2. 2
Anatomic malformation of the heart or great
vessels which occurs during intrauterine
development, irrespective of the age at
presentation.
Congenital heart disease occurs in
approximately 0.8% of live births.
The incidence is higher in stillborns (3-4%),
spontaneous abortuses (10-25%), and
premature infants (about 2% excluding
patent ductusarteriosus [PDA]
3. 3
Environmental factors
Viral Infections
◾rubella during the first three months of pregnancy
Medication
◾lithium (used to manage bipolor disorder), Accutane
(acne medication), some anti-seizure medications
Alcohol
◾with fetal alcohol syndrome (FAS)
Smoking
Cocaine
Maternal chronic illnesses –diabetes, phenylketonuria
(PKU) and a deficiency in the B vitamin folic acid.
4. in siblings or offspring of
heart defects than those
4
Genetic factors
Heredity –occur
individuals with
without.
Mutations –can affect the formation of the
heart and lead to congenital heart
malformations
Linked with other birth defects – More than
one-third of children born with Down
syndrome have heart defects. About 25% of
girls with Turner syndrome have heart defects
11. 11
An opening in the atrial septum
An atrial septal defect allows oxygenated (red) blood to pass
from the left atrium, through the opening in the septum, and
then mix with unoxygenated (blue) blood in the right atrium
During fetal heart devt. 🡲 The partitioning process does not
occur completely, leaving an opening in the atrial septum
Occur in 4-10% of all infants w/CHD
Effects: when blood passes through the ASD from the left
atrium to the right atrium 🡲 a larger volume of blood than
normal must be handled by the right side of the heart 🡲 extra
blood then passes through the pulmonary artery into the lungs
🡲 pulmonary hypertension and pulmonary congestion
12. If the ASD is left uncorrected-->pulmonary
hypertension progresses -->pressure in the right
side of the heart will become greater than the
left side of the heart.
This reversal of the pressure gradient across the
ASD causes the shunt to reverse --> a right-to-
left shunt will exist. This phenomenon is known
as Eisenmenger's syndrome
Once right-to-left shunting occurs, a portion of
the oxygen-poor blood will get shunted to the
12
to the
left side of the heart and ejected
peripheral vascular system.
This will cause signs of cyanosis
15. Opening near the center of the septum
The secundum atrial septal defect usually
arises from an enlarged foramen ovale,
inadequate growth of the septum
secundum, or excessive absorption of the
septum primum.
If the ostium secundum ASD is
accompanied by an acquired mitral valve
stenosis, that is called Lutembacher's
syndrome.
15
heart
Ostium secundum atrial septal defect
most common type of atrial septal defect
comprises 6–10% of all congenital
diseases.
16. Patent foramen ovale
A small channel that has some hemodynamic
consequence
It is a remnant of the fetal foramen ovale.
On echocardiography, there may not be any
shunting of blood noted except when the
patient coughs.
16
17. Ostium primum atrial septal defect
Opening at the lower end of the septum
A defect in the ostium primum is occasionally
classified as an atrial septal defect but it is
more commonly classified an atrioventricular
septal defect. Ostium primum defects are less
common than ostium secundum defects
17
18. Sinus venosus atrial septal defect
Opening near the junction of superior vena
cava and right atrium, may be associated
with partial anomalous pulmonary venous
connection
Common or single atrium
It is a failure of development of the
embryologic components that contribute to
the atrial septal complex. It is frequently
associated with heterotaxy syndrome.
18
20. 20
History.
usually
Infants and children with ASDs are
asymptomatic
Physical Examination
A relatively slender body build is typical.
A widely split and fixed S2 and a systolic ejection
murmur are characteristic findings of ASD in older
infants and children. .
Classic auscultatory findings of ASD are not
present unless the shunt is reasonably large
21. Electrocardiography
Right axis deviation of +90 to +180 degrees
and mild right ventricular hypertrophy (RVH)
or right bundle branch block (RBBB) with an
rsR' pattern inV1 are typical findings
21
22. X-rayStudies
Cardiomegaly with enlargement of the RA and
right ventricle (RV) may be present.
A prominent pulmonary artery (PA) segment and
increased pulmonary vascular markings are seen
when the shunt is significant
22
23. Echocardiography
A two-dimensional echo study is diagnostic.
shows the position as well as the size of the
defect,
In secundum ASD, a dropout can be seen in the
midatrial septum.
The primum type shows a defect in the lower atrial
septum
Indirect signs of a significant left-to-right atrial
shunt include RV enlargement and RA
enlargement, as well as dilated PA
M-mode echo may show increased RV dimension
and paradoxical motion of the interventricular
septum, which are signs of RV volume overload.
23
27. 27
If agitated saline is injected into a
peripheral vein during echocardiography,
small air bubbles can be seen on
echocardiographic imaging.
It may be possible to see bubbles travel
across an ASD either at rest or during a
cough. (Bubbles will only flow from right
atrium to left atrium if the RA pressure is
greater than LA).
29. 29
spontaneous closure of the secundum defect
occurs in about 40% of patients in the first 4
years of life
Most children with an ASD remain active and
asymptomatic.
Rarely, congestive heart failure (CHF) can
develop in infancy.
If a large defect is untreated, CHF and
pulmonary hypertension develop in adults who
are in their 20s and 30s
With or without surgery, atrial arrhythmias
(flutter or fibrillation) may occur in adults.
30. 30
Medical
Exercise restriction is unnecessary.
Prophylaxis for infective endocarditis indicated
in patients with primumASD.
In infants with CHF, medical management is
recommended because of its high success rate
and the possibility of spontaneous closure of
the defect.
31. 31
catheter-delivered closure device has become
a preferred method
Devices available for clinical use have
included the Sideris buttoned device, the
Angel Wings device, the CardioSEAL device,
and theAmplatzerASDOcclusion Device.
The amplatzer septal occluder has the
widespread use.
32. 32
To close a secundum ASD, measuring 5 mm
or more in diameter (but less than 32 mm),
A significant left-to-right shunt with clinical
evidence of right ventricular volume overload
There must be enough rim (4 mm) of septal
tissue around the defect for appropriate
placement of the device.
The timing of the device- because of the
possibility of spontaneous closure, it is not
used in infancy unless the patient is
symptomatic with heart failure.
34. 34
Complete avoidance of cardiopulmonary
bypass
Avoidance of pain and residual thoracotomy
scars
A less than 24-hour hospital stay
Rapid recovery
All these devices are associated with a higher
rate of small residual leak than is operative
closure.
35. 35
The patients are administered aspirin 81
mg/day for 6 months.
Postprocedure echo studies
36. 36
Indications andTiming
A left-to-right shunt with a pulmonary-to-
systemic blood flow ratio ( p/ s) of ≥1.5:1 .
Surgery is usually delayed until 2 to 4 years of
age because the possibility of spontaneous
closure.
Surgery is performed during infancy-if CHF
does not respond to medical management
infancy,.
37. Infants with associated
37
bronchopulmonary
dysplasia and the device closure is not
considered appropriate, surgery is performed
during infancy.
High pulmonary vascular resistance may be a
contraindication for surgery
38. 38
For secundum ASD, the defect is traditionally
repairedwith a simple suture or a pericardial
or Teflon patch through a midsternal incision
under cardiopulmonary bypass by either
For sinus venosus defect without associated
anomalous pulmonary venous return, the
defect is closed using an autologous
pericardial patch.
39. When it is associated with a pulmonary
venous anomaly, a tunnel is created between
the anomalous pulmonary vein and the ASD
by using aTeflon or pericardial patch
For coronary sinus ASD, the ostium of the
coronary sinus is closed with an autologous
pericardium
39
41. Fewer than 0.5% of patients die
Complications.
Cerebrovascular accident
postoperative arrhythmias
Postoperative Follow-up
1. Cardiomegaly on x-ray film and enlarged RV
dimension on echo as well as the wide splitting of
theS2 may persist for 1 or 2 years postoperatively.
The ECG typically demonstrates RBBB (or RV
conduction disturbance).
2. Atrial or nodal arrhythmias occur in 7% to 20%
of postoperative patients.
3. Rarely, patients with residual shunt may be
administered aspirin 81 mg to prevent paradoxical
embolization 41
42. 42
an opening in the ventricular septum
allows oxygenated blood to pass from the left
ventricle, through the opening in the septum, and
then mix with unoxygenated blood in the right
ventricle.
VSDs are the most commonly occurring type of
congenital heart defect, occurring in 14-17 % of
babies born each year.
occur when the partitioning process does not occur
completely, leaving an opening in the ventricular
septum.
44. EFFECTS:
When blood passes through the VSD from the
left ventricle to the right ventricle 🡲 a larger
volume of blood than normal must be handled
by the right side of the heart 🡲 extra blood then
passes through the pulmonary artery into the
lungs 🡲 pulmonary hypertension and pulmonary
congestion 🡲 pulmonary arteries become
44
to increased
thickened and obstructed due
pressure
.
45. IfVSD is not repaired, and lung disease
begins to occur 🡲 pressure in the right
side of the heart will eventually exceed
pressure in the left 🡲 R to L shunt 🡲
cyanosis
Due to high pressure --- tissue damage
may eventually occur in the right ventricle
🡲 bacteria in the bloodstream can easily
infect this injured area 🡲 bacterial
endocarditis
45
46. 46
History
With a small VSD, the patient is asymptomatic
with normal growth and development.
With a moderate to large VSD, delayed
growth and development, decreased exercise
tolerance, repeated pulmonary infections, and
CHF are relatively common during infancy.
With long-standing pulmonary hypertension,
a history of cyanosis and a decreased level of
activity may be present.
47. Physical Examination
Infants with small VSDs are well developed and
acyanotic.
Before 2 or 3 months of age, infants with large
VSDs may have poor weight gain or show signs
ofCHF.
Cyanosis and clubbing may be present in
patients with Eisenmenger's syndrome
A systolic thrill may be present at the lower left
sternal border.
Precordial bulge and hyperactivity are present
with a large-shuntVSD.
The S2 is loud and single in patients with
pulmonary hypertension or pulmonary vascular
obstructive disease.
47
48. A grade 2 systolic murmur is audible at the
lower left sternal border .It may be
holosystolic or early systolic.
An apical diastolic rumble is present with a
moderate to large shunt because of increased
flow through the mitral valve during diastole.
48
49. Electrocardiography
With a smallVSD, the ECG is normal.
With a moderate VSD, left ventricular
hypertrophy (LVH) and occasional left atrial
hypertrophy (LAH) may be seen.
With a large defect, the ECG shows
biventricular hypertrophy (BVH) with or
without LAH
If pulmonary vascular obstructive disease
develops, the ECG shows RVH only
49
51. X-rayStudies
Cardiomegaly of varying degrees is present and
involves the LA, left ventricle (LV), and sometimes RV.
Pulmonary vascular markings increase.
The degree of cardiomegaly and the increase in
pulmonary vascular markings directly relate to the
magnitude of the left-to-right shunt.
51
53. 53
Spontaneous closure occurs in 30% to 40% of
patients with membranous VSDs and muscular
VSDs during the first 6 months of life.
CHF develops in infants with large VSDs but
usually not until 6 to 8 weeks of age.
Pulmonary vascular obstructive disease may
begin to develop as early as 6 to 12 months of
age in patients with large VSDs, but the resulting
right-to-left shunt usually does not develop until
the teenage years.
Infective endocarditis rarely occurs.
54. 54
Treatment of CHF if it develops, (digoxin
and diuretics for 2 to 4 months )
Addition of spironolactone may be helpful
to minimize potassium loss.
Concomitant use of an afterload-reducing
agent, such as captopril,
Frequent feedings of high-calorie
formulas, by either nasogastric tube or
oral feeding, may help.
55. Anemia, if present, should be corrected by oral
iron therapy..
No exercise restriction is required in the absence
of pulmonary hypertension.
Maintenance of good dental hygiene and
antibiotic prophylaxis against infective
endocarditis are important
Nonsurgical closure of selected muscular VSDs is
possible using the “umbrella” device, but this is
still in the experimental stage.
55
56. 56
Small infants who have large VSDs and develop
CHF and growth retardation - If growth failure
cannot be improved by medical therapy, the VSD
should be operated on within the first 6 months
of life.
if the PA pressure is greater than 50% of
systemic pressure, surgical closure should be
done by the end of the first year.
After 1 year of age, a significant left-to-right
shunt with p/ s of at least 2:1 indicates that
surgical closure is needed, regardless of PA
pressure.
57. Palliative – pulmonary artery banding
Placing a band around the pulmonary artery
to decrease the pulmonary blood flow
It increases the resistance to blood flow
through the pulmonary artery. Pressure
increases in the right ventricle and prevents
excess shunting from left to right
57
58. Complete repair-small defects are repaired
with a purse-string approach.
Large defects usually require a Knitted
Dacron patch sewn over the opening
Both procedures requireCPB
The repair is generally approached through
the right atrium and tricuspid valve
Post operative complications include residual
VSD and conduction disturbances
58
59. 59
Surgical mortality is less than 1%. Mortality is
higher for small
months of age,
infants younger than 2
infants with associated
defects, or infants with multipleVSDs
60. 60
Activity should not be restricted unless complications
have resulted from surgery.
The ECG shows RBBB in 50% to 90% of patients who had
VSD repair through right ventriculotomy and up to 40%
of the patients who had repair through a right atrial
approach.
Bacterial endocarditis prophylaxis may be discontinued
6 months after surgery. If a residual shunt is present,
endocarditis prophylaxis should be continued indefinitely
when the indications arise.
A patient with a postoperative history of transient heart
block with or without pacemaker therapy requires long-
term follow-up.
61. 61
characterized by a connection between the aorta and the
pulmonary artery
All babies are born with a ductus arteriosus.
As the baby takes the first breath, the blood vessels in
the lungs open up, and blood begins to flow 🡲 the
ductus arteriosus is not needed to bypass the lungs
Most babies have a closed ductus arteriosus by 72 hours
after birth.
In some babies, however, the ductus arteriosus remains
open (patent) .
The opening between the aorta and the pulmonary
artery allows oxygenated blood to pass back through the
blood vessels in the lungs.
PDA occurs in 6-11 % of all children withCHD
63. In many children, there is no known reason for the ductus
arteriosus remaining open. However, PDA is seen more
often in the following:
premature infants
infants born to a mother who had rubella during the first
trimester of pregnancy
EFFECTS:
PDA 🡲 oxygenated blood passes from the aorta to the
pulmonary artery & mixes w/ the unoxygenated blood w/c
goes to the lungs 🡲 🡲blood volume to the lungs 🡲
pulmonary hypertension & congestion
Further, because blood is pumped at high pressure through
the PDA, the lining of the pulmonary artery will become
irritated and inflamed. Bacteria in the bloodstream can
easily infect this injured area 🡲 bacterial endocarditis.
63
64. 64
History
Patients are usually asymptomatic when the
ductus is small.
A large-shunt PDA may cause a lower
respiratory tract infection, atelectasis, and
CHF (accompanied by tachypnea and poor
weight gain).
Exertional dyspnea may be present in
children with a large-shunt PDA
65. Physical Examination
Tachycardia and tachypnea may be present in
infants withCHF.
Bounding peripheral pulses with wide pulse
pressure are characteristic findings.
A systolic thrill may be present at the upper left
sternal border.
A grade 1 to 4/6 continuous (“machinery”)
65
murmur is best audible at the left
area or upper left sternal
infraclavicular
border..
If pulmonary vascular obstructive disease
develops, a right-to-left ductal shunt results in
cyanosis only in the lower half of the body
66. Electrocardiography.
The ECG findings in PDA are similar to those in
VSD.
A normal ECG or LVH is seen with small to
moderate PDA. BVH is seen with large PDA.
66
obstructive disease
If pulmonary vascular
develops, RVH is present.
X-rayStudies.
X-ray findings are also similar to those ofVSD.
Chest x-ray films may be normal with a small-
shunt PDA.
Cardiomegaly of varying degrees occurs in
moderate- to large-shunt PDA with enlargement
of the LA, LV, and ascending aorta. Pulmonary
vascular markings are increased.
67. Echocardiography
Its size can be assessed by two-dimensional
echo in a high parasternal view or in a
suprasternal notch view
67
68. 68
Spontaneous closure of a PDA does not
usually occur in full-term infants and
children. This is because the PDA in term
infants results from a structural abnormality
of the ductal smooth muscle
CHF or recurrent pneumonia or both
develop if the shunt is large.
Pulmonary vascular obstructive disease may
develop if a large PDA with pulmonary
hypertension is left untreated.
Infective endocarditis may occur.
Although rare, an aneurysm of PDA may
develop and possibly rupture in adult life.
69. 69
Medical
Indomethacin is ineffective in term infants
with PDA and should not be used.
Standard anticongestive measures with
digoxin and diuretics are indicated when CHF
develops.
No exercise restriction is needed in the
absence of pulmonary hypertension.
bacterial
Prophylaxis
endocarditis
for subacute
(SBE) is indicated when
indications arise.
70. 70
Small ductus less than 4 mm in diameter are
closed by coils
Larger ones by an amplatzer PDA device.
73. 73
Surgical closure is reserved for patients in whom
a nonsurgical closure technique is not considered
applicable
Procedure
Ligation and division through left posterolateral
thoracotomy without cardiopulmonary bypass is
the standard procedure.
The technique of video-assisted thoracoscopic
clip ligation has become the standard of care for
surgical management of a ductus with adequate
length
75. 75
Clinical evidence of PDA appears in 45% of
infants with birth weight less than 1750 g and
in about 80% of infants with birth weight less
than 1200 g.
Significant PDA with CHF occurs in 15% of
premature infants with birth weight less than
1750 g and in 40% to 50% of those with birth
weight less than 1500 g
76. 76
Medical
Fluid restriction to 120 mL/kg per day and a
diuretic (e.g., furosemide, 1 mg/kg, two to three
times a day) may be tried for 24 to 48 hours
Pharmacologic closure of the PDA can he
achieved with indomethacin (a prostaglandin
synthetase inhibitor).
The dose is given intravenously every 12 hours
for a total of three doses. For infants less than 48
hours old, 0.2 mg/kg is followed by 0.1 mg/kg
2 times .
77. For those 2 to 7 days old, 0.2 mg/kg times 3, and
for infants older than 7 days, 0.2 mg/kg followed
by 0.25 mg/kg times 2
Contraindications to the use of indomethacin
High blood urea nitrogen (>25 mg/dl) or creatinine
(>1.8 mg/dl) levels
Low platelet count (<80,000/mm3)
Bleeding tendency (including intracranial hemorrhage)
Necrotizing enterocolitis, and hyperbilirubinemia.
A multicenter prospective study from Europe
showed that intravenous ibuprofen (10 mg/kg,
followed at 24-hour intervals by two doses of 5
mg/kg) starting on the third day of life was as
effective as indomethacin in closing the ductus in
preterm newborns..
77
78. 78
Also known as endocardial cushion defects
They account for about 5 percent of all
congenital heart disease, and are most
common in infants with down syndrome.
(About 15 percent to 20 percent of newborns
with down syndrome have atrioventricular
septal defects).
80. 80
Complete atrioventricular canal (CAVC) is a
severe defect in which there is a large hole in
the the septum that separates the left and
right sides of the heart.
The hole is in the center of the heart, where
the upper chambers and the lower chambers
meet.
In a child with a complete atrioventricular
canal defect, there is one large valve, and it
may not close correctly.
81. 81
The hole does not extend between the lower
chambers of the heart and the valves are
better formed.
Partial atrioventricular canal is also called
atrioventricular septal defect, orAVSD.
83. 83
defect in the septum
blood to travel from the left side of the heart
to the right side of the heart, or the other way
around.
The oxygenated and unoxygenated blood
being mixed up
The extra blood being pumped into the lung
arteries makes the heart and lungs work
harder and the lungs can become congested.
84. 84
Dyspnea
MILDCYANOSIS
A newborn baby will show signs of heart
failure such as edema, fatigue, wheezing,
sweating and irregular heartbeat
CHARACTERSTIC MURMUR
88. 88
Narrowing of the aorta
can occur anywhere, but is most likely to happen in the
segment just after the aortic arch.
This narrowing restricts the amount of blood to the
lower part of the body
occurs in about 8-11 % of all children withCHD
89. EFFECTS:
The left ventricle has to work harder to try to move
blood through the narrowing in the aorta 🡲 left-
sided heart failure
BP is higher above the narrowing, and lower below
the narrowing.
Older children may have headaches from too
much pressure in the vessels in the head, or
cramps in the legs or abdomen from too little
blood flow in that region.
The walls of the arteries may become weakened
by high pressure 🡲 spontaneous tears 🡲 cause a
stroke or uncontrollable bleeding.
🡲risk for bacterial endocarditis.
89
92. 92
History.
Poor feeding, dyspnea, and poor weight gain
or signs of acute circulatory shock may
develop in the first 6 weeks of life.
Physical Examination
Infants with COA are pale and experience
varying degrees of respiratory distress.
Oliguria or anuria, general circulatory shock,
and severe acidemia are common.).
Peripheral pulses may be weak and thready
as a result ofCHF.
93. A blood pressure differential may become
apparent only after improvement of cardiac
function with administration of rapidly acting
inotropic agents.
The S2 is single and loud; a loud S3 gallop is
usually present.
No heart murmur is present in 50% of sick
infants.
A nonspecific ejection systolic murmur is
audible over the precordium.
93
94. Electrocardiography.
A normal or rightward QRS axis and RVH or
right bundle branch block (RBBB) are present
X-rayStudies.
Marked cardiomegaly and pulmonary edema
or pulmonary venous congestion are usually
present
94
96. 96
Two-dimensional echo and color flow
Doppler studies usually show the site and
extent of the coarctation.
In the suprasternal notch view, a thin wedge-
shaped “posterior shelf” is imaged in the
posterolateral aspect of the upper
descending aorta
98. 98
About 20% to 30% of all patients with COA
developCHF by 3 months of age.
If it is undetected or untreated, early death
may result from CHF and renal shutdown in
symptomatic infants
99. 99
Medical
In symptomatic neonates, PGE1 infusion should
be started to reopen the ductus arteriosus and
establish flow to the descending aorta and the
kidneys during the first weeks of life.
Intensive anticongestive measures with short-
acting inotropic agents (e.g., dopamine,
dobutamine), diuretics, and oxygen should be
started.
Balloon angioplasty can be a useful procedure
for sick infants in whom standard surgical
management carries a high risk.
100. Surgical
Indications andTiming
If CHF or circulatory shock develops early in life,
surgery should be performed on an urgent basis.
Procedures
Resection and end-to-end anastomosis consists
of resecting the coarctation segment and
anastomosing the proximal and distal aortas .
Subclavian flap aortoplasty consists of dividing
the distal subclavian artery and inserting a flap of
the proximal portion of this vessel between the
two sides of the longitudinally split aorta
throughout the coarctation segment.
100
101. With patch aortoplasty, the aorta is opened
longitudinally through the coarctation
segment and extending to the left subclavian
artery, and the fibrous shelf and any existing
membrane are excised. An elliptic woven
Dacron patch is inserted to expand the
diameter of the lumen.
101
103. 103
Management
Medical
Children with mild COA should be watched
closely for hypertension in the arm or for
increasing pressure differences between the
arm and leg.
Balloon angioplasty
A balloon-expandable stainless-steel stent
implanted concurrently with balloon
angioplasty
An absorbable metal stent is in the
experimental stage
104. Surgical
Indications andTiming
COA with hypertension in the upper
extremities or with a large systolic pressure
gradient equal to or greater than 20 mm Hg
between the arms and the legs indicates that
elective surgical correction is necessary
between the ages of 2 and 4 years.
Reduction of aortic diameter by 50% at the
level ofCOA is also an indication for surgery.
Older children are operated on soon after the
diagnosis is made.
104
105. In asymptomatic children, surgery is
performed by age 4 to 5; late surgery may
increase the risk of developing early essential
hypertension.
If severe hypertension, CHF, or cardiomegaly
is present, surgery is performed at an earlier
age.
105
106. 106
Resection of the coarctation segment and
end-to-end anastomosis
Occasionally, subclavian artery aortoplasty or
circular or patch grafts may be performed.
107. 107
Narrowing or stricture o the aortic valve
Resistance to blood flow in the left ventricle,
decreased cardiac out put, left ventricular
hypertrophy and pulmonary vascular
congestion
Valvular stenosis is the most common type
and is usually caused by malformed cusps
Sub valvular stenosis is a stricture caused by
a fibrous ring below the normal valve
Supra valvular stenosis occurs infrequently
109. 109
A stricture in the aortic outflow tract -->
resistance
ventricle
ventricle
to ejection of blood from left
->
->
extra work load of the left
hypertrophy -> left ventricular
failure -> left atrial pressure increases ->
increased pressure in the pulmonary veins ->
pulmonary edema
110. 110
History
Neonates with critical or severe stenosis of the
aortic valve may develop signs of hypoperfusion
or respiratory distress related to pulmonary
edema within days to weeks after birth.
Most children with mild to moderate AS are
asymptomatic. Occasionally, exercise
intolerance may be present.
Exertional chest pain, easy fatigability, or
syncope may occur in a child with a severe
degree of obstruction
111. Physical Examination
Infants and children with AS are acyanotic
and are normally developed.
blood pressure is normal in most patients, but
a narrow pulse pressure is present in severe
AS.
A systolic thrill may be palpable at the upper
right sternal border, in the suprasternal
notch, or over the carotid arteries.
An ejection click may be heard with valvular
AS.
111
112. Newborns with critical AS may develop signs
of reduced peripheral perfusion (with weak
and thready pulses, pale cool skin, and slow
capillary refill)
112
113. Electrocardiography.
In mild cases the ECG is normal. LVH with or
without strain pattern may be present in
severe cases
X-rayStudies
The heart size is usually normal in children,
but a dilated ascending aorta or a prominent
aortic knob may be seen occasionally in
valvular AS, resulting from poststenotic
dilatation.
Significant cardiomegaly does not develop
unlessCHF occurs later
113
115. 115
Chest pain, syncope, and even sudden death
(1% to 2% of cases) may occur in children
with severeAS.
Heart failure occurs with severe AS during the
newborn period or later in adult life.
Mild stenosis becomes more severe with time
in a significant number of patients
116. 116
Medical
For critically ill newborns withCHF
patients are stabilized before surgery
balloon valvuloplasty
use of rapidly acting inotropic agents and diuretics
to treatCHF
intravenous infusion of PGE1 to reopen the
ductus.
Percutaneous balloon valvuloplasty is now
regarded as the first step in the management
of symptomatic neonates
117. Surgical
ValvularAS
Closed aortic
117
valvotomy, using calibrated
dilators or balloon catheters without
cardiopulmonary bypass, may be performed
in sick infants if balloon valvuloplasty has
been unsuccessful or if it is not available
Aortic valve commissurotomy is usually tried
if stenosis is the predominant lesion
Aortic valve replacement may be necessary if
AR is the predominant lesion
118. Subvalvular AS- Excision of the membrane is
done for discrete subvalvularAS
Supravalvular AS- a reconstructive surgery is
done using aY-shaped patch
118
119. Postballoon and Postoperative Follow-up
An annual follow-up examination is necessary for all
patients who have the aortic valve balloon procedure or
surgery in order to detect development of stenosis or
regurgitation.
Anticoagulation is needed after a prosthetic mechanical
valve replacement.
The International Normalized Ratio (INR) should be
maintained between 2.5 and 3.5 for the first 3 months
and 2.0 to 3.0 beyond that time.
Low-dose aspirin (75 to 100 mg/day for adolescents) is
indicated in addition to warfarin (American College of
Cardiology, 2006).
After aortic valve replacement with a bioprosthesis and
no risk factors, aspirin (75 to 100 mg), but not warfarin, is
indicated.
Restriction from competitive, strenuous sports may be
necessary for children with moderate residual AS or AR,
or both 119
120. 120
Narrowing at the entrance of pulmonary
artery
Resistance to blood flow causes right
ventricular hypertrophy
Pulmonary atresia is the extreme form – total
fusion of commissures and no blood flows to
the lungs
rt .Ventricle may be hypoplastic
122. 122
PS--> Resistance to blood flow-->RVH
If Rt . Ventricular failure develops
-->increase in rt, atrial pressure -->re-opening
of foramen ovale-->shunting of un oxy. blood
in to the Lt.atrium--> systemic cyanosis
123. 123
May be asymptomatic
Some had mild cyanosis
Newborn with severe narrowig- cyanotic
Characteristic murmur
Cardiomegaly on chest radiograph
Pt are at risk for infective endocarditis
124. 124
Surgical
In infants trans ventricular valvotomy (brock
procedure)
In children pulmonary valvotomy withCPB
Non surgical treatment
Balloon angioplasty
127. 127
a complex condition of several congenital defects that occur
due to abnormal devt. of the fetal heart during the first 8
weeks of pregnancy.These problems include the following:
1. ventricular septal defect (VSD)
2. Pulmonary valve stenosis
3. overriding aorta - The aorta sits above both the left and
right ventricles over the VSD, rather than just over the left
ventricle. As a result, oxygen poor blood from the right
ventricle can flow directly into the aorta instead of into the
pulmonary artery to the lungs.
4. Right ventricular hypertrophy - The muscle of the right
ventricle is thicker than usual because of having to work
harder than normal.
129. EFFECTS:
If the right ventricle obstruction is severe, or if the
pressure in the lungs is high 🡲 a large amount of oxygen-
poor (blue) blood passes through the VSD, mixes with
the oxygen-rich (red) blood in the left ventricle, and is
pumped to the body 🡲 cyanosis
The more blood that goes through the VSD, the less
blood that goes through the pulmonary artery to the
lungs 🡲 🡲 oxygenated blood to the left side of the
heart.
Soon, nearly all the blood in the left ventricle is oxygen-
poor (blue). This is an emergency situation, as the body
will not have enough oxygen to meet its needs.
129
130. 130
History
A heart murmur is audible at birth.
Most patients are symptomatic with cyanosis
at birth or shortly thereafter. Dyspnea on
exertion or hypoxic spells develop later, even
in mildly cyanotic infants.
Immediately after birth, severe cyanosis is
seen in patients with TOF and pulmonary
atresia.
131. Physical Examination
Varying degrees of cyanosis, tachypnea, and
clubbing (in older infants and children) are
present.
An RV tap along the left sternal border and a
systolic thrill at the upper and mid-left sternal
borders are commonly present (50%).
An ejection click that originates in the aorta
may be audible
131
132. Electrocardiography
Right axis deviation (RAD) (+120 to +150
degrees) is present in cyanoticTOF.
RVH is usually present
BVH may be seen in the acyanotic form. RAH
is occasionally present.
132
133. X- ray
Decreased pulmonary markings
Black lung fields
Boot shaped heart
133
134. 134
Infants with acyanotic TOF gradually become
cyanotic.
Patients who are already cyanotic become more
cyanotic as a result of the worsening condition of
the infundibular stenosis and polycythemia.
Polycythemia develops secondary to cyanosis.
Hypoxic spells may develop in infants.
Growth retardation may be present if cyanosis is
severe.
135. HYPOXICSPELL
Hypoxic spells are characterized by a
paroxysm of hyperpnea (i.e., rapid and deep
respiration), irritability and prolonged crying,
increasing cyanosis, and decreasing intensity
of the heart murmur.
Hypoxic spells occur in infants, with a peak
incidence between 2 and 4 months of age.
These spells usually occur in the morning
after crying, feeding, or defecation.
A severe spell may lead to limpness,
convulsion, cerebrovascular accident, or even
death.
135
138. 138
The infant should be picked up and held in a
knee-chest position.
Morphine sulfate, 0.2 mg/kg administered
subcutaneously or intramuscularly, suppresses
the respiratory center and abolishes hyperpnea
Oxygen is usually administered, but it has little
demonstrable effect on arterial oxygen
saturation.
Acidosis should be treated with sodium
bicarbonate (NaHCO3), 1 mEq/kg administered
intravenously. The same dose can be repeated in
10 to 15 minutes..
140. MANAGEMENT OFTOF
Medical
educate parents to recognize the spell and know
what to do.
Oral propranolol therapy, 0.5 to 1.5 mg/kg every
6 hours, is occasionally used to prevent hypoxic
spells while waiting for an optimal time for
corrective surgery
Balloon dilatation of the right ventricular outflow
tract and pulmonary valve, it is not widely
practiced,
Maintenance of good dental hygiene and
practice of antibiotic prophylaxis against SBE are
important .
A relative iron deficiency state should be
detected and treated
140
141. Surgical
Palliative Shunt Procedures
Classic Blalock-Taussig shunt,
141
anastomosed
between the subclavian artery and the ipsilateral
PA, is usually performed for infants older than 3
months because the shunt is often thrombosed
in younger infants with smaller arteries
143. Blalock-Taussig (BT)
143
shunt. A
placed
interposition shunt is
artery and the
Modified
Gore-Tex
between
ipsilateral
the subclavian
PA. This is the most popular
procedure for any age, especially for small
infants younger than 3 months of age
145. TheWaterston shunt, anastomosed between
the ascending aorta and the right PA, is no
longer performed because of a high incidence
of surgical complications
145
146. The Potts operation
Anastomosed between the descending aorta
and the left PA, is no longer performed
146
147. Complete Repair Surgery
Usually done in the first year of life
Total repair of the defect is carried out under
cardiopulmonary bypass
The procedure includes patch closure of the
VSD, preferably through a transatrial and
transpulmonary artery approach
widening of the RVOT by division and/or
resection of the infundibular tissue; and
pulmonary valvotomy,).
The operative mortality for total correction of
TOF is 5%
147
149. 149
In this condition, there is no tricuspid valve, therefore, no
blood flows from the right atrium to the right ventricle.
Blood in right atrium 🡲 foramen ovale 🡲 left atrium and
left ventricle 🡲 aorta
There is complete mixing of the oxy. Blood and un oxy.
blood
Tricuspid atresia defect is characterized by the following:
a small right ventricle
a large left ventricle
SmallVSD and PDA
diminished pulmonary circulation
cyanosis - bluish color of the skin and mucous
membranes caused from a lack of oxygen.
151. 151
History
Cyanosis is usually severe from birth.
Tachypnea and poor feeding usually manifest.
History of hypoxic spells may be present in infants
with this condition.
Physical Examination
Cyanosis, either with or without clubbing, is always
present.
A systolic thrill is rarely palpable when associated
with PS.
A grade 2 to 3/6 holosystolic (or early systolic)
murmur ofVSD is usually present at the lower left
sternal border
152. Electrocardiography
LVH is usually present;
RAH or biatrial hypertrophy (BAH) is
common.
X-rayStudies.
The heart size is normal or slightly increased,
with enlargement of the RA and LV
Echocardiography.
Absence of the tricuspid orifice, marked
hypoplasia of the RV, and a large LV can be
imaged in the apical four-chamber view.
152
154. 154
Initial Medical Management
PGE1 should be started in neonates with severe
cyanosis to maintain the patency of the ductus
before planned cardiac catheterization or
cardiac surgery.
The Rashkind procedure (balloon atrial
septostomy) may be performed as part of the
initial catheterization to improve the RA-to-LA
when the interatrial
considered inadequate by
shunt, especially
communication is
echo studies.
155. Surgical.
Most infants with tricuspid atresia require
one or more palliative procedures before a
Fontan-type operation
Ideal candidates for a Fontan-type operation
are those who have normal LV function and
low pulmonary resistance
Stage I
Blalock-Taussig shunt, when PBF is small
This procedure results in the volume load on
the LV because the LV supplies blood to both
the systemic and pulmonary circulations.
155
156. Damus-Kaye-Stansel and shunt operation
the aorta and pulmonary artery are joined using a
patch (pink). The blue tube is known as a Modified
Blalock-Taussig Shunt.
156
157. Pulmonary artery banding. PA banding is
rarely necessary for infants withCHF resulting
from increased PBF. PAbanding protects the
pulmonary vasculature from developing
pulmonary hypertension
Medical follow-up after stage I.Watch for:
Cyanosis (O2 saturation <75%)—cardiac
catheterization or MRI to find out its cause.
Poor weight gain (CHF from too much PBF)—
tightening of PA band may be necessary.
157
158. Stage II (at 3 months or by 6 months).
BidirectionalGlenn operation (BDG).
also called bidirectional superior
cavopulmonary shunt
An end-to-side SVC-to-RPA shunt (also
called bidirectional superior cavopulmonary
shunt) can be performed by 2.5 to 3 months
of age
This procedure satisfactorily increases
oxygen saturation
158
160. The hemi-Fontan operation.
SVC is connected to PA.
Blood coming back from the upper body now
flows directly to the lungs without going through
the heart
The Blalock-Taussig (BT) shunt is removed.
A patch is placed over the top part of the heart's
right upper chamber . This prevents blood from
the upper body from entering the heart and
blood from the lower body from entering the
lungs. It also maintains a connection that is used
for the final stage of the repair and greatly
simplifies the last operation.
160
162. Medical follow-up after stage II.Watch for
the following:
A gradual decrease inO2 saturation (<75%)
may be caused by: .
Opening of venous collaterals
PulmonaryAVfistula (due to the absence of
hepatic inhibitory factor)
Transient hypertension—1 to 2 weeks
postoperatively—may useACE inhibitors
162
163. Stage III ( Fontan operation)—within 1 to 2
years after stage II operation
The whole premise of the Fontan operation is
directing the entire systemic venous blood to
the pulmonary arteries without an
intervening pumping chamber.
The Fontan operation is usually completed
when the child is around 2 years of age. This
procedure can even be performed on infants.
163
165. 165
Patients should maintain a low-salt diet.
Medications:
Some patients need continued digoxin and diuretic
therapy.
An angiotensin-converting enzyme (ACE) inhibitor is
generally recommended.
Aspirin (or even warfarin) is used to prevent
thrombus formation in the RA.
Patients should not participate in competitive,
strenuous sports.
Antibiotic prophylaxis against SBE should be
observed when indications arise.
166. 166
Difference in the PA pressure and aortic pressure--> pulmonary
congestion
Volume load in ventricles -->decresed cardiac out put
Relative desaturation of systemic blood,
Mixing of blood from pulmonary and systemic circulation within
the heart chambers
167. 167
the aorta is connected to the right ventricle, and the pulmonary artery is
connected to the left ventricle
Oxygen-poor (blue) blood returns to the right atrium from the body 🡲
passes through the right atrium and ventricle, 🡲 into the misconnected
aorta back to the body.
Oxygen-rich (red) blood returns to the left atrium from the lungs 🡲
passes through the left atrium and ventricle, 🡲 into the pulmonary artery
and back to the lungs.
Other heart defects are often associated withTGA
- atrial or ventricular septal defect
- may be necessary in order for the infant withTGA to survive
- Allow mixing of blood – providing at least smaller amounts of oxygen
to the body
169. 169
cyanosis from birth is always
History
History of
present.
Signs of congestive heart failure (CHF) with
dyspnea and feeding difficulties develop
during the newborn period.
170. Physical Examination
Moderate to severe cyanosis is present,
TheS2 is single and loud..
If CHF supervenes, hepatomegaly and
dyspnea develop.
170
171. 171
There is a rightward QRS axis (i.e., +90 to
+200 degrees).
Right ventricular hypertrophy (RVH) is
usually present
Biventricular hypertrophy (BVH) may be
present
Occasionally right atrial hypertrophy (RAH) is
present.
172. 172
In the parasternal short-axis view, the “circle
and sausage” appearance of the normal great
arteries is not visible. Instead, the great
arteries appear as “double circles”
3. In the apical and subcostal five-chamber
views, the PA arises from the LV, and the
aorta arises from the RV.
175. 175
Without surgical intervention, death occurs in
90% of patients before they reach 6 months
of age.
176. 176
Medical
Arterial blood gases and pH should be
obtained and metabolic acidosis should be
corrected
PGE1 infusion should be started to improve
arterial oxygen saturation by reopening the
ductus.
Oxygen administration
A balloon atrial septotomy (Rashkind
procedure) may be performed to increase the
mixing by opening the atrial septum
177. 177
An arterial switch procedure- performed in
first week of life
Transecting the great arteries and
anastomosing the main pulmonary artery to
the proximal aorta and anastomosing the
ascending aorta to the proximal pulmonary
artery
The coronary arteries are switched from
proximal aorta to the proximal pulmonary
artery to create a new aorta
179. Intra atrial baffle repairs –An intraatrial baffle
is created to divert the venous blood to the
mitral valve and pulmonary venous blood to
the tricuspid valve using using patients atrial
septum or a prosthetic valve.
179
180. Rastelli procedure-operative choice in
patients withTGA,VSD, and severe pulmonic
stenosis.
It involves closure ofVSD with baffle->LV
blood directed throughVSD in to aorta
Pulmonic valve is then closed , and a conduit
is placed from RV to PA
180
181. 181
No direct communication between the pulmonary
veins and the left atrium
Drain anomalously into the systemic venous
tributeries or into right atrium
4 types
Supracardiac:( 50% of TAPVR ). The common
pulmonary venous sinus drains into the rightSVC
Cardiac: (20% of TAPVR) .The common
pulmonary venous sinus drains into the coronary
sinus
182. Infracardiac:( 20% of TAPVR patients) The
common pulmonary venous sinus drains to
the portal vein, ductus venosus, hepatic vein,
or inferior vena cava (IVC).
Mixed type: This type, which is a
combination of the other types, accounts for
10% ofTAPVR patients
182
184. 184
History
CHF with gowth retardation
Frequent pulmonary infection
Mild cyanosis
Physical examination
Undernourished
Signs of CHF
Precordial bulge
ECG
RVH and occational RAH
185. TOTALANOMALOUS PULMONARYVENOUS
RETURN – Clinical Manifestations
X- ray studies
Cardiomegaly
Kerley B lines
Snowmans sign/ figure of 8
Echo
A large RA and a small LA, with deviation of
the atrial septum to the left and dilated
PAs, are also present.
185
187. 187
medical
Intensive anticongestive measures
Metabolic acidosis should be corrected,
Infants with severe pulmonary edema-should
be intubated and receive ventilator support
In some patients with pulmonary
hypertension, PGE1 can increase systemic
flow by keeping the ductus open
188. 188
SupracardiacType.
A large, side-to-side anastomosis is made
between the common pulmonary venous
sinus and the LA. The ASD is closed with a
cloth patch.
TAPVR to the RightAtrium.
The atrial septum is excised and a patch is
sewn in such a way that the pulmonary
venous return is diverted to the LA . The
ASD may have to be enlarged.
189. TAPVR to theCoronary Sinus.
An incision is made in the anterior wall of the
coronary sinus (“unroofing”) to make a
communication between the coronary sinus
and the LA. A single patch closes the original
ASD and the ostium of the coronary sinus. This
results in the drainage of coronary sinus blood
with low oxygen saturation into the LA
InfracardiacType.
A large vertical anastomosis is made between
the common pulmonary venous sinus and the
LA. The common pulmonary vein, which
descends vertically to the abdominal cavity, is
ligated above the diaphragm
189
190. 190
The aorta and pulmonary artery start as a single blood vessel, which
eventually divides and becomes two separate arteries.
Truncus arteriosus occurs when the single great vessel fails to separate
completely, leaving a connection between the aorta and pulmonary artery.
Usually accompanied by a ventricular septal defect
EFFECTS:
oxygen-poor (blue) and oxygen-rich (red) blood mix back and forth through
the ventricular septal defect.
This mixed blood then flows through the common truncal vessel. Some of it
will flow to pulmonary artery and on to the lungs, and some of the mixed
blood will go into the aortic branch and to the body.
The mixed blood that goes to the body does not have as much oxygen as
normal, and will cause varying degrees of cyanosis
192. 192
History
Cyanosis may be seen immediately after
birth.
Signs of CHF develop within several days to
weeks after birth.
History of dyspnea with feeding, failure to
thrive, and frequent respiratory infections is
usually present in infants.
193. Physical Examination
Varying degrees of cyanosis and signs of CHF
with tachypnea and dyspnea are usually
present.
The peripheral pulses are bounding, with a
wide pulse pressure.
A systolic click is frequently audible at the
apex and upper left sternal border.
193
194. Electrocardiography.
BVH is present in 70% of cases
X-rayStudies.
Cardiomegaly is usually present
Echocardiography.
A large, single great artery arises from the
heart .The type of persistent truncus
arteriosus can be identified, and the size of
the PAs can be determined.
194
195. 195
measures with
Vigorous anticongestive
digitalis and diuretics
surgical
Corrective repair
Closing theVSD
from aorta
Arteries , and
to the RV by means of
Excising the pul.
attaching them
homograft
Prognosis
Mortality greater than 10%
196. 196
HLHS occurs in 1% of all congenital heart
defects or 9% of such defects in critically ill
newborns
Underdevelopment of the left side of the heart
resulting in a hypoplastic left ventricle and
aortic atresia
Most of the blood from LA Flows across PFO
to RA RV PA
The descending aorta receives blood from pda
supplying systemic blood flow
198. Effects
PFO allows saturated blood from LA to mix
with desaturated blood from RA-->RV -->PA
from PA blood flows to lung and then
through ductus arteriosus in to the aorta and
out f the body
The coronary and cerebral vessels receive
blood by retrograde flowthrough the
hypoplastic ascending aorta
198
199. CLINICAL MANIFESTATIONS
A neonate with HLHS becomes critically ill within
the first few hours to the first few days of life.
Tachycardia, dyspnea, pulmonary crackles, weak
peripheral pulses, and vasoconstricted
extremities are characteristic.
The patient may not have severe cyanosis but
has a grayish blue color of the skin with poor
perfusion.
TheS2 is loud and single..
The ECG almost always shows RVH.
Chest x-ray films characteristically show
pulmonary venous congestion or pulmonary
edema
Arterial blood gas levels reveal a slightly
decreased Po2 and a normal Pco2. 199
200. Therapeutic management
PGE1 infusion to maintain ductal patency
Surgical procedure
Several staged approach
1st stage- Norwood procedure
Anastomosis of main PA to the aorta to create a
new aorta, placement of a shunt or inserting a
conduit from the RV to PA to provide pulmonary
blood flow , and creation of a largeASD.
2nd stage-Bidirectional GlennShunt
Done at 6-9 months of age to relieve cyanosis
and reduce overload in RV
200
203. 203
heart
Ebstein anomaly is a congenital
defect in which the septal leaflet of
the tricuspid valve is displaced towards the
apex of theright ventricle of the heart.
The valve leaflets, however, are to a varying
degree, attached to the walls and septum of
the right ventricle.
There is subsequent 'atrialization' of a portion
of the morphologic right ventricle
205. 205
The right ventricle is thus divided into 2 parts
by the abnormal tricuspid valve
the 1st, a thin-walled “atrialized” portion, is
continuous with the cavity of the right
atrium;
the 2nd, often smaller portion consists of
normal ventricular myocardium.
The right atrium is enlarged as a result of
tricuspid valve regurgitation,
206. In more severe forms of Ebstein anomaly, the
effective output from the right side of the
heart is decreased due to a combination of
the poorly functioning small right ventricle,
tricuspid valve regurgitation, and obstruction
206
produced
of the right ventricular outflow tract
by the large, sail-like, anterior
tricuspid valve leaflet.
The increased volume of right atrial blood
shunts through the foramen ovale (or
through an associated atrial septal defect) to
the left atrium and produces cyanosis
207. CLINICAL MANIFESTATIONS
History
In severe cases, cyanosis and CHF develop
during the first few days of life.
Children with milder cases may complain of
dyspnea, fatigue, cyanosis, or palpitation on
exertion.
207
208. Physical Examination
Mild to severe cyanosis is present, as well as
clubbing of the fingers and toes in older infants
and children.
Characteristic triple or quadruple rhythm is
audible.
Electrocardiography
1. Characteristic ECG findings of RBBB and RAH
are present in most patients with this condition
x-rayStudies.
. In severe cases, an extreme cardiomegaly with
a balloon-shaped heart and decreased
pulmonary vascular markings are present
208
209. Echocardiography
The tricuspid valve leaflets are elongated,
redundant, and dysplastic
A large RA, including the atrialized RV, and a
small functional RV represent anatomic
severity
209
210. 210
Medical
In severely cyanotic newborns, intensive
treatment with mechanical ventilation,
PGE1 infusion
inotropic agents
correction of metabolic acidosis
211. 211
Palliative procedures
Blalock-Taussig shunt
Starnes operation- a procedure to reduce the
RV or RA
Classic Glenn anastomosis or its modification
may be considered in severely cyanotic infants
212. Definitive procedures
Two-ventricular repair
Danielson technique:
tricuspid valve
Carpentier technique:
212
For repair of the
This repair also
plicates the atrialized portion of the RV and
the tricuspid annulus
One-ventricular repair:
For patients with inadequate size of the RV,
a Fontan-type operation
performed in stages following
is usually
the initial
palliative procedures such as bidirectional
Glenn operation
213. 213
Impaired gas exchange related to altered pulmonary blood flow
or oxygen deprivation
Altered cardiac output related to specific anatomic defect
Activity intolerance related to decreased oxygenation in blood
and tissues
Altered Nutrition: less than body requirements related to the
excessive energy demands required by increased cardiac
workload
Increased potential for infection related to poor nutritional status
Anxiety related to diagnostic procedures and hospitalization
Developmental delay related to decreased energy, inadequate
nutrition, physical limitations and social isolation
Alteration in parenting related to parental perception of the child
as vulnerable
215. Relieve the respiratory distress associated with increased pulmonary
blood flow or oxygen deprivation
Determine degree of respiratory distress
Position child at 45 degree angle to decrease pressure of the
viscera on the diaphragm and increase lung volume
Pin diapers loosely and provide loose-fitting pajamas for older
children
Feed slowly
Tilt infant’s head slightly
Suction the nose and throat if unable to cough out secretions
Provide oxygen therapy as needed
Improve oxygenation o that the body functions may be
maintained
Provide effective oxygen environment
Observe response to oxygen therapy
Observe response to oxygen weaning therapy
◾Relieve Hypoxic spells associated with cyanotic types of
Congenital heart disease
◾Observe for “tet” spells
◾Encourage fluid intake
◾Obtain vital signs
215
216. 216
A. Provide adequate nutritional and fluid
intake to maintain the growth and
developmental needs of the child
Feed in semi-erect position
Provide small frequent feedings
Provide foods with high nutritional value
Determine child’s likes and dislikes
Strict input and output
Daily weight
217. B. Prevent infection
Prevent exposure to communicable diseases
Immunizations should be up-to-date
Handwashing should be observed
Be certain that the child receives prophylactic
medication for infective endocarditis
217
218. C. Reduce the workload of the heart since
decreased activity and expenditure of energy
will decrease oxygen requirements
Uninterrupted rest
Avoid unnecessary activities
Prevent excessive crying
Provide diversional activities
Prevent constipation
218
219. D. Observe child for symptoms of Congestive
Heart Failure that occur frequently as a
complication ofCongenital Heart Disease
E. Observe for the development of symptoms of
infective endocarditis that may occur as a
complication of congenital heart disease
F. Observe for the development of thrombosis
that may occur as a complication of congenital
heart disease
G. Prepare the child for diagnostic and treatment
procedures
H. Explain cardiac problems to child and parents
219
220. 220
A. Instruct the family in necessary measures
to maintain the child’s health
B.Teach the family about the defect and its
treatment
C. Encourage the parents and other persons
to treat child in a normal manner as possible
![2
Anatomic malformation of the heart or great
vessels which occurs during intrauterine
development, irrespective of the age at
presentation.
Congenital heart disease occurs in
approximately 0.8% of live births.
The incidence is higher in stillborns (3-4%),
spontaneous abortuses (10-25%), and
premature infants (about 2% excluding
patent ductusarteriosus [PDA]](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)