**6. Clinical presentation**

Small VSDs: Patients with small VSDs are usually asymptomatic and are detected incidentally on routine physical examination. A holosystolic murmur with or without a thrill is best heard at the left lower sternal border in muscular and membranous defects while the holosystolic murmur is heard at the left upper sternal border in subarterial defects due to direction of VSD jet towards the pulmonary outflow tract. In very small defects, the murmur is shorter and does not last through the entire systole.

*Ventricular Septal Defects: A Review DOI: http://dx.doi.org/10.5772/intechopen.104809*

Moderate to large VSDs: Subjects with hemodynamically significant, moderate to large VSDs usually present with signs of congestive heart failure due to pulmonary over-circulation and left ventricular volume overload. Due to equalization of pressures in both right and left ventricles, the right ventricular impulse in the lower left sternal border or subxiphoid region is prominent. In patients with chronic left ventricular overload, the left ventricular impulse is hyperdynamic and shifts laterally. A mid diastolic flow rumble may be heard at the apex due to relative mitral stenosis from increased left to right shunt. This usually indicates a Qp:Qs >2:1.

Eisenmenger syndrome: Patients with ES may present with central cyanosis, clubbing, peripheral edema, abdominal tenderness, right ventricular heave, a loud pulmonary ejection click and an accentuated pulmonary component of the second heart sound.
