Structures of the heart

Normal Heart

Atrial Septal defect( ASD )Insidence : + 10 % : ratio = 1,5 to 2 : 1Anatomy : Defect on foramen ovale : Secundum ASD Defect at SVC and RA junction: sinus venosus ASD Defect at ostium primum : primum ASD

ASD

Atrial Septal Defect

Atrial Septal DefectDiagram of ASD

LALVRVRAPAAOSystemicLungsQp > QsAtrial septal defect

RARVLALVRARVLALVAtrial septal Defect

Atrial septal DefectClinical findingsAsymptomaticAuscultation : Normal 1st HS or loudWidely split and fixed 2nd HSEjection systolic murmur

Atrial Septal DefectAuscultation :1st HS N or loudwidely split and fixed 2nd HS Ejection Sistolic Murmur

ECG : IRBB , right ventricular hypertrophyAtrial Septal Defect

Right atrial enlargementProminence the MPA segmentIncreased pulmonary vascular marking Atrial Septal DefectChest X-Ray

Atrial Septal DefectDiagnosis Differential

Primary Atrial Septal DefectECG : LADPartial Anomalous Pulmonary Vein DrainagePulmonary StenosisInnocent Murmur

Atrial Septal defect

ManagementSurgery : Preschool ageRecent treatment: transcatheter closure using ASO (Amplatzer septal occluder)

ASDSmall ShuntLarge ShuntObservationEvaluationAt age 5-8 yrsCathFR1.5ConservativeInfantsChildren/AdultsHeart Failure (-)Heart Failure (+)Age >1yrsW >10kgTranscatheter closure (Secundum ASD) /Surgical Closure(others)ConservativeAnti failureFailSuccessPH (-)PH (+)PVD (-)PVD (+)HyperoxiaReac-tiveNonreactiveSurgicalClosure

Atrial septal defect

Ventricular septal defectInsidence 20 % of all CHD No sex influencedAnatomy Subarterial defect : below pulmonary andaortic valve Perimembranous defect: below aortic valve at pars membranous septum Muscular defect

VSD

Ventricular Septal Defect

SystemicLungsQp > QsVentricular Septal defect

LA

LV

RV

RA

PA

AO

RARVRALALARVLVLVVentricular septal defect

Ventricular Septal Defect

Ventricular Septal DefectClinical findingsDay 1st after birth: murmur (-)After 2-6 weeks : murmur (+)Murmur : pansystolic grade 3/6 or higher at LSB 3 Small muscular defect: early systolic murmurSignificant defect: Mid diastolic murmur at apex

Small VSD Large VSD Ventricular Septal DefectMurmur: pansystolic grade 3/6 or higher at LSB 3

Ventricular septal DefectDiagnosis Differential

PDA with PHTetralogy Fallot non cyanoticInoscent murmur

Ventricular septal defectManagement:

Definitive : VSD closure Surgery Transcatheter closure

DSVHeart failure (+)Heart failure (-)Anti failureFailSuccessPABEvaluate in 6 mthsSurgical closure/Transcatheter closureAortic valve prolapsInfundibular stenosisPHSmallerSpontaneousclosureCathPVD(-)PVD(+)CathCathReactiveNon-reactiveConservativeFR>1.5FR

Patent Ductus Arteriosus Insidence+ 10%Female : Male = 1.2 to 1.5 : 1Premature and LBW higherAnatomyFetus: ductus arteriosus connects PA and aorta. If ductus does not closs Patent Ductus arteriosus

PDA

LALVRVRAPAAOSystemicLungsQp > QsPatent Ductus Arteriosus

RARVLALVRALARVLVPatent Ductus Arteriosus

Patent Ductus ArteriosusClinical findings

Small defect: Symptom (-) Growth and development normalSignificant defect:Decreased exercise tolerantWeigh gained not goodFrequent URTISpecific case: pulsus seler at 4th extremities

Patent Ductus Arteriosus DiagnosisPulsus seler and continuous murmur heard

Patent Ductus ArteriosusChest X- RaySimilar to VSD

Patent Ductus ArteriosusAuscultation : continuosus murmur at upper LSB 2

Patent Ductus ArteriosusDiagnosis DifferentialAP-windowArterio-venous fistulae

Management premature: indometasinPDA closure : surgery transcatheter closure

PDANeonates/InfantsChildren/AdultsHeart failure (+)Heart failure (-)PrematureFull termAnti failureIndometacinSuccessFailSpontaneous closureAnti failureSuccessFailSurgical ligationTranscatheter closurePH (-)PH (+)LRRLHyperoxiaReactiveNonreactiveConservativeAge >12wksW >4kg

Patent Ductus Arteriosus

Patent Ductus Arteriosus

Pulmonary Stenosis Incidence : 8-10%

Anatomy:Pulmonary stenosis valvular : Bicuspid pulmonary valve Valve leaflet thickening and adhession Pulmonary stenosis infundibular : Hyperthropy infundibulum

Pulmonary Stenosis Clinical findingsValvular stenosis Mild : Ejection systolic Wide 2nd HS ejectiin clickModerate: ejection systolic, early systolic clickSevere : ejecstion systolic, ejection click (-) Stenosis infundibular Ejection click ( - )1st HS normal, 2nd HS weak, ejection systolic Pulmonary stenosis periphery1st & 2nd HS normal, ejection systolic

Pulmonary StenosisMild : ejection systolic 2nd HS wide split ejection clickModerate: ejecsi systolic , early ejection click Severe : ejection systolic, click ejection (-)

Poulmonary StenosisDiagnosisAsymptomatic patient:click systolic (stenosis valvular)systolic murmurwide split 2nd HS vary with respiration

Pulmonary Stenosis ECG : RADEchocardiograhhy : confirmation diagnosisCatheterization: increased RV pressure without increased oxygen saturation

Pulmonary StenosisManagement

Medicamentosa : uselessMild stenosis: intervention (-)Moderate stenosis: observationSevere stenosis: balloon valvuloplasty

Pulmonary Stenosis

Tetralogy FallotInsidence5-8% from all CHD

AnatomyCause: Left-anterior deviation of infundibular septum

Sindroma consist of 4 items: VSD pulmonary stenosis aortic over-riding RVH

Tetralogy Fallot

Tetralogy FallotHemodynamic acyanoticHemodynamic cyanotic

Tetralogy FallotDiagnosis

Clinically : cyanosis Single 2nd HS, ejection systolic murmur

Tetralogy FallotSingle 2nd HS, ejection systolic murmur

Tetralogi Fallot

Tetralogy FallotCXR : Boot-shapedConcave pulmonary segmentApex upturnedDecreased pulmonary blood flow

Tetralogy FallotECG : RADEchocardiography : to confirm diagnosis

Tetralogy FallotDiagnosis Differential Pulmonary Atresia Double outlet right ventricle and pulmonary stenosis Transposisi of great arteri and pulmonary stenosis

Management Paliative treatment: Blalock-Taussig shunt Definitive: total correction

Tetralogy of Fallot< 1 yr> 1 yrspell (+)spell (-)propranololfailedsucceedBTStotal correction cathsmall PAgood sized PA clinically ECG CXR echoage 1 yrcathBTS/PDA Stentevaluation

Tetralogy Fallot

Tetralogy Fallot