Dextro-transposition of the great arteries physical examination

Cyanosis and Clubbing can be seen on physical examination. The findings on physical examination are modified depending on the accompanying lesion seen i.e. ventricular septal defect, fossa ovalis, patent ductus areriosus.

• There is a prominent impulse at the LLSB (the right ventricle which is actually the morphologic left ventricle).
• The first heart sound (S1) is normal in intensity and splitting because the PR interval and ventricular activation is normal. Due to the anterior location of the aorta, the second heart sound (S2) is accentuated and is usually single.
• The murmur of a large patent ductus arteriosus in d-TGA, is usually systolic, seldom continuos, due to the almost exclusive flow during systole from the aorta to the pulmonary artery.
• Systolic murmus 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 resistence is low, a midsystolic murmur is originated in the posterior pulmonary artery, but the murmur is dump by the anterior aorta.
• A VSD murmur (holosystolic)is absent at birth, until the pulmonary vascular resistence fall. A subsequent increase in pulmonary resistence shortens and later abolishes the murmur.

• Symmetric cyanosis
• Delayed mild cyanosis, and the apearence of congestive heart failure accompanies non-restrictive VSD.
• Reversed differential cyanosis (feet less cyanotic than hands) can be a manifestation in patients with d-TGA and large patent ductus arteriosus that has develop 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 distribuited to the lower extremities.

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