CHD (Bedside Diagnosis)

CONGENITAL HEART DISEASE
BEDSIDE DIAGNOSIS
2/3/2020 CHD (Bedside diagnosis) (New Updated April, 2007) 1

DEFN.:
Structural heart disease present from birth.
2
INCIDENCE :-
10 to 20/1000 live births (10 /1000 Cong.
Bic. Ao.V.)
Higher if premature babies are included.
3
CHD - Incidence
19502, Newborns (5 yr.)
% 98.8
100 88.3
80
60 46
40
20
0
1 week 1 year 4 years
HOFFMAN. Am J. Card. 42 : 641 - 47:1978
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5
DIAGNOSIS :-
1. Does the child have heart disease?
2. Is it congenital heart disease ?
3. What group does he belong to ?
4. What is the specific diagnosis ?
5. What is the severity?
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Criteria for the presence of heart disease (Nadas)
MAJOR MINOR
• Syst. murmur Grade-III or  • Abnormal BP
• Diastolic murmur • Abnormal S2
• Cyanosis • Syst. murmur  Grade-III
• Congestive failure • Abnormal ECG
• Abnormal X-ray
Heart Disease : 1 major or 2 minor criteria

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DIAGNOSIS :-
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Is it CHD
1. Diagnosis by 2 to 3 yrs of age.
2. Parasternal murmur
3. Cyanosis
4. Abnormal BP
5. Extra cardiac anomalies
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HELPFUL POINTERS
Abn. of forearms : VSD
Syndactyly, polydactyly : VSD
Down’s syndrome : ECD / VSD
Arachnodactyly : ASD
Turmer’s synd. : Coarct. of the Ao
Rubella Synd. : PDA / PS
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DIAGNOSIS :-
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CLASSIFICATION
L  R shunts Obstr. lesions Cyanotic pts
•Atrial level Right sided With PS

•Vent. Level Left sided With PAH
•PA level
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DIAGNOSIS :-
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L  R SHUNTS :
• Frequent respiratory infections
•  Sweating
• No cyanosis
• Tendency for CCF.
• Precordial bulge
• Cardiomegly
• Hyperkinetic precordium.
• Shunt and flow murmurs
• X-ray : CE; Vase 
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Ventricular Septal Defect
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OBSTRUCTIVE LESIONS
• No CE or cyanosis
• No precordial bulge
• Forcible, heaving cardiac impulse
• Systolic thrill.
• Eject. Systolic murmur.
• Delayed corresponding S2
• ECG - Vent.. hypertrophy, x-ray normal.
• Severe – CE & Congestive cardiac failure
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CYANOTIC Pts
Cyanosis
Clubbing
Polycythemia
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CYANOTIC
Syst. Ven. : bl. delivered to syst. arterial
circulation without oxygenation
R  L shunt.
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CYANOSIS
Uniform
Differential
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CYANOSIS : Uniform
R  L shunt at atrial, ventricular
or ascending Ao level.
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CYANOSIS : Differential
Indicates severe PAH with R  L shunt
through PDA.
Presence or absence of the coarct. of the
Ao has no significance.
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CYANOSIS : EFFECT OF PULM. BL. FLOW
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PS present PS absent
a) VSD absent PA pr normal PA pr 
b) VSD present  PBF  PBF P. ven. obstr.
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CYANOTIC : Subgroups
1. PS, no VSD
2. PS with VSD (TOF physiology).
3. pulm flow (Transposition physiol.)
4. PA pr ,  pulm. flow (Eisenmenger physiol).
5. Pulm. ven. obst.
6. PA pr. normal, No PS.
39
CYANOTIC : PS +, No VSD
(R  L shunt at atrial level)
1. Large ‘a’ in JVP.
2. CE +, Parast heave
3. S2 widely split, P2 soft and late
4. S3 +, S4 +.
5. Pulm. eject. m.; TR. m.
40
CYANOTIC : PS, No VSD

Severe pure PS  TR
Ebstein’s anomaly.
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Book fig 9.11 43
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CYANOTIC : VSD + PS
(TOF physiology)
1. Heart size normal.
2. Mild parasternal impulse
3. Thrill uncommon
4. Single S2 (wide split, P2 inaudible)
5. Stenotic murmur.
6. Ischaemic lungs on x-ray.
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TOF, Absent Pulmonary Valve Syndrome
10 year old boy with mild cyanosis 53

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CYANOTIC : VSD with PS

1. Fallot’s tetralogy
2. Tricuspid atresia
3. Double outlet RV.
4. Single ventricle.
5. Transposition and malposition
complexes.
55
CYANOTIC : Transp. Physiology

( pulm. blood flow with cyanosis)
1. Failure to thrive
2. CE +, CCF +
3. S2 single  split
4. S3 / S4 +
5. Murmurs insignificant.
6. Cardiomegaly with  vasc.
56
57
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CYANOTIC : Trans. Physiology

Cyanosis with cardiomegaly, CCF and
pulmonary plethora on x-ray indicates
abnormal mixing.
59
CYANOTIC : Transp. physiology ( pulm. flow)
Complete TGA PTA
TAPVC Tr. atresia
DORV Single vent.
Malposition complexes.
60
CYANOTIC : PAH &  Pulmonary flow

(Eisenmenger physiology)
1. No CE (ASD +)
2. No parast. heave (ASD +)
3. S2 palpable, P2 +++
4. Constant click
5. Insignificant syst. murmur
6. PR m , TR m 
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CYANOTIC :
TGA, DORV Eisenmenger
TAPVC, SV ASD, VSD, PDA
Tr. atr., PTA APW, ECD.
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67
CYANOTIC : Pulm. ven. obstr.

1. Cyanosis with CCF.
2.  ‘a’ in JVP
3. Parast heave, No CE.
4. S2 normalty, split, P2 +++
5. TR murmur
6. ECG : ‘P’ pulm., RVH.
7. X-ray : No CE, PVH+++
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CYANOTIC : Pulm. ven. obstr.

1. Hypoplastic left heart
2. Obstructed TAPVC.
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CYANOTIC : Normal PA pr, No PS

1. TAPVC
2. SVC to LA
3. Pulm. A-V fistula
4. Single atrium.
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CYANOTIC : PA pr – normal, No PS
• TAPVC - Findings of ASD
• SVC to LA Normal findings with
• Pulm. AV fistula unexplained cyanosis
• Single atrium : Echo. Dx.
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CYANOTIC : Pan systolic murmur

a) MR / TR Ebstein’s
CCTGA
ECD
PS with TR
ASD PAH (AF)
b) Obligatory VSD Tricuspid atresia

DORV with small VSD
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CYANOTIC : Continuous m.
1. TOF physiology with PDA or bronchial
collaterals
2. TAPVC
3. Peripheral PS
4. Pulm. AV fistula
5. Surgical shunt
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CYANOTIC : CRITICAL DECISION
PA PRESSURE
Normal Increased
With PS Without PS  flow  flow
Operable Inoperable
Curable Incurable
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DIAGNOSIS :-
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Assessment of severity
Determines the line of management.
• Medical treatment.
• Surgical treatment.
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Severity: L  R shunts
• Symptoms
• CCF ; Ht. size
• S2, P2
• S3 and flow murmur
• Degree and type of PAH.
80
Severity: Obstructive lesions
• Vent. hypertrophy and size

• S2, S3, S4
• Systolic murmur
• BP, ECG
• Doppler gradient
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Severity: Cyanotic pts.
• Age Ischaemic lungs

• Symptoms CCF
• Degree of cyanosis
• Heart size.
• Pulm. vasculature
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Severity: Left to Right shunts
• Size of shunt
• Severity of PAH
• Size of defect
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Severity: Left  Right shunts

Size of shunt
• Cardiomegaly
• S2
• Shunt murmur
• S3, Flow murmur
84
Severity : Left to Right shunts : S2
ASD : Wide fixed split, P2+

Large shunt - No PAH
Small shunt - PAH
Not useful in assessing size of shunt

or PAH.
85
Severity : Left to right shunt : S2
V.S.D. : Small - S2 normal

Large flow, No PAH - wide variable, P2 +
Large flow, PAH - wide variable P2++
Small flow, PAH-normal but closely split, P2 +++
R  L shunt PAH – single
Small flow, PS – widely split, P2 
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Severity : Left to right shunt : S2
PDA :
• Normally split, P2 + : mod. size
• Paradoxically split : large shunt
• Normally split, P2 +++ : small shunt with significant
PAH.
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Severity : Left to right shunt
S3 : shunt about 1.5 to 2 : 1

Flow murmur : more than 2 : 1
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Severity : Left to right shunts
Shunt murmur
ASD : Absent
VSD : Pansyst : moderate size
Eject. Syst : small or large
PDA : Continuous : small to mod. Size
Eject. Syst : large
89
Severity : PAH
Hyperkinetic Obstructive
Click of PAH Absent Present

S2, P2 ++ ASD-Wide & fixed Wide & fixed
VSD- Wide & Variable Single
PDA-Paradoxically split Normally split
Shunt M. Loud Short
Flow M. Present Absent
90
Severity : Left to right shunt
Size and number of defects cannot be

determined by physical examination.
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Obstructive lesions : Severity
• Click
• S2
• S3, S4
• Murmur
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Obstructive lesions : Click
AS : CoA - Constant, no relation
PS : Inconstant, the closer the click to

S1, the more severe the PS
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Obstructive lesions : Severity
Prolonged vent. ejection time

• Delayed P2 / A2
• Longer and louder eject. syst. murmur till
vent. failure occurs.
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Obstructive lesions : S2
AS : Delayed A2
Mild - Normal split, moderate - single,
severe - paradoxically split
PS : The more the severity the wider the split;

A2 P2 int. 60 msc indicates systemic pr. in
RV.
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Obstructive lesions : Murmur
The more severe the obstruction the louder and

longer the murmur with delayed peak. With the
onset of ventricular failure the murmur
becomes softer and shorter due to fall in
forward output.
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Obstructive lesions : S4 & S3
Indirect evidence for severity vent. hypertrophy 

poor relaxation   edp  S4
AS : S4 LV edp.  12 mmHg
PS : Right S4 – Severe PS.
S3 : Ventricular failure : Severe
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Cyanotic lesions :-
All cyanotic patients have severe disease.
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CHD - Incidence
19044, Newborns (5 yr.)
% 98.8
100 88.3
80
60 46
40
20
0
1 week 1 year 4 years
HOFFMAN. Am J. Card. 42 : 641 : 100
101
102
103
104

CHD (Bedside Diagnosis)

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CHD (Bedside Diagnosis)

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CONGENITAL HEART DISEASE

2/3/2020 CHD (Bedside diagnosis) (New Updated April, 2007) 1

Structural heart disease present from birth.

Heart Disease : 1 major or 2 minor criteria

L  R shunts Obstr. lesions Cyanotic pts

•Atrial level Right sided With PS

a) VSD absent PA pr normal PA pr 

b) VSD present  PBF  PBF P. ven. obstr.

CYANOTIC : PS, No VSD

10 year old boy with mild cyanosis 53

CYANOTIC : VSD with PS

CYANOTIC : Transp. Physiology

CYANOTIC : Trans. Physiology

CYANOTIC : PAH &  Pulmonary flow

CYANOTIC : Pulm. ven. obstr.

CYANOTIC : Pulm. ven. obstr.

CYANOTIC : Normal PA pr, No PS

CYANOTIC : Pan systolic murmur

b) Obligatory VSD Tricuspid atresia

With PS Without PS  flow  flow

Severity: Obstructive lesions

• Vent. hypertrophy and size

Severity: Cyanotic pts.

• Age Ischaemic lungs

Severity: Left to Right shunts

Severity: Left  Right shunts

Severity : Left to Right shunts : S2

ASD : Wide fixed split, P2+

Not useful in assessing size of shunt

Severity : Left to right shunt : S2

V.S.D. : Small - S2 normal

Severity : Left to right shunt : S2

Severity : Left to right shunt

S3 : shunt about 1.5 to 2 : 1

Severity : Left to right shunts

Click of PAH Absent Present

Severity : Left to right shunt

Size and number of defects cannot be

Obstructive lesions : Severity

Obstructive lesions : Click

AS : CoA - Constant, no relation

PS : Inconstant, the closer the click to

Obstructive lesions : Severity

Prolonged vent. ejection time

PS : The more the severity the wider the split;

Obstructive lesions : Murmur

The more severe the obstruction the louder and

Obstructive lesions : S4 & S3

Indirect evidence for severity vent. hypertrophy 

All cyanotic patients have severe disease.

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