Acyanotic Congenital Heart

Disease

Dr David Coleman

Consultant Paediatric CardiologistOur Lady’s Children’s Hospital, Crumlin

Dublin

Common Shunt Lesions

♥ Ventricular septal defect (VSD)

♥ Atrial septal defect (ASD)

♥ Patent ductus arteriosus (PDA)

* All 3 lesions can lead to Eisenmenger’s Syndrome if a large lesion is not detected and treated early enough

Common Stenotic Lesions

♥ Pulmonary stenosis (PS)

♥ Aortic stenosis (AS)

♥ Coarctation of the aorta (CoA)

VSD’s

♥ Commonest form of CHD

♥ Commonest types:membranous (perimembranous)

~75%muscular

♥ Can be single or multiple

VSD’s

♥ Symptoms relate to the degree of shunt (VSD size, pulmonary vascular resistance)if small: no symptoms

if large (high pulmonary blood flow, CHF):tachypnoeadyspnoeaslow feeding failure to thrivesweating

VSD’s

♥ Exam (smaller VSD):pinknormal pulsesnormal S1 and S2± systolic thrillharsh pansystolic murmur LLSE

♥ ECG: normal (smaller VSD)or LVH ± RVH (larger VSD)

VSD’s♥ Larger defect:

MDM @ apex (mitral flow murmur)

narrowly split S2 and loud P2

± S3

CXR: cardiomegaly increased pulmonary vascularity

VSD’s

♥ Treatment options:

Nil (spontaneous closure)

Surgical closure

Device closure

ASD’s

♥ Three types: secundumprimumsinus venosus

♥ Commonest: secundum

♥ Primum: a form of atrioventricular septal (canal) defect

Secundum ASD

♥ Usually no symptoms in childhood

♥ Exam: pinknormal pulseswide ± ‘fixed’ split S2soft ESM @ ULSE

♥ ECG: incomplete RBBB (95%)

♥ CXR: often normal sometimes pulmonary plethora

Secundum ASD

♥ Haemodynamic significance of ASD is assessed to decide if closure appropriate

♥ Usually closed age 3-5 years (earlier if symptomatic) or when diagnosed if later

♥ Two options for closure:surgery - suture or patchinterventional catheter - device

Amplatzer ASD Occluder

PDA

♥ CHF symptoms if large ductus in very young infant, otherwise often asymptomatic

♥ Exam: pinkfull volume pulsesharsh systolic (1st few weeks) or continuous ‘machinery’ murmur loudest under left clavicle

♥ ECG: normal (small PDA)LVH ± RVH (large PDA)

PDA

♥ CXR: ± cardiomegaly, pulm plethora

♥ Options for closure:surgery - ligationinterventional catheter - coil(s) or

device

Pulmonary Stenosis

♥ Usually asymptomatic

♥ Exam: pinknormal pulses± systolic ejection clickESM loudest @ ULSE if severe, S2 widely split (not

fixed)

Pulmonary Stenosis

♥ ECG:RAD, RVH

♥ CXR: normal ± prominent MPA (post-stenotic dilatation)

♥ Treatment of valvar PS (moderate/severe):balloon valvuloplasty preferreduncommonly surgical

valvotomy

Aortic Stenosis♥ Often asymptomatic;

otherwise SOB, syncope or chest pain on exertion

♥ Exam: pinksmall volume pulse, small pulse pressure± LV lift± systolic thrill (suprasternal, URSE)± systolic ejection clickharsh ESM loudest @ URSE & radiating to carotidsif severe, narrow split S2 (even reversed)

Aortic Stenosis

♥ ECG:normal (mild AS)LVH ± strain (more severe AS)

♥ CXR: often normal± dilated ascending aorta

♥ Treatment of valvar AS (moderate/severe):balloon valvuloplastysurgical valvotomy

Coarctation of the Aorta

♥ CHF in neonate if severe CoA;often asymptomatic in older child

♥ Exam: pinkreduced or absent femoral pulsessoft systolic murmur mid LSE and/or mid left back

♥ ECG:RVH in 1st few months of life,LVH if older

Coarctation of the Aorta

♥ CXR: cardiomegalyevidence of CHFrib notching (older child)

♥ Treatment:surgery for ‘native’ CoAballoon angioplasty for re-

CoA