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)

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