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Congenital Heart Diseases. Dr Swati Prashant MD Paediatrics Index Medical College, Indore,MP,India drprahantw@gmail.com . www.paediatrics4all.com. Left To Right Shunts. The most common L →R Shunts are : 1 . VSD : 27% 2 . ASD : 13 % 3. PDA : 11 % .

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congenital heart diseases

Congenital Heart Diseases

Dr Swati Prashant

MD Paediatrics

Index Medical College, Indore,MP,India

drprahantw@gmail.com.

www.paediatrics4all.com

left to right shunts
Left To Right Shunts
  • The most common L →R Shunts are :
  • 1. VSD : 27%
  • 2. ASD : 13 %
  • 3. PDA : 11 % .
atrial septal defect
Atrial Septal Defect
  • It constitutes 13 % of all CHD .
  • There is an abnormal communication between the 2 Atrias .
  • ASD’ s are of 3 types .
  • 1OstiumSecundumdefect : 70% .Defect is at the fossa Ovalis or rarely superior or Posterior to fossa .
  • 2. Ostium Primum defect : 30% . Defect is
atrial septal defect1
Atrial Septal Defect
  • Defect is an Endocardial Cushion defect lying Inferior to fossa . It may be associated with Mitral Valve defect .
  • 3. Sinus Venosus defect : 10% ,associated with defect at entry of SVC in Rt. Atrium .
atrial septal defect2
Atrial Septal Defect
  • Haemodynamics
  • 1. Oxygenated blood from Lt Atrium
  • Right Atrium
  • It receives extra blood , causing
  • Right Atrial enlargement
  • Large volume of Blood passes through Normal Tricuspid Valve
atrial septal defect3
Atrial Septal Defect
  • Causing Delayed Diastolic Murmur ( DDM ).
  • large Volume is received by RV
  • Rt. Ventricle enlarges ( cardiac impulse
  • Large vol . Thru. Pulmonary Artery
  • causes Ejection Systolic Murmur
  • & delayed closure of P2 , Therefore A2 --P2
  • WIDE split & loud p2 . As age advances PH OCCURS .
clinical features
Clinical Features
  • Mild effort intolerance
  • Chest infections
  • CCF Rare .
  • Parasternal Impulse
  • A2—P2 Wide split fixed
  • Systolic Thrill & Murmur in P2 area due to flow thru. Pulmonary valve .
  • .
atrial septal defect4
Atrial Septal Defect
  • Complications are rare
  • After age 20 yrs. PH occurs .
  • ECG---RVH & RBB
  • X-Ray---mild cardiomegaly , RAH ,RVH ,PA prominent , plethora.
atrial septal defect5
Atrial Septal Defect
  • TREATMENT :
  • 1. T/t of Infections , ccf
  • 2. Surgery
  • Common syndromes asso. With ASD :
  • Down’s Syndrome , Holt Oram syndrome , Lutembachker , Noonans syndrome .
ventricular septal defect
Ventricular Septal Defect
  • It is most common amongst the CHD .
  • Constitutes 27% of all CHD’s .
  • Location : 90% of VSD are in Membranous part of the Septum
  • Others occur in Muscular part & can be multiple .
  • Syndromes: Trisomy 13 - 15 , 17-18. Absent Radius & Ulna , poly & Syndactyly .
ventricular septal defect1
Ventricular Septal Defect
  • HAEMODYNAMICS
  • Left → Right shunt .
  • Lt. Ventricle blood →enters Rt. Ventricle through the defect .
  • At the same time Rt. Ventricle is also contracting. So the blood is almost directly going to Pulmonary Artery .
  • Large vol. Thru. PA → CAUSE Ejection Sys. Murmur + delayed P2 , due to delayed empting .Also there is early empting of LV causing early A2 .
ventricular septal defect2
Ventricular Septal Defect
  • Therefore there is a wide split A2 P2 .
  • ↑ blood in LA causes LA ENLARGEMENT.
  • ↑ blood flow thru. Mitral valve causes DDM at apex .
  • Shunt itself causes PANSYSTOLIC Murmur as blood is going thru. The shunt in systole ----in Tricuspid area --lt. Sternal border 3,4,5 space .
clinical features ventricular septal defect
Clinical Features-Ventricular Septal Defect
  • Symptomatic around 6 –10 wks.
  • CCF develops .
  • Palpitation , dyspnea on exertion .
  • Frequent chest infections .
  • Wide pulse pressure .
  • Hyperkinetic precordium with systolic Thrill .
  • Cardiomegaly with Left ventricular Apex .
ventricular septal defect3
Ventricular Septal Defect
  • Wide split 2 ndHEART SOUND
  • P2 accentuated
  • Pansystolic Murmur at Lt. Sternal border ( 3 ,4 ,5th IC SPACE .
  • ECG : 1) RVH initially & in newborn .
  • 2) IN small & mod . Size VSD ,RVH comes to normal after ↓ of pulmonary resistance .
ventricular septal defect4
Ventricular Septal Defect
  • 3) In large VSD without PAH there is LVH
  • 4) In large VSD + PS /PAH : ECG shows RVH + LVH or purely RVH .
  • X-RAY CHEST
  • 1. LVH—Depends on size of shunt .
  • 2. Plethora
  • 3. Aorta N or small in size .
ventricular septal defect5
Ventricular Septal Defect
  • 4. LAH in large shunts .
  • 5. If VSD is small : Heart size normal, pulmonary vasculature is normal .
  • 6. If VSD + PS : Heart size is normal , normal lung fields .
  • 7. If VSD + PAH : Heart size is normal ,but lung fields are Plethoric .
assessment of severity
Assessment of Severity
  • Small VSD : PSM + normal P2 , disappearance of murmur + ECG becomes Normal .
  • Large VSD : RV pressure = LV pressure , therefore murmur becomes softer + PAH + accentuated P2
  • Large VSD + PS : ejection systolic murmur +↑ RV pressure + normal PA pressure + P2 soft
treatment ventricular septal defect
Treatment-Ventricular Septal Defect

Medical : T/t --CCF , Infections , Anemia , Endocarditis .

Surgery : Indications

1. CCF in infancy not responding to medical t/t .

2. L→ R shunt is large

3. VSD ( large) + PS / PH or AR .

4. Surgery : contraindicated in PAH + reversal of shunt .

ventricular septal defect6
Ventricular Septal Defect
  • Surgery : Closure of VSD WITH A Dacron patch , through Rt. Atrial approach .
  • Surgery is advised if PAH develops , within 2 yrs.
  • Complications of Surgery :
  • Complete Heart Block , residual VSD .
patent ductus arteriosus
Patent Ductus Arteriosus
  • It is a communication between the Pulmonary Artery & the Aorta .
  • Aortic attachment is just distal to the Left Subclavian Artery .
  • Ductus arteriosus is normally present in fetal life .
  • It closes normally after birth .
  • It constitutes 11% of all cardiac defects .
haemodynamics patent ductus arteriosus
Haemodynamics- Patent Ductus Arteriosus
  • L→R shunt from Aorta to Pulmonary Artery .
  • Flow is both during systole as well as Diastole , as pressure is always higher in Aorta with normal Pulm . Artery .
  • This L →R shunt causes murmur . Murmur starts in systole after 1st HS & Continues in Diastole but with diminished intensity , therefore Continuous murmur.
patent ductus arteriosus1
Patent Ductus Arteriosus
  • LA receives large amt. of blood ,therefore LA enlarges In size .
  • ↑ blood flow through Mitral valve -> causes accentuated 1st HS + DDM .
  • LV also receives more blood → overloading → prolongation of lt. Ventricular systole & ↑ in LV size .
  • Prolonged systole → cause delayed closure of Aortic valve ---late A2 .
patent ductus arteriosus2
Patent Ductus Arteriosus
  • Late A2 causes paradoxical split in large shunts .
  • Large vol. Coming to Aorta causes Aortic dilatation ( ascending ) , this causes Ejection click & Ejection systolic murmur , but this is masked by continuous murmur .
clinical features patent ductus arteriosus
Clinical Features- Patent Ductus Arteriosus
  • Patient becomes symptomatic early in life .
  • Develops CCF around 6-10 wks of life , or even earlier within 7 days of birth with murmur + ccf .
  • In older children there is effort intolerance , palpitation , chest infections .
patent ductus arteriosus3
Patent Ductus Arteriosus
  • As there IS a leak of blood to PDA from systemic blood there is a wide pulse pressure + collapsing pulse .
  • Prominent CAROTID pulsations + features L → R shunt is s/o PDA .
  • Cardiac impulse & Apex Beat are Hyperkinetic s/o LVH due to ↑ blood Volume .
patent ductus arteriosus4
Patent Ductus Arteriosus
  • Continuous / systolic murmur + Thrill at Lt. 2nd space .
  • SO IF SHUNT IS LARGE :
  • 1. 1 st HS is accentuated due to ↑ Mitral flow .
  • 2. 2 nd HS is narrow /paradoxically split
  • 3. P2 is louder than normal .
  • Continuous murmur best heard in P2 AREA
patent ductus arteriosus5
Patent Ductus Arteriosus
  • ECG : LVH--- ‘ Q’ & tall ‘T’ waves are characteristic of Lt . Ventricular vol. Overload .
  • X-Ray chest : cardiomegaly with LV enlargement .( large shunt -- large size, large shunt --narrow split , small shunt --- no split .)
  • LA enlarged , Ascending Aorta ( knuckle) prominent .
course complications
Course & Complications
  • In Newborn & infants ---PH is +nt at birth causing Ejection syst. Murmur .
  • Later as PH ↓ the murmur becomes continuous .
  • CCF same as in VSD .
  • In PDA ,PH later due to flow develops earlier than VSD .
  • As PH develops later diastolic component ↓ ,so the murmur becomes Ejection syst. Murmur .
slide29

If PH --P2 is loud + DDM +nt

  • If PS --P2 is soft or N + no DDM
  • If L→ R becomes R→L there is no murmur , but DIFFERENTIAL CYANOSIS is present
  • In PDA + PH causing reversal .
treatment patent ductus arteriosus
Treatment- Patent Ductus Arteriosus
  • For closure of PDA
  • 1. Indomethacin ( prostaglandin synthetase inhibitor ) given orally
  • Dose is 0.1 mg /kg / day 12 hourly in 3 doses.
  • Hepatic / Renal / Bleeding tendency----CI
  • 2. Surgical ligation PDA .
thank you all
Thank you all
  • Paediatrics4all.com
  • Pharmacology4students.com
  • Psm4students.com
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