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2. Congenital Heart Diseases
Congenital heart disease-6-8 /1000 live births
CHD- Cyanotic/Acyanotic
Further subdivided based on CxR- evidence of
increased (Plethoric)/decreased pulmonary vascular
marking (Oligemic)
ECG- to determine R/ L / biventricular hyertrophy
Character of HS/murmur
Final diag-by echocardiography &/or cardiac
catheterization
3. Assessment of a child for the
presence of heart disease-
Nadas criteria
Major
1. Systolic murmur
grade III or more
2. Diastolic murmur
3. Cyanosis
4. CCF
Minor
1. Systolic murmur less
than grade III
2. Abnormal 2nd HS
3. Abnormal ECG
4. Abnormal –x-ray
5. Abnormal BP
1 major or 2 minor criteria
4.
5. Fetal Circulation
• For the fetus the placenta is the oxygenator so the
lungs do little work
• RV & LV contribute equally to the systemic
circulation and pump against similar resistance
• Shunts are necessary for survival
• Ductus venosus (bypasses liver)
• Foramen ovale (R→L atrial level shunt)
• Ductus arteriosus (R→L arterial level shunt)
6.
7.
8.
9. Transitional Circulation
• With first few breaths lungs expand and
serve as the oxygenator (and the placenta is
removed from the circuit)
• Foramen ovale functionally closes
• Ductus arteriosus usually closes within first
1-2 days
10.
11. Neonatal Circulation
• RV pumps to pulmonary circulation and LV
pumps to systemic circulation
• Pulmonary resistance (PVR) is high; so initially
RV pressure ~ LV pressure
• By 6 weeks pulmonary resistance drops and
LV becomes dominant
12.
13. Normal Pediatric Circulation
• LV pressure is 4-5 x RV pressure (this is
feasible since RV pumps against lower
resistance than LV)
• RV is more compliant chamber than LV
14. Classification- Cyanotic CHD
Decreased PBF
1. Tetralogy of Fallots
2. Pulmonary atresia with
VSD
3. Tricuspid atresia
4. Double outlet RV with
Pulm Stenosis
5. Ebstein anomaly of the
tricuspid valve
Increased PBF
1. Transposition of the great
arteries(TGA)
2. DORV without Pulm
Stenosis
3. Total anomalous
Pulmonary venous return
4. Truncus arteriosus
5. Hypoplastic left heart
syndrome
15. Tetralogy of Fallots
Commonest CCHD in
children >2 yr
Contituents-
i-VSD
ii-pulmonic stenosis
iii –overriding or
dextroposed aorta
iv-Right ventricular
hypertrophy
16.
17. TOF- hemodynamics
Pulmonary stenosis-concentric RV hypertrophy
without cardiac enlargement & increase in RV
pressure
Increase in RV pressure- leads R-L shunt
Once RV &LV pressure equals ,increasing severity of
pulmonic stenosis reduce pulm blood flow
VSD-silent
Flow across the pulmonary stenosis – ejection
systolic murmur
18. TOF- hemodynamics
The more severe PS –The shorter the ejection systolic
murmur and more the cyanosis
The VSD of TOF is always large-effectively decompress RV
and so CCF never occurs in TOF
Exceptions-anemia,infective endocarditis, systemic HTN,
Myocarditis and associated AR
The late and soft P2 –inaudible and 2nd HS is single and due to
aortic component
RV HT –large a wave
19. TOF- Clinical features
Anoxic spells-paroxysmal attack of dyspnea any time
after birth
Cyanosis-since birth or may present some yrs after
Commonest presentation-dyspnoea on exertion and
exercise intolerance--- squatting position
Anoxic spells occur predominantly after waking up or
following exertion-starts crying,dyspneic, may loose
consciousness. Convulsion may occur.
20. TOF- Clinical features
Cyanosis,clubbing, slightly prominent ‘a’ waves
Others: growth retardation, chest pain, headache,
tachypnoea
ECG-right axis deviation with RV hypertrophy. ‘T’
waves usually inverted in right precordial leads.
CxR-N sized heart with upturned apex .
Oligemic lung fields. Absence of main pulmonary
artery segment, boot shaped heart or “cor-en –
sabot”
23. Treatment
Oral beta-blockers to prevent cyanotic spells
Iron supplementation to prevent anaemia
(Hb>12)
Palliative Sx: Blalock –Taussig shunt
Definitive SX: closure of VSD and relief of
RVOT obstruction
24. Management of anoxic spells
1. Knee chest position
2. Humidified oxygen
3. Morphine - 0.1-0.2mg/kg subcutaneous
4. Correct acidosis- soda bicarbonate iv
5. Propranolol-o.1mg/kg/IV(during spell) o.5 to
1mg/kg 4-6hrly orally
6. Vasopressors-Methoxamine IM/IV Drip
7. Correct hypovolemia, anemia
25. Pink TOF:PS not severe enough to result in
decreased pulmonary flow.
Pentalogy of fallot: TOF + ASD
Trilogy of fallot: PS, RVH and ASD
26. Tricuspid atresia
Congenital absence of the tricuspid valve
RA LA LV………..RV
Symptoms- same as TOF
Features suggestive of TA
1.LV type of apical impulse
2.Prominent a wave in the JVP
3.Enlarged liver with presystolic pulsation
4.ECG-left axis deviation with LV HT
Palliative T/t—GLENN shunt(SVC-RPA)
-FONTAN OPERATION (all systemic return
to pulmonary artery)
27. Ebstein’s anomaly
Posterior as well as the septal leaflet of the
tricuspid valve is displaced downwards---
arterialized RV
Heart sounds: split S1, S2; S3,S4; pansystolic
murmur (TR)
ECG-`p’ pulmonale as well as `p’ mitrale;
prolonged PR interval; RBBB
CXR: enlarged cardiac size ( enlarged RA, RV)
28. Cyanotic CHD -Increased PBF
Abnormal mixing of pulmonary venous blood and
absence of pulmonary blood flow obstruction
Clinical presentation-
-Cyanosis
- CHF
- Recurrent chest infection
-Failure to thrive
Prognosis-Poor-80% of Pts expire within 3 months
29. Transposition of great vessels
5% 0f CHDs
M/C CCHD presenting in the NB
M:F –3:1
RA…………LA RA LA
RV…….. LV LV RV
AO……….PA PA AO
Complete corrected
30. Transposition of great vessels
C/F- Cyanosis-at birth or 1st week of life
Congestive Heart Failure
ECG-Rt axis deviation& Rt ventricular hyertrophy
CxR- Cardiomegaly with a narrow base and
plethoric lung fields.(EGG ON side apearance)
Treatment-Rx-CHF &acidosis
If hypoxemia –prostaglandin infusion
Operative- septostomy-- Jatene’ s switch over
-Mustard operation
32. Total Anomalous Pulmonary
venous connection
All the pulmonary veins instead of joining
LA are connected anomolously to RA -
There is complete mixing of the two
venous returns