1. Acyanotic Congenital Heart Disease
Dr David Coleman
Consultant Paediatric Cardiologist
Our Lady’s Children’s Hospital, Crumlin
Dublin

2. Common Shunt Lesions ♥ Ventricular septal defect (VSD)
♥ Atrial septal defect (ASD)
♥ Patent ductus arteriosus (PDA)
* All 3 lesions can lead to Eisenmenger’s Syndrome if a large lesion is not detected and treated early enough

3. Common Stenotic Lesions
♥ Pulmonary stenosis (PS)
♥ Aortic stenosis (AS)
♥ Coarctation of the aorta (CoA)

4. VSD’s ♥ Commonest form of CHD ♥ Commonest types:
membranous (perimembranous) ~75%
muscular
♥ Can be single or multiple

6. VSD’s
♥ Symptoms relate to the degree of shunt (VSD size, pulmonary vascular resistance)
if small: no symptoms
if large (high pulmonary blood flow, CHF):
tachypnoea
dyspnoea
slow feeding
failure to thrive
sweating

7. VSD’s ♥ Exam (smaller VSD): pink normal pulses normal S1 and S2
± systolic thrill
harsh pansystolic murmur LLSE
♥ ECG: normal (smaller VSD)
or LVH ± RVH (larger VSD)

8. VSD’s ♥ Larger defect: MDM @ apex (mitral flow murmur)
narrowly split S2 and loud P2
± S3
CXR: cardiomegaly
increased pulmonary vascularity

9. VSD’s ♥ Treatment options: Nil (spontaneous closure) Surgical closure
Device closure

10. ASD’s ♥ Three types: secundum primum sinus venosus
♥ Commonest: secundum
♥ Primum: a form of atrioventricular septal (canal) defect

13. Secundum ASD ♥ Usually no symptoms in childhood ♥ Exam: pink
normal pulses
wide ± ‘fixed’ split S2
soft ULSE
♥ ECG: incomplete RBBB (95%)
♥ CXR: often normal
sometimes pulmonary plethora

14. Secundum ASD
♥ Haemodynamic significance of ASD is assessed to decide if closure appropriate
♥ Usually closed age 3-5 years (earlier if symptomatic) or when diagnosed if later
♥ Two options for closure:
surgery - suture or patch
interventional catheter - device

15. Amplatzer ASD Occluder

16. PDA
♥ CHF symptoms if large ductus in very young infant, otherwise often asymptomatic
♥ Exam: pink
full volume pulses
harsh systolic (1st few weeks) or continuous ‘machinery’ murmur loudest under left clavicle
♥ ECG: normal (small PDA)
LVH ± RVH (large PDA)

18. PDA ♥ Options for closure: ♥ CXR: ± cardiomegaly, pulm plethora
surgery - ligation
interventional catheter - coil(s) or device

19. Pulmonary Stenosis ♥ Usually asymptomatic ♥ Exam: pink normal pulses
± systolic ejection click
ESM ULSE if severe, S2 widely split (not fixed)

21. Pulmonary Stenosis ♥ ECG: RAD, RVH ♥ CXR: normal
± prominent MPA (post-stenotic dilatation)
♥ Treatment of valvar PS (moderate/severe):
balloon valvuloplasty preferred
uncommonly surgical valvotomy

22. Aortic Stenosis ♥ Often asymptomatic;
otherwise SOB, syncope or chest pain on exertion
♥ Exam: pink
small volume pulse, small pulse pressure
± LV lift
± systolic thrill (suprasternal, URSE)
± systolic ejection click
harsh ESM URSE & radiating to carotids
if severe, narrow split S2 (even reversed)

24. Aortic Stenosis ♥ ECG: normal (mild AS) LVH ± strain (more severe AS)
♥ CXR: often normal
± dilated ascending aorta
♥ Treatment of valvar AS (moderate/severe):
balloon valvuloplasty
surgical valvotomy

25. Coarctation of the Aorta
♥ CHF in neonate if severe CoA;
often asymptomatic in older child
♥ Exam: pink
reduced or absent femoral pulses
soft systolic murmur mid LSE
and/or mid left back
♥ ECG: RVH in 1st few months of life,
LVH if older

27. Coarctation of the Aorta
♥ CXR: cardiomegaly
evidence of CHF
rib notching (older child)
♥ Treatment:
surgery for ‘native’ CoA
balloon angioplasty for re-CoA