Heart Diseases 2 PDF

‫‪Page1‬‬ ‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‪َ ،‬و َعِّلْمِني َما َيْنَفُعِني‪َ ،‬وِزْدِني ِعْلًما"‬ ‫َّ‬ ...

‫‪Page1‬‬ ‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‪َ ،‬و َعِّلْمِني َما َيْنَفُعِني‪َ ،‬وِزْدِني ِعْلًما"‬ ‫َّ‬  Heart Diseases2 1) VSD Page 3 2) ASD Page 8 3) PDA Page 13 4) Pulmonary stenosis Page 17 5) Aortic Stenosis Page 18 6) COA Page 20 Page2 "‫ َوِزْدِني ِعْلًما‬،‫ َو َعِّلْمِني َما َيْنَفُعِني‬،‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‬ َّ ▪ Etiology: Chromosomal & Genetic Factors: Down Syndrome, Turner‘s Syndrome,… Environmental Factors: Congenital Rubella, Maternal Diabetes, Drugs,… Hereditary Factors: If A Parent Or A Sibling Has CHD, the Risk is increased. ▪ Classification of CHD: 1) Cyanotic Heart Disease 2) Acyanotic Heart Disease Decreased pulmonary flow: Left - Right shunt lesions:  Tetralogy of Fallot  Ventricular septal defect  Tricuspid atresia  Atrial Septal Defect  Other univentricular heart with pulmonary  Atrio-ventricular Septal Defect stenosis.  Patent Ductus Arteriosus  Increased pulmonary flow: Obstructive lesions:  Transposition of great arteries  Aortic stenosis  Total anomalous pulmonary venous return.  Pulmonary valve stenosis & Coarctation of Aorta [A] Acyanotic Congenital Heart Diseases: VSD: Ventricular Septal Defect ASD: Atrial Septal Defect PDA: Patent Ductus Arteriosus PS : Pulmonary Stenosis AS : Aortic Stenosis CoA: Coarctation of Aorta 1) Ventricular Septal Defect  Incidence- Description- Pathophysiology- Symptoms- Signs - Investigations  Complications- Differential Diagnosis- Fate (natural history)- Treatment ▪ Incidence: The Commonest ≫ about 25-30% of all congenital heart diseases. Site of defect:  Defect In interventricular septum ( septum between 2 ventricles) that composed of 2 parts ≫ muscular part (lower 2/3) and membranous part ( upper 1/3). Page3 "‫ َوِزْدِني ِعْلًما‬،‫ َو َعِّلْمِني َما َيْنَفُعِني‬،‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‬ َّ   Muscular part closes faster than membranous part.  Common: single defect in membranous part of the ventricular septum.  Less common: single or multiple defects in muscular part of the septum. ▪ Pathophysiology :  The pathophysiology and amount of shunting depend on: Size Of The Defect. Degree Of Pulmonary Resistance.  Blood is shunted from the left ventricle (higher pressure) to the right ventricle (lower pressure) ≫ Increased pulmonary blood flow ≫ Pulmonary congestive symptoms ≫ Volume overload over right ventricle,left atrium and left ventricle.  → → →↑ →↑ → → → → Membranous VSD MUSCULAR VSD Page4 "‫ َوِزْدِني ِعْلًما‬،‫ َو َعِّلْمِني َما َيْنَفُعِني‬،‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‬ َّ  Symptoms Signs: Small defect : Small defect :  No symptoms.  Systolic thrill ≫ grade 4.  Harsh pan- systolic murmur at 3rd & 4th Large defect (pulmonary congestion left inter-costal spaces. symptoms) Large defect:  Dyspnea on exertion then at rest.  Prominent precordium.( pericardial  Chronic cough bulge) ≫ in prolonged cases.  Repeated lower respiratory tract infections  Cardiomegaly with laterally displaced  Excessive sweating during feeding. apex.  Failure to thrive.  Systolic thrill at LLSB.  Harsh pan systolic murmur at 3rd & 4th left intercostal spaces.  Functional flow murmurs on mitral (mid- diastolic) & pulmonary (ejection systolic). ▪ Size of VSD: Small (< 3 mm in diameter) Moderate (3-5 mm in diameter) Large (6-10 mm in diameter)  hemodynamically insignificant  Least common group of  Develop CHF and FTT by  Between 80% and 85% of all children (3-5%) age 3-6 months VSDs  Without evidence of CHF or  Usually requires surgery.  All close spontanously pulmonary hypertension, may  Muscular close sooner than be followed until spontaneous membranous closure occurs Restrictive VSD NON- Restrictive VSD  Small lesion & Asymptomatic  Large lesion & Symptomatic  75% close spontaneously within fist 3 y of  Rarely close spontaneously. life.  1.0 cm² (Equal to or greater than to Ao valve  100 mmHg → critical. area. In most cases  and right ventricular  no symptoms heave are palpable in severe cases In severe cases:  In critical stenosis, cyanosis and gallop  exertional dyspnea, tachypnea, fatigue, and exertional rhythm develop. chest pain, may be symptoms of  No repeated chest infection  No lung congestion ▪ Investigations:  Chest X ray: Post-stenotic dilatation of pulmonary artery (in valvular type), oligemic lung fields ± enlarged, hypertrophy.  RV and RA  ECG: Rt ventricular hypertrophy  Echocardiography: important for diagnosis and measurement of pulmonary valve gradient → if pulmonary or infundibulum & the degree is mild , moderate or severe → according it decide if there will be intervention or just follow up.  Cardiac Catheterization Page17 "‫ َوِزْدِني ِعْلًما‬،‫ َو َعِّلْمِني َما َيْنَفُعِني‬،‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‬ َّ ▪ Differential Diagnosis:  Other causes of ejection systolic murmur  Aortic stenosis  Coarctation of aorta  ASD  Pulmonary Hypertension ▪ Prognosis: Mild degree: compatible with long life Severe degree: Ht failure before middle age ▪ Treatment: Prophylactic: as VSD Standard ttt Medical: Propranolol therapy in some cases with  Follow up infundibular stenosis  Balloon Pulmonary Vulvoplasty Surgical: pulmonary valvotomy by Catheter Others: dilatation if pulmonary  Pulmonary valvotomy valve gradient > 60 mmHg is very successful and now considered standard treatment ] 5) Aortic stenosis ▪ Description: 1) Valvular Stenosis 2) Subvalvular Stenosis 3) Supravalvular Stenosis:  Ao valve is bicuspid and  fibrous ring around the left  narrowed ascending Ao cusps are fused at their ventricular outflow tract above the valve. edges → stenosis. ▪ Pathophysiology:  The left ventricular pressure AS: Aortic Stenosis increases to maintain cardiac output.  Left ventricular hypertrophy occurs. Page18 "‫ َوِزْدِني ِعْلًما‬،‫ َو َعِّلْمِني َما َيْنَفُعِني‬،‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‬ َّ  1) Symptoms 2) Signs  In most cases: no symptoms.  Low systolic and pulse pressure  In severe cases: few can develop  Cardiomegaly with prominent left ventricular impulse Anginal pain Dizziness, fainting or  A is palpable at the loss of consciousness on effort and along  Some may present with the neck vessels. manifestations of congestive heart  Diminished and delayed aortic component of S2 failure Harsh over the aortic  Easy fatigue area (2nd right intercostal space) or aortic area (3rd  Syncope left intercostal space).  The murmur is transmitted upwards to the neck. ▪ Investigations: Chest X ray:  Poststenotic in Valvular stenosis  Left ventricular enlargement( ) may be present ECG:  left ventricular  Left ventricular ischemia indicates severe stenosis  Exercise ECG may be needed Echocardiography: can detect:  Valvular , subvalvular or supravalvular.  Left ventricular hypertrophy  Bicuspid valve, supravlavular or subaortic stenosis can be detected.  Poststenotic dilatation can be detected  Pressure gradient across the valve can be measured Cardiac Catheterization can detect:  Site of obstruction  Accurate pressure gradient measurement  Calculation of valve area ▪ Differential Diagnosis:  Other causes of ejection systolic murmur  Pulmonary stenosis  Coarctation of aorta  ASD  Pulmonary Hypertension Page19 "‫ َوِزْدِني ِعْلًما‬،‫ َو َعِّلْمِني َما َيْنَفُعِني‬،‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‬ َّ ▪ Complications:  Infective endocarditis  Heart failure  Sudden death on vigorous exercise ▪ Treatment: Prophylactic : as VSD avoidance of competitive sports Follow up ≫ mild cases. If severe ≫ aortic balloon valvuplasty (> 50 mmHg) Medical: in cases of heart failure Surgical: aortic valvotomy for Valvular stenosis. Resection of subaortic membrane in subaortic stenosis. Others: Balloon dilatation in cardiac catheterization laboratory may be successful. 6) CoA: Coarctation of Aorta ▪ Description:  It is a narrowing of varying degrees of a segment of the aorta.  It is mostly (98%) located ▪ Pathophysiology:  Coarctation is a mechanical obstruction between the proximal and distal aorta.  The whereas that of  Collateral vessels including internal mammary and intercostal vessels develop in response to pressure difference. 1) Symptoms 2) Signs  In most cases no symptoms  Normal brachial pulses and  In some cases leg cramp, chest pain and headache.   Dizziness , HTN ≫ UPPER (hypertension if B.P. is measured in  Abdominal pain , intestinal ischemia upper limbs). ≫ LOWER  Collateral vessels may be visible or palpable around the  Heart failure may be the presentation scapula in 10% of cases.  Left ventricular hypertrophy with forcible apex beat Page20 "‫ َوِزْدِني ِعْلًما‬،‫ َو َعِّلْمِني َما َيْنَفُعِني‬،‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‬ َّ   It occurs in the first few days of life in  over the aortic area severe cases. or aortic area.  It may present with a complication e.g.  The murmur is heard also in the bacterial endocarditis or rupture of intracranial aneurysm.  Heart failure may be the only presentation in neonatal period. ▪ Diagnosis:  Reversed B.P. gradient in limbs at any age + absent or weak femoral pulse. ▪ Investigations: Chest X ray:  Notch of aortic shadow at site of Coarctation and poststenotic dilatation of aorta Rib notching due to erosion by dilated intercostals  Notching of barium filled esophagus by dilated ECG:  May be normal or  Echocardiography  Left ventricular hypertrophy  Coarctation segment  Pressure gradient across coarctation can be measured  Other associated anomalies as bicuspid valve and mitral valve anomalies Cardiac Catheterization:  Site of coarctation  Accurate pressure gradient measurement  Adequacy of collateral vessels ▪ Differential Diagnosis:  CoA: Coarctation of Aorta  Other causes of hypertension  Other causes of heart failure in neonates  Other causes of ejection systolic murmur. ▪ Complication : Diagnosed as primary hypertension ≫ must exclude COA. ICT ≫ ( ICHge – convulsions – blurred vision- disturbance conscious level. Renal ischemia. Page21 "‫ َوِزْدِني ِعْلًما‬،‫ َو َعِّلْمِني َما َيْنَفُعِني‬،‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‬ َّ ▪ Treatment: Prophylactic: as VSD ≫ from infective endocarditis. Medical ✓ Treatment of hypertension ✓ Treatment of heart failure Surgical ✓ Resection with end to end anastomosis or graft repair Others ✓ in cardiac catheterization laboratory is successful with varying results. ▪ Pulmonary area : LEFT ejection systole( PS) RIGHT ejection systole ( Aortic stenosis) Machinery murmur (PDA) Pulmonary HTN. 1) pulmonary HTN 2) pulmonary stenosis  BECAUSE of neglected : VSD – ASD -PDA.  Mostly Not associated with heart failure.  ssociated with heart failure.  If critical ≫ heart failure  ccentuated 2nd heart sound.  Accidently discovered.  jection systolic murmur  ( in severe  ullness on percussion on pulmonary area. cases≫ )  alpable thrill called diastolic shock ▪ Heart Failure Symptoms: cardia- pnea diomegaly Increase cardio-thoracic ratio > 50 % ▪ Lazix ≫ cause hypokalemia so give k+ or spironolactone. ▪ NB ( NOT IMPORTANT) :  After ECHO ≫ Perform Multicilica Angiography Of The Heart & Great Vessels : ✓ Show the heart & the vessels obviously ✓ Help in diagnosis. Page22 "‫ َوِزْدِني ِعْلًما‬،‫ َو َعِّلْمِني َما َيْنَفُعِني‬،‫"اللُهَّم ْانَفْعِني ِبَما َعَّلْمَتِني‬ َّ