Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.
-
Upload
martin-bishop -
Category
Documents
-
view
217 -
download
4
Transcript of Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.
![Page 1: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/1.jpg)
Prof. S. Shanmuga SundaramK.S. Hospital, Chennai
![Page 2: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/2.jpg)
PULMONARY HYPERTENSION AT SYSTEMIC LEVEL, DUE TO HIGH PULMONARY
VASCULAR RESISTANCE ( > 800 dynes sec cm-5 ) WITH REVERSED OR BIDIRECTIONAL SHUNT…..
8% (1950) → → → → 4%
![Page 3: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/3.jpg)
Vongpatanasin, W. et. al. Ann Intern Med 1998;128:745-755
Complications associated with the Eisenmenger syndrome
DEATH: Sudden death 30% , Heart failure 23% , Hemoptysis 11%
Death during noncardiac surgery & pregnancy
![Page 4: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/4.jpg)
DISSECTION OF PULMONARY ARTERY
PROXIMAL PA THROMBOSIS
![Page 5: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/5.jpg)
PULMONARY ARTERIAL HYPERTENSION IN SHUNT LESIONSmPAP > 25 mmHg at rest / > 30 mm Hg post exercisePAWP < 15 mm Hg ; PVR > 3 Wood Units• TRANSMISSION OF SYSTEMIC ARTERIAL PRESSURE • VASOCONSTRICTION• VASCULAR OBLITERATION – MEDIAL HYPERTROPHY INTIMAL
PROLIF + FIBROSIS ARTERIAL
THROMBI
HYPERKINETIC OBLITERATIVE
PVR < 5 W.U > 5 W.U
PA PP/PA SP > 60% < 40%
![Page 6: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/6.jpg)
ASD VSD PDA CA, APVC TGA VSD, DORV APWINDOW SINGLE VENTRICLE TRUNCUS > 2 cm > 1 cm > 1 cm
![Page 7: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/7.jpg)
PULMONARY CIRCULATION - STRUCTURAL REMODELING
Elastic > Fully muscular > Partially muscular > Non muscular
At birth the smallest muscular arteries dilate with medial thinning
By 4 months, this process involves larger arteries & get completed
Alveoli and Arteries grow both in number & size Al : Art = 20:1 > 8:1
With shunt lesions resulting in increased flow ± pressure, proximal arteries dilate, distal arteries reduce in number and size bcause of extension of muscle in media of partially or non muscular arteries
![Page 8: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/8.jpg)
NORMAL VSD
![Page 9: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/9.jpg)
MATURATION OF PULMONARY VASCULAR BED Lucas R. Am J Dis Child
![Page 10: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/10.jpg)
![Page 11: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/11.jpg)
PAH IN L > R SHUNTSNONRESTRICTIVE VSD = 15 % < 2 yrs of life
MODERATE DEFECTS = 3% ; LARGE DEFECTS (1.5cm) = 50%
LARGE PDA = similar incidenceLARGE ASD = 6-10% > 3rd
decade Frequent in SVC, partial AV Canal defects & in
Lutembacher’sTGA = 8% (intact IVS ) 40% ( VSD/PDA ) < 1 yr 75% at 2 yrsCOMMON AV CANAL all develop PAHTRUNCUS ARTERIOSUS by 1-2 yrsSYSTEMIC - PA SHUNTS: BT Shunt (<10%) Waterston / Pott’s ~
30%
![Page 12: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/12.jpg)
MECHANISMS OF PAH IN L>R SHUNTS LESION ↑Qp ↑PAP ↑PVP ↓ pH
↑ Ht ASD + - - -
- VSD + + + -
- PDA + + + -
- AV CANAL + + ++ -
- TGA, TA + + +
+ +
![Page 13: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/13.jpg)
PLATELET ADHESION + THROMBUS
ENDOTHELIAL DYSFUNCTION↑ ET, TXA2 , SEROTONIN ↓
NO ,PGI2,VIP
![Page 14: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/14.jpg)
GENETIC SUSCEPTIBIILITY BMPR2 MUTATION = 6 % 26%(IPAH) 50% (FPAH)
![Page 15: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/15.jpg)
![Page 16: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/16.jpg)
MORPHOMETRIC GRADING Rabinovitch M
Grade A : Extension of muscle into small peripheral arteries
Wall thickness increased but < 1.5 times the normal
↑ ↑ PBF ↑ PA PP + NORMAL MEAN PAP PBF ↑ PA PP + NORMAL MEAN PAP Grade B : Mild : medial thickness 1.5 – 2.0 times
the normal Severe : medial thickness > 2 times
the normal PAH - MEAN PAP > 50 % OF PAH - MEAN PAP > 50 % OF
SYSTEMIC LEVELSYSTEMIC LEVEL Grade C : Size and number of arteries reduced PAH - PVR > 3.5 - 6.0 u.m2PAH - PVR > 3.5 - 6.0 u.m2
![Page 17: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/17.jpg)
CLINICAL RECOGNITION• Apparent improvement of neonatal HF• Reduction of frequency of respiratory
infections• Precordium becomes less tumultous• Flow murmur decreases > disappears• Shunt murmur decreases in intensity &
duration• S2 split decreases and P2 increases in
intensity
![Page 18: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/18.jpg)
EISENMENGER’S SYNDROMESYMPTOMS:
1) Low C.O + Hypoxia > DOE, Dizziness, Syncope, Fatigue
2) Hemoptysis : Rupture of plexiform, dilatation lesions, pulmonary arterioles, Broncho Pulmonary connexions, Pulmonary Embolism / in situ thrombosis
3) Hyperviscosity: Headache, dizziness, Visual sx 4) Right Heart failure : Edema, RHC pain 5) CVA : Hyperviscosity, Parad. emboli,
Cerebral abscess
6) Sudden cardiac death: Arrhythmia
![Page 19: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/19.jpg)
EISENMENGER’S SYNDROMESIGNS : 1) Cyanosis and Clubbing 2) JVP inconspicuous 3) Pulmonary Ejection Sound 4) 2-3/6 Ejection Systolic Murmur
5) Loud P2 6) Murmurs of TR and PR
![Page 20: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/20.jpg)
EISENMENGER’S SYNDROME FEATURE ASD VSD PDA
Neonatal HF - + + Age 30-40 2-12 2-12
Syncope ± ± -
Cyanosis Uniform Uniform Differential
Cardiomegaly,PSH + - - Wide pulse pressure - - ± Prominent ‘a’ JVP + -
- S2 split Fixed Single Normal Long PR murmur - - +
![Page 21: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/21.jpg)
![Page 22: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/22.jpg)
![Page 23: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/23.jpg)
![Page 24: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/24.jpg)
![Page 25: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/25.jpg)
PDA
DOPPLER
PATTERNS
PAH
PULSATILE CLOSING CLOSED
GROWING
![Page 26: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/26.jpg)
DOPPLER IN PDA
![Page 27: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/27.jpg)
SHUNT LESIONS - OPERABILITY
Qp : Qs = > 2:1 No or mild PAHQp : Qs = < 1.5:1 Severe PAH - INOPERABLE
Qp = O2 Consumption / PV – PA O2 content Qs = O2 consumption / SA - MV O2 content
O2 content = O2 saturation x O2 carrying capacity x Hb
Qp : Qs = SA – MV O2 sat / PV – PA O2 sat
![Page 28: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/28.jpg)
Why to assess operability ?
![Page 29: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/29.jpg)
CHD PAH – REVERSIBILITY TESTING HIGH SURGICAL RISK ( 20% ) RIGHT VENTRICULAR FAILURE
( IPAH like ! ) PROGRESSION OF PAH
AGENTS CRITERIA
100% OXYGEN (10 mts) ↓Rp /Rs > 20% NITRIC OXIDE (10-80ppm) Rp:Rs < 0.33 02 + N.O (Se 97% Sp 90%) Rp < 8 u.m2 ADENOSINE (50-500µg/kg/mt) EPOPROSTENOL (2-10 ng/kg/mt) ILOPROST (2.5-5.0 µg )
![Page 30: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/30.jpg)
ASSESSING OPERABILITY BASED ON PVR
MISTAKES & MISCONCEPTIONS
Expecting PAP to decline ( ↓ PVR > ↑ FLOW )Assuming O2 consumptionIgnoring dissolved O2 in calculating PVR
O2 sat x 1.36 x Hb = 60 x 1.36 x 12 = 98 ml/L ( 0.03 x 55 = 1.7ml ) 98 x 1.36 x 12 = 160 ml/L ( 0.03 x 95 = 2.9ml ) PVR = 60 – 8 = 52 / 3.2 = 16 units ( 16.5 units ) After 100% oxygen : 72 x 1.36 x 12 = 118 ml/L ( 0.03 x 100 = 3 ml ) 98 x 1.36 x 12 = 160 ml/L ( 0.03 x 500 = 15 ml) PVR = 55 – 8 = 47 / 4.8 = 9.8 units ( 12.7 units )
22 to
44%40 to60%
60 to 100%
![Page 31: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/31.jpg)
PVR INDEXED TO BODY SURFACE AREA A child of BSA of 0.5 m2 has a PBF of 2 l/mt PA mean pressure = 20 mmHg ; mean LAP = 8
mmHg
PVR absolute value = 20-8/2 = 6 units
If corrected for BSA = 6/0.5 = 12 units
PBF corrected to BSA = 2/0.5 = 4 l/mt/m2
PVR indexed to BSA = 20-8/4 = 3 u.m2
![Page 32: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/32.jpg)
ROLE OF ECHOCARDIOGRAPHY• Qp/Qs by doppler, PAcT not reliable• PA peak velocity > 1.0 m/s predictive• PVR = TR Velocity/ TVI RVOT x 10 +
0.16• Vp > 18 cm/s = PVR < 6 units
12.4 cm/s
23.1 cm/s
4 WU8.8 W.U
16.4 W.U
![Page 33: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/33.jpg)
![Page 34: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/34.jpg)
PULMONARY WEDGEANGIO
![Page 35: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/35.jpg)
PREDICTION OF PVOD Wilson NJ CCVD 1993;28:22
PREDICTING HEATH EDWARDS Grade III - IV
Sensitivity Specificity
PVR > 6 units 100% 94%
Monopedial count<3 83% 100% Abnormal blush 83% 69%
Combination of all 100% 100%
![Page 36: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/36.jpg)
LUNG BIOPSYMORPHOMETRIC GRADING Rabinovitch M
Grade A : Extension of muscle into small peripheral arteries
Wall thickness increased but < 1.5 times the normal
↑ ↑ PBF ↑ PA PP + NORMAL MEAN PAP PBF ↑ PA PP + NORMAL MEAN PAP Grade B : Mild : medial thickness 1.5 – 2.0 times
the normal Severe : medial thickness > 2 times
the normal PAH - MEAN PAP > 50 % OF PAH - MEAN PAP > 50 % OF
SYSTEMIC LEVELSYSTEMIC LEVEL Grade C : Size and number of arteries reduced PAH - PVR > 3.5 - 6.0 u.m2PAH - PVR > 3.5 - 6.0 u.m2
![Page 37: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/37.jpg)
CARDIAC MRDEFECT SIZE &
LOCATIONPA SIZE ↑ WITH PAHRV FUNCTIONQp/Qs RATIO Phase
contrast velocity mapping
MR OXIMETRY ( T2 relaxation time)
DEGREE OF PAH
![Page 38: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/38.jpg)
BALLOON OCCLUSION IN HYPERTENSIVE DUCTUS Roy A IHJ 2005;57:332
Fall in m/d PAP > 20 mmHg
![Page 39: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/39.jpg)
TRIAL OCCLUSION OF PDA Yan C Heart 2007;93:514
Trial occlusion for 30 mts with ADO Reduction of mPAP 78 ± 19.3 to 41 ± 13.8 mm
Hg FU for 3 to 6 months – clinical improvement
![Page 40: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/40.jpg)
PAH IN ATRIAL SEPTAL DEFECT
• 6% ( Mayo clinic); 9% - half were below 20 yrs(CMC)
• PAH (mPAP>30 mmHg) 26% SVC (9% FO) ↑PVR 16% SVC (4% FO ) ; at younger age • 85 % were women ( overall F:M = 2:1 )• PVR > 15 units do poorly – death / progression of
PAH• PVR < 10 units do well with surgery• PVR 10 – 15 units – if SPO2 is < 90% surgery
not useful
![Page 41: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/41.jpg)
DEVICE CLOSURE IN ASD + PAH Balint OH Heart 2008;94:1189
PAH Moderate Severe
PASP 50-59 >60
At 3 m PASP ↓ 57± 11 to
51±17 At 3 yrs PASP ↓ to 44 ±16 Only in 43.6% PAP
normalised 15.4% had persistent
severe PAH
![Page 42: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/42.jpg)
EISENMENGER’S SYNDROMEMANAGEMENT ISSUESAvoid dehydration, living at high altitude
Air travel safe (supplemental O2) Avoid pregnancy ( No OCP – tubal
ligation/vasectomy)Treat Iron deficiency ( MCV < 82 ) ;
hyperuricemiaVensection for hyperviscosity syndromeAntiplatelet / Anticoagulants ?Disease targeting therapies : Prostacyclin &
analogues, sildenafil, bosentanSurgery: Correction after PA banding,
prolonged vasodilator therapy, Heart Lung Transplant
![Page 43: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/43.jpg)
Vongpatanasin, W. et. al. Ann Intern Med 1998;128:745-755
Management of the patient with the Eisenmenger syndrome and erythrocytosis
![Page 44: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/44.jpg)
Vongpatanasin, W. et. al. Ann Intern Med 1998;128:745-755
Causes of and Therapy for Hemoptysis in Patients with the Eisenmenger Syndrome
![Page 45: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/45.jpg)
![Page 46: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/46.jpg)
BOSENTAN IN CHD + PAH Diller GP Heart 2007;93:974
![Page 47: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/47.jpg)
BOSENTAN IN CHD + PAH Alto MD, Heart
2007;93:621
![Page 48: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/48.jpg)
![Page 49: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/49.jpg)
PROGNOSIS EISENMENGER SYNDROME ~ IPH
ACTUARIAL
SURVIVAL
E.S IPAH
1 yr 97 % 77 %
2 yr 89 % 69 %
3 yr 77 % 35 %
![Page 50: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/50.jpg)
MORPHOMETRIC GRADING Rabinovitch M
Grade A : Extension of muscle into small peripheral arteries
Wall thickness increased but < 1.5 times the normal
↑ ↑ PBF ↑ PA PP + NORMAL MEAN PAP PBF ↑ PA PP + NORMAL MEAN PAP Grade B : Mild : medial thickness 1.5 – 2.0 times
the normal Severe : medial thickness > 2
times the normal PAH - MEAN PAP > 50 % OF PAH - MEAN PAP > 50 % OF
SYSTEMIC LEVELSYSTEMIC LEVEL Grade C : Size and number of arteries reduced PAH - PVR > 3.5 - 6.0 u.m2PAH - PVR > 3.5 - 6.0 u.m2
![Page 51: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/51.jpg)
![Page 52: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/52.jpg)
Vongpatanasin, W. et. al. Ann Intern Med 1998;128:745-755
Pooled Data from Studies of Pregnant Patients with the Eisenmenger Syndrome*
![Page 53: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/53.jpg)
VENTRICULAR SEPTAL DEFECT
![Page 54: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/54.jpg)
PATENT DUCTUS ARTERIOSUS
![Page 55: Prof. S. Shanmuga Sundaram K.S. Hospital, Chennai.](https://reader030.fdocuments.us/reader030/viewer/2022032518/56649ccd5503460f94997391/html5/thumbnails/55.jpg)