Introductory lecture with overview of congenital heart diseases including fetal circulation and the changes that occur after birth. Simple approach to CHD

1. Fetal Circulation and
Approach to CHD
Dr Tushar Jagzape,
Pediatrics ,
AIIMS, Raipur

2. Learning objectives:
• At the end of this lecture, the learner should be able
to:
• Describe fetal circulation and changes that occur at birth.
• Highlight the salient differences between fetal and
neonatal circulation.
• Describe the classification of CHD.
• Enlist common acyanotic and cyanotic congenital heart
diseases.
• Approach to a child with suspected CHD.
• Describe the hemodynamics of Lt to Rt shunts

3. Fetal circulation and difference between fetal
and neonatal circulation.
• Parallel vs series circulation.
• Structures responsible for parallel circulation.
• Ductus venosus
• Foramen ovale
• Ductus arteriosus.

4. 413-1-15 4
30-35 mm of
Hg
26-28 mm of
Hg
12-14 mm of
Hg

5. • After birth
• Lung expansion -- ↓ in pulmonary pressure.
• Increase in paO2 of blood.
• Loss of low pressure placental circulation.
• Functional closure of foramen ovale.
• Closure of ductus venosus and arteriosus.
• Series circulation.

6. Heart diseases in children:
• Heart, Pericardium, blood vessels.
• Congenital or acquired.
• Isolated or as a part of other systemic diseases.

7. Prevalence
• Congenital
• Cyanotic: 22%
• Acyanotic: 68%
• VSD 25%
• ASD 6%
• PDA 6%
• TOF 5%
• PS 5%
• AS 5%
• Acquired
• Kawasaki disease
• Rheumatic
• Tubercular
• Collagen
• Viral myocardidits
• Storage disorders
• Myopathies.
• Iron overload
• Infective endocarditis

8. 8
Congenital Heart Diseases:-
• Incidence and prevalence:-
-Initial estimate 6-8 per 1000 live births.
-Recent estimate1/100 live births.
-Accounts to 15-20% of cardiac cases.

9. Etiology:-
-90% cases etiology not known.
-Both sexes are equally affected.
-Rt. Sided lesions common in female and left sided in male.

10. 10
• Heredity
• Environmental factors
• Maternal diseases or factors
• Intrauterine infections:- TORCH group
• Drugs like thalidomide
• Metabolic factors like idiopathic hypercalcemia.
• Genetic diseases:- Marfan syndrome, Ehlers-Danlos syndrome,
Hurler syndrome
• Chromosomal aberrations:- Turner, Down and other trisomy
syndromes.

11. Presenting complaints/signs
• Failure to thrive
• Exercise intolerence
• Easy fatigability
• Chest indrawing
• Sweating during feeding
• Bluish spells
• Fever with rigor
• Palpitation
• Convulsion
• Fast breathing
• Oedema
• Hepatomegaly,
• spleenomegaly
• Clubbing
• Cyanosis
• Focal neurological lesion
• Other organ defects
• Chromosomal anomalies

12. 12
Nadas` Criteria:-
• Major
i. Systolic murmur grade
III or more specially
with a thrill.
ii. Diastolic murmur
iii. Cyanosis
iv. Congestive cardiac
failure
• Minor
i. Systolic murmur less
than grade III
ii. Abnormal S2
iii. Abnormal ECG
iv. Abnormal X ray
v. Abnormal BP

13. Cyanosis: is it a cardiac cause or lung cause
• Hyperoxia test
• Neonates with cyanotic congenital heart disease usually do not have
significantly raised arterial Pao2 during administration of 100% oxygen.

14. Classification
Acyanotic
ASD
VSD
PDA
Cyanotic
TOF
TGA
Tru Art
TAPVC
Tri Atresia
Obstructive
PS
AS
COA

15. Approach to CHD
• History
• Physical examination
• Investigations

16. Left To Right Shunt
• Acyanotic CHD

17. Acyanotic heart disease ( VSD / ASD /PDA )
COMMON FINDING
• Frequent chest infections (6-8 attacks 1st year of life)
• Increased sweating / Perspiration / FTT
• Precordial bulge / Hyperkinetic precordium
• Loud S2 / Murmur +
• X-ray: Plethoric + Cardiomegaly

18. Cyanotic heart disease with increase
pulmonary flow.
• Clinical features similar to acyanotic heart diseases with left to right
shunt. In addition the patient is cyanosed.

19. Cyanotic heart disease with decreased blood
flow:
• Cyanosis
• Age of onset or age at which cyanosis noticed.
• Cyanotic spells or squatting episodes.
• Exertional dyspnea.
• Clubbing.
• Precordium silent
• Single second heart sound.
• Murmur of collaterals.

20. Some common chromosomal diseases
associated with CHD.
Which is the commonest CHD
associated with Down syndrome?

21. CHD associated with Turner syndrome?

23. Pulmonary oligemia Pulmonary plethora

24. Approach to a Patient with Congenital Heart Disease
Suspected CHD
Cyanosis
Present Absent
Repeated RTI Repeated RTI
Present PresentAbsent Absent
Obstructive/
Regurgitant
lesions
R
-Coarctation
of Aorta
-Aortic
Stenosis
-Mitral
Stenosis
-Aortic
Regurgitaion
-Mitral
Regurgitation
Left to Right
Shunt
Second
Heart Sound
Wide &
Variable
Wide &
Fixed
Not
Applicable
VSD ASD PDA
Cyanotic
Heart
Disease with
Increased
Pulmonary
Flow
Cyanotic
Heart
Disease with
Decreased
Pulmonary
Flow
-TGA
-TAPVC
-TA
-TOF
-Tricuspid
atresia
-Pulmonary
atresia

25. Summary
• Fetal circulation – parallel which becomes series after birth.
• Heart diseases – congenital , acquired
• CHD : acyanotic, cyanotic or obstructive.
• Nadas criteria helpful.
• Proper history and clinical examination helps to reach diagnosis.