acyanotic congenital heart disease - vsd - dr. gunasekaran
TRANSCRIPT
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
DISEASES OF THE CARDIOVASCULAR SYSTEM
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Outlet (infundibular)(Supra cristal)
Membranous (80%)
Muscular(5-20%)
Inlet
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Based on size:
Mild, Moderate, Severe:
0.5 cm, 0.5 -1 cm, >1 cm
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
RARVPV PALungsPVLAMVLVAortaOther parts of the body
What organic murmur? Why?
What flow murmurs? Why?
Which chamber gets enlarged? Position of AI? Type of AI?
Why recurrent RTI?
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Symptoms in VSD
Small VSD:Asymptomatic; growth is normal;
Murmur - routine clinical examination.
Moderate to Large VSD: Breathlessness on exertion
Exercise intolerance
Feeding difficulties
Failure to thrive
Frequent RTI
Forehead sweating
Chest pain, palpitation, syncope ???
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Vitals in VSD
Pulse: Volume? Rate? Character? Rhythm?
Blood pressure?
If there is CCF:
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
General examination
Undernourished, pallor +/-
Pedal edema, Pre sacral edema
Signs of I.E
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Examination of heart
Inspection:
Precordial bulge (Cardiomegaly – Pliable chest)
Harrison sulcus +/-
Respiratory distress (CCF, LRTI)
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Examination of heartPalpation:
Position of apical impulse
Shifted down & out (LV enlarge)
Type of apical impulse
Hyper dynamic
Palpate in the lower sternal area:
Thrill in 3, 4, & 5th LICS – Parasternal area
Palpate in the PA for the presence of PHT:
Palpable P2 ; also Systolic thrill
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Examination of heart -AuscultationHeart sounds:
Usually normal
S1: loud (the cusps of MV are kept wide apart till the end of LV diastole)
S2 : may be widely split; but, varies with respiration.
Murmurs:
PSM – left lower parasternal area - grade 3,4 or 5(heard throughout the systole, as the pressure in the LV>RV)
Other possible murmurs: Flow murmurs –ESM at PA,MDM at MA – often drowned by the loud PSM
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Complications
Congestive Cardiac Failure
Pulmonary Hypertension
Failure to thrive
Infective Endocarditis
Recurrent LRTI (for any LR shunt)
Eisenmenger’s syndrome
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Complications Congestive Cardiac Failure:
Symptoms:
Gen Exam:
Vitals: Pulse:
BP:
Auscultation of Heart:
RS:
Abdomen examination:
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
ComplicationsCongestive Cardiac Failure:
Symptoms: Breathlessness, PND or Orthopnoea, cough
Gen Exam: Pedal edema
Vitals: Pulse:
BP:
Auscultation of Heart: Gallop
RS: Basal creps
Abdomen examination: Tender hepatomegaly
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
ComplicationsPulmonary Hypertension:
Palpable P2
P2 loud
Narrow S2
Ejection click + after S1 (dilated PA)
Soft & short systolic murmur (occassionally, followed by
EDM + due to Pulmonary regurgitation)
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
ComplicationsEisenmenger’s syndrome
In LR shunt; shunt reversal severe PHT & cyanosis
Can occur in all LR (VSD, ASD & PDA or Aortopulmonray shunts)
Usually occurs in non-restrictive lesions, in late teens age
If it occurs in VSD, then it is called as Eisenmenger Complex
If it occurs in VSD:
PSM Murmur intensity decrease
P2 becomes loud; Early Diastolic murmur +
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Differential diagnosisTricuspid Regurgitation:
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Natural History – What is the fate of VSD?Spontaneous closure :
Possible-small sized membranous, muscular (even large) and inlet
Outlet (of any size), large membranous with CCF: do not close
In smaller VSD: Risk of IE is more
In larger VSDs: Risk of CCF is more (8 weeks of age)
(Infundibular stenosis may develop: decrease in L R shunt: acyanotic TOF)
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Investigations
Chest X Ray: Cardiomegaly, Increased PBF, Lung Infection
ECG: Chamber enlargement
ECHO:
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
ManagementMedical:
Anemia correction
Proper nutrition (feed frequently)
Dental Hygiene
Infective Endocarditis Prophylaxis
Treatment for Cardiac failure
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Management - Surgical
Closure: Patch of woven dacron or PTFE
Decision based on
Size of defect
Size of shunt (LR)
CCF
PVR
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Management - Surgical
Decision based on
Size of defect - Small
Size of shunt (LR)- Small (PBF:SBF <1.5:1)
CCF-Absent
PVR Normal
No need for Surgery; Only life-long IE Prophylaxis
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Management - Surgical
Decision based on
Size of defect - large
Size of shunt (LR)- large (PBF:SBF >2:1)
CCF+ not responding to medical management
PVR slightly increased
Outlet defects- associated with aortic cusp prolapse
Surgery is indicated
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Management - Surgical
Contraindications for surgery: severe PHT
PVR > 8 wood units/m2 BSA not responding to isoproterenol infusion
> 12 wood units / m2 BSA
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Syndromes associated with VSD
1. Chromosomal anomalies: Trisomies 21 (Down synd)
Trisomy 18 (Edward synd)
Trisomy 13 (Patau synd)
2. Syndromes: CHARGE, VATER, Cornelia-de-Lange
3. Maternal conditions: Phenytoin, Valproate, Diabetes
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Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD