Factors Controlling Sites of Loudness

1. What is the usual site of maximal loudness of the VSD murmur?

ANS: The left lower sternal border.

2. When may a VSD murmur be louder between the apex and the left lower sternal border than at the left sternal border?

ANS: When the VSD is in the muscular part of the septum near the apex. This is not an unusual site for a ruptured septum secondary to infarction.

Loud pansystolic harsh murmur found in a patient with a large VSD.

3. What is meant by maladie de Roger?

ANS: In 1861, the French pediatrician Henri Roger presented the first comprehensive description of an asymptomatic VSD and described the murmur through the defect as loud and long, with its maximum intensity over the upper third of the medial precordial area [9]. The expression is now used to refer to a small VSD with a loud murmur at the left lower sternal border. Roger, however, neither specified the size of the VSD nor placed the murmur at the lower sternal border.

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