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

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The pulse is small to normal in volume and although the praecordium may be turbulent it is right ventricular in character. The characteristically fixed wide-splitting of the second heart sound and the electrocardiographic picture (fig. 29) should establish the diagnosis. Ventricular septal defect. Here the distinction may be difficult or impossible clinically, particularly where a continuous ductus murmur is absent. Again, there may be a pulmonary regurgitant murmur present in ventricular septal defect which resembles the continuous murmur of ductus.

See Anomalies of Venous Drainage under Atrial Septal Defect, p. 50) Anatomy and Embryology The pulmonary veins may drain into a persistent left superior vena cava which in turn drains into the left innominate vein and superior vena cava. Alternatively, they may drain into the coronary sinus as in the usual left superior caval drainage pattern. In some cases the drainage of the pulmonary veins is into a common posterior chamber which drains directly into the right atrium or the pulmonary drainage may be to the right atrium via the inferior vena cava.

An associated ventricular septal defect is usual. 7hnlile fret/uclal Fig. 24. Illustration of the types of coarctation commonly encountered Anatomy The condition is in some way related to the complicated embryological development of the aortic arch from the fourth left branchial arch (vol. I, p. 7). The obstruction is in most cases efficiently compensated for by the development of a rich collateral circulation. This is derived mainly from the branches of the subclavian and axillary arteries. There is an adequate blood flow to the lower half of the body.

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