Congenital Heart Diseases

1. Congenital Heart Diseases Dr Swati Prashant MD Paediatrics Index Medical College, Indore,MP,India drprahantw@gmail.com. www.paediatrics4all.com

2. Left To Right Shunts • The most common L →R Shunts are : • 1. VSD : 27% • 2. ASD : 13 % • 3. PDA : 11 % .

3. Atrial Septal Defect • It constitutes 13 % of all CHD . • There is an abnormal communication between the 2 Atrias . • ASD’ s are of 3 types . • 1OstiumSecundumdefect : 70% .Defect is at the fossa Ovalis or rarely superior or Posterior to fossa . • 2. Ostium Primum defect : 30% . Defect is

4. Atrial Septal Defect • Defect is an Endocardial Cushion defect lying Inferior to fossa . It may be associated with Mitral Valve defect . • 3. Sinus Venosus defect : 10% ,associated with defect at entry of SVC in Rt. Atrium .

5. Atrial Septal Defect • Haemodynamics • 1. Oxygenated blood from Lt Atrium • ↓ • Right Atrium • It receives extra blood , causing • Right Atrial enlargement • ↓ • Large volume of Blood passes through Normal Tricuspid Valve

6. Atrial Septal Defect • Causing Delayed Diastolic Murmur ( DDM ). • ↓ • large Volume is received by RV • Rt. Ventricle enlarges ( cardiac impulse • ↓ • Large vol . Thru. Pulmonary Artery • causes Ejection Systolic Murmur • & delayed closure of P2 , Therefore A2 --P2 • WIDE split & loud p2 . As age advances PH OCCURS .

7. Clinical Features • Mild effort intolerance • Chest infections • CCF Rare . • Parasternal Impulse • A2—P2 Wide split fixed • Systolic Thrill & Murmur in P2 area due to flow thru. Pulmonary valve . • .

8. Atrial Septal Defect • Complications are rare • After age 20 yrs. PH occurs . • ECG---RVH & RBB • X-Ray---mild cardiomegaly , RAH ,RVH ,PA prominent , plethora.

9. Atrial Septal Defect • TREATMENT : • 1. T/t of Infections , ccf • 2. Surgery • Common syndromes asso. With ASD : • Down’s Syndrome , Holt Oram syndrome , Lutembachker , Noonans syndrome .

10. Ventricular Septal Defect • It is most common amongst the CHD . • Constitutes 27% of all CHD’s . • Location : 90% of VSD are in Membranous part of the Septum • Others occur in Muscular part & can be multiple . • Syndromes: Trisomy 13 - 15 , 17-18. Absent Radius & Ulna , poly & Syndactyly .

11. Ventricular Septal Defect • HAEMODYNAMICS • Left → Right shunt . • Lt. Ventricle blood →enters Rt. Ventricle through the defect . • At the same time Rt. Ventricle is also contracting. So the blood is almost directly going to Pulmonary Artery . • Large vol. Thru. PA → CAUSE Ejection Sys. Murmur + delayed P2 , due to delayed empting .Also there is early empting of LV causing early A2 .

12. Ventricular Septal Defect • Therefore there is a wide split A2 P2 . • ↑ blood in LA causes LA ENLARGEMENT. • ↑ blood flow thru. Mitral valve causes DDM at apex . • Shunt itself causes PANSYSTOLIC Murmur as blood is going thru. The shunt in systole ----in Tricuspid area --lt. Sternal border 3,4,5 space .

13. Clinical Features-Ventricular Septal Defect • Symptomatic around 6 –10 wks. • CCF develops . • Palpitation , dyspnea on exertion . • Frequent chest infections . • Wide pulse pressure . • Hyperkinetic precordium with systolic Thrill . • Cardiomegaly with Left ventricular Apex .

14. Ventricular Septal Defect • Wide split 2 ndHEART SOUND • P2 accentuated • Pansystolic Murmur at Lt. Sternal border ( 3 ,4 ,5th IC SPACE . • ECG : 1) RVH initially & in newborn . • 2) IN small & mod . Size VSD ,RVH comes to normal after ↓ of pulmonary resistance .

15. Ventricular Septal Defect • 3) In large VSD without PAH there is LVH • 4) In large VSD + PS /PAH : ECG shows RVH + LVH or purely RVH . • X-RAY CHEST • 1. LVH—Depends on size of shunt . • 2. Plethora • 3. Aorta N or small in size .

16. Ventricular Septal Defect • 4. LAH in large shunts . • 5. If VSD is small : Heart size normal, pulmonary vasculature is normal . • 6. If VSD + PS : Heart size is normal , normal lung fields . • 7. If VSD + PAH : Heart size is normal ,but lung fields are Plethoric .

17. Assessment of Severity • Small VSD : PSM + normal P2 , disappearance of murmur + ECG becomes Normal . • Large VSD : RV pressure = LV pressure , therefore murmur becomes softer + PAH + accentuated P2 • Large VSD + PS : ejection systolic murmur +↑ RV pressure + normal PA pressure + P2 soft

18. Treatment-Ventricular Septal Defect Medical : T/t --CCF , Infections , Anemia , Endocarditis . Surgery : Indications 1. CCF in infancy not responding to medical t/t . 2. L→ R shunt is large 3. VSD ( large) + PS / PH or AR . 4. Surgery : contraindicated in PAH + reversal of shunt .

19. Ventricular Septal Defect • Surgery : Closure of VSD WITH A Dacron patch , through Rt. Atrial approach . • Surgery is advised if PAH develops , within 2 yrs. • Complications of Surgery : • Complete Heart Block , residual VSD .

20. Patent Ductus Arteriosus • It is a communication between the Pulmonary Artery & the Aorta . • Aortic attachment is just distal to the Left Subclavian Artery . • Ductus arteriosus is normally present in fetal life . • It closes normally after birth . • It constitutes 11% of all cardiac defects .

21. Haemodynamics- Patent Ductus Arteriosus • L→R shunt from Aorta to Pulmonary Artery . • Flow is both during systole as well as Diastole , as pressure is always higher in Aorta with normal Pulm . Artery . • This L →R shunt causes murmur . Murmur starts in systole after 1st HS & Continues in Diastole but with diminished intensity , therefore Continuous murmur.

22. Patent Ductus Arteriosus • LA receives large amt. of blood ,therefore LA enlarges In size . • ↑ blood flow through Mitral valve -> causes accentuated 1st HS + DDM . • LV also receives more blood → overloading → prolongation of lt. Ventricular systole & ↑ in LV size . • Prolonged systole → cause delayed closure of Aortic valve ---late A2 .

23. Patent Ductus Arteriosus • Late A2 causes paradoxical split in large shunts . • Large vol. Coming to Aorta causes Aortic dilatation ( ascending ) , this causes Ejection click & Ejection systolic murmur , but this is masked by continuous murmur .

24. Clinical Features- Patent Ductus Arteriosus • Patient becomes symptomatic early in life . • Develops CCF around 6-10 wks of life , or even earlier within 7 days of birth with murmur + ccf . • In older children there is effort intolerance , palpitation , chest infections .

25. Patent Ductus Arteriosus • As there IS a leak of blood to PDA from systemic blood there is a wide pulse pressure + collapsing pulse . • Prominent CAROTID pulsations + features L → R shunt is s/o PDA . • Cardiac impulse & Apex Beat are Hyperkinetic s/o LVH due to ↑ blood Volume .

26. Patent Ductus Arteriosus • Continuous / systolic murmur + Thrill at Lt. 2nd space . • SO IF SHUNT IS LARGE : • 1. 1 st HS is accentuated due to ↑ Mitral flow . • 2. 2 nd HS is narrow /paradoxically split • 3. P2 is louder than normal . • Continuous murmur best heard in P2 AREA

27. Patent Ductus Arteriosus • ECG : LVH--- ‘ Q’ & tall ‘T’ waves are characteristic of Lt . Ventricular vol. Overload . • X-Ray chest : cardiomegaly with LV enlargement .( large shunt -- large size, large shunt --narrow split , small shunt --- no split .) • LA enlarged , Ascending Aorta ( knuckle) prominent .

28. Course & Complications • In Newborn & infants ---PH is +nt at birth causing Ejection syst. Murmur . • Later as PH ↓ the murmur becomes continuous . • CCF same as in VSD . • In PDA ,PH later due to flow develops earlier than VSD . • As PH develops later diastolic component ↓ ,so the murmur becomes Ejection syst. Murmur .

29. If PH --P2 is loud + DDM +nt • If PS --P2 is soft or N + no DDM • If L→ R becomes R→L there is no murmur , but DIFFERENTIAL CYANOSIS is present • In PDA + PH causing reversal .

30. Treatment- Patent Ductus Arteriosus • For closure of PDA • 1. Indomethacin ( prostaglandin synthetase inhibitor ) given orally • Dose is 0.1 mg /kg / day 12 hourly in 3 doses. • Hepatic / Renal / Bleeding tendency----CI • 2. Surgical ligation PDA .

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