Transposition of the great vessels physical examination

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Dextro-transposition of the great arteries
L-transposition of the great arteries

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]; Keri Shafer, M.D. [4]; Kristin Feeney, B.S. [5]

Overview

Newborns with transposition of the great arteries are usually well developed, without dysmorphic features. Physical findings at presentation depend on the presence of associated lesions. In many cases, TGV is accompanied by other heart defects, the most common type being intracardiac shunts such as atrial septal defect (ASD), patent foramen ovale (PFO), ventricular septal defect (VSD), and patent ductus arteriosus (PDA). Stenosis, or other defects, of valves and/or vessels may also be present.

Physical Examination

Vitals

Heart

Palpation

  • There is a prominent impulse at the lower left sternal border (the right ventricle which is actually the morphologic left ventricle).

Auscultation

Heart Sounds
  • The first heart sound (S1) is normal in intensity because ventricular contraction is normal.
  • Due to the anterior location of the aorta, the second heart sound (S2) is accentuated and is usually single.
Murmurs
  • The murmur of a large PDA in d-TGA, is usually systolic, due to the almost exclusive flow during systole from the aorta to the pulmonary artery.
  • If d-TGA is accompanied by both a VSD and pulmonary stenosis, a systolic murmur will be present. Systolic murmurs are absent in neonates unless a subpulmonic stenosis is present. Short midsystolic murmur originate in the anterior aorta when hypervolemia is present. When the pulmonary vascular resistance is low, a midsystolic murmur is originated in the posterior pulmonary artery, but the murmur is reduced by the anterior aorta.
  • A VSD murmur (holosystolic) is absent at birth, until the pulmonary vascular resistance decreases. A subsequent increase in pulmonary resistance shortens and later abolishes the murmur.

Extremities

  • In dextro-Transposition of the great arteries (dextro-TGA) deoxygenated blood from the right heart is pumped immediately through the aorta and circulated to the body and the heart itself, bypassing the lungs altogether, while the left heart pumps red blood continuously back into the lungs through the pulmonary artery.
  • In effect, two separate "circular" (parallel) circulatory systems are created.
  • It is called a cyanotic congenital heart defect (CHD) because the newborn infant turns blue from lack of oxygen.
  • Reversed differential cyanosis (feet less cyanotic than hands) can be a manifestation in patients with d-TGA and large patent ductus arteriosus that has developed early pulmonary vascular disease, reversing the ductal flow if the patient has survived. At this point in time, the pulmonary arterial blood of high oxygen content enters the aorta and is selectively distributed to the lower extremities.
  • Levo-Transposition of the great arteries is an acyanotic heart defect in which the primary arteries are transposed, with the aorta anterior and to the left of the pulmonary artery, and the morphological left and right ventricles are also transposed.


Common physical findings of TGA with associated conditions[2]
Transposition of the great arteries with intact ventricular septum
  • Progressive central (perioral and periorbital) cyanosis
  • A loud, single second heart sound (S2)
Transposition of the great arteries with large ventricular septal defect
  • Mild cyanosis (more apparent with stress or crying).
  • Increased right ventricular impulse
  • A loud, single second heart sound (S2)
  • Possibly a mid-diastolic rumble; and gallop rhythm.
  • Hepatomegaly
Transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction
  • Prominent cyanosis at birth
  • A single second heart sound (S2)
  • Systolic ejection murmur
  • Hepatomegaly (rare)
Transposition of the great arteries with ventricular septal defect and pulmonary vascular obstructive disease
  • Progressive pulmonary vascular obstructive disease is not always evident from physical examination findings.
  • A loud, single second heart sound (S2)
  • Cyanosis is usually present and can progress despite palliative therapy in the newborn period.

References

  1. Hornung TS, Kilner PJ, Davlouros PA, Grothues F, Li W, Gatzoulis MA (October 2002). "Excessive right ventricular hypertrophic response in adults with the mustard procedure for transposition of the great arteries". Am. J. Cardiol. 90 (7): 800–3. doi:10.1016/s0002-9149(02)02619-x. PMID 12356407.
  2. Latham GJ, Joffe DC, Eisses MJ, Richards MJ, Geiduschek JM (September 2015). "Anesthetic Considerations and Management of Transposition of the Great Arteries". Semin Cardiothorac Vasc Anesth. 19 (3): 233–42. doi:10.1177/1089253215581852. PMID 25900898.




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