Hemodynamics and Physical ExaminationIn

Congenital Heart Disease

Azaria JJT Rein, MD

A Gene, Fetus, Baby, Child and Adult Saga

History of Cardiac Imaging

1995 3-D ECHOCARDIOGRAPHY1997 TISSUE VELOCITY IMAGING

New Approaches in Diagnosis

3 D Imaging

4 CHAMBERS

Coarctation

of the Aorta

Prenatal CardiologyPrenatal Cardiology

THE FETAL KINETOCARDIOGRAM

a a

FKCG~

ECG

Interventional Pediatric Cardiology

Atrial Septal Defect (ASD)

Fetal Interventions

Direct Puncture of LVin a Fetus

"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

CC 2003

HEMODYNAMICS & PHYSICAL EXAMINATION

- Medical History.- Inspection.- Palpation.- Percussion.- Auscultation.

Antenatal- Family History.- Fetus.- Mother disease.

Perinatal- Delivery.- APGAR score.- First sign & symptom.

Postnatal...

Medical History

HEMODYNAMICS & PHYSICAL EXAMINATION

- Medical History- Inspection- Palpation- Percussion- Auscultation

InspectionHi, I’m

Alfred E. Neuman, you know, from Mad

magazine?

InspectionWhy, me

worry???

InspectionWhy, me

worry???

InspectionYes, we both

have Williams’ syndrome!

InspectionMe

too!!!

InspectionWith SVAS, SVPS, PPS

and more!!!

HEMODYNAMICS & PHYSICAL EXAMINATION

AUSCULTATION

- Heart Sounds.

- Murmur.

- Click/Snap

Murmur and Hemodynamics

Flow & PressureTHE SIMPLIFIED BERNOULLI EQUATION

P = 4 VP = 4 V2.

P in mm Hg

V in m/sec.

Murmur and HemodynamicsMURMUR

LAMINAR FLOW -> TURBULENT FLOW

INCREASED FLOW VELOCITY > 1.5 m/sec

INCREASED PRESSURE GRADIENT> 10 mmHg

Murmur Characteristics

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

Murmur CharacteristicsTiming

Systole•Pansystolic•Ejection Type•Exceptions (Late SM, Short SM)

Diastole•Early•Mid

Continuous

Systolic Murmur

systoleS1 S2

IVC

SEM

PSM

Ejection

Systolic Ejection Murmur

systoleS1 S2

EjectionIVC

systoleS1 S2

Pansystolic Murmur

EjectionIVC

Diastole

S1 S2diastole

mo

FillingIVR

S1 S2

Early Diastolic Murmur

FillingIVR

S1 S2

Mid-Diastolic Murmur

FillingIVR

Continuous ( machinery) Murmur

Aorta

PA

The Evolving PDA Murmur

1 day

few days

> 1-2 weeks

The Amplitude of a Murmur

Factors influencing the amplitude grading:- Acoustic energy- Media- Stethoscope- Ears & acoustic nerve- perception

- subjective interpretation

The Pitch of a Murmur

ΔP Pitch

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.

CLICKS & SNAPS

H

HADASSAHPediatricCardiology

Wind Pressure Gradient =

Sail Pliable valve

Systolic Ejection Click

S1 S2

S1 S2

Opening Snap

OS

•Timing•Amplitude

•Pitch•Location•Radiation

•Response to maneuver

Murmur Characteristics

Auscultation

•Aortic Murmurs•“Downstream”

from Aortic Valve

•RUSB

Auscultation

•Aortic Murmurs•“Downstream”

from Aortic Valve

•Aortic Stenosis- Radiates to Carotids

Auscultation

• Pulmonary Murmurs

• “Downstream” from Pulmonary Valve

• LUSB

Auscultation

• Tricuspid Murmurs

• “Downstream” from Tricuspid Valve

• Manubrium Sterni

Auscultation

• Mitral Murmurs• “Downstream”

from Mitral Valve• LLSB

PALPATION

PulsesRateCharacteristics

PrecordiumVolume overloadPressure overloadThrill

PHYSICAL EXAMINATION IN CHD

- Medical History - Anatomical

- Inspection. Diagnosis.

- Palpation. -Hemodynamic assessment

- Auscultation.

CONCLUSION