Table of Contents

Valve replacement

See viva notes on valve replacements
Midline sternotomy
Abnormal S1 = mitral
Abnormal S2 = aortic

Assess for valve function: signs of regurgitation or stenosis of replaced valve

Assess for signs of cardiac decompensation: signs of heart failure

Assess for signs of infective endocarditis: splinter haemorrhages, Osler’s nodes/Janeway lesions

Assess for complications of over-anticoagulation: bruising, pale conjunctiva

Assess for haemolysis: jaundice, pale conjunctiva

Heart failure

Tachypnoea/tachycardia
Cool peripheries
Raised JVP
Displaced apex
S3 (ventricular gallop)
Bi-basal fine crepitations
Peripheral oedema

Atrial septal defect

Soft ejection systolic flow murmur (pulmonary area)
Fixed, widely split S2
RV heave

Signs of associations: low set ears/prominent epicanthic folds/flat nasal bridge (Down’s syndrome), hypoplastic triphalangeal thumb/radial hypoplasia (Holt-Oram syndrome)

Signs of complications: loud P2 (pulmonary hypertension), peripheral oedema (right heart failure); cyanosis (Eisenmenger’s syndrome – late reversal of shunt)

Ventricular septal defect

Pansystolic murmur (loudest at left lower sternal edge)
Associated thrill
RV heave/loud P2

Signs of complications: raised JVP/peripheral oedema (right heart failure)

Midline sternotomy scar

Bruising from anticoagulation

Peripheral cyanosis

Clubbing

Splinter haemorrhages

Osler’s nodes

Janeway lesions

Cor pulmonale

Plethoric facial appearance
Central cyanosis
Raised JVP (large ‘a’ waves)
Giant V waves + pansystolic murmur (if secondary TR)
Right ventricular heave
Palpable/loud S2
Pedal oedema

Signs of aetiology: end-inspiratory crepitations (pulmonary fibrosis),clubbing (idiopathic pulmonary fibrosis), signs of COPD

Hypertrophic obstructive cardiomyopathy

Pacemaker/implantable cardioverter defibrillator
Jerky pulse/pulsus bisferiens
Double apex beat
Ejection systolic murmur (left lower sternal edge)
S4

Signs of complications: signs of heart failure

Tetralogy of Fallot repair

Sternotomy scar (from repair)
Lateral thoracotomy scar (if had Blalock-Taussig shunt)
Left pulse weaker (if had Blalock-Taussig shunt)
Clubbing
Loud pulmonary stenosis

Signs of associations: syndromic features

Signs of complications: aortic regurgitation, raised JVP/peripheral oedema (right heart failure)

Coarctation of aorta

Pre-repair

Radio-femoral delay
Weak left radial pulse (if stenosis proximal to left subclavian artery)
Systolic vascular murmur over region of stenosis (most commonly left interscapular or left infraclavicular)
Severe hypertension

Post-repair

Left lateral thoracotomy scar

Signs of associations: short/webbed neck/short 4^th metacarpals (Turner syndrome)

Signs of complications: splinter haemorrhages/Osler’s nodes/Janeway lesions (infective endocarditis), severe hypertension, signs of heart failure