Congenital Heart

Disorder
ASD, VSD, PDA
Presented by:
SACHIN
DWIVEDI
M.Sc.(N) MSN
KGMU, College Of
Nursing
Congenital heart disease
• CHD is the structural malformations of the
heart or great vessels, present at birth. It is
the most common congenital
malformations.
Classification of CHD
1. Acyanotic CHD- There is increased pulmonary blood flow
due to left to right shunt. It includes:
• Ventricular septal defect
• Atrial septal defect
• Patent ductus arteriosus
• Atrio-ventricular canal
2. Cyanotic CHD- there is diminished pulmonary blood flow
due to right to left shunt. It includes:
• Tetralogy of fallot
• Tricuspid atresia
• Transposition of great arteries
• Truncus arteriosus
• Hypoplastic left heart syndrome
• Total anomalous pulmonary venous return
• Eisenmenger syndrome or complex
Classification …contd
3. Obstructive lesions
• Coarctation of aorta
• Aortic valve stenosis
• Pulmonary valve stenosis
• Congenital mitral stenosis
Fetal circulation
Fetal circulation
ASD ( atrial septal defect)

Introduction
• The most common heart diseases in
children are congenital heart disease.
Atrial septal defect (ASD) is the most
common congenital heart lesion in
adults and most frequently occurs in
women.
Definition
• It is the abnormal opening between
the atria, allowing blood from the
higher pressure left atrium to flow
into the lower pressure right atrium
Types of ASD
• Ostium Primum (ASD1) Opening at
the lower end of septum; may be
associated with mitral valve
abnormalities.
• Ostium Secundum (ASD 2) Opening
near centre of septum
• Sinus venosus defect- Opening near
junction of superior vena cava and
right atrium; may be associated with
partial anomalous pulmonary venous
connection
Causes
• Down syndrome – Patients with Down Syndrome
have higher rates of ASDs. As many as one half of
Down Syndrome patients have some type of septal
defect. (Trisomy 21)
• Ebstein's anomaly- About 50% of individuals with
Ebstein anomaly have an associated shunt between
the right and left atria, either an atrial septal defect.
(Apical Displacement)
• Fetal alcohol syndrome – about one in four patients
with fetal alcohol syndrome has either an ASD or
a VSD.
• Holt–Oram syndrome – Both the osteium secundum
and osteum primum types of ASD are associated with
Holt–Oram syndrome (TBX5 Gene)
• Lutembacher's syndrome – the presence of a
congenital ASD along with acquired mitral stenosis.
 Pathophysiology
Due to defect in the Atrial Septum

Oxygenated blood flows from higher pressure left atrium to

lower pressure Right atrium

Volume overload in right atrium and ventricles

Dilation of right atrium and ventricles

Increased pulmonary artery pressure

Eventually cardiac failure( if Left unrepaired for long)

 Clinical Manifestations
• Asymptomatic
• May develop congestive heart failure
• In ostium secundum ASD soft systolic flow
murmur heard best at the left upper sternal
border.
• In Ostium Primum ASD, systolic murmur
heard best at the lower left sternal border
because of mitral regurgitation.
• Patient are at risk for Atrial dysrhythmias and
pulmonary vascular obstructive disease and
emboli formation later in life from chronically
increased pulmonary blood flow
..contd
• Chest infections

• Dyspnea on exertion

• Easy fatigability

• Bulging of the chest

• Poor weight gain

Diagnosis :

• Physical examination:
• Echocardiography: Visualization of
adjacent structure.
• Transcranial doppler (TCD) bubble study
• Electrocardiogram: P-R interval is normal,
Incomplete right bundle branch block, right
ventricular hypertrophy.

• Chest X ray: Increased Heart size,

pulmonary vascularity is increased.
Management
• Medical management : It should include
prompt treatment of respiratory-tract
infections;
• Anti-arrhythmic medications for atrial
fibrillation or supraventricular tachycardia;
and the usual measures for hypertension,
coronary disease, or heart failure if these
complications occur.
• The risk of infective endocarditis is quite
low unless the defect is complicated by
valvular regurgitation or has recently been
repaired with a patch or device
Surgical Treatment
• Operative repair, ideally in children between
3 to 6 years of age, should be advised for all
patients with uncomplicated ASD in whom
there is significant left –to- right shunting.
• Excellent results may be anticipated, at low
risk, even in patients >40 years, in the
absence of severe pulmonary hypertension.
• In ostium primum ASD, cleft mitral valves
may require repair in addition to patch
closure of the ASD. Closure should not be
carried out in patients with small defects
Contd…
• Surgical patch closure is done for
moderate to large defects.
• Open repair with cardiopulmonary bypass
is usually performed before school age
Complications
• Eisenmenger's syndrome
• If a net flow of blood exists from the left atrium to the
right atrium, called a left-to-right shunt, then there is
an increase in the blood flow through the lungs.
• Initially, this increased blood flow is asymptomatic,
but if it persists, the pulmonary blood vessels may
stiffen, causing pulmonary hypertension.
• The pulmonary hypertension increases the pressures
in the right side of the heart, leading to the reversal of
the shunt into a right-to-left shunt.
• Once the reversal of the shunt occurs, and the blood
begins flowing in the opposite direction through the
ASD, that is called Eisenmenger's syndrome. The
syndrome is a rare and late complication of an ASD.
Compications contd..
• Paradoxical embolus
• Venous thrombus  are quite common.
Embolization's (dislodgement of thrombi)
normally go to the lung and
cause pulmonary emboli. In an individual
with ASD, these emboli can potentially
enter the arterial system.
• This is known as a paradoxical embolus
because the clot material paradoxically
enters the arterial system instead of going
to the lungs
Prognosis
• - Operative mortality is very low(<1%)
Ventricular Septal Defect (VSD
Introduction
• This is the most common congenital
cardiac lesion identified at birth accounting
for one quarter of all CHD.
Definition
VSD consists of an abnormal
communication between the right and left
ventricles
Epidemiology

• VSDs are the most common congenital

cardiac abnormalities. They are found in
30-60% of all newborns with a congenital
heart defect, or about 2-6 per 1000 births.
 Types
• There are four basic types of VSD:
1. MuscularVSD.-
The most common type of VSD,it is an opening in the
muscular portion of the lower section of theventricular
septum.A large number of these close spontaneously
and do not require surgery.
2. Perimembranous VSD.-
This opening is in an area of the upper section of the
ventricular septum called the membranous septum,
located near the valves. This type of VSD is the one
that is most commonly treated  by surgery because 
most do not close on their own.
Types …..contd..
3. Trioventricular canal type VSD-
This VSD is associated with 
atrioventricular canal defect. The VSD is 
located underneath the tricuspid and
mitral valves.
4. Conal septal VSD-
The rarest of VSDs, it occurs in the 
ventricular septum just below the 
pulmonary valve.

 
Types…. Contd
Causes
• Congenital VSDs are frequently
associated with other congenital
conditions, such as down syndrome.
• A VSD can also form a few days after
myocardial infarction due to mechanical
tearing of the septal wall.
• Heredity.
 Pathophysiology:

Due to etiological factor such as down syndrome

Shunting of blood from Higher pressure left ventricles to lower pressure,

flow of blood to pulmonary artery.

Increased amount of blood pumped to the lungs.

Increased pulmonary vascular resistance.

Increase pressure in the right side cause hypertrophy.

Clinical Features :

• Patients with VSD can become

symptomatic
• Premature babies with a VSD can become
symptomatic even earlier
• Palpitation, dyspnea on exertion and
frequent chest infection are the main
symptoms in older children.
• History of cyanosis and a decreased level
of activity.
• CHF is common
Clinical manifestations …contd..
• Loud pansystolic murmur heard best at left
sternal border
• The heart size is moderately enlarged
• Diastolic murmur
• Patients of VSD who have either pulmonic
stenosis or pulmonary arterial
hypertension may show right as well as left
ventricular hypertrophy
Diagnosis
• 1. Chest X­ray-
With a VSD, the heart may be enlarged due to the 
right ventricle handling larger amounts of blood flow
than normal. Also, there may be changes that take place
in the lungs due to extra blood flow.
• 2.Electrocardiogram (ECG or EKG)-It reveals
biventricular hypertrophy. In this
abnormal rhythms (arrhythmias or dysrhythmias)
are detected and heart muscle stress.
• 3.Echocardiogram (or “echo”) - An echo can show the
pattern of blood flow through the septal
opening, and determine how large the opening is, 
as well as much blood is passing through it. It helps in
identifying the size, number, site of defect and
associated problems.
Diagnosis
• 4.Cardiac catheterization -
Treatment

• Medications. Some children have no symptoms and
 require no medication. 
• Digoxin. -
A medication that helps strengthen the heart muscle, 
enabling it to pump more efficiently.
• Diuretics. -
The body's water balance can be affected when the heart
 is not functioning well. These medications help the 
kidneys remove excess fluid from the body.
• ACE inhibitors. -
Medications that lower the blood pressure in the body, 
Non-Pharmacological MM
• Adequate nutrition. -
Infants with a larger VSD may become tired when feeding, and a
re not able to eat enough to gain weight. Options that
ensure a baby has adequate nutrition include:
• High­calorie formula or breast milk-
Special nutritional supplements may be added to formula 
 breast milk that increase the number of calories per ounce, thus
allowing a baby to drink
less and still consume enough calories to grow properly.
• Supplemental tube feedings
-Feedings given through a small, flexible tube that passes 
through the nose, down the esophagus, and into the stomach,
can either supplement or replace bottle feedings.
• Infection control. It is important for parents to inform all
medicalpersonnel that their child has a VSD so it can be determi
ned if antibiotics are necessary before a procedure.
 
Indication of surgical
intervention:
• Some cases may necessitate surgical
intervention, i.e. with the following
indications:
• 1. Failure of congestive heart failure to
respond to medications
• 2. VSD with pulmonary stenosis
• 3. Large VSD with Pulmonary
hypertension
• 4. VSD with aortic regurgitation
Surgical management :
• Depending on the size of the heart defect and a 
physician's recommendations, the ventricular
septal defect will be closed with stitches or a
special patch.
• Interventional cardiac catheterization-
A child's VSD may be repaired by a cardiac cathete
rization procedure. One technique uses a device
called a septaloccluder. During this procedure, the
child is sedated and a small, thin flexible tube is
inserted into a blood vessel in the groin and guided
into the heart.
Once the catheter is in the heart, the cardiologist 
passes the septal occluder into the VSD. The septal o
ccludercloses the ventricular septal defect, 
providing a permanent seal.
Preoperative Assessment

• History and physical examination:

• Preoperative studies:
• Vital Signs :
• Height and weight measurement
Preoperative teaching
• Teaching of parents and child is done throughout the
preoperative period.
• Too much detail given at a time can lead to confusion
• Any anxiety producing information is given when the
nurse believes that it can be best handled.
• The nurse continually evaluates the response to
teaching to determine whether further clarification is
necessary.
• Depending upon the child’s level of understanding ,
the equipment that will be used can be explained .
• Equipments that the child may not have seen before
such as dressings , cardiac leads , intravenous lines,
endotracheal tube, suction etc is described in greater
detail.
Preoperative Nursing diagnosis
• Anxiety related to surgical procedure as evidenced
by restlessness, expression of feelings of threat.
• Expected outcome: To decrease the level of anxiety
Intervention :
• use a calm , reassuring approach to increase
confidence in caregiver and relive anxiety.
• Explain all procedure, including sensations to be
experienced during a procedure, to promote sense of
security
• Help patient identify situations that precipitate anxiety to
plan appropriate use of anxiety reducing techniques.
• Create a atmosphere to facilitate trust to promote sense
of security
Contd..
• Risk for impaired gas exchange related
to fluid overload from left ventricular
dysfunction
• GOAL: Absence of respiratory distress
• Nursing Interventions
• Initially, every 4 hours, and with chest
discomfort or symptoms, assess,
document, and report to the physician
abnormal heart sounds , decreased
oxygenation, and activity intolerance.
• Strict Intake output monitoring
Contd..
• Risk for ineffective peripheral tissue perfusion related
to decreased cardiac output
• GOAL: Maintenance/attainment of adequate tissue
perfusion
• Nursing Interventions
• 1. Initially, every 4 hours, and with chest discomfort,
assess, document, and report to the physician the
following:
• a. Hypotension
• b. Tachycardia and other dysrhythmia
• c. Activity intolerance
• d. Mental changes
• e. Reduced urine output (less than 30 mL/h)
• f. Cool, moist, cyanotic extremities, decreased peripheral
pulses, prolonged capillary refill
Contd..
• Risk for decreased Cardiac Output related to disease
condition.
• Expected outcome: to improve the decreased cardiac output.
• Interventions:
• Monitor and document trends in heart rate and BP, especially
noting hypertension. Be aware of specific systolic and diastolic
limits defined for client.
• Observe client response to dysrhythmias, such as drop in BP,
chest pain, and dyspnea.
• Observe for changes in usual mental status, orientation, and
body movement or reflexes, such as onset of confusion,
disorientation.

• Measure and document intake and output (I&O) and calculate fluid
balance.
• Schedule uninterrupted rest and sleep periods
 
Postopertive Care
• The child is transferred to the intensive care
unit or the recovery room for 24-48 hours or
longer until the vital signs and all systems
of the body are stabilized..
• The goals of nursing management are to
assist in restoring optimal functioning of the
cardiopulmonary, gastrointestinal, renal,
and central nervous systems and to
maintain them at this level.
• Adequate rest is essential in order to
minimize the demands on the heart and to
promote healing of the operative area.
Contd…
• The nurse continues to evaluate the child’s cardiac
status or the effectiveness of cardiac output
through clinical observation and routine
measurements. Serial readings of B.P, Heart rate,
CVP, and arterial pressure from modules are
observed and recorded.
• Fluid intake by mouth is usually restricted during
the first 24 hours of the postoperative period to
prevent hypervolemia that could result in cardiac
failure. All the intake and output of fluids should be
measured accurately.
• The functioning of the CNS must be assessed
postoperatively because brain damage may have
occurred during open heart surgery
Postoperative nursing
diagnosis
Risk for bleeding related to surgical procedure
• Expected Outcome: To decrease the risk for
bleeding.
• Interventions:  Monitor the bleeding
• Measure the chest tube output per hour
• Assess the presence of a clot in the chest tube
• Assess the presence of lesions and ecchymoses
• Record the output of blood for diagnostic studies
• Monitor intake and output strictly
• Give fluids as much as 50% to 75% volume
maintenance during the first 24 hours
• Provide the necessary blood products
Contd..
• Fluid volume deficit related to surgical
procedure.
• Expected outcome: To improve the fluid
volume status.
• Interventions:
• Assess the hydration status of the patient.
• Monitor the intake output of the patient.
• Administer fluids as prescribed by the
doctor
Contd..
• Risk for infection related to less care to
surgical site
• Expected Outcome: To reduce the risk for
infection.
• Interventions:
• Check the WBC count of the patient.
• Advise the patient and parents to follow
aseptic techniques.
• Teach about the importance of hand hygiene.
• Reduce the visitors
• Give antibiotics as prescribed by the doctor
Postoperative Complications

• Cardiovascular Complications: Arrhythmias,

hypotension, hypovolemia, cardiac tamponade,
cardiac failure, formation of emboli,
hematological changes
• Respiratory complications : accumulation of
mucus in the respiratory tract , atlectasis ,
pneumonia and pnemothorax
• Central nervous system: decreased cerebral
blood flow, possibility of embolus
• Infections : nurse observes for the signs of
infection such as fever, local redness and
swelling of the skin, respiratory symptoms,
among others