16) Congenital heart diseases -ASD, VSD Flashcards
what are the clinical features of atrial septal defect ?
asymptomatic up to 30 years
frequent respiratory infections in children
failure to thrive
complaints associates with pulmonary hypertension
right heart failure
what are the physical findings in those individuals with atrial septal defect ?
Widely fixed split OF s2 second heart sound (S2) over the second left ICS,- pulmonary zone
systolic ejection murmur in pulmonary auscultary zone (2 intercostal space left parasternal ) - some pulmonary valve stenosis
Low-pitched mid diastolic murmur in tricuspid auscultatory zone - due to increased flow though the tricuspid valve
Right-ventricular S3 gallop
what are the diagnostic findings in atrial septal defect ?
ECHO - dilated right atria and ventricle
paradoxiacl septal movemnet in hemodynamically significant
doppler view
or we can use contrast echo - to see the contrast bubles being shunted left to right
Trasn esophageal echo - we can see a direct visualisation
ecg - in ostium secindum - we see right axis deviation
with incomlete or complete rbbb
in ostium primum - we see left axis deviation
with complete or incomlete RBBB
chest x ray - we see dilated pulmonary arteries
cardiomegaly
what is eisenmenger syndrome ?
long-standing left-to-right cardiac shunt caused by a congenital heart defect (typically by a ventricular septal defect, atrial septal defect, or less commonly, patent ductus arteriosus)
causes pulmonary hypertension
and eventual reversal of the shunt into a cyanotic right-to-left shunt.
INVASIVE ASSESSMENT OF THE INTERATRIAL SEPTAL DEFECT
cardiac catheterisation :
oxohemometry
jump in SaО2 > 7 % in LA
SaО2 in RV and PA > 80 %
Manometry -ELEVATED pressures in
PA,-92mmhg
RV,-92mmhg
RA - 90 mmhg
Quantitative assessment:
• PBF : SBF < 1.5 (in low
pressures) hemodynamically insignificant LR shunting
• PBF : SBF > 1.5 hemodynamically significant LR shunting
• PBF : SBF > 2.0 absolute indication for correction
PBF more than SBF =it means pulmonary hypervolemia
what is SBF ?
О2 consumption /
О2 (Ао) – О2 (mixed venous blood)
what is bpf ?
О2 consumption
О2 (pulmonary vein) – О2 (pulmonary artery)
what are associated with atrial septal defect secundum ?
5-10% in combination with pulmonary stenosis
- 10% combination of anomalous inflow of pulmonary veins (mainly in sinus venosus type)
- 2-8% in combination with mitral stenosis (Lutembacher’s syndrome)
what are the treatment method for atrial septal defect ?
in children - spontaneous closure
Hemodynamically insignificant defect – Conservative, symptomatic
Hemodynamically significant defect
Interventional methods
Use of CardioSEAL, Amplatzer (including closure of patent foramen ovale, a common sourse of paradoxical embolism which is the cause of strokes in young people).
– Surgical closure
Eisenmenger’s syndrome – heart lung transplant
what are the complication of all types of atrial septal defects ?
Paradoxical embolism
venous thromboembolus passes through a shunt from the inferior vena cava entering into the arterial circulation
and stroke and infraction
what are the causes for all types of atrial septal defect ?
Down syndrome
Fetal alcohol syndrome
what are the associations with ASD1 (PRIMUM TYPE)
Equally prevalent in men and women
in secundum it’s majorly more women
usually isolated from other heart defects
Relatively earlier development of pulmonary hypertension and cardiomegaly
Mitral regurgitation often present
Often supraventricular arrhythmias
Often AV-block
what is the evolution of atrial septal defect
volume overload and dilation of the right atrium and ventricle
tricuspid an pulmonary annuli may dilate and becomeincompettent
pulmonary arteries dilate - so does pulmonary vein
flow related pulmonary artery hypertension
medial hypertrophy of pulmonary arteries and muscularisation of arterioles - pulmonary vascular obstructive disease
reversion shunt- Eisenmenger syndrome
what are other ASD?
COMMON (SINGLE) ATRIUM
• Complete lack of interatrial septum
• Clinical features similar to those in large interatrial septum defect
COMMON AV-CANAL • Distally positioned ASD1 -partial • Proximally situated VSD - complete • Fissure of anterior mitral leaflet • Fissure of septal tricuspid leaflet
symptoms of COMMON AV-CANAL
Large L-to-R shunt at atrial and ventricular level
pulmonary hypertension
Symptoms include difficulty breathing (dyspnoea) and bluish discoloration on skin and lips (cyanosis). A newborn baby will show signs of heart failure such as edema, fatigue, wheezing, sweating and irregular heartbeat.
diagnosis of COMMON AV-CANAL
ЕCG
– biatrial hypertrophy
right atrium enlargmnet - p pulmonate
lead 2 - with amplitude of 2,5mm, and v1 - 1.5mm
p - mitrale
lead 2 - we see notched p wave - 40ms between each peak
and the whole p wave duration is more than 120ms
in v1 terminal portion of biphasic P wave = 1mm deep and 40ms wide
- biventrcular hypertrophy
katz watchel phenomena
Large biphasic QRS complexes (tall R waves + deep S waves) in V2-5
– Left axis deviation
– Various degrees of AV-block
• Echo in different modalities – direct
visualization of the defect
• Cardiac catheterization – definitive lesions evaluation and assessing the hemodynamic changes
what are the physical findings of ventricular septal defect ?
palpation
widened and uplifting apical heart beat
thrill at the fourth left intercostal space
palpable p2
auscultation holosystolic murmurs - heard best in 3rd and 4 th intercostal space radial propagation and starts immediately after S1 band shaped crosses A2
mid diastolic murmur over cardiac apex (mitral auscutatroy zone - 5th intercostal space mid clavicular ) - increase flow through the mitral valve
pathologicaly split S2
pathological left ventricular S3 -increased atrial pressure leading to increased flow rates, as seen in congestive heart failure, which is the most common cause of a S3
WHAT ARE THE SIGNS FOR HEMODYNAMICALLY Significant VSD ?
pulmonary arterial hypertension
ECG - RA and RV hypertrophy
or ECG - volume overloadd LV hypertrophy
in cardiac catheterisation one of the diagnostic invasive assessment tools for intraventricular septal defect what do we find ?
elevated pressure in the RV - 88
PA - 87
LA - 93
jump in sa02 by more than 5 percent in rv
SaO2 - in RV and PA more than 80 percent
PBF over SBF = pulmonary hypervolemia
what are the diagnostic modalities for ventricular septal defect ?
echo
pulse doppler
ecg
medium and large size effects
LV hypertrophy : increase in amplitude of qrs , left axis deviation and left atrial enlargnet sign - p mitral
signs of rv hypertrophy - vright axis deviation , p pulmonate , PR prolongation , complete or incomplete right bundle branch block
chest x ray enhanced pulmonary vasculature
left atrial and ventricular enlargements
later stages - enlarged right ventricle and pulmonary artery
what are the clinical features of VSD ?
small asymptomatic
medium to large
heart failure in 2-3 months
what are the causes of VSD
down syndrome , edward , pat au
TORCH
maternal risk fctors- diabetes and smoking
what is the treatment of VSD
symptomatic and large defects
surgical repair
in children less than 1 yr indicating pulmonary hypertension
in older children
Special modifications of dual- sided occluders – CardioSEAL, STARFlex and Amplatzer (often not suitable for the more frequent perimembranous VSD)
if eisenmenger syndrome has occurred - heart lung transplant or lung heart transplant
what are the complications of VSD ?
arrhythmia
heart failure
eisenmenger syndrome
what are the causes for patent ductus arteriosus ?
prematurity
rubella infections during first trim
alcohol consumption whilst pregnant
Down sydruome
what is the patent ductus arteries do hemodynamically ?
persistent communication between the aorta to the pulmonary artery
effectively making a left to right shunt - this causes volume overload on pulmonary vessels - strain on right ventricle - leading to heart failure
what are the clinical features with patent ductus arteriosus ?
small
large - failure to thrive
heart failure symptoms
what are the physical findings for patent ductus arteriosus ?
palpation
laterally displaced apical pulse
BOUNDING PERIPHERAL PULSE - wide pulse pressure
AUSCULTATION
machien like murmur of systolic and diastolic period
onset is after s1 and passes over s2 and end before the next S1
heard best at the 2-3 left intercostal space parasternally
propagation towards left subclavian space , left axilla and left paravertebrla space
ECHO
ANGIOGRAPHY
in right catheterisation -passes through pulmonary artery to aorta - typical shape of TREBLE CLEF
direct visualisation if injected with contrast dye
invasive assessment through cardiac catheterisation :
slightly increase pa pressure
leap in sa02 of more than 5 percent in PA
sao2 in pa more than 80 percent
bff is more than SBF
chest x ray
prominent pulmonary artery
what are the complications of PDA?
frequent lung infections
infective endocarditis
left and right ventricle failure
what is the treatment for PDA?
= pharmacological closure in premature infants with infusion of indomethacin and ibuprofen
small ductus
diameter less than 2.5mm
occlusion with special wire coil through a catheter - gianturco coils
large ducts
diameter more tha 2.5mm
amplatzer or cardioseal system
