acyanotic congenital heart disease - asd (dr. gunasekaran)
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Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
ACYANOTIC CONGENITAL HEART DISEASE
Dr. D. Gunsekaran Consultant Paediatrician
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Atrial Septal Defect
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD Types of ASD
Sinus venous defect – near the entry of
SVC, IVC Coronory
sinus
Ostium primum- lower part of septum
Down Syn(MVPS)
Ostium Secondum – in the upper part of
septum (Most common)
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD ASD
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
RATV RVPV PALungsPVLALVAorta
Other parts of the body
What organic murmur? Why?What flow murmurs? Why?Which chamber gets enlarged? Position of AI?
Type of AI?Why recurrent RTI?
Hemodynamic changes
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Size: Defect of what size of ASD , usually cause symptoms in infancy?
2 cm
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Symptoms in ASDSmall ASD: Asymptomatic; growth is normal; Murmur & Change in HS - routine clinical
examination.Large ASD: Breathlessness on exertionExercise intoleranceFeeding difficultiesFailure to thriveFrequent RTI (in all RTIs)Forehead sweating (if failure)Chest pain, palpitation, syncope ???
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Vitals in ASD
Pulse: Volume? Rate? Character? Rhythm?Blood pressure?
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Examination of heart
Inspection: Precordial bulge (Cardiomegaly – Pliable chest)
Harrison sulcus +/-
Respiratory distress (LRTI)
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Examination of heart
Palpation:
Apical position: Shifted out (RV enlarge) Apical impulse type: Normal Palpate in the para-sternal area: Para-sternal lift due to volume
overload to RV
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Examination of heartAuscultation: Heart sounds: what is the change in S2S2 wide & fixed split; do not vary with respiration.
Murmurs: what murmur is common? Why it occurs?ESM – Pulmonary area - grade 2 0r 3 (Remember, shunt remains silent)Other possible murmurs: Flow murmurs –MDM at TA
Inspn: A2 P2
Expn: A2 P2
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Differential diagnosis of Wide S2Late Pulmonary Valve closure:Electrical:RBBB (Delayed excitation & hence, delayed emptying of RV)WPWMechanical: PS: Systolic overload ASD , TAPVC: Diastolic overloadRVF: Combined Systolic & Diastolic overloadEarly Aortic Valve closure: MR
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Complications
Frequent LRTIFailure to thrive
Congestive Cardiac Failure – Very rare (only in 3rd or 4th decade)
Pulmonary Hypertension- Very rareEisenmenger’s syndrome – Very rare
Infective Endocarditis-Unknown in OS type
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Natural History
Spontaneous closure : based on size & age
< 3 mm: 100% close, by 1 ½ years of age
>8 mm / > 2 years: rarely, close
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Investigations
Chest X Ray: Cardiomegaly, Increased PBF, Lung Infn.
ECG: Chamber enlargement
ECHO:
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
ManagementMedical: Diet: High calorie & high protein Anemia correction
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Management - Surgical
Closure: Simple suture Patch of Pericardium or Teflon
Decision based on Size of defect Age: surgery is usually delayed until 2-4
years of age
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Management - Surgical
Contraindications for surgery: severe PHT
PVR > 8 wood units/m2 BSA not responding to isoproterenol infusion
> 12 wood units / m2 BSA
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Syndromes associated with ASD1. Chromosomal anomalies: Trisomies 21 (Down
synd) Trisomy 18
(Edward synd) Trisomy 13 (Patau
synd)
2. Syndromes: Holt - Oram syndrome (Thumb with extra
phalanx & deformities of radius
and ulna) TAR syndrome: Thrombocytopenia & Absent
Radius
3. Maternal conditions: Phenytoin, Congenital Rubella
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD OS ASD OP ASD
More common Less common
Defect is high in the septum
Defect is low in septum
Not connected with Down
Often associated with Down’s
No Valve defects MVPS is seen in 8-37%
PHT is very rare PHT is possible
ECG: RAD (+60-90) (N: +40-60)
ECG: LAD (0-30)
Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Bye-Bye