Structures of the heart

Normal Heart

Atrial Septal defect

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

ANATOMY

ASD

Atrial Septal Defect

Diagram of ASD

Clinical Features
Symptoms
Most infants : asymptomatic ..undetected
The first present at age 6 to 8 weeks with a soft
murmur and possibly a fixed and somewhat widely
split S2
Infant with large ASD may present with poor
growth, recurrent lower respiratory tract
infection and heart failure

Atrial septal defect

Lungs

LV

LA

AO

PA

RV

RA

Qp > Qs

Systemic

Atrial septal Defect

RA

RV

RA

LA

RV

LV

LA

LV

Atrial Septal Defect

Auscultation :1st HS N or loud

widely split and fixed 2nd HS
Ejection Sistolic Murmur

Atrial Septal Defect

Diagnosis Differential
Primary Atrial Septal Defect
ECG : LAD
Partial Anomalous Pulmonary Vein
Drainage
Pulmonary Stenosis
Innocent Murmur

Atrial Septal defect

Management
Surgery : Preschool age
Recent treatment: transcatheter closure using
ASO (Amplatzer septal occluder)

ASD
Large Shunt

Small Shunt
Observation
Evaluation
At age 5-8 yrs
Cath
FR<1.5

Heart
Failure (-)

Children/Adults
PH (-)
Heart
Failure (+)
PVD
(-)
Anti failure

Success

FR>1.5

Conservative

Infants

Age >1yrs
W >10kg

PH (+)
PVD
(+)
Hyperoxia

Fail

Surgical
Closure

Reactive

Transcatheter closure (Secundum ASD) /

Surgical Closure(other tipe of ASD)

Non
reactive

Conservative

Transchateter closure of ASD

Atrial septal defect

Ventricular septal defect

Insidence
20 % of all CHD
No sex influenced
Anatomy
Subarterial defect : below pulmonary and
aortic valve
Perimembranous defect: below aortic valve at pars
membranous septum
Muscular defect

VSD

Ventricular Septal defect

Lungs

LV

LA

AO

PA

RA

RV

Qp > Qs

Systemic

Ventricular septal defect

RA

RV

LA

LV

RA

LA

RV

LV

Ventricular Septal Defect

Clinical findings
Day 1st after birth: murmur (-)
After 2-6 weeks : murmur (+)
Murmur : pansystolic grade 3/6 or higher
at LSB 3
Small muscular defect: early systolic murmur
Significant defect: Mid diastolic murmur at apex

Ventricular Septal Defect

Murmur: pansystolic
grade 3/6 or higher at
LSB 3

Small VSD

Large VSD

Ventricular Septal Defect

Cardiomegaly
Apex down ward
Prominence pulmonary
artery segment
Increased pulmonary vascular
marking

Ventricular septal Defect

Diagnosis Differential

PDA with PH
Tetralogy Fallot non cyanotic
Inoscent murmur

Ventricular septal defect

Management:
Definitive : VSD closure
Surgery
Transcatheter closure

DSV
Heart failure (+)

Heart failure (-)

Anti failure
Aortic valve
prolaps
Fail

Infundibular
stenosis

PVD(-)

Success
PAB
Evaluate
in 6 mths

PH Spontaneous
closure

Cath

PVD(+)
Cath

Reactive

Smaller
Cath

FR<1.5 FR>1.5

Nonreactive
Conservative

Surgical closure/Transcatheter closure

Patent Ductus Arteriosus

Anatomy
Fetus: ductus arteriosus connects PA and aorta
If ductus does not closs Patent Ductus arteriosus

PDA

Patent Ductus Arteriosus

RA

RV

LA

LV

RA

LA

RV

LV

Patent Ductus Arteriosus

Lungs

LV

LA

AO

PA

RA

RV

Qp > Qs

Systemic

 PDA is more common in :

Premature infants

BW < 1750 g : 45%

BW < 1200 g : 80%
Genetic abnormalities
Infants whose mother had German
measles (Rubella)

PDA in preterm haemodynamic

instability co-morbidity &
mortality EARLY DIAGNOSIS

Patent Ductus Arteriosus

Clinical findings
Small defect:
Symptom (-)
Growth and development normal
Moderate and large defect:
Decreased exercise tolerant
Weigh gained not good
Frequent URTI

DIAGNOSIS

Patent Ductus Arteriosus

Auscultation : continuosus murmur

at upper LSB 2

Chest X-Ray

Large PDA:
Prominence of the left
atrium,
left ventricle, ascending
aorta,
Pulmonary vascular
marking

ECG

Small PDA : normal

Moderate PDA : LVH
Large PDA : BVH
PDA with PVOD : RVH

Patent Ductus Arteriosus

Diagnosis Differential
AP-window
Arterio-venous fistulae
Management
premature: ibuprofen
PDA closure : surgery
transcatheter closure

MANAGEMENT
Medical treatment : prostaglandin synthesis
inhibitor
Preterm neonates : usefull
Aterm neonates : useless

Transcatheter closure : mostly choice treatment

Surgical closure :
Infant < 5 kg with large PDA
Preterm neonates : medical treatment unsuccessful
or contraindicated

PDA IN PRETERM NEONATES

Special problem : haemodynamic instability
Treatment should be started as soon as PDA
suspected
Once a significant shunt is present
increased pulmonary blood flow damage to
premature lungs
PDA can be closed with prostaglandin
synthesis inhibitors

TRANSCATHETER CLOSURE

*Transcatheter occlusion is effective with a high rate

of complete occlusion
*Complication rare

Tetralogy Fallot
Incidence
5-8% from all CHD
Anatomy
Cause: Left-anterior deviation of infundibular septum
Sindroma consist of 4 items:
VSD
pulmonary stenosis
aortic over-riding
RVH

Tetralogy Fallot

Central cyanosis

Central cyanosis

Pathophysiology
Cyanosis is a bluish discoloration of the
skin and mucous membranes resulting
from an increased concentration of
reduced hemoglobin
Clinical cyanosis occurs when the amount
of reduced hemoglobin in the cutaneous
vein may result 5 g/100ml
The critical level of reduced hemoglobin in
the cutaneous vein may result from either
desaturation of arterial blood or increased
extraction of oxygen by peripheral tissue

Cardiac causes of cyanosis

Inadequate pulmonary blood flow (severe
cyanosis)
Tricuspid atresia
Pulmonary atresia
Tetralogy of Fallot

Independent pulmonary and systemic

circulation (severe cyanosis)
Tranpose great artery

Mixing (moderate cyanosis)

Truncus arteriosus

Diagnosis
Clinically : cyanosis
Single 2nd HS, ejection systolic murmur
X Ray : Boot Shaped
ECG: RAD, RVH

Tetralogy Fallot

Single 2nd HS, ejection systolic murmur

CXR :
Boot-shaped
Concave pulmonary segment
Apex upturned
Decreased pulmonary blood flow

Tetralogy Fallot

ECG : RAD, RVH

Echocardiography : to confirm diagnosis

Tetralogy Fallot

Diagnosis 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

 clinically
ECG

Tetralogy of Fallot

< 1 yr

> 1 yr

spell (+)
propranolol

spell (-)
age 1 yr

failed

CXR
echo

succeed

cath

BTS
evaluation

cath

BTS/
PDA Stent

small PA

total correction

good sized PA