Dr. aso faeq salih Pediatric cadiologist 2013-2014 Congenital heart disease.
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Transcript of Dr. aso faeq salih Pediatric cadiologist 2013-2014 Congenital heart disease.
Most common cardiac malformation 25-30 %
Types of VSD : According to position
perimembranous , inlet , muscular . According to size small , medium
, large .
Membranous : most common , are usually single ,
( called peri membranous ) may extend into adjacent muscle
Muscular : mid portion of septum to the
apex .Single or multiple (Swiss cheese
septum )Inlet :At level of both Av valve s
Size of defect :
Small (restrictive ) : Trivial L R shunt . (LV pressure
> RV ) Normal pulmonary arterial &RV
pressure . Normal cardiac chambers .
Large (non restrictive ) :
> aortic annulus RV, LV pressure equalizes . Direction & magnitude of shunt
determined by ratio of pulmonary to systemic vascular resistance .
RV , pulmonary arterial hypertension .
Main pulmonary artery , LA , LV are enlarged
Medium will be in between
Clinical features :
Varies according to : size of defect , pulmonary blood flow & pressure .
Small VSD : Most often asymptomatic . Loud , harsh , blowing ,
holosystolic murmur heard best over LLSB frequently accompanied by thrill .
Large VSD : Dyspnea , feeding difficulties , poor growth ,
profuse perspiration , recurrent chest infection & cardiac failure in early infancy .
Cyanosis usually absent , duskiness noted during crying or infection .
Physical signs : Prominent L precordium , palpable para
sternal lift . Lateral displacement of apex beet , apical
thrust . Holosystolic murmur ( less harsh , more
blowing ). Pulmonary component of S2 may be
increased pulmonary hypertension
Investigations :
CXR : Small VSD : normal or minimal cardiomegaly . borderline increase in pul.
Vasculature . Large VSD : gross cardiomegaly ( RV , LV, LA PA
). prominent pulmonary vascularity .ECG: Small VSD : normal or may suggest LV
hypertrophy Large VSD: biventricular hypertrophy P- wave notched or peaked .
Treatment :
Small VSD: Reassurance & encourage to live
normal life with no restriction of activities .
Protection against infective endocarditis .
Regular follow – up
Large VSD :
Aim of treatment : Control the symptoms of H.F . Prevent the development of pulmonary
vascular disease .Surgical closure of defect : Indications :1.Patient at any age with large defect in
whom clinical symptoms , FTT cannot be controlled medically .
2.Supracristal VSD .3.VSD complicated with AR or subvalvular
PS
Prognosis & complications :
Small VSD : Spontaneous closure : 30 – 50 %
most often during first 2 years of live ( small muscular are > likely to close ( up to 80 % ) than membranous (up to 35 % ) .
Most often asymptomatic . Infective endocarditis .
Moderate – Large VSD :
• Early & successful therapy may become smaller & up to 8 % may close completely .
• Repeated episodes of chest infection .• H.F & FTT .• Pulmonary HT & evidence of pulmonary
vascular disease .• Eisen menger complex .• Aortic valve regurgitation • Acquired infundibular pulmonary stenos
is .
6 – 8 % of CHD , F:M 2 : 1
Ass. With maternal rubella infection in early pregnancy .
Common problem in premature infants .
Ductus Arteriosus : Fetal life , patency of Ductus is
maintained by : Relaxant effect of low O2 tension . Prosta glandines (E2) .
•In full term neonates , once Po2 passing through Ductus reaches 50 mmHg Ductal wall constricts . Functional closure of Ductus 10 – 15 hrs. in normal neonate , anatomical occlusion 4 m of age Ligamentum arteriosum
Types &clinical manifestations :Small PDA :
Usually asymptomatic . Normal cardiac size . Pressure within PA , RA & RV are
normal .
Large PDA :
PA pressure may be elevated to a systemic pressure .
Risk of pulmonary vascular disease . Often symptomatic ( HF & growth
retardation ). Bounding peripheral pulsations . Wide pulse pressure . Moderate – gross cardiomegaly . heaving apical impulse. Thrill (systolic ) max. in 2nd L ICS +/_
radiation . Machinery continuous murmur max. in 2nd L
ICS .
Investigations :
CXR :Small PDA : normal .Large PDA : moderate – gross
cardiomegaly ( LV , LA ). Prominent intra pul. Vascular
marking . normal or prominent aortic
knob .ECG : Small normal. Large LV or biventricular
hypertrophy.
Prognosis & complications : Small PDA : May live a normal span with a
few or no symptoms . Spontaneous closure after
infancy is extremely rare. Infective endocarditis .
Treatment :
Surgery :Ligation & division of Ductus ,
preferably before 1st year of live .
Trans catheter closure of defect.