Structures of the heart

Normal Heart

Atrial Septal defect ( ASD )

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

ASD

Atrial Septal Defect

Atrial Septal Defect

Diagram of ASD

Atrial septal defect

Lungs
PA

LA

LV

AO Systemic RV RA

Qp > Qs

Atrial septal Defect

RA RA LA RV

LA

RV

LV

LV

Atrial septal Defect

Clinical findings Asymptomatic Auscultation : Normal 1st HS or loud Widely split and fixed 2nd HS Ejection systolic murmur

Atrial Septal Defect

Auscultation :1st HS N or loud widely split and fixed 2nd HS Ejection Sistolic Murmur

Atrial Septal Defect

ECG : IRBB , right ventricular hypertrophy

Atrial Septal Defect Chest X-Ray

Right atrial enlargement Prominence the MPA segment Increased pulmonary vascular marking

Atrial Septal Defect

Diagnosis Differential Primary Atrial Septal Defect ECG : LAD Partial Anomalous Pulmonary Vein Drainage Pulmonary Stenosis Innocent Murmur

Atrial Septal defect

Management Surgery : Preschool age Recent treatment: transcatheter closure using ASO (Amplatzer septal occluder)

ASD

Small Shunt
Infants Observation Evaluation At age 5-8 yrs Cath Heart Failure (-)

Large Shunt Children/Adults

PH (-) Heart Failure (+) PVD (-) Anti failure

Fail

PH (+)
PVD (+) Hyperoxia

Success

FR<1.5

FR>1.5

Age >1yrs W >10kg

Surgical Closure

Reactive

Non reactive

Conservative

Transcatheter closure (Secundum ASD) / Surgical Closure(others)

Conservative

Atrial septal defect

Ventricular septal defect

Insidence 20 % of all CHD No sex influenced Anatomy Subarterial defect : below pulmonary and aortic valve Perimembranous defect: below aortic valve at pars membranous septum Muscular defect

VSD

Ventricular Septal Defect

Ventricular Septal defect

Lungs
PA

LA

LV

AO

RV

RA

Systemic

Qp > Qs

Ventricular septal defect

RA

LA

RA

LA

RV

LV

RV

LV

Ventricular Septal Defect

Ventricular Septal Defect

Clinical findings Day 1st after birth: murmur (-) After 2-6 weeks : murmur (+) Murmur : pansystolic grade 3/6 or higher at LSB 3 Small muscular defect: early systolic murmur Significant defect: Mid diastolic murmur at apex

Ventricular Septal Defect

Murmur: pansystolic grade 3/6 or higher at LSB 3

Small VSD

Large VSD

Ventricular Septal Defect

Cardiomegaly Apex down ward Prominence pulmonary artery segment Increased pulmonary vascular marking

Ventricular septal Defect

Diagnosis Differential PDA with PH Tetralogy Fallot non cyanotic Inoscent murmur

Ventricular septal defect

Management:
Definitive : VSD closure Surgery Transcatheter closure

DSV

Heart failure (+)

Anti failure

Heart failure (-)

Aortic valve prolaps

Fail Success PAB Evaluate in 6 mths

Infundibular stenosis

PH Spontaneous closure PVD(+)

Smaller

PVD(-) Cath

Cath

Cath
Reactive

FR<1.5 FR>1.5

Nonreactive Conservative

Surgical closure/Transcatheter closure

Patent Ductus Arteriosus

Insidence
+ 10% Female : Male = 1.2 to 1.5 : 1 Premature and LBW higher

Anatomy
Fetus: ductus arteriosus connects PA and aorta. If ductus does not closs Patent Ductus arteriosus

PDA

Patent Ductus Arteriosus

Lungs PA

LA

LV

AO Systemic RV RA

Qp > Qs

Patent Ductus Arteriosus

RA

LA

RA

LA

RV

RV LV

LV

Patent Ductus Arteriosus

Clinical findings
Small defect: Symptom (-) Growth and development normal Significant defect: Decreased exercise tolerant Weigh gained not good Frequent URTI Specific case: pulsus seler at 4th extremities

Patent Ductus Arteriosus

Diagnosis
Pulsus seler and continuous murmur heard

Patent Ductus Arteriosus

Chest X- Ray
Similar to VSD

Patent Ductus Arteriosus

Auscultation : continuosus murmur at upper LSB 2

Patent Ductus Arteriosus

Diagnosis Differential AP-window Arterio-venous fistulae

Management premature: indometasin PDA closure : surgery transcatheter closure

PDA Neonates/Infants Heart failure (+) Premature Anti failure Indometacin Success Heart failure (-) Full term Anti failure Fail Success Children/Adults PH (-) LR PH (+) RL

Hyperoxia
Non reactive

Fail

Reactive
Age >12wks W >4kg

Spontaneous closure

Surgical ligation

Transcatheter closure

Conservative

Patent Ductus Arteriosus

Patent Ductus Arteriosus

Pulmonary Stenosis
Incidence : 8-10%
Anatomy: Pulmonary stenosis valvular : Bicuspid pulmonary valve Valve leaflet thickening and adhession Pulmonary stenosis infundibular : Hyperthropy infundibulum

Pulmonary Stenosis

Clinical findings Valvular stenosis

Mild : Ejection systolic Wide 2nd HS ejectiin click Moderate: ejection systolic, early systolic click Severe : ejecstion systolic, ejection click (-) Stenosis infundibular Ejection click ( - ) 1st HS normal, 2nd HS weak, ejection systolic Pulmonary stenosis periphery 1st & 2nd HS normal, ejection systolic

Pulmonary Stenosis

Mild

: ejection systolic 2nd HS wide split ejection click Moderate: ejecsi systolic , early ejection click Severe : ejection systolic, click ejection (-)

Poulmonary Stenosis

Diagnosis Asymptomatic patient:

click systolic (stenosis valvular) systolic murmur wide split 2nd HS vary with respiration

Poulmonary Stenosis

Normal or mild cardiomegaly Marked pulmonary valve post stenotic dilatation Normal pulmonary vascularity

Pulmonary Stenosis

ECG : RAD Echocardiograhhy : confirmation diagnosis Catheterization: increased RV pressure without increased oxygen saturation

Pulmonary Stenosis

Management
Medicamentosa : useless Mild stenosis: intervention (-) Moderate stenosis: observation Severe stenosis: balloon valvuloplasty

Pulmonary Stenosis

Tetralogy Fallot
Insidence 5-8% from all CHD Anatomy Cause: Left-anterior deviation of infundibular septum Sindroma consist of 4 items: VSD pulmonary stenosis aortic over-riding RVH

Tetralogy Fallot

Tetralogy Fallot

Hemodynamic acyanotic

Hemodynamic cyanotic

Tetralogy Fallot

Diagnosis Clinically : cyanosis Single 2nd HS, ejection systolic murmur

Tetralogy Fallot

Single 2nd HS, ejection systolic murmur

Tetralogi Fallot

Tetralogy Fallot

CXR : Boot-shaped Concave pulmonary segment Apex upturned Decreased pulmonary blood flow

Tetralogy Fallot

ECG : RAD Echocardiography : to confirm diagnosis

Tetralogy Fallot

Diagnosis 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

 clinically ECG

Tetralogy of Fallot

CXR echo

< 1 yr
spell (+) propranolol
age 1 yr

> 1 yr
spell (-) cath

failed BTS

succeed

evaluation

cath

BTS/ PDA Stent

small PA

good sized PA

total correction

Tetralogy Fallot

Tetralogy Fallot