A Surgeons’ Guide to Cardiac Diagnosis: Part II The Clinical by Donald N. Ross B. Sc., M. B., CH. B., F. R. C. S. (auth.)

By Donald N. Ross B. Sc., M. B., CH. B., F. R. C. S. (auth.)

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Special Investigations A plain radiograph of the chest confirms the diagnosis by showing the characteristic notching of the lower borders of the ribs caused by the enlarged intercostal arteries. These are not seen clearly before 6-8 years of age. In addition, there is an "absent" or double aortic knuckle produced by the shadow of the enlarged left subclavian artery and descending aorta beyond the coarctation. A more accurate impression of the coarcted segment can be obtained by means of retrograde aortography although this is seldom necessary.

There is no central cyanosis or clubbing unless there is a reversed atrial shunt. The arterial pulse is not remarkable but the venous pulse may show a giant a wave due to the vigour of the right atrial contractions. Pressure over the liver accentuates this venous pulsation. In addition, there may be a praecordial bulge and an obstructive type of heave over the right ventricle. At the same time, a long systolic thrill is felt over the pulmonary valve area. This combination of a giant a wave, thrill and a right ventricular heave is almost diagnostic of the condition.

Also, a ductus with pulmonary regurgitation will show an apparent shunt at right ventricular level. The passage of the catheter across the defect may provide the best evidence but again, this does not exclude the co-existence of the two lesions. For these reasons retrograde aortography is increasingly used to establish the presence or absence of a ductus in difficult cases with pulmonary hypertension. Aorto-pulmonary window (p. 61) may be impossible to distinguish from ductus, although the clinical features are more likely to be those of a big ventricular septal defect than a ductus.

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