Management of ASDs and VSDs.pdf

PAEDIATRICS AND CHILD HEALTH
• Paediatrics and Child Health
• Management of Common CHDs
Dr. Chongo Shapi (BSc.HB, MBChB)
- Medical Doctor.
3/20/2022 Dr. Chongo Shapi, BSc.HB, MBChB, CUZ. 1

Common CHDs
• ASD
• VSD
• AVSD
• PDA
• TOF (separate lecture)

ASD
• Clinical Presentation
- Asymptomatic
- Exercise intolerance
- FTT
O/E:
- LT precordial bulge
- RT ventricular systolic lift at the lower LT sternal border (LSB)
- Loud S1, widely split and fixed S2 in all phases of respiration
- Pulmonic ejection click
- Murmur: Ejection systolic murmur (ESM) best heard at the
LT middle/upper sternal border. The murmur is produced
not by blood passing via the ASD but increased flow across
the RV outflow tract into the pulmonary artery
- Rumbling mid-diastolic murmur (MDM) at lower LSB

• Diagnosis
1. CXR:
- Large pulmonary artery
- Increased vascularity in the
lungs
2. ECG
- Volume overload of RV
produces RV hypertrophy
- Normal or RAD
- RV conduction delay (rSR
pattern)
3. Echo
- RV volume overload
4. Cardiac catheterisation
• Treatment
- Surgical or transcatheter
device closure is adviced
for symptomatic as well as
asymptomatic
- Timing: after 1 year and
before entry into school
- Mortality is high if done in
adulthood due to increased
risk of arrhythmias
3/20/2022
Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
.
4

Prognosis of ASD
• Some close spontaneously
• Secundum ASDs well tolerated during childhood
• Symptoms until 3rd decade or later of life
• Pulmonary HTN, atrial arrthythmias, tricuspid
regurgitation (TR), or mitral regurgitation (MR),
and CCF are late manifestations
• Infective endocarditis (IE) is rare, prophylaxis is
not recommended
• Results after surgery: excellent

VSD
• Is about 25% of CHDs
• Is the most common of all CHDs
• Most are membranous
• Clinical presentation depends on the size of
the defect
3/20/2022
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6

Clinical Presentation of VSD
• Small VSD
- Asymptomatic
- Murmur: loud, harsh or
blowing holosystolic, best
heard on lower LSB,
accompanied by a thrill
- Murmur ends before S2
due to closure of defect
during late systole
• Large VSD
- SOB
- Feeding intolerance
- FTT
- Profuse perspiration
- Recurrent pneumonia
- CCF in early infancy
3/20/2022
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7

• O/E:
- Cyanosis is absent but duskiness noted during infections or
cying
- LT precordial bulge
- Palpable parasternal heave
- Displaced apical impulse/thrust laterally
- Systolic thrill
- Holosystolic murmur: less harsh than that of a small VSD;
more blowing because of a significant pressure gradient
across the defect
- Increased pulmonic component of S2 due to pulmonary
HTN
- Low pitched rumbling MDM best heard with a bell of the
stethoscope at the apex due to increased blood flow
across the mitral valve

Diagnosis of VSDs
• Small VSDs
1. CXR:
- Normal, minimal cardiomegaly
- Slightly increased pulmonary
vascularity
2. ECG:
- normal; suggest LVH
- Presence of RVH is a warning
that defect not small and
patient has pulmonary HTN or
an associated pulmonary
stenosis
• Large VSDs
1. CXR:
- Gross cardiomegaly with
prominence of both ventricles,
LA and pulmonary artery
- Increased pulmonary vascular
markings (plethoric)
- Frank pulmonary oedema,
including pleural effusions
2. ECG:
- Biventricular hypertrophy,
notched or peaked P waves
3. Echo:
- Shows position/size of the VSD
- Other defects can be detected
3/20/2022
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9

Treatment of VSDs
• 30-50% of small VSDs close spontaneously during
1st 2 years of life
• Muscular VSDs more likely than membranous VSDs
to close
• Risk: IE, arrhythmias (long term), subaortic
stenosis, exercise intolerance
• Large VSDs rarely close spontaneously
3/20/2022
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10

• Small VSDs:
- Reassurance
- Live normal life with no restriction on physical activity
- Surgery is not recommended
- As protection against IE; integrity of primary and secondary
teeth should be carefully be maintained
- Antibiotic prophylaxis during surgery:
a. Dental
b. Tonsillectomy
c. Adenoidectomy
d. Oropharyngeal
e. GIT/GUT
- ECG/ECHO as screening tools for possible pulmonary HTN
or PS and to confirm spontaneous closure

• Large VSDs
a. Medical treatment
- Control CCF and prevent pulmonary vascular
disease (PVD)
- Aim to control symptoms of heart failure and
maintain normal growth
- Medical treatment not to be pursued in
symptomatic patients (infants) after an initial
unsuccessful trial
b. Surgery:
- Performed within 1st year of life
- Prevents PVD
3/20/2022
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12

• Indications for surgery in large VSDs:
1. Patients at any age with large defects in whom
clinical and FTT cannot be controlled medically
2. Infants between 6-12 mo of age with large defects
associated with pulmonary HTN, even if
symptoms are controlled by medication
3. Patients > 24 mo (2 years)
4. Supracristal VSD due to high risk for AR
Contraindication for surgery:
- Severe PVD

AVSD
• Produced by ostium primum, atrioventricular
(AV) canal, or endocardial cushion defects
• This causes deficiency of AV septum
• Ventricular septum is intact
• Lesion is common in Down syndrome and may
occasionally occur in PS
• Basic abnormality pathophysiologically is a a
combination of LT to RT shunt + MR
• Physiology is the same as that of a secundum ASD
• Eisenmenger physiology occurs with time
3/20/2022
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14

• Clinical Presentation
- Asymptomatic
- AVSD + MR: additional apical murmur caused by MR
Hx:
- Exercise intolerance
- Easy fatigability
- Recurrent pneumonia
- Severe MR (hyperdynamic precordium)
O/E:
- Normal or loud S1 due to AVSD
- Wide, fixed splitting of S2
- Pulmonary ESM sometimes preceeded by a click
- Low pitched MDM at lower LSB due to increased flow via the AV
valves
- MR: harsh or high pitched apical holosystolic murmur that radiates
to the left axilla
- CCF + pneumonia in infancy
- Precordial bulge maybe present

• Diagnosis
1. CXR:
- Cardiomegaly
- Large PA
- Increased pulmonary vascularity
2. ECG
Is distinctive
a. Superior LAD
b. Signs of BVH or isolated RVH
c. RV conduction delay (RSR’
pattern in leads V3R and V1)
d. Normal or tall P waves
e. Occasional PR prolongation
3. Echo:
- RV enlargement with “gooseneck”
deformity on LV outflow tract
Treatment of AVSD
- Surgery: during infancy
- This is due to risk of
pulmonary vascular disease
developing as early as 6 mo-
12 mo
3/20/2022
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16

PDA
• Is a LT to RT shunt
• Clinically:
- Asymptomatic: small PDA
- Symptomatic: large PDA
- HF similar to that of a large VSD with FTT
O/E:
- Wide pulse pressure
- Prominently bounding peripheral arterial pulses
- Heart size: normal if PDA is small, enlarge if large PDA
- Prominent apical impulse with cardiac enlargement heaving
- Thrill in 2nd LT ICS, usually systolic and radiates
- Murmur: classic continuous murmur described as machinery or
rolling thunder in quality
- Begins soon after S1 and reaches maximum intensity at the end
of systole and wanes in late diastole
3/20/2022
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• Diagnosis of PDA:
1. ECG:
- Small PDA: normal
- Large PDA: LVH or BVH
2. CXR:
- Large pulmonary artery
with increased vascularity
in large PDA
- Cardiomegaly if large PDA
3. Echo
- Detects the defect
• Treatment of PDA:
- Surgery: irrespective of age
- Catheter closure can be
done also
- Timing: asymptomatic by 1
year of life
- Pulmonary HTN is not a
contraindication

Management of ASDs and VSDs.pdf

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