(drindriwanto) hcd - 19 september 2012

8/18/2019 (Drindriwanto) HCD - 19 September 2012

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C&''I*A+ HA*C&''I*A+ HA*

DISASDISAS

Anomalies of the heart structure andcirculatory function which is present since

birth due to disturbances or failure in thedevelopment of the heart during early fetallife

Incidence : 8 – 10 per 1000 live births


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O SURGICAL

A D

SURGICAL

I TERVE TIO

O SURGICAL

A D

SURGICAL

I TERVE TIO

UNDERSTANDUNDERSTAND

CARDIOVASCULAR CARDIOVASCULAR

ANATOMYANATOMY

PHYSIOLOGYPHYSIOLOGY

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

HistoryHistory

Physical ExamiatioPhysical Examiatio

ECGECGCh!st "#RayCh!st "#Ray

Echocar$io%ra&hyEchocar$io%ra&hy

Car$iac Cath!t!ri'atioCar$iac Cath!t!ri'atio


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(o)l!$%! o* *!tal a$ &!riatal circ+latio is h!l&*+l i

+$!rsta$i% th! cliical mai*!statios a$ at+ral history o* CHD

CHANGES IN CIRCULATION

A,TER -IRTHShift of blood flow for gas exchange from placenta to the lungs

1. Interruption of the umbilical cord• Increase of SVR

• Closure of ductus venosus2. ung expansion

• Reduction of !VR • "unctional closure of !"#• Closure of !$%

CHANGES IN CIRCULATION

A,TER -IRTHShift of blood flow for gas exchange from placenta to the lungs

1. Interruption of the umbilical cord• Increase of SVR

• Closure of ductus venosus2. ung expansion

• Reduction of !VR • "unctional closure of !"#• Closure of !$%


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Fetal

Circulation

hunts:

1! "lacenta#! $uctus %enosus&! Foramen 'vale(! $ustusArteriosus


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)ormal

"ost*)atalCirculation


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"+,-')A./ %AC+,A. ".+.

A)$ .IA)C


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,C.'CA.$I'2.

A-

ADULT

EO ATE

I FA T

RV dominant

V dominant


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HA* A$SC$+*A*I&'

HEART SOUNDS AND MURMURS

vibrations produced b& cessation or

propulsion of blood within the heart

radiates through the thorax s'in

stethoscopeevaluation of heart disease


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3A. '+)$

• ,irst H!art So+$ .S/0 closure of the (itral and )ricuspid valves

• S!co$ H!art So+$ .S10 closure of the %ortic and !ulmonar& Valves

splitting of the S2 %2 procedes !2 splits with respiration

• Thir$ H!art So+$ .S20 earl& in diastole rapid filling phase of the ventricle

heard in normal children

• ,o+rth H!art So+$ .S30 atrial contraction rare in children


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3A. -+.-+.

• T+r4+l!t 4loo$ *lo) produces vibrations

stenosis

regurgitation shunt

• Classi*icatiotiming during cardiac c&cle

* s&stolic murmur * diastolic murmur * continuous murmur


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C3'CA.$I'2.A"3/


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CH&CADI&APHCH&CADI&APH - -


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CA.$IACCA3.I4AI')


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Congenital Heart Disease

Acyanotic/noncyanotic

cyanotic


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)on Cyanotic,eft to .ight hunt

• Atrial eptal $efect

• %entricle eptal $efect

• "atent $uctusArteriosus

Outflow tract Obstruction

•Pulmonal stenosis• Aorta stenosis


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oligaemic lungoligaemic lung plethoric lungplethoric lung

!H oF "A 5 %$ $'.% 5 " A$6%$ 5"

!H oF "A 5 %$ $'.% 5 " A$6%$ 5"

+!H A 5 " "A 5 .% hipoplasti7

+!H A 5 " "A 5 .% hipoplasti7

!H 2A * I% $'.% 5 %$ A"%$

!H 2A * I% $'.% 5 %$ A"%$

!H runcus Art 2A 5 %$

!H runcus Art 2A 5 %$


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Non Cyanotic


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+et to ig/t S/unt* sie of the defect

* compliance of .% is greater than ,% A, ! and PA enlargement

Pulmonary Hypertension* large A$ large left to right shunt

* develop in the third to fourth decades of life

* "ulmonary %ascular 'bstructive $isease

* bidirectional shunt right to left shunt sianosis

IS'"' S-'D&"

HEMODYNAMICHEMODYNAMIC


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AUSCULTATIONAUSCULTATION

9idely split and ;ed #9idely split and ;ed #< .% volume overload prolonged .% e=ection time

delays the closure of the pulmonary valve< large pulmonary venous return to .A ;ed split

ystolic e=ection murmurystolic e=ection murmur< not caused by the shunt< originates from the increased blood >ow passing

through the normal*sied pulmonary valve relative"

-id diastolic murmur-id diastolic murmur< increased blood >ow through the tricuspid valve

relative < large left to right shunt

Accentuated "#Accentuated "#< pulmonary hypertension


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• R%+ RV and !% dilatation

• prominent pulmonar& arter&segment• increased pulmonar&

vascular mar'ing ,plethora-

CHEST "#RAYCHEST "#RAY


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L!*t to Ri%ht Sh+t* sie of the defect

* level of pulmonar& vascular resistance

LA5 LV a$ PA !lar%!m!t

P+lmoary Hy&!rt!sio* large VS$ large left to right shunt

* high pulmonar& vascular resistance* !ulmonar& Vascular #bstructive $isease


EISENMENGER SYNDROME


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Small VS$Small VS$• normal !2 intensit&• holos&stolic murmur

produced b& left to right shunt

arge VS$arge VS$• accentuated !2 pulmonar& h&pertension• e/ection clic' ,occasionall& -• holos&stolic murmur left to right shunt

• mid diastolic murmur increased blood flow through the mitralvalve relative (S

arge VS$ with !ulmonar& Vascular #bstructive $iseasearge VS$ with !ulmonar& Vascular #bstructive $isease• loud and single S2• decreased loudness of the holos&stolic murmur ,or disappear-

AUSCULTATIONAUSCULTATIONSmall VSD

Large VSD


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• %+ V and !% dilatation

• prominent pulmonar& arter&segment

• increased pulmonar&

vascular mar'ing ,plethora-


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L!*t to Ri%ht Sh+t

* sie of the ductus diameter+ length and turtuosit&* level of pulmonar& vascular resistance

LA5 LV5 asc!$i% Ao a$ PA !lar%!m!t

P+lmoary Hy&!rt!sio* large !$% large left to right shunt

* high pulmonar& vascular resistance

* !ulmonar& Vascular #bstructive $isease


EISENMENGER SYNDROME


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0ormal !2 0ormal !2 intensit&intensit&• small !$% normal !% pressure• accentuated if pulmonar& h&pertension is present

Continuous ,machiner&- murmur Continuous ,machiner&- murmur • left to right shunt occurs throughout the cardiac c&cle

significant pressure gradient between %o and !% during s&stole

and diastole %pical mid diastolic murmur %pical mid diastolic murmur

• increased blood flow through the mitral valve relative (S

arge !$% with 3isenmenger S&ndromearge !$% with 3isenmenger S&ndrome• single and loud S2 pulmonar& h&pertension• no longer continuous murmur e/ection s&stolic murmur



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• %+ V+ ascending %o and !%

dilatation• prominent pulmonar& arter&

segment• increased pulmonar& vascular

mar'ing ,plethora-


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NONCYANOTIC CHDNONCYANOTIC CHD

OUT,LO6 TRACT O-STRUCTIONOUT,LO6 TRACT O-STRUCTION

VENTRICLE OUT,LO6 TRACT O-STRUCTIONVENTRICLE OUT,LO6 TRACT O-STRUCTION

6ITHOUT SHUNT6ITHOUT SHUNT


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Left ventricle outflow tractLeft ventricle outflow tract

obstructionobstruction


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• narrow split S2• ejection systolic click • harsh ejection systolic murmur



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• asymptomatic• symptomatic

depend ofseverity of lesion

myocardial function

dyspneuFeeding difficulty Failure to thriveHeart Failure

Syncope painchest

Sudden death

dyspneuFeeding difficulty Failure to thriveHeart Failure

Syncope painchest

Sudden death


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NEONATUSduct dependent systemic circulationClosed duktus arteriosus

deteriorate systemiccirculationhypoperfusion

BABY AND CHILD

• asymptomatic – mild lesion• symptomatic :headacheepitasisulsless


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Ri!t ventricle outflow tractRi!t ventricle outflow tract

obstructionobstruction

• !" pressure overload• R"H

valvar infun#ibular su$ravalvar


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NEONATUS % critical &Sduct dependent pulmonary circulation

closed duktus arteriosus severe cyanosis – acidosis

BABY an# CHILD• asymptomatic – mild lesion• symptomatic :

!ight Heart failureoedemahepatomegaly acites

C'anosis

#ila ada F$


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• S2 weak ejection systolic click

• harsh ejection systolic murmur



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LESI OBSTRU(TI) ALUR (ELUARLESI OBSTRU(TI) ALUR (ELUAR

"ENTRI(EL (IRI DAN (ANAN "ENTRI(EL (IRI DAN (ANANNeonatus % Duct De$en#ent %&'

sementara dipersiapkan intervensi

non(#edah ) #edah*

INTER"ENSI NON BEDAH

*ra#ien te+anan , -. % /. 00H

• +alloon ,ortic "alvyuloplasty -,S valv*

• +alloon ulmonal "alvuloplasty -S valv*

• +alloon ,ngioplasty -Co,*

./0&!"&/S. +&1,H

• "alvotomy -S ) ,S valvar*

• !eseksi otot -S ) ,S su#valvar*

• !ekonstruksi -S ) ,S Supravalvar*


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FKUI International

Cyanotic


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OligemicOligemic

cyanosis spell hypoxia squatting

Pulmonary StenosisPulmonary Stenosisor Atresiaor Atresia

++

PFO / ASD / VSDPFO / ASD / VSD( R L S!"#$ %( R L S!"#$ %

• $etralogi Fallot$etralogi Fallot

• PS + PFO / ASDPS + PFO / ASD• PA + VSDPA + VSD


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• ess than1 &ear , 2 4 5 month -

• minute * hour

Spell cyanotic

Em!r%rcyEm!r%rcy

S!rio+s com&licatioS!rio+s com&licatio

• CVDCVD• (EMATIAN(EMATIAN

&nee'chest position

Oxigen

Seasion !ia"e#am

or morfin aciosis correction $

%ic Nat

Propranolol

)$ Shunt/ surgery


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TOTAL CORRECTION

• 7 8 moth• %oo$ si'! o* PA

PALIATI, o&!ratio

-T SHUNT

• s&!ll hy&oxia

• 9 8 moth

• small PA si'!


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PlethoraPlethora

*eeing i**iculty Failure to $hrie reccurence R$ in*ection ,!Fpulmonary !ypertention

Increase Pulmonary blood flow

TGATGA

COMMON MI"INGCOMMON MI"ING

TGATGA

COMMON MI"INGCOMMON MI"ING

P+lmoary

:asc+lar r!sist!c!

P+lmoary

:asc+lar r!sist!c!

,ommon -ixing. $APVD "nientricular ,onnection $run&us Arteriosus


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Paral!l circ+latioParal!l circ+latio

atrial . PFO ASDatrial . PFO ASD

entricle . VSDentricle . VSD

0eart o* Arteries. PDA0eart o* Arteries. PDA

www&sc'nei!erc'il!ren'os#ital&org


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Inter(ension non surgery

For Congenital Heart Diseases


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FKUI International

'cclusion of Intracardiac and %ascular


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'cclusion of Intracardiac and %ascularhuntsCoil emboliation of "$A

)eft* to# Cat'eter crosses t'e PDA

from t'e aortic si!e an! !eli(ers a coil&

)eft* bottom +it'!rawal of cat'eter*

lea(ing coil in PDA



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'cclusion of Intracardiac and %ascularhuntsAmplater $uctal 'ccluders

Am#lat"er !uctal occlu!er

Illustration courtesy A,A -e!ical ,rou# Aorta angiogram wit' !e(ice

occlusion of PDA* lateral (iew


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Amplater $uct 'ccluder


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Amplater $uct 'ccluder



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'cc us o o aca d ac a d ascu ahuntsAmplater occlusion of atrial septal defect

,loc&1ise *rom a2oe.

$ranscatheter eliery o*

Amplat3er eice 1hich is

positione across theatrial septal e*ect

Le*t. Amplat3er eice in

place



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hunts$evices for occlusion of the "F' and A$

A2oe.

0ore !elex septal occluer

Illustration courtesy +& )& ,ore an! Associates

"pper le*t.

,arioS4AL occluer

Illustration courtesy N-. -e!ical

Lo1er le*t.

Amplat3er PFO occluer

Illustration courtesy A,A -e!ical ,rou#


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l l


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Amplater septal

occluder

'cclusion of Intracardiac and %ascular hunts


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'cclusion of Intracardiac and %ascular hunts%entricular eptal $efect 'cclusion

A2oe. 4chocariogram o* muscular VSD"pper right. Fluoro image o* ,arioS4AL

eice occlusion o* a VSD5 $ransesophageal

echo pro2e ($44% an pigtail catheter in place5

Lo1er right. Amplat3er muscular entricular

septal occluer Illustration courtesy A,A -e!ical ,rou#

' l i f I t di d % l h t


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'cclusion of Intracardiac and %ascular hunts%$ 'cclusion with CardioA, $evice

%alloon Pulmonary


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y

(al(ulo#lasty


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Angioplasty


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AngioplastyAortic Coarctation Angioplasty

Illustrations s'owing left0 uninflate! an! rig't0 inflate! angio#lasty

balloon #ositione! wit'in coarctation of t'e !escen!ing aorta

Intravascular tents


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Intravascular tentsCoarctation of the Aorta

)eft uninflate! angio#lasty balloon an! stent wit'in coarctation

-i!!le e2#ansion of balloon an! stent

3ig't !eflation of balloon lea(ing stent wi!e o#en


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(drindriwanto) hcd - 19 september 2012

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