approach to patient with congenital heart disease
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Approach to a patient with congenital heart disease
Guide : Dr.Vijay G.Somannavar
Introduction
• Congenital heart diseases or Congenital heart anomalies are defects in the structure of the heart and great vessels which are present at birth.
• CHD are the leading cause of birth defect-related deaths.
D E F I N I T I O N
When to suspect CHD
•-Cyanosis -Respiratory distress -Poor peripheral
perfusion -Decreased pulsations-Difference in pulses
(arm vs. leg)
-Single 2nd heart sound -Abnormally loud 2nd
heart sound -Prominent heart
murmur -Hyperactive precordium
F I N D I N G S T H A T S H O U L D A L E R T O N E T O T H E P O S S I B I L I T Y O F C H D
Incidence
• 1 in 10 stillborn infants have a cardiac anomalies.
• 8 out of 1000 live born children have significant cardiac malformations.
• Every year 1,80,000 children are born with heart defects in India.
Lesions % of all Lesions
- Ventricular septal defect 25-30
- Atrial septal defect (Secundum) 10
- Patent ductus arteriosus 10
- Coarctation of aorta 7
- Tetralogy of Fallot 6
- Pulmonary Valve Stenosis 5-7
- Aortic Valve Stenosis 4-7
- Transposition of great arteries 4
- 0thers 20
Classification
CHD
Acyanotic Cyanotic
Left-to-right shunts
Outflow obstruction
- Ventricular Septal Defect (VSD)- Patent Ductus Arteriosus (PDA)- Atrial Septal Defect (ASD
- Pulmonary Stenosis- Aortic Stenosis-Coarctation of aorta
• Teralogy of fallot• Tricuspid atresia• Transposition of
great vessels• Truncus arteriosus• Total anomalous
pulmonary venous return (TAPVR)
• Ebstein’s anomaly
Etiology
Maternal disorders
• Rubella infection (30-35%)• PDA,
pulmonary stenosis
• SLE (35%)• Complete heart
block• DM (2%)
Maternal drugs
• Warfarin therapy (5%)• PDA,
pulmonary stenosis
• Fetal alcohol syndrome (25%)• ASD, VSD,
tetralogy of Fallot
Chromosomal abnormality
• Down’s syndrome (30%)• Atrioventricular
septal defect, VSD
• Edward’s and Patau’s syndrome (60-80%)• Complex
• Turner’s syndrome (15%)• Aortic valve
stenosis, coarctation of the aorta
Left to right shunts
• L to R shunts are characterised by RV enlargement and RV failure.
• Usually present with recurrent chest infections.
• They are not typically cyanotic.
Ventricular Septal Defect (VSD)
• Most common congenital cardiac lesion.• Accounts for 25% of all CHDs. • Defect may be –
perimembranous(adjacent to tricuspid valve) or muscular(surrounded by muscle)
• Spontaneous closure occurs by 10 years.
Peri membranous
Muscular
Clinical features
• Children with small defects will remain asymptomatic .
• Infants with moderate to large defects will become symptomatic within the first few weeks of life.
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S I G N S A N D S Y M P T O M S V A R Y W I T H T H E S I Z E O F T H E D E F E C T
Small VSDs
– Symptoms• Asymptomatic
– Physical signs• Thrills at lower sternal edge• Loud pansystolic murmur at lower left sternal edge• Quiet second heart sound (P2)
Large VSDs
– Symptoms• Breathlessness and failure to thrive.• Recurrent chest infections
– Physical signs• Prominence of the left precordium• Soft pansystolic murmur • Mid-diastolic murmur at the apex• Loud pulmonary second sound (P2)
Investigations
– Chest X-ray • Cardiomegaly• Enlarged pulmonary arteries• Pulmonary vascular markings• Pulmonary oedema
– ECG• Biventricular hypertrophy and
signs of pulmonary HTN right ventricular enlargement and hypertrophy
– Echocardiography• Demonstrates the anatomical
defect, haemodynamic effects and severity of pulmonary HTN.
Atrial Septal Defect(ASD)• Seen in 10% of all CHDs
• Females > males.
• It is an abnormal opening between the atria
• Spontaneous closure ocurrs with in 1st year of life.
Clinical features
Symptoms :• Fatigue and SOB• Palpitations • Recurrent respiratory
infections
Physical signs :• Ejection Systolic murmur • Diastolic murmur (large
shunts).• Wide fixed split S2• Tachypnea, tachycardia and
enlarged liver from heart failure
M O S T I N F A N T S A N D C H I L D R E N A R E A S Y M P T O M A T I C .
Diagnostic tests
- CXR – enlarged heart,increased pulmonary vascular markings
- ECG- Ostium secundum:Right axis deviation with Right bundle branch block.
- 2D echo – show pattern of blood flow through the septal opening
Patent Ductus Arteriousus (PDA)
• PDA occurs in 6-11 % of all children with CHD
• It is a connection between the aorta and the pulmonary artery
• Most babies have a closed ductus arteriosus by 72 hours after birth.
Clinical features
• Fatigue • Sweating • Tachypnea • Shortness of breath
Physical examination• Widened pulse pressure
• Collapsing/ bounding pulse
• Left infraclvicular/upper left sternal edge continuos machinery
murmur
• Differential cyanosis (cyanosis of lower limb but upper limb pink)
Coarctation of aorta
• Accounts for 7 % of all CHD.• is narrowing of the aorta at varying
points anywhere from the transverse arch to the iliac bifurcation.
• 98% of coarctations are juxtaductal.
Clinical presentation
• In older children:– Leg discomfort with
exercise– Headache– Epistaxis
• Systolic hypertension of upper extremities.
• Ejection systolic murmur at upper sternal edge
• Diminished lower extremity pulses– Radio-femoral delay:
• blood bypassing the obstruction via collateral vessels in the chest wall
Right to Left Shunts
• R L shunts cause hypoxia and central cyanosis.
• Blood is shunted from the R to the L side of the heart w/o passing through the lungs for oxygenation.
• Unoxygenated blood circulates in arteries cyanosis
Tetrology of fallot
Components• Ventricular septal defect• Pulmonary stenosis• Overriding of aorta• RVH
M O S T C O M M O N C Y A N O T I C H E A R T D I S E A S E
Clinical features
– Cyanosis– Shortness of breath– Rapid breathing– Loss of consciousness– Clubbing of fingers and toes– Restless and agitated– Poor weight gain
S Y M P T O M A T I C A N Y T I M E A F T E R B I R T H
Posture
– It is a compensatory mechanism
– Squatting increases the peripheral vascular resistance, diminishes the right-to-left shunt and increases pulmonaryblood flow.
S I T T I N G P O S T U R E O R S Q U A T T I N G
• Chest X-ray– Normal sized, boot
shaped heart– Concavity of Left heart
border– Oligaemic lung fields
• ECG– At birth normal– Older: Right axis
deviation and RVH
• Echocardiography– Degree of stenosis– Coronary anomalies(5%
in TOF)
Thank You
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