Asd case dr. bayazid

1. A 40 yrs old woman presented with recurrentA 40 yrs old woman presented with recurrent
breathlessness and palpitation since childhoodbreathlessness and palpitation since childhood
Dr. Muhammad BayazidDr. Muhammad Bayazid
Thesis Part StudentThesis Part Student
MD (Cardiology)MD (Cardiology)
Case presentationCase presentation

2. Particulars Of The PatientParticulars Of The Patient
 Name: ChompaName: Chompa
 Age : 40 yearsAge : 40 years
 Sex : FemaleSex : Female
 Occupation: HousewifeOccupation: Housewife
 Marital status: MarriedMarital status: Married
 Religion: HinduReligion: Hindu
 Address: Moth Baria, PirojpurAddress: Moth Baria, Pirojpur
 Date of Admission: 15/09/2017 through OPDDate of Admission: 15/09/2017 through OPD
 Date of Examination: 20/09/2017Date of Examination: 20/09/2017

3. Chief ComplaintsChief Complaints
 Recurrent palpitation since childhoodRecurrent palpitation since childhood
 Recurrent breathlessness for sameRecurrent breathlessness for same
durationduration
 Recurrent swelling of body sinceRecurrent swelling of body since
childhood.childhood.
 Chest pain for last 4 monthsChest pain for last 4 months
 |Admitted for cardiac evaluation which was|Admitted for cardiac evaluation which was
required before cholelithiasis operationrequired before cholelithiasis operation

4. H/O Present IllnessH/O Present Illness
 According to the statement of the patient , she has beenAccording to the statement of the patient , she has been
suffering from recurrent palpitation since childhood. Itsuffering from recurrent palpitation since childhood. It
aggravated on exertion and relieved by rest. She did not giveaggravated on exertion and relieved by rest. She did not give
any H/O heat intolerance, weight loss and diarrhoea.any H/O heat intolerance, weight loss and diarrhoea.
 She also complains of recurrent breathlessness sinceShe also complains of recurrent breathlessness since
childhood . It aggravates on lying flat and she feel comforts onchildhood . It aggravates on lying flat and she feel comforts on
sitting position. Occasionally, she experiences nocturnalsitting position. Occasionally, she experiences nocturnal
breathlessness, usually at late hours of night, for which shebreathlessness, usually at late hours of night, for which she
has to get up from sleep, walk and take deep breath to behas to get up from sleep, walk and take deep breath to be
comfortable. It is not associated with cough.comfortable. It is not associated with cough.
 It is not associated diurnal or seasonal variation. There is noIt is not associated diurnal or seasonal variation. There is no
history of exacerbation on exposure to dust, cold or otherhistory of exacerbation on exposure to dust, cold or other
allergen.allergen.

5.  She also gives the H/O recurrent swelling of whole bodyShe also gives the H/O recurrent swelling of whole body
which was first appeared on the leg then spread all overwhich was first appeared on the leg then spread all over
the body. It was not associated with any change ofthe body. It was not associated with any change of
volume and color of urine. She did not give any history ofvolume and color of urine. She did not give any history of
jaundice, bloody vomiting , black tarry stool . Swellingjaundice, bloody vomiting , black tarry stool . Swelling
aggravated at the end of the day and relieved by takingaggravated at the end of the day and relieved by taking
medication which was associated with increasedmedication which was associated with increased
urination but she could not mention the name.urination but she could not mention the name.
 She also complains of chest pain for last 4 monthsShe also complains of chest pain for last 4 months
which is retrosternal, compressive in nature radiates towhich is retrosternal, compressive in nature radiates to
back, aggravates on exertion and relieved by rest.back, aggravates on exertion and relieved by rest.
 She also complains of generalized weakness andShe also complains of generalized weakness and
fatigue for last one month which is gradually increasing.fatigue for last one month which is gradually increasing.

6.  She did not give any H/O loss of consciousness,She did not give any H/O loss of consciousness,
syncope, hoarseness of voice, difficulty in swallowing,syncope, hoarseness of voice, difficulty in swallowing,
skin rash.skin rash.
 She gave no history of joint pain or abnormal movementShe gave no history of joint pain or abnormal movement
of the body. On query she give the history of recurrentof the body. On query she give the history of recurrent
fever and cough at her childhood. She is normotensive ,fever and cough at her childhood. She is normotensive ,
nondiabetic and non asthmatic . Her bowel and bladdernondiabetic and non asthmatic . Her bowel and bladder
habit is normal. She also mentioned that four monthshabit is normal. She also mentioned that four months
back she diagnosed as cholelithiasis, for which sheback she diagnosed as cholelithiasis, for which she
advised for cholecystectomy, though she had not anyadvised for cholecystectomy, though she had not any
abdominal pain . She at first went to general surgeryabdominal pain . She at first went to general surgery
department for operation but surgery doctor referred herdepartment for operation but surgery doctor referred her
to cardiology department for cardiac evaluation.to cardiology department for cardiac evaluation.

7. H/O Past IllnessH/O Past Illness
 She gave h/o several visit to local doctorShe gave h/o several visit to local doctor
due to breathlessness and she was tolddue to breathlessness and she was told
that she had some cardiac abnormality.that she had some cardiac abnormality.
But she could not mention the name.But she could not mention the name.
 She did not give any history suggestive ofShe did not give any history suggestive of
rheumatic fever.rheumatic fever.

8. Family HistoryFamily History
 She has one son and two daughter . Her son isShe has one son and two daughter . Her son is
12 years old . He also suffered from palpitation12 years old . He also suffered from palpitation
since childhood and he has history ofsince childhood and he has history of
generalized body swelling two years back whichgeneralized body swelling two years back which
was relieved by taking some medication.was relieved by taking some medication.
 Daughters are well and healthy.Daughters are well and healthy.
 Parents are not alive. Her brothers and sistersParents are not alive. Her brothers and sisters
are also free from any significant/relevantare also free from any significant/relevant
illness.illness.

9. Socio-economic HistorySocio-economic History
 She comes from low class family.She comes from low class family.
 She lives in tin made house, drinksShe lives in tin made house, drinks
arsenic free tube well water and usesarsenic free tube well water and uses
sanitary latrine.sanitary latrine.

10. Personal HistoryPersonal History
 She is nonsmoker, nonalcoholic.She is nonsmoker, nonalcoholic.
 She has no habit of betel nut.She has no habit of betel nut.

11. Drug HistoryDrug History
 She took some medication for bodyShe took some medication for body
swelling which was associated withswelling which was associated with
increased urination but she could notincreased urination but she could not
name of drugs.name of drugs.

12. Allergic HistoryAllergic History
 No significant allergic history found.No significant allergic history found.

13. Obstetric and Menstrual HistoryObstetric and Menstrual History
 Para 5 : All were normal vaginal deliveryPara 5 : All were normal vaginal delivery
 She is on menopause for last one yearShe is on menopause for last one year
 On the last pregnancy her breathlessnessOn the last pregnancy her breathlessness
was increased but she had not to admit inwas increased but she had not to admit in
a hospital.a hospital.

14. General ExaminationGeneral Examination
 Appearance: ill lookingAppearance: ill looking
 Body built: averageBody built: average
 Co-operation: cooperativeCo-operation: cooperative
 Decubitus: on sitting positionDecubitus: on sitting position
 Anaemia: absentAnaemia: absent
 Jaundice: absentJaundice: absent
 Cyanosis: absentCyanosis: absent
 Clubbing: presentClubbing: present
 Koilonychia, leukonychia, lymphadenopathy absentKoilonychia, leukonychia, lymphadenopathy absent
 Thyroid gland not palpableThyroid gland not palpable
 Oedema: absentOedema: absent

15.  Pulse: 68 beats/min, regular in rhythm, noPulse: 68 beats/min, regular in rhythm, no
radio radial and radio femoral delayradio radial and radio femoral delay
 BP: 110/70 mm of Hg on both upper limbsBP: 110/70 mm of Hg on both upper limbs
 Respiratory rate: 20 breaths/minRespiratory rate: 20 breaths/min
 Temp: 99 degree farenheitTemp: 99 degree farenheit
 JVP:JVP: not raisednot raised

16. Cardiovascular SystemCardiovascular System
 Pulse:Pulse:
 68beats/min, normal volume, regular in rhythm68beats/min, normal volume, regular in rhythm
 Normal is characterNormal is character
 No radio radial and radio femoral delayNo radio radial and radio femoral delay
 Condition of vessel wall normalCondition of vessel wall normal
 All the peripheral pulses are normalAll the peripheral pulses are normal
 Precordium :Precordium :
 InspectionInspection::
 No visible apical impulseNo visible apical impulse
 No epigastric pulsation.No epigastric pulsation.
 No scar mark or bony deformity.No scar mark or bony deformity.

17.  Palpation:-Palpation:-
 Apex beat is left 5Apex beat is left 5thth
intercostal space, 9intercostal space, 9
cm away from mid sternal line, just medialcm away from mid sternal line, just medial
to mid clavicular line, normal in characterto mid clavicular line, normal in character
 Thrill:- present in pulmonary area andThrill:- present in pulmonary area and
tricuspid area.tricuspid area.
 No Palpable P2 in pulmonary areaNo Palpable P2 in pulmonary area
 Left parasternal heave presentLeft parasternal heave present
 No epigastric pulsationNo epigastric pulsation

18. AuscultationAuscultation
 11stst
heard sound is normal in all areasheard sound is normal in all areas
 22ndnd
heart sound is wide and fixedheart sound is wide and fixed
 There is an ejection systolic murmur in theThere is an ejection systolic murmur in the
left 2left 2ndnd
and 3and 3rdrd
intercostal space radiated tointercostal space radiated to
left side of neck and grading of theleft side of neck and grading of the
murmur was 4/6.murmur was 4/6.
 There is also pan systolic murmur inThere is also pan systolic murmur in
tricuspid area.tricuspid area.
 Bilateral basal crepitations: absent.Bilateral basal crepitations: absent.

19. Other Systemic ExaminationOther Systemic Examination
 Reveals no abnormalityReveals no abnormality

20. Provisional DiagnosisProvisional Diagnosis
Atrial septal defect with tricuspidAtrial septal defect with tricuspid
regurgitationregurgitation

21. Differential DiagnosisDifferential Diagnosis
 ASD with pulmonary stenosisASD with pulmonary stenosis
 Ventricular septal defectVentricular septal defect
 Partial anomalous pulmonary venousPartial anomalous pulmonary venous
connectionconnection
 Pulmonary stenosisPulmonary stenosis

22. Clinical DifferentiationClinical Differentiation
In pulmonary stenosis-In pulmonary stenosis-
Soft or absent P2Soft or absent P2
 wide splitting 2wide splitting 2ndnd
heart sound present butheart sound present but
not fixednot fixed
 ESM present, intensity increase withESM present, intensity increase with
inspiration, may radiate to neckinspiration, may radiate to neck

23. PAPVC-PAPVC-
Second heart sound widely split, but notSecond heart sound widely split, but not
fixedfixed
ESM both sides of sternal borderESM both sides of sternal border
VSD-VSD-
Systolic thrill over left lower parasternalSystolic thrill over left lower parasternal
areaarea
Pansystolic murmur in left lowerPansystolic murmur in left lower
parasternal areaparasternal area

24. INVESTIGATIONSINVESTIGATIONS
 CBC:CBC:
Hb : 12.0 gm/dlHb : 12.0 gm/dl
TWBC : 8500/mm3TWBC : 8500/mm3
Neu : 51.3 %Neu : 51.3 %
Lym : 39.3%Lym : 39.3%
ESR : 35 mm in 1ESR : 35 mm in 1stst
hourhour
HCT : 40%HCT : 40%
Platelet : 275k/uLPlatelet : 275k/uL

25. Continue-Continue-
 S.CreatinineS.Creatinine : 0.77 mg/dl: 0.77 mg/dl
 RBS : 5.7 mmol/IRBS : 5.7 mmol/I
 S.Electrolytes : Na : 138mmol/lS.Electrolytes : Na : 138mmol/l
K: 4.30 mmol/lK: 4.30 mmol/l
Cl: 101 mmol/lCl: 101 mmol/l
HCO3: 27 mmol/lHCO3: 27 mmol/l

26. ECGECG

29. EchocardiographyEchocardiography
 Echo findings are:Echo findings are:
 Congenital heart diseaseCongenital heart disease
 ASD ( secundum) , size 15 mm , flow from LA toASD ( secundum) , size 15 mm , flow from LA to
RA through IAS is presentRA through IAS is present
 Severe valvular pulmonary stenosis with PRSevere valvular pulmonary stenosis with PR
(grade:I) , PV 4.47 m/s, PPG 80 mm of Hg(grade:I) , PV 4.47 m/s, PPG 80 mm of Hg
 RV free wall hypertrophiedRV free wall hypertrophied
 PA annulus 18 mmPA annulus 18 mm
 No regional wall motion abnormalityNo regional wall motion abnormality
 Good LV systolic functionGood LV systolic function

30. Cardiac CathterizationCardiac Cathterization
 Catheter trajectory:Catheter trajectory:
RA ›› LA ›› LUPVRA ›› LA ›› LUPV

31. Oxygen SaturationOxygen Saturation
Measurement(%)
SVC (H) 65.4
SVC (L) 67.9
IVC ( H ) 74.7
RA (H) 75.5
RA (M) 76.1
LA 97.2

32. Pressure StudyPressure Study
LOCATION MEASUREMENT(mmHg)
RA 09/02/07
RV 133/53/(-5)
LA 10/01/06

33. Final DiagnosisFinal Diagnosis
 Atrial septal defect (ASD secundum) withAtrial septal defect (ASD secundum) with
severe valvular pulmonary stenosissevere valvular pulmonary stenosis

34.  Medical managenent:Medical managenent:
Congestive symptoms by diureticCongestive symptoms by diuretic
Rhythm disturbance such as AFRhythm disturbance such as AF
Tranrscathetrer or surgical:Tranrscathetrer or surgical:
Indication:Indication:
Haemodynamically significant shunt ( Qp/Qs> 1.5 )Haemodynamically significant shunt ( Qp/Qs> 1.5 )
Associated symptomsAssociated symptoms
Evidence of right heart dilatationEvidence of right heart dilatation
Should not be done:Should not be done:
Advanced pulmonary HTN ( Eisenmenger syndrome)Advanced pulmonary HTN ( Eisenmenger syndrome)
Severe LV systolic dysfunctionSevere LV systolic dysfunction

35. Trans catheterTrans catheter
 ASD secundumASD secundum
 Size < 35 mmSize < 35 mm
 Adequate rimAdequate rim
 Not close to AV valve, pulmonary vein,Not close to AV valve, pulmonary vein,
coronary sinuscoronary sinus
Two types of device are used.Two types of device are used.
1.1. Amplatzer septal occluderAmplatzer septal occluder
2.2. Helex septal occluderHelex septal occluder

37. Surgical closureSurgical closure
 ASD primumASD primum
 Sinus venosus ASDSinus venosus ASD
 Not amenable to percutaneous closure,Not amenable to percutaneous closure,
size > 35 mm , in adequte septal rim ,size > 35 mm , in adequte septal rim ,
 Very close to AV valve, coronary sinus orVery close to AV valve, coronary sinus or
venacavavenacava

38. Pulmonary stenosisPulmonary stenosis
ManagementManagement
 Mild to moderate PS have good prognosis andMild to moderate PS have good prognosis and
intervention rarely necessaryintervention rarely necessary
 In severe PS, Balloon valvuloplasty ( 75% decrement ofIn severe PS, Balloon valvuloplasty ( 75% decrement of
transvalvular gradient after a successful procedure)transvalvular gradient after a successful procedure)
 Valve replacementValve replacement
If concomitant TR or valve is severely calcifiedIf concomitant TR or valve is severely calcified