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CARDIOVASCULAR CONFERENCE: Approach to a patient with cyanotic heart disease. General Data:. Name: Baby Boy G Neonate. History of the Present Illness.

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general data
General Data:
  • Name: Baby Boy G
  • Neonate
history of the present illness
History of the Present Illness
  • Baby Boy Guadiz is born to 22-year old primigravid 2nd year nursing student mother, married to a 23-year old unemployed partner. Initial pre-natal check up of the mother was at 6 month at a local health center. CBC and urinalysis results done revealed normal results.
history of the present illness1
History of the Present Illness
  • UTZ done showed Single Live Intrauterine pregnancy, cephalic, good cardiac and somatic activity, 24-25 weeks AOG, to rule out hypoplastic Right Ventricle. For further evaluation, the mother consulted at our institution and was advised fetal 2D echo.
history of the present illness2
History of the Present Illness
  • The fetal 2D echo revealed pertinent findings of hypoplastic Left Ventricle, hypoplastiv Mitral Valve, and a patent foramen ovale. At 26-27 weeks AOG, the mother had trichomoniasis for which she was given metronidazole tablet for 7 days. At 37-38 weeks, the mother developed UTI. Cefuroxime 500mg BID was given for 7 days that provided symptomatic relief.
history of the present illness3
History of the Present Illness
  • The mother denied any exposure to viral exanthems and radiation. No illicit drugs and abortifacients use. She is a non-smoker; however, was a previous alcoholic beverage drinker. Hep B screening was non-reactive and OGCT was normal. No history of hypertension, allergy, thyroid disease, diabetes, asthma, or blood dyscrasia.
history of the present illness4
History of the Present Illness
  • Family history is negative for diabetes mellitus, hypertension, and cardiovascular disease. The mother came in our institution for follow up but was 3cm dilatation, 70% effacement intact BOW, there was progression of labor alongside with spontaneous rupture of BOW. Clear, non-foul smelling amniotic fluid was observed. Repeat fetal 2D echo was not done due to lack of funds.
history of the present illness5
History of the Present Illness
  • Patient was born live, term, singleton, male, delivered via normal spontaneous delivery, BW 2.75 kg, BL 48 cm, AS 6 and 7, MT 38-39 weeks AOG, AGA.
physical examination on admission
Physical Examination on Admission:
  • HR 134, RR 58, T 37.2˚C
  • BW 2.75 kg, BL 48 cm, HC 33 cm, CC 31 cm, AC 29 cm, AS 6 and 7, MT 38-39 weeks, AGA
  • Blue, pale; some flexion of extremities, good respiratory effort, cyanotic
  • (-) Rash, (-) birth marks,
  • (+) Molding, (+) caput succedaneum (-) cephalhematoma
  • (+) ROR OU, (-) eye discharge, normal set ears, (-) preauricular pits, patent nares, (-) Epstein’s pearls
physical examination on admission1
Physical Examination on Admission:
  • (-) Palpable neck masses, intact clavicle, no crepitations
  • (-) Chest deformities, symmetrical chest expansion, (-) retractions, clear and equal breath sounds
  • Adynamicprecordium, regular heart rate and rhythm, S1 and S2 normal, (-) murmurs
  • Globular abdomen, (+) umbilical stump with 2 arteries and 1 vein, (-) organomegaly, (-) palpable masses
  • Grossly male, bilaterally descended testes, good rugae, patent anus
  • Femoral pulses full and equal, (-) Barlow, (-) Ortolani
  • Straight spine, (-) sacral dimpling, (-) tuft of hair
  • (+) Moro, grasp, rooting, plantar, and sucking reflexes
indicators that heart disease may exist
Indicators that heart disease may exist
  • Cyanosis
  • Cardiomegaly (Radiologic or Pericardial bulge)
  • Pathologic heart murmur
  • Tachypnea or overt respiratory distress (dyspnea)
  • Sweating especially during feeding
  • Increased or decreased pulses
  • Failure to thrive
major considerations
Major Considerations
  • Is there a shunt (LR or RL)
  • Is there obstruction to inflow or outflow
  • Abnormal heart valves
  • Abnormal connections of great vessels
  • Combination
subgroups of acyanotic diseases
Subgroups of Acyanotic Diseases
  • Shunt anomalies
  • Valvular defects
  • Obstructive lesions
  • Inflow anomalies
  • Primary myocardial diseases
shunt anomalies
Shunt Anomalies
  • L  R shunt
  • Increased pulmonary blood flow
  • Increased pulmonary vascular arterial markings on chest Xray
  • ASD, VSD, PDA
obstructive lesion
Obstructive Lesion
  • Discrepancy in amplitude of the peripheral pulses
  • Coarctation of the Aorta
inflow anomalies
Inflow Anomalies
  • Increased pulmonary venous markings on chest Xray
  • No murmur
  • Cor Triatriatum, Pulmonary vein stenosis
valvular defects
Valvular Defects
  • Stenosis or regurgitant
  • Characteristic murmur
  • AS, AR, PS, PR, MS, MR, TS, TR
primary myocardial diseases
Primary Myocardial Diseases
  • No murmur
  • Disparity between cardiac size and pulmonary vascular markings
  • Glycogen storage disease
  • Cardiomyopathy
hemodynamic consequences
Hemodynamic Consequences

A) Volume (Diastolic) overload

B) Pressure (Systolic) overload

slide22
ASD

Hemodynamic Consequence

Diastolic overload of RV

slide23
VSD
  • Hemodynamic Consequence
  • MODERATE SIZE
    • Volume overload of LV
  • LARGE SIZE
    • Volume overload of LV
    • Pressure overload of RV
cyanotic heart disease
Cyanotic Heart Disease
  • Cyanotic heart disease exist when one defect or association of defects allow the mixture of saturated and de-saturated blood to reach the systemic circulation
do you suspect that patient is cyanotic
Do you suspect that patient is Cyanotic?
  • When in doubt
    • Clubbing
    • CBC
    • Hyperoxia test
hyperoxia test
Hyperoxia Test
  • Hyperoxia test is considered positive for intracardiac shunting if PO2 < 150 mmHg (torr) after 10 minutes of 100% fiO2
pva ivs
PVA / IVS
  • Hemodynamic Consequence
  • Pressure overload of RV
pva vsd
PVA / VSD
  • Hemodynamic Consequence
  • Pressure overload of RV
pda dependent pulmonary circulation
PDA Dependent Pulmonary Circulation
  • Pulmonary valve atresia (PVA) with intact interventricular septum
  • Other lesions with accompanying PVA
cardiac work up
Cardiac Work-Up
  • EKG
  • Chest Xray
  • 2D echocardiography

(TTE, TEE, ICE, IVUS)

  • Cardiac catheterization
  • CT angiography, cardiac MRI
slide36

PLACE THE:

    • ECG
    • 2-D ECHO
modalities of management
Modalities of Management
  • Pharmacologic
  • Catheter based therapy
  • Surgical
pharmacologic
Pharmacologic
  • digoxin, diuretics, inotropes (pressor), vasodilators
  • Prostaglandin
catheter based therapy di ko pa alam ito examples lang to
Catheter Based Therapy (DI KO PA ALAM ITO, EXAMPLES LANG TO)
  • Balloon atrioseptostomy (Rashkind)
  • Balloon valvuloplasty
  • Balloon angioplasty
  • Delivery of occlusion devices
  • Radio frequency ablation
surgical di ko pa alam ito examples lang to
Surgical (DI KO PA ALAM ITO, EXAMPLES LANG TO)
  • Shunts like Modified Blalock-Taussig
  • PA band
  • Complete repair
  • Glenn, Fontan
  • Norwood
  • Jatene, Mustard, Senning