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Hemodynamics and Physical Examination In Congenital Heart Disease Azaria JJT Rein, MD. A Gene, Fetus, Baby, Child and Adult Saga. History of Cardiac Imaging. 3-D ECHOCARDIOGRAPHY 1997 TISSUE VELOCITY IMAGING. New Approaches in Diagnosis. 3 D Imaging. 4 CHAMBERS. Coarctation of the

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slide1

Hemodynamics and Physical Examination

In

Congenital Heart Disease

Azaria JJT Rein, MD

slide3

History of Cardiac Imaging

  • 3-D ECHOCARDIOGRAPHY
  • 1997 TISSUE VELOCITY IMAGING
slide7

Coarctation

of the

Aorta

slide18
"That it will ever come into general use, not withstanding its value, I am extremely doubtful; because its whole hue and character is foreign, and opposed to all our habits and associations.”

"מבלי להמעיט בערכה של צורת בדיקה זו, אני בספק רב אם אי פעם השימוש בה יהפוך לנחלת הכלל, מפני שכל אופייה ומהותה זרים ומנוגדים להרגלינו ולדרך החשיבה שלנו."

John Forbes, 1821

slide20

HEMODYNAMICS & PHYSICAL EXAMINATION

- Medical History.

- Inspection.

- Palpation.

- Percussion.

- Auscultation.

slide21

Medical History

Antenatal

- Family History.

- Fetus.

- Mother disease.

Perinatal

- Delivery.

- APGAR score.

- First sign & symptom.

Postnatal...

slide22

HEMODYNAMICS & PHYSICAL EXAMINATION

- Medical History

- Inspection

- Palpation

- Percussion

- Auscultation

inspection
Inspection

Hi, I’m

Alfred E. Neuman, you know, from Mad magazine?

inspection1
Inspection

Why, me worry ???

inspection2
Inspection

Why, me worry ???

inspection3
Inspection

Yes, we both have Williams’ syndrome !

inspection4
Inspection

Me too !!!

inspection5
Inspection

With SVAS, SVPS, PPS and more !!!

slide29

HEMODYNAMICS & PHYSICAL EXAMINATION

AUSCULTATION

- Heart Sounds.

- Murmur.

- Click/Snap

slide31

.

2

P = 4 V

P = 4 V

Flow & Pressure

THE SIMPLIFIED BERNOULLI EQUATION

P

in mm Hg

.

V

in m/sec

slide32

Murmur and Hemodynamics

MURMUR

LAMINAR FLOW -> TURBULENT FLOW

INCREASED FLOW VELOCITY

> 1.5 m/sec

INCREASED PRESSURE GRADIENT

> 10 mmHg

slide33

Murmur Characteristics

  • Timing
  • Amplitude
  • Pitch
  • Location
  • Radiation
  • Response to maneuver
slide34

Murmur Characteristics

  • Timing
  • Systole
    • Pansystolic
    • Ejection Type
    • Exceptions (Late SM, Short SM)
  • Diastole
    • Early
    • Mid
  • Continuous
slide36

Systolic Murmur

Ejection

IVC

systole

S1

S2

SEM

PSM

slide37

Systolic Ejection Murmur

Ejection

IVC

S1

S2

systole

slide38

Pansystolic Murmur

Ejection

IVC

systole

S1

S2

slide39

Diastole

mo

Filling

IVR

diastole

S1

S2

slide40

S1

S2

Early Diastolic Murmur

Filling

IVR

slide41

S1

S2

Mid-Diastolic Murmur

Filling

IVR

slide43

The Evolving PDA Murmur

1 day

few days

> 1-2 weeks

slide44

The Amplitude of a Murmur

Factors influencing the amplitude grading:

-

Acoustic energy

- Media

- Stethoscope

- Ears & acoustic nerve

- perception

- subjective interpretation

slide45

ΔP Pitch

The Pitch of a Murmur

slide46

Response to Maneuver

Change in loading condition ( pre/ after load).

Change in loading of right & left cardiac chambers.

Change in timing of auscultatory event.

Change in pressure gradient.

slide47

CLICKS & SNAPS

Wind Pressure Gradient

=

Sail Pliable valve

HADASSAH

Pediatric

Cardiology

H

slide50

Murmur Characteristics

  • Timing
  • Amplitude
  • Pitch
  • Location
  • Radiation
  • Response to maneuver
auscultation
Auscultation
  • Aortic Murmurs
  • “Downstream” from Aortic Valve
  • RUSB
auscultation1
Auscultation
  • Aortic Murmurs
  • “Downstream” from Aortic Valve
  • Aortic Stenosis- Radiates to Carotids
auscultation2
Auscultation
  • Pulmonary Murmurs
  • “Downstream” from Pulmonary Valve
  • LUSB
auscultation3
Auscultation
  • Tricuspid Murmurs
  • “Downstream” from Tricuspid Valve
  • Manubrium Sterni
auscultation4
Auscultation
  • Mitral Murmurs
  • “Downstream” from Mitral Valve
  • LLSB
slide56

PALPATION

Pulses

Rate

Characteristics

Precordium

Volume overload

Pressure overload

Thrill

slide57

PHYSICAL EXAMINATION IN CHD

CONCLUSION

- Medical History - Anatomical

- Inspection. Diagnosis.

- Palpation.

  • Hemodynamic
  • assessment

- Auscultation.