Presentation on theme: "Dr Swati Prashant MD Paediatrics Index Medical College, Indore,MP,India"— Presentation transcript:
Dr Swati Prashant MD Paediatrics Index Medical College, Indore,MP,India firstname.lastname@example.org@gmail.com. www.paediatrics4all.com
The most common L → R Shunts are : 1. VSD : 27% 2. ASD : 13 % 3. PDA : 11 %.
It constitutes 13 % of all CHD. There is an abnormal communication between the 2 Atrias. ASD’ s are of 3 types. 1 Ostium Secundum defect : 70%.Defect is at the fossa Ovalis or rarely superior or Posterior to fossa. 2. Ostium Primum defect : 30%. Defect is
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.
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
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.
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. .
Complications are rare After age 20 yrs. PH occurs. ECG---RVH & RBB X-Ray---mild cardiomegaly, RAH,RVH,PA prominent, plethora.
TREATMENT : 1. T/t of Infections, ccf 2. Surgery Common syndromes asso. With ASD : Down’s Syndrome, Holt Oram syndrome, Lutembachker, Noonans syndrome.
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.
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.
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.
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.
Wide split 2 nd HEART SOUND P2 accentuated Pansystolic Murmur at Lt. Sternal border ( 3,4,5 th IC SPACE. ECG : 1) RVH initially & in newborn. 2) IN small & mod. Size VSD,RVH comes to normal after ↓ of pulmonary resistance.
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.
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.
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
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.
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.
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.
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 1 st HS & Continues in Diastole but with diminished intensity, therefore Continuous murmur.
LA receives large amt. of blood,therefore LA enlarges In size. ↑ blood flow through Mitral valve -> causes accentuated 1 st 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.
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.
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.
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.
Continuous / systolic murmur + Thrill at Lt. 2 nd 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
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.
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.
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.
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.