congenital heart disease

1. Acyanotic
Congenital Heart Disease
Classification
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. Al Quran surah Al-Imran 3:8

3. Congenital Heart Disease - Classification
• Cyanotic Congenital Heart Disease (R to L shunts)
• Tetralogy of Fallot (TOF)
• Transposition of the Great Arteries (TGA)
• Acyanotic Congenital Heart Disease
• L to R shunts
 Ventricular Septal Defect (VSD)
 Atrial Septal Defect (ASD)
 Patent Ductus Arteriosus (PDA)
• Obstructive lesions
 Aortic Stenosis (AS)
 Pulmonary Stenosis (PS)

4. Acyanotic Congenital Heart Defects
(Relative Frequency)
• Ventricular Septal Defect (25% of total Congenital
Heart Defects)
• Atrial Septal Defect (7%)
• Patent Ductus Arteriosus (12%)
• Co-arctation of Aorta (5%)
• Aortic Stenosis (5%)
• Pulmonary Stenosis (5%)

5. VSD
Ventricular Septal Defect
Pathophysiology, Clinical Features, Diagnosis
Complications, Management, Prognosis
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

6. VSD - anatomy

7. VSD – anatomical types
• Membranous VSD
• Muscular VSD

8. Clinical Scenario
• A 3 months old baby presents to the OPD with complaints of
frequent cough and cold for the last 2 months.
• Baby is on mother feeding, but takes feeding for a short time
only. He remains fussy and cries often
• Weight of the infant is 4 kg.
• On examination, his heart rate is 150/min and respiration is
60/min.
• Chest examination: apex beat at 5th intercostal space 1 cm left to
mid-clavicular line. A pan-systolic murmur is audible at left lower
sternal border.
• Abdominal examination shows enlarged liver palpable by 4 cm
below the right costal margin
• What is your diagnosis ?

9. VSD – Clinical Presentation
• Small VSD:
• Asymtomatic child
• Heart murmur (pan-systolic murmur at left lower sternal
border) detected on examination
• Large VSD:
• Signs of Heart failure (tachypnea, tachycardia, shifted apex
beat, hepatomegaly)
• Frequent respiratory infections
• Failure to thrive
• Heart murmur (pan-systolic murmur at left lower sternal
border) detected on examination

10. VSD - Symptoms
• Poor feeding
• Sweating on feeding
• Respiratory distress on feeding
• Bluish discoloration of lips on excessive crying
• Lethargy
• Frequent respiratory infections
• Poor Weight gain

11. VSD - Signs
• Tachycardia
• Tachypnea – fast breathing
• Cardiac Examination
• Cardiac Apex beat shifted outwards and
downwards (normal is at 4th intercostal space in the
mid-clavicular line)
• Apical heave. Thrill may be present
• S1 and S2 normal. Pan-systolic murmur at LLSB (left
lower sternal border)
• Hepatomegaly

12. Heart sounds - Normal

13. VSD – Heart murmur
Pan-systolic murmur at LLSB (left lower sternal border)

14. VSD – Investigations
• Chest X-ray – enlarged heart
• ECG – Left Axis deviation,
- Left Ventricular Hypertrophy
• Echocardiography –
- Defect in interventricular septum
- Left Ventricular Hypertrophy
• Cardiac catheterization – cardiac angiography
reveals the exact anatomy

15. Chest Radiograph in VSD
• Heart shadow
enlarged
• Apex of heart shifted
downwards and
outwards
• Increased pulmonary
vascular markings

16. Normal ECG

17. ECG in VSD
(deep S wave in V1, tall R wave in V5)

18. Echocardiography in VSD

19. VSD - Complications
• Respiratory Infections – frequent bronchitis and
pneumonia
• Congestive Heart Failure – due to volume overload
• Infective endocarditis – bacterial infection of
endocardium
• Failure to Thrive – Low weight, Short height
• Pulmonary Hypertension – seen in large VSD due to
increased pulmonary blood flow
• Eisenmenger Syndrome – severe pulmonary
hypertension results in reversal of shunt through VSD
and systemic cyanosis

20. Eisenmenger Syndrome

21. VSD – Choice of Specific Management
• Wait for spontaneous closure – asymptomatic small VSD
• Medical management – symptomatic small VSD
• Trans-catheter Device closure – symptomatic suitable VSD
• Open heart surgical closure – large membranous VSD

22. VSD - Medical Management
• Supportive Management:
• Adequate Hydration and Nutrition
• Correction of Anemia – iron supplements
• Management of Complications:
• Respiratory Infections – antibiotics, bronchodilators
• Congestive Heart Failure – diuretics, digoxin, ACE
inhibitors
• Infective endocarditis – IV antibiotics

23. VSD device closure
by a device through cardiac catheter

24. VSD – Surgical Management
• VSD closed by Open cardiac surgery

25. Prognosis
• Prognosis depends upon size of VSD
• Small VSD in muscular portion of inter-ventricular
septum is likely to close spontaneously
• Large VSD is likely to develop more complications
and needs early surgical management

26. PDA
Patent Ductus Arteriosus
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

27. Patent Ductus Arteriosus
• Ductus Arteriosus connects Pulmonary Artery with
descending Aorta in fetal life
• It closes shortly after birth
• It may remain patent as congenital heart defect especially in
preterm newborns
• PDA makes a Left-to-Right shunt in the heart
• It may result in Pulmonary hypertension or CHF

28. Patent Ductus Arteriosus – clinical features
• Poor feeding and respiratory distress may occur in the
newborn infant or child
• Continuous (systolic + diastolic) machinery murmur is heard
at LUSB (left upper sternal border)
• Echocardiography confirms the diagnosis

29. Patent Ductus Arteriosus – clinical features
• Continuous (systolic + diastolic) machinery murmur is heard
at LUSB (left upper sternal border)

30. Patent Ductus Arteriosus – Management
• Medical management in the preterm infant – Oral
paracetamol or Ibuprofen may result in closure of PDA in
preterm newborn
• Device Closure – intravascular catheter is used to transport
a closing device which closes the open duct
• Surgery is used to tie the PDA

31. Patent Ductus Arteriosus – Management
• Device Closure – intravascular catheter is used to transport
a closing device which closes the open duct

32. Medical Profession

33. Thankyou