General Data: Name: Baby Boy G Neonate History of the Present Illness Baby Boy Guadiz is born to...
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Transcript of General Data: Name: Baby Boy G Neonate History of the Present Illness Baby Boy Guadiz is born to...
CARDIOVASCULAR CONFERENCE: APPROACH TO A PATIENT WITH CYANOTIC HEART DISEASE
General Data:
Name: Baby Boy G Neonate
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 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 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 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 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 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: 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 Admission: (-) Palpable neck masses, intact clavicle, no
crepitations (-) Chest deformities, symmetrical chest expansion, (-)
retractions, clear and equal breath sounds Adynamic precordium, 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
APPROACH TO DIAGNOSIS OF A PATIENT PRESENTING WITH CYANOSIS AT BIRTH
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
Classification of Congenital Heart Diseases
A) Acyanotic
B) Cyanotic
Major Considerations
Is there a shunt (LR or RL) Is there obstruction to inflow or
outflow Abnormal heart valves Abnormal connections of great
vessels Combination
Subgroups of Acyanotic Diseases
Shunt anomalies Valvular defects Obstructive lesions Inflow anomalies Primary myocardial diseases
Shunt Anomalies
L R shunt Increased pulmonary blood flow Increased pulmonary vascular
arterial markings on chest Xray
ASD, VSD, PDA
Obstructive Lesion
Discrepancy in amplitude of the peripheral pulses
Coarctation of the Aorta
Inflow Anomalies
Increased pulmonary venous markings on chest Xray
No murmur
Cor Triatriatum, Pulmonary vein stenosis
Valvular Defects
Stenosis or regurgitant Characteristic murmur
AS, AR, PS, PR, MS, MR, TS, TR
Primary Myocardial Diseases No murmur Disparity between cardiac size and
pulmonary vascular markings
Glycogen storage disease Cardiomyopathy
Hemodynamic Consequences
A) Volume (Diastolic) overload
B) Pressure (Systolic) overload
ASD
Hemodynamic Consequence
Diastolic overload of RV
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 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?
When in doubtA) ClubbingB) CBCC) 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
Hemodynamic Consequence
Pressure overload of RV
PVA / VSD
Hemodynamic Consequence
Pressure overload of RV
PDA Dependent Pulmonary Circulation
Pulmonary valve atresia (PVA) with intact interventricular septum
Other lesions with accompanying PVA
Approach to diagnosis
A) Chest Xray Increased or decreased pulmonary vascular arterial markings
B) EKG RVH, LVH, CVH
C) Character of second heart sound
S2 single, loudS2 single, normalSplit S2
CHEST X-RAY
Causes of Cyanosis
Noncardiac Cardiac
•Pulmonary disorders (structural abnormalities of the lung, ventilation-perfusion mismatching, congenital or acquired airway obstruction, pneumothorax, hypoventilation)•Abnormal forms of hemoglobin (methemoglobin)•Poor peripheral perfusion (sepsis, hypoglycemia, dehydration, hypoadrenalism)•primary or persistent pulmonary hypertension
Increased pulmonary vascularity•D-TGA•TAPVR without obstruction•PTA•Single ventricle•DORV w/o PS•PPHN
Decreased pulmonary vascularity•TOF•Ebstein’s anomaly•PS•PA•TA with PS•DORV with PS
Pulmonary Vascular MarkingsDecreased: Cyanotic
TOF Tricuspid Atresia
Complex heart with PS PVA / IVS
Second Heart Sound (S2)
Single Loud Single Normal Split S2
TGA TOF TAPVR without obstruction
Aortic / Mitral atresia
Tricuspid atresia
Truncus Arteriosus
PVA
Cardiac Work-Up
A) EKGB) Chest XrayC) 2D echocardiography
(TTE, TEE, ICE, IVUS)D) Cardiac catheterizationE) CT angiography, cardiac MRI
PLACE THE: ECG 2-D ECHO
Modalities of Management
A) PharmacologicB) Catheter based therapyC) Surgical
Pharmacologic
A) digoxin, diuretics, inotropes (pressor), vasodilators
B) Prostaglandin
Catheter Based Therapy (DI KO PA ALAM ITO, EXAMPLES LANG TO)A) Balloon atrio septostomy (Rashkind)B) Balloon valvuloplastyC) Balloon angioplastyD) Delivery of occlusion devicesE) Radio frequency ablation
Surgical (DI KO PA ALAM ITO, EXAMPLES LANG TO)A) Shunts like Modified Blalock-TaussigB) PA bandC) Complete repairD) Glenn, FontanE) NorwoodF) Jatene, Mustard, Senning