BLUE BABIES BLUE BABIES AND PINK KIDSAND PINK KIDS

Dr Ravi NarayanDr Ravi NarayanSenior Consultant Ped.Cardiologist,& Senior Consultant Ped.Cardiologist,&

Assoc. Prof. CardiologyAssoc. Prof. CardiologyRAMAIAH NARAYANA HRUDAYALAYARAMAIAH NARAYANA HRUDAYALAYA

OVERVIEW OF MANAGEMENT IN OVERVIEW OF MANAGEMENT IN COMMON CHDCOMMON CHD

IntroductionIntroduction

CongenitalCongenital—means from birth—means from birth

Congenital heart defects (CHD) can Congenital heart defects (CHD) can vary from vary from small holessmall holes in the heart to in the heart to very very serious malformationsserious malformations

Some defects can manifest in Some defects can manifest in teenage or adults (GUCH)teenage or adults (GUCH)

Cyanosis)—Cyanosis)—note the nails are very blue note the nails are very blue because of deoxygenated blood entering the because of deoxygenated blood entering the

aortaaorta

Pink Kid!!!!Pink Kid!!!!IS HIS MURMUR INNOCENT???IS HIS MURMUR INNOCENT???

CLASSIFICATIONCLASSIFICATION

• ACYANOTIC//CYANOTIC• SHUNT LESIONS• ASD,VSD,PDA• STENOSIS-- AS, PS, • Narrowing of a pipe -- COA of aorta• Weak heart muscle Cardiomyopathy

CYANOTICCYANOTIC

• TOF,TGA, TAPVC, • Truncus,Tricuspid Atresia• E’S –EBSTEIN EISENMENGER• SINGLE ATRIUM

• SINGLE VENTRICLE

How big is the How big is the problem problem ???? CHD—1/1000 live birthsCHD—1/1000 live births India---180,000 babies/year India---180,000 babies/year KARNATAKA STATE—5-8,000KARNATAKA STATE—5-8,000 Estimated Estimated 5,000/year will have 5,000/year will have

shunt lesions(“Holes in heart”)shunt lesions(“Holes in heart”) Easy to diagnoseEasy to diagnose Reasonably easy to treat unlike Reasonably easy to treat unlike

complex heart diseasecomplex heart disease

HISTORY AND EXAMHISTORY AND EXAM CYANOSIS PRESENT OR NOTCYANOSIS PRESENT OR NOT DYSPNOEA//TACHPNEADYSPNOEA//TACHPNEA FAILURE TO THRIVEFAILURE TO THRIVE MURMUR, CREPS++MURMUR, CREPS++ CCFCCF CHEST XRAYCHEST XRAY

WHAT IS ECHO??WHAT IS ECHO??

ULTRASOUND OF ULTRASOUND OF HEART.HEART.

M MODE, 2D, M MODE, 2D, DOPPLER AND DOPPLER AND COLOUR COLOUR DOPPLERDOPPLER

3 D3 D TEETEE

EchocardiographyEchocardiography Second

Stethoscope * * Exquisite anatomy Exquisite anatomy

even in neonates even in neonates •••Structure and •••Structure and functionfunction

More than 95% of More than 95% of cases can be sent for cases can be sent for surgery without cath.surgery without cath.

MANAGEMENTMANAGEMENT

• MEDICAL• INTERVENTION• SURGERY

ASD--- left to right shuntASD--- left to right shunt

ASD

•TYPES•Secundum•Primum•Sinus venosus

•SIZE•PAH

ASD –ManagementASD –Management

• >> 10mm• Volume overload• 3-5 years—Device//surgery• 12-15 kg• Moderate ASD or large with good

rims >> Device

ASD—SPECIAL ASD—SPECIAL CIRCUMSTANCESCIRCUMSTANCES

SPECIAL CIRCUMSTANCES•SYMPTOMATIC IN INFANCY•PFO AND STROKE•AGE MORE THAN 50 YEARS

Pinhole surgery—another term for Pinhole surgery—another term for cardiac interventionscardiac interventions

• Key hole—laparoscopic surgery• Pin hole surgery--- like doing

angioplasty AND STENT in adults• Small tubes called catheters are passed

through the leg veins• A Device is then put into the catheter and

released in the heart to block the hole(ASD,VSD,PDA)

ASD Device PDA Device

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ASD DEVICEASD DEVICE

Clockwise from above: Transcatheter delivery of Amplatzer device, which is positioned across the atrial septal defect

Left: Amplatzer device in place

ASD CASEASD CASE 10 YEAR OLD BOY10 YEAR OLD BOY 16 MM SECUNDUM ASD16 MM SECUNDUM ASD ALL RIMS (EXCEPT AORTIC RIM ) ALL RIMS (EXCEPT AORTIC RIM )

MORE THAN 5 MMMORE THAN 5 MM POST. AND INF RIMS SLIGHTLY POST. AND INF RIMS SLIGHTLY

FLOPPYFLOPPY

PLAN– 20 MM ASD DEVICEPLAN– 20 MM ASD DEVICE

ASD Device closureASD Device closure

Fluoroscopy showing ASD Fluoroscopy showing ASD devicedevice

Atrial Septal Defect

Patch Repair

VSDVSD

Large VSD

VSD --Doppler

VSD—ManagementVSD—Management

• Small to moderate VSD and no PAH• Wait upto 5-6 years• Moderate VSD, Mod PAH• Operate 1-2 years of age• Large VSD, severe PAH, preferably

4-5 kg. weight

VSD deviceVSD device

Ventricular Septal Defect RepairVentricular Septal Defect Repair

Patent Ductus Patent Ductus Arteriosus (PDA)Arteriosus (PDA) PDA(connection PDA(connection

between the 2 great between the 2 great arteries—aorta and arteries—aorta and pulmonary artery)pulmonary artery)

PDA -- ManagementPDA -- Management

• PDA preterm,Indomethacin//Ibugesic• Term neonate • Large << 5 Kg -- surgery,• >> 5 Kg -- device• Small and moderate –1-2 years,• Device// coil

COILING OF PDACOILING OF PDA

Left, top: Catheter crosses the PDA from the aortic side and delivers a coil.Left, bottom: Withdrawal of catheter, leaving coil in PDA

Amplatzer Ductal OccludersAmplatzer Ductal Occluders

Amplatzer ductal occluderIllustration courtesy AGA Medical Group

Aorta angiogram with device occlusion of PDA, lateral view

Note—dumbell device closing Note—dumbell device closing the PDAthe PDA

Cable has been detached—Cable has been detached—device in good positiondevice in good position

Hypertensive PDA – Closed with 16/18 Device

49© 2012 Vascular Innovations

50© 2012 Vascular Innovations

PS (pulmonary stenosis—narrowing of PS (pulmonary stenosis—narrowing of pulmonary valve)pulmonary valve)

ValvuloplastyPulmonary Balloon Valvuloplasty

Lateral angiograms

Aortic stenosis(AS– narrowing of aortic Aortic stenosis(AS– narrowing of aortic valve)valve)

Coarctation(narrowing of aorta)Coarctation(narrowing of aorta)

AngioplastyAortic Coarctation Angioplasty

Angiograms showing (left) post-surgical coarctation of the aorta and (right) angioplasty balloon inflated across coarctation site

Intravascular StentsCoarctation of the Aorta

Left: uninflated angioplasty balloon and stent within coarctation Middle: expansion of balloon and stent

Right: deflation of balloon leaving stent wide open

Advantages of InterventionsAdvantages of Interventions

• Short hospital stay• Child can start walking sam day or the

next day• Almost 95-99% success can be achieved

by interventions

Cardiac Surgery

Breakthroughs in Cardiac Breakthroughs in Cardiac SurgerySurgery

• Heart lung machine

• Cardioplegia

• Deep Hypothermia

• Circulatory arrest

Tetralogy of FallotTetralogy of Fallot

1 – ventricular septal defect (VSD), 2 –pulmonary stenosis2a – infundibular stenosis, 3 – enlarged aorta overriding

VSD4 – right ventricular hypertrophy

Tetralogy of Fallot Repair

(Above) With Transannular Patch

(Right) With Pulmonary annulus retained

In the “pink of health”In the “pink of health”

TGA “Switch operation”TGA “Switch operation”

How do we reach the How do we reach the common man?common man?

Take Diagnosis to the door stepTake Diagnosis to the door stepMobile Cardiac ClinicMobile Cardiac Clinic

INFECTIVE ENDOCARDITIS INFECTIVE ENDOCARDITIS PROPHYLAXISPROPHYLAXIS

• REQUIRED• CHD---VSD/PDA• VALVE—BICUSPID AV AND AS• RHD—MR• OPERATED AND DEVICE CLOSURE OF

ASD AND PDA ,• FIRST 6 MTHS• PROSTHETIC VALVE

IE PROPHYLAXIS NOT REQDIE PROPHYLAXIS NOT REQD

• ASD/ PS• MVP WITH NO MR• POST CABG OR STENTING• PACEMAKER

REGIMEREGIME

• AMPICILLIN OR AMOXYCILLIN• WITH OR WITHOUT GENTA• CEFATOXIME• 1 HR BEFOR PROCEDURE• 2 DOSES AFTER PROCEDURE

CONCLUSIONS•Early diagnosis•Intervention//surgery•Hybrid//minimally invasive

Team Effort

A parent’s dream---A parent’s dream---