ATRIUM, LARGE ASD.

42. Pulse and BP
•
Examine pulse and BP in all four limbs.
•
Weak lower limb pulses suggestive of
coarctation of aorta.
•
BP compared against age specific percentile
curves.

43. JUGULAR VENOUS PLUSE (JVP)
 TOF: INCONSPICUOUS; AGEING , SYSTEMIC HTN, ETC. CAN
PRODUCE PROMINENT A WAVE. POSTOPERATIVE : A AND V
WAVES.
 PROMINENT A WAVE: TRICUSPID ATRESIA, PULMONARY
ATRESIA WITH INTACT SEPTUM AND PS WITH STRETCHED
PFO.
EISENMENGER PHYSIOLOGY: PROMINENT A AND V WAVES;
SOMETIMES V WAVE CAN BECOME VERY PROMINENT,
SIMULATING VENOUS CORRIGAN.
 TAPVC: PROMINENT V WAVE.
 EBSTEIN’S ANOMALY: PROMINENT A AND V WAVES ARE
OCCASIONALLY FOUND DUE TO HYPOKINETIC TR AND
COMMODIOUS RIGHT ATRIUM.

44. EXAMINATION OF THORAX- INSPECTION
1.PRECORDIAL BULGE - CARDIAC ENLARGEMENT BEFORE
PUBERTY.
2.PECTUS EXCAVATUM & CARINATUM - ASD, NOONAN SYNDROME
3.FEMALE HYPOMASTIA - TURNER'S SYNDROME
(SHIELD CHEST)
4.HARRISON'S GROOVE -CHRONIC DYSPNOEA DUE TO LARGE
LEFT TO RIGHT SHUNT LESIONS
5.HEAVY MUSCULAR THORAX WITH - CO–ARCTATION OF AORTA
LESS DEVELOPED EXTREMITES (VISIBLE COLLATERAL ARTERIES IN

45. PALPATION OF PRECORDIUM
THRILL
 PS, STRETCHED PFO.
 DORV, RESTRICTIVE VSD.
 TRICUSPID ATRESIA, PS RESTRICTIVE VSD.
 UNIVENTRICULAR HEART, ACROSS THE
BULBOVENTRICULAR COMMUNICATION.
 TOF WITH ABSENT PV.

46. APICAL IMPULSE (COMMONEST IS RV
TYPE APEX)
LV TYPE APEX
• TRICUSPID ATRESIA.
• PULMONARY ATRESIA
WITH INTACT SEPTUM
• UNIVENTRICULAR (LV)
HEART
• EBSTEIN’S ANOMALY
• LSVC TO LEFT ATRIAL
COMMUNICATION.
ABSENT RV
ACTIVITY
• HYPOPLASTIC RIGHT
HEART SYNDROME.

47. HEART SOUND – S1
 WIDE SPLIT WITH LOUD T1 COMPONENT:
EBSTEIN’S ANOMALY.
 ABSENT T1 COMPONENT :
TRICUSPID ATRESIA.

48. HEART SOUNDS - SINGLE S2
ABSENT P2
1. PULMONARY ATRESIA
2. SEVERE PS AND
DYSPLASTIC PULMONARY
VALVE
3. TRUNCUS ARTERIOSUS
4. ABSENT PULMONARY
VALVE.
INAUDIBLE P2
1. D–TGA
2. MPGA.
ABSENT A2
1. AORTIC ATRESIA.
INAUDIBLE A2
1. LOUD P2 IN PULMONARY
AREA (SEVERE PHT.)
SYNCHRONOUS A2 AND P2
1. VSD WITH BIDIRECTIONAL
FLOW
2. SINGLE VENTRICLE.

49. HEART SOUND – S2
 FIXED, WIDE : TAPVC, ASD WITH SHUNT REVERSAL.
 NORMAL / NARROW / SINGLE : PDA WITH SHUNT REVERSAL.
 SINGLE LOUD S2 (A2) : ANY ENTITY IN TETRALOGY
PHYSIOLOGY WITH SEVERE PS, CCHD WITH MALPOSED GREAT
ARTERIES.
 SINGLE LOUD S2 (P2) : VSD WITH SHUNT REVERSAL.
 WHEN CYANOSIS IS MILD AND GREAT ARTERIES ARE
NORMALLY RELATED, P2, THOUGHT SOFT, MAY BE
PRESERVED IN TETRALOGY PHYSIOLOGY.
 A PRESERVED P2, WHATEVER MAY BE THE DEGREE
OF CYANOSIS, EXCLUDES TRUNCUS ARTERIOSUS,
PULMONARY ATRESIA AND TOF WITH ABSENT PULMONARY
VALVE.

50. HEART SOUNDS – S3/S4
 MULTIPLE HEART SOUNDS : EBSTEIN’S
ANOMALY.
 S4 : PS WITH STRETCHED PFO, ASD/ EP.
 S4 (LV) : CORRESPONDS THE RIGHT
ATRIAL A WAVE AND DENOTING A
NONRESTRICTIVE ASD IN TRICUSPID
ATRESIA.

51. EJECTION CLICK
 PULMONARY CLICK : EISENMENGER
PHYSIOLOGY.
 AORTIC CLICK : MORE SEVERE THE
PULMONARY STENOSIS, MORE IS THE
PROBABILITY OF GETTING IT IN TETRALOGY
PHYSIOLOGY.
 VERY PROMIENT, HIGH PITCHED : TRUNCUS
ARTERIOSUS.

52. MURMUR
SYSTOLIC MURMUR
 SEVERE THE CYANOSIS, LESSER IS THE GRADE
OF THE MURMUR.
 EXCEPTION IS THE OBLIGATORY MURMURS
IN DORV/ VSD/ PS, TRICUSPID ATRESIA/ VSD
(MORE SO WHEN VSD IS RESTRICTIVE) AND IN
UNIVENTRICULAR HEART (BULBOVENTRICULAR
FLOW).

53. DIASTOLIC MURMUR
 TRUNCUL REGURGITION.
 TOF WITH ABSENT PULMONARY
VALVE.
 TOF WITH AORTIC REGURGITION.
 GRAHAM STEEL MURMUR IN
EISENMENGER PHYSIOLOGY.

54. DD OF A CONTINOUS MURMUR
WITH OR WITHOUT CYANOSIS ?
CONTINOUS OR A TO & FRO
MURMUR ?

55. CONTINOUS MURMURS WITHOUT CYANOSIS
 PDA
 AP WINDOW
 VENOUS HUM
 CORONARY AV
FISTULA
 ALCAPA
 RSOV
• PERIPH PULM.
STENOSIS
• SYSTEMIC AV FISTULA
• COLLATERALS IN COA
• MAMMARY SOUFFLE
• AORTICO-LV TUNNEL

56. CONTINOUS MURMUR WITH CYANOSIS
DUCT IN TETRALOGY
PULM ATRESIA WITH DUCT
MAPCAS IN PULM ATRESIA
SUPRACARD. TAPVR
PULM AV FISTULAE
POST BT SHUNT (THOMAS-BLALOCK-TAUSSIG SHUNT)
POST - POTT’S, WATERSTON, CENTRAL SHUNTS

57. MAPCAS

58. TO & FRO MURMUR
WITHOUT CYANOSIS WITH CYANOSIS
 VSD AR
 MR AR
 AS AR
 PS PR
 POST OP
TETRALOGY
 MR AR
 TR PR ETC
• TETRALOGY WITH AR
• TRUNCUS WITH
REGURG
• ABSENT PV SYNDROME

59. DIAGNOSIS OF CYANOTIC CHD

60. CCHD WITH
DECREASED PULMONARY BLOOD FLOW
 TETRALOGY OF FALLOT
 VSD - PS
 DORV – VSD – PS
 TRICUSP. ATRESIA - PS
 SINGLE VENTRICLE - PS
 TGA WITH VSD – PS
 CORR.TRANSP.-VSD-PS
 ASD - PS

61. CCHD - ↓ PBF
- INSPECTION /PALPATORY FINDINGS
 CYANOSIS & CLUBBING
 POLYCYTHEMIA
 QUIET PRECORDIUM TO INSPECTION
& PALPATION
 NO HARRISONS SULCUS (OR)
PRECORDIAL BULGE
 APEX WELL WITHIN LIMITS IF VISIBLE
 NO PALPABLE SOUNDS (OR) THRILLS

62. CCHD WITH ↓ PB FLOW
AUSCULTATORY FINDINGS
 NORMAL FIRST HEART SOUND
 SINGLE SECOND HEART SOUND
 PULM COMPONENT INAUDIBLE
 STENOTIC PULMONARY MURMUR
SLIGHTLY AFTER S1
STOPS SHORT OF S2
 OTHER MURMURS – DUCTAL/ MAPCA/ AR

63. Tetralogy of Fallot (TOF)
 TOFTOF: Cyanosis: Cyanosis
proportional to RVOTproportional to RVOT
obstructionobstruction
 RV apex, parasternalRV apex, parasternal
heave ,heave , Single S2,Single S2, EjectionEjection
systolic murmur at Leftsystolic murmur at Left
upper sternal edgeupper sternal edge
 TOF with PATOF with PA: Single S2: Single S2
but soft murmurbut soft murmur
sometimessometimes continuouscontinuous
from the MAPCASfrom the MAPCAS..
Occasionally CCFOccasionally CCF

64. EJECTION MURMUR IN FALLOT
PHYSIOLOGY
 LENGTH & LOUDNESS INVERSELY
PROPORTIONAL TO SEVERITY OF STENOSIS
IN ISOLATED PVS – THE OPPOSITE
 ABSENT MURMUR – ACQUIRED PULM ATRESIA
- MAPCA MURMUR OVER BACK
- SOFT DUCTAL MURMUR
 TO & FRO – AORTIC REGURG / ABS PV
SYNDROME

65. TETROLOGY OF FALLOT

66. Tetralogy of Fallot
TETRALOGY OF FALLOT

67. TRICUSPID ATRESIATRICUSPID ATRESIA
• Clinical feautures:Clinical feautures:
cyanosiscyanosis, LV, LV
impulse,impulse,
S2 single,S2 single,
Holosystolic murmurHolosystolic murmur
along left sternalalong left sternal
edgeedge

68. TRICUSPID ATRESIA

69. TRICUSPID ATRESIA
TRICUSPID ATRESIA

70. CYANOSIS WITH INCREASED FLOW
 TRANSPOSITION PHYSIOLOGY
 TAPVC
 COMMON MIXING LESIONS
WITH UNOBSTRUCTED PULMONARY
FLOW
 PA, VSD WITH SEVERAL MAPCAS.

71. CCHD WITH ↑ P B FLOW - SYMPTOMS
 RESPIRATORY SYMPTOMS PREDOMINATE
 GROWTH RETARDED – WEIGHT & HEIGHT
 SCRAWNY, SICK, DYSPNOEIC PATIENT
 RECURRENT LRTI/PNEUMONIAS
 CHRONIC LUNG DISEASE- BRONCHIECTASIS
ETC
 DIAPHORESIS/ BREATHLESSNESS AT REST
 EXERTIONAL DYSPNOEA, LIMITED ACTIVITY.

72. CCHD WITH ↑ P B FLOW
INSPECTION FINDINGS
SICKLY UNDERWEIGHT INDIVIDUAL
CYANOSIS & CLUBBING -MILD TO MODERATE
SEVERE PHT, EISENMENGER – MODIFIES FINDINGS
HARRISSON’S SULCUS, PRECORDIAL BULGE
ACTIVE PRECORDIUM, RV, LV, PA PULSATIONS
OBVIOUS CARDIOMEGALY

73. CCHD WITH ↑ P B FLOW
PALPATORY FINDINGS
ACTIVE PRECORDIUM
RV IMPULSE – DORV, TAPVR, TGA VSD PS
LV IMPULSE – SINGLE VENTRICLE, AVSD-AV
REGURG
PALPABLE SECOND SOUND / THRILLS RARE

74. Transposition of the Great Arteries
(TGA)
 D-TGA with IVS-D-TGA with IVS-
cyanosis and tachypnea,cyanosis and tachypnea,
S2 single and loudS2 single and loud, soft, soft
or absent MURMUR.or absent MURMUR.
 D-TGA with VSD-D-TGA with VSD-
presents with cardiacpresents with cardiac
failure, subtle cyanosisfailure, subtle cyanosis
and holo systolic VSDand holo systolic VSD
murmurmurmur..

75. D-TGA- EGG ON END APPERANCE

76. RVH IN D-TGA
RVH IN D-TGA

77. Tetralogy of Fallot
Total Anomalous Pulmonary Venous
Return
• Pulmonary veins drain
anomalously into RA or
systemic venous tributaries
– Supracardiac – 50%
– Cardiac – 20%
– Infracardiac - 20%
• Presentation and severity
depends on pulmonary
venous obstruction
• ASD or PFO essential for
survival

78. TAPVR- Snowman Appearance
TAPVR- SNOWMAN APPEARNCE

79. TRUNCUS ARTERIOSUS
• CLINICALCLINICAL
PRESENTATIONPRESENTATION
-in neonates-in neonates murmurmurmur
and mild cyanosis,and mild cyanosis,
-later develops-later develops CardiacCardiac
failure, valvefailure, valve
insufficiency, single S2,insufficiency, single S2,
Loud ESM with thrill andLoud ESM with thrill and
MDM due to mitral flowMDM due to mitral flow
murmurmurmur

80. Truncus Arteriosus
TRUNCUS ARTERIOSUS

81. Ebstein’s Anomaly of TVEbstein’s Anomaly of TV
 Clinical feautures-Clinical feautures-
- depends on degree of- depends on degree of
displacement ofdisplacement of
Tricuspid ValveTricuspid Valve, can be, can be
mild till teenage ormild till teenage or
severe with cyanosis insevere with cyanosis in
neonate.neonate.
 WPW syndromeWPW syndrome is anis an
association, multipleassociation, multiple
clicks, holo systolic TRclicks, holo systolic TR
murmur, gallop.murmur, gallop.

82. Ebstein’s anomaly
EBSTEIN ANOMALY

83. Ebstein’s with WPW Syndrome
EBSTEIN’S WITH WPW SYNROME

84. DIAGNOSIS OF ACYANOTIC CHD

85. ATRIAL SEPTAL DEFECT (ASD)
A.S.D[O.S type]
PRECORDIUM
-hyper dynamic RV apical impulse
-systolic pulsation in 2nd
LICS
AUSCULATION
-fixed splitting of S2
-split S1 [loud T1]
-ESM in pulmonary area
-tricuspid mid-diastolic flow murmur
X-RAY
-pulmonary plethora
-markeoly dilated pulmonary
trunk and its branches
-dilated RA and RV
ECG
-RSR’ in V1

86. Ventricular Septal Defect (VSD)
• Clinical representation
depends on size of VSD
&PVR.
• Moderate sized defect with
low PVR.
-CCF in infancy
-murmur detected at first
well baby examination
-retarded growth &
development
-hyper dynamic LV
-PSM in L+ 2 to 4 ICS with
thrill
-flow MDM across mitral
valve

87. Patent Ductus Arteriosus (PDA)
• HISTORY : Premature birth,
maternal rubella, birth at
high altitude.
• CLINICAL SIGNS:
1.Continuous murmur
-peak around S2
-maximal in 1st
or 2nd
LICS
-contains eddy
sounds[later
systole and early
diastole]
2.LV apical impulse
3.Brisk arterial pulse with
wide pulse pressure

88. Coarctation of the Aorta
• Systemic hypertension
• Abnormal differences in upper
and lower limb pulses and
systolic BP[Radio femoral
delay]
• Prominent carotid and
suprasternal pulsations
• Systolic murmur over posterior
interscpular region, Lt sternal
border and suprasternal notch
• Co-existing BCAV-
AEC,ejection systolic
murmur/EDM in aortic or 2nd
aortic area.
• X-RAY
-3RD
to 8th
posterior
ribs [Rib notching]
-seldom before 6yrs of age

89. COARCTATION OF AORTA
ASYMPTOMATIC ADULTS –
COLLATERALS
HYPERTENSION !
FEMORALS !!
BICUSPID AV IN 80% - EJECTION CLICK !
COLLATERAL MURMUR OVER BACK

90. COARCTATION OF AORTA- RIB NOTCHING

91. KEYS TO CLINICAL DIAGNOSIS
 WORK IN ORDER
 COLOUR - CYANOSIS, PALLOR, POLYCYTHEMIA
 EXAMINE THE PATIENT HEAD TO FOOT FOR CONGENITAL DEFECTS
 PALPATE ALL PERIPHERAL PULSES & RECORD BOTH UL & LL BP
 INSPECT – FOR CHEST FORM, PULSATIONS
 PALPATE TO DETERMINE – WHICH VENTRICLE ?
 FORGET THE MURMUR !!
 LISTEN FIRST TO S1, AND THEN TO S2
 CAN YOU SPLIT THE SECOND SOUND ??
 THEN CONCENTRATE ON THE COMPONENTS
 FINALLY THE MURMURS – SYSTOLIC – EJECTION OR PANSYST.
 IS THERE A DIASTOLIC MURMUR (OR) CONTINOUS MURMUR

92. CONCLUSION
-
-INTELLIGENT SELCTION OF INVESTIGATIVE
-
PROCEDURES FROM AN EVER - INCREASING ARRAY
-
REQUIRES FAR MORE SOPHISTICATED DECISION
-
MAKING.
-THE BASIC CLINICAL ASSESSMENT PROVIDES THE
INFROMATION NECESSARY FOR MOST OF THESE
DECISIONS.
-WITH INCREASING EMPHASIS ON THE COST OF MEDICAL
CARE, A RESURGENCE OF INTEREST IN THE
INEXPENSIVE AND SAFE CLINICAL EXAMINATION IS
LIKELY.

93. S.H.P