Structures of the heart

Normal Heart

Atrial Septal defect( ASD )Insidence : + 10 % : ratio = 1,5 to 2 : 1Anatomy : Defect on foramen ovale : Secundum ASD Defect at SVC and RA junction: sinus venosus ASD Defect at ostium primum : primum ASD

ANATOMY

ASD

Atrial Septal DefectDiagram of ASD

Clinical FeaturesSymptomsMost infants : asymptomatic ..undetectedThe first present at age 6 to 8 weeks with a soft murmur and possibly a fixed and somewhat widely split S2Infant with large ASD may present with poor growth, recurrent lower respiratory tract infection and heart failure

LALVRVRAPAAOSystemicLungsQp > QsAtrial septal defect

RARVLALVRARVLALVAtrial septal Defect

Atrial Septal DefectAuscultation :1st HS N or loudwidely split and fixed 2nd HS Ejection Sistolic Murmur

Atrial Septal DefectDiagnosis Differential

Primary Atrial Septal DefectECG : LADPartial Anomalous Pulmonary Vein DrainagePulmonary StenosisInnocent Murmur

Atrial Septal defect

ManagementSurgery : Preschool ageRecent treatment: transcatheter closure using ASO (Amplatzer septal occluder)

ASDSmall ShuntLarge ShuntObservationEvaluationAt age 5-8 yrsCathFR1.5ConservativeInfantsChildren/AdultsHeart Failure (-)Heart Failure (+)Age >1yrsW >10kgTranscatheter closure (Secundum ASD) /Surgical Closure(other tipe of ASD)ConservativeAnti failureFailSuccessPH (-)PH (+)PVD (-)PVD (+)HyperoxiaReac-tiveNonreactiveSurgicalClosure

Transchateter closure of ASD

Atrial septal defect

Ventricular septal defectInsidence 20 % of all CHD No sex influencedAnatomy Subarterial defect : below pulmonary andaortic valve Perimembranous defect: below aortic valve at pars membranous septum Muscular defect

VSD

SystemicLungsQp > QsVentricular Septal defect

LA

LV

RV

RA

PA

AO

RARVRALALARVLVLVVentricular septal defect

Ventricular Septal DefectClinical findingsDay 1st after birth: murmur (-)After 2-6 weeks : murmur (+)Murmur : pansystolic grade 3/6 or higher at LSB 3 Small muscular defect: early systolic murmurSignificant defect: Mid diastolic murmur at apex

Small VSD Large VSD Ventricular Septal DefectMurmur: pansystolic grade 3/6 or higher at LSB 3

Ventricular Septal DefectCardiomegalyApex down wardProminence pulmonary artery segmentIncreased pulmonary vascular marking

Ventricular septal DefectDiagnosis Differential

PDA with PHTetralogy Fallot non cyanoticInoscent murmur

Ventricular septal defectManagement:

Definitive : VSD closure Surgery Transcatheter closure

DSVHeart failure (+)Heart failure (-)Anti failureFailSuccessPABEvaluate in 6 mthsSurgical closure/Transcatheter closureAortic valve prolapsInfundibular stenosisPHSmallerSpontaneousclosureCathPVD(-)PVD(+)CathCathReactiveNon-reactiveConservativeFR>1.5FR

Patent Ductus Arteriosus Anatomy

Fetus: ductus arteriosus connects PA and aorta

If ductus does not closs Patent Ductus arteriosus

PDA

RARVLALVRALARVLVPatent Ductus Arteriosus

LALVRVRAPAAOSystemicLungsQp > QsPatent Ductus Arteriosus

PDA is more common in : Premature infants BW < 1750 g : 45% BW < 1200 g : 80% Genetic abnormalities Infants whose mother had German measles (Rubella)PDA in preterm haemodynamic instability co-morbidity & mortality EARLY DIAGNOSIS

Patent Ductus ArteriosusClinical findings

Small defect: Symptom (-) Growth and development normalModerate and large defect:Decreased exercise tolerantWeigh gained not goodFrequent URTI

DIAGNOSIS

Patent Ductus ArteriosusAuscultation : continuosus murmur at upper LSB 2

Chest X-RayLarge PDA:Prominence of the left atrium,left ventricle, ascending aorta,Pulmonary vascular marking

ECGSmall PDA : normalModerate PDA : LVHLarge PDA : BVHPDA with PVOD : RVH

Patent Ductus ArteriosusDiagnosis DifferentialAP-windowArterio-venous fistulae

Management premature: ibuprofenPDA closure : surgery transcatheter closure

MANAGEMENT

Medical treatment : prostaglandin synthesis inhibitorPreterm neonates : usefullAterm neonates : useless

Transcatheter closure : mostly choice treatment

Surgical closure :Infant < 5 kg with large PDAPreterm neonates : medical treatment unsuccessful or contraindicated

PDA IN PRETERM NEONATESSpecial problem : haemodynamic instability

Treatment should be started as soon as PDA suspected Once a significant shunt is present increased pulmonary blood flow damage to premature lungs

PDA can be closed with prostaglandin synthesis inhibitors

TRANSCATHETER CLOSURE *Transcatheter occlusion is effective with a high rate of complete occlusion

*Complication rare

Tetralogy FallotIncidence5-8% from all CHD

AnatomyCause: Left-anterior deviation of infundibular septum

Sindroma consist of 4 items: VSD pulmonary stenosis aortic over-riding RVH

Tetralogy Fallot

Central cyanosis

Central cyanosis

PathophysiologyCyanosis is a bluish discoloration of the skin and mucous membranes resulting from an increased concentration of reduced hemoglobinClinical cyanosis occurs when the amount of reduced hemoglobin in the cutaneous vein may result 5 g/100mlThe critical level of reduced hemoglobin in the cutaneous vein may result from either desaturation of arterial blood or increased extraction of oxygen by peripheral tissue

Cardiac causes of cyanosisInadequate pulmonary blood flow (severe cyanosis)Tricuspid atresiaPulmonary atresiaTetralogy of Fallot

Independent pulmonary and systemic circulation (severe cyanosis)Tranpose great artery

Mixing (moderate cyanosis)Truncus arteriosus

Diagnosis

Clinically : cyanosis Single 2nd HS, ejection systolic murmur

X Ray : Boot ShapedECG: RAD, RVH

Tetralogy FallotSingle 2nd HS, ejection systolic murmur

CXR : Boot-shapedConcave pulmonary segmentApex upturnedDecreased pulmonary blood flow

Tetralogy FallotECG : RAD, RVHEchocardiography : to confirm diagnosis

Tetralogy FallotDiagnosis Differential Pulmonary Atresia Double outlet right ventricle and pulmonary stenosis Transposisi of great arteri and pulmonary stenosis

Management Paliative treatment: Blalock-Taussig shunt Definitive: total correction

Tetralogy of Fallot< 1 yr> 1 yrspell (+)spell (-)propranololfailedsucceedBTStotal correction cathsmall PAgood sized PA clinically ECG CXR echoage 1 yrcathBTS/PDA Stentevaluation