Upload
prof-dr-aswini-kumar
View
1.691
Download
0
Embed Size (px)
Citation preview
1
DIAGNOSIS OF CHD
Dr. S. Aswini Kumar. MD
Professor of Medicine
Government Medical College Hospital
Thiruvananthapuram
2
RA
RV
LA
LV
VC PV
PA AO
LUNG
SVC
IVC
NORMAL
3
History & Symptomatology
Mother’s marriage?
Consanguinity?
Age of Child Birth?
Antenatal History?
Natal History?
Postnatal events?
Physical development?
Mental development?
Breathlessness?
Exertional Syncope?
Cough with sputum?
Bluish discoloration?
History of squatting?
Cyanotic spells?
Pedal edema?
Hemoptysis?
4
Questions to be answered
Anatomic and Functional?
Acyanotic or Cyanotic?
Pulmonary Artery Blood flow?
Malformation of right or left?
Dominant Ventricle?
Pulmonary Hypertension?
What is the hemo-dynamics?
Feasibility of surgical correction?
Finally which CHD is it?
ASD VSD PDA AS PS
COA RSOV CAVF ALCAPA TOF
PA TA EM ASD EM VSD EM PDA
EA cTGA CcTGA PAVF DC
5
Planning for investigations
Electrocardiogram
Chest X Ray
Trans-thoracic Echocardiography
Trans-esophageal Echocardiography
Color Doppler Imaging
Magnetic Resonance Imaging
Hemo-dynamic Studies
Angiographic Studies
6
Diagnosis of Congenital Heart Disease
CHD
Acyanotic
LR shunt
Atrial
Ventricular
Ductal
Obstructive
Aortic
Pulmonary
Aortic arch
Ao-RtHt Shunt
Ao-RA
Ao-CoSi
LCA-PA
Cyanotic
With PS
4 defects
Valvular
Tricuspid
With PAH
PAH in ASD
PAH in VSD
PAH in PDA
With Normal PAP
EA
cTGA
PAVF
7
Acyanotic
Frequent Respiratory Infections
Bulging precordium
Hyperkinetic precordium
Tendency to sweat
Tendency to CHF
Shunt murmur
Flow murmur
CXR: Plethoric lung fields
ASD
•30-50 age
•FemaleVSD
•5-15 aged
•MalePDA
•1-5 aged•child
L-R SHUNT
8
ACYANOTIC L-R SHUNT
Normal pulse and BP
Normal JVP and waves
Displaced apex beat
Left Para-sternal Heave
Wide fixed split of S2
Pulmonary ESM
Tricuspid Diastolic flow
murmur
ECG – RAD RVH rSR’ in V1
CXR: CE+ RAE RVH Pul plethora
9
Patent foramen ovale - allows a continuation of the atrial shunting of blood, in 25% of people
RA
RV
LA
LV
VC PV
PA AO
LUNG
SVC
IVC
ASD
Hemodynamics in ASD:
10
In ASD there is fixed splitting of S2, with no ventilatory variation of the interval between A2 & P2.
In PS, there is an ejection sound (c), P2 is diminished, A2 and P2 interval with inspiration
In idiopathic dilatation of the pulmonary artery, there is an ejection sound, but P2 is preserved.
Left precordial bulge in a patient with congenital Atrial Septal Defect
Produced by right ventricular enlargement occurring during the growth period.
11
ostium secundum (OS) type lies within the fossa ovalis
ostium primum (OP) atrial communication at the endocardial cushion
An SVC Sinus venosus (SV) defect within RA at junction of SVC and PV
An IVC sinus venosus (SV) defect at the junction of RA with IVC
A communication through the coronary sinus (CS)
Five potential spaces of inter-atrial communication
12
Development of IA septum
Septum primum
Ostium primum
Septum secundum
Ostium secundum
Foramen ovale
Fossa ovalis
Endocardial cushion
Interventricular foramen
AV Valves
13
ECG in Ostium Primum ASDAbnormal LAD of QRS & Incomplete RBBB
ECG in Sinus Venosus ASD
LAD RBBB RVH and I0
Heart Block
ECG in Ostium Secundum ASDRAD RVH Incomplete RBBB
14
CXR: CE RAE RVH Plethora
Doppler ECHO showing shunt
Diagrammatic representation
Necropsy specimen - ASD
Cardiac cathetrization
Contrast injection LA-RA
15
ACYANOTIC L-R SHUNT
High volume NC pulse
Normal BP and JVP
Normal JVP and waves
LV type apical impulse
Systolic thrill at the LSB
Pansystolic murmur
Mitral diastolic flow murmur
LAE LVH in ECG
CXR: CE+ LV+ Pul Plethora
16
A defect in the ventricular septum, the wall dividing the left and right ventricles of the heart
The membranous portion, which is close to the atrio-ventricular node, is most commonly affected
inferior muscular portion is less commonly involved
RA
RV
LA
LV
VC PV
PA AO
LUNG
SVC
IVC
VSD
17
I = inlet component, extending from tricuspid annulus to attachments of tricuspid valve
T = trabecular septum, extending from the inlet to the apex and up to the smooth-walled outlet
O = outlet septum or infundibular septum
a = outlet defect; b = papillary muscle of the conus; c = perimembranous defect; d = marginal
muscular defects; e = central muscular defects; f = inlet defect; g = apical muscular defects
18
Necropsy (when dead) in VSD
1. Tiny membranous VSD
2. Nonrestrictive perimembranous VSD
19
ACYANOTIC L-R SHUNT
High volume collapsing
pulse
Wide pulse pressure
Normal JVP and waves
LV type apical impulse
Systolic or continuous
thrill
Train in tunnel murmur
Multiple clicks
Mitral diastolic flow murmur
LAE and LVE in ECG
20
A congenital disorder in heart wherein a neonate's ductus arteriosus fails to close after birth
It can be idiopathic (i.e. without an identifiable cause), or secondary to another condition
Contributing factors in humans include: - Preterm birth - Congenital rubella syndrome - Down syndrome
RA
RV
LA
LV
VC PV
PA AO
LUNG
SVC
IVC
PDA
21
Chest X-Ray in PDA
severe pulmonary hypertension, and reversed shunt
arrows indicate the enlarged pulmonary artery segment
Diagrammatic representation of PDA
shunt of oxygenated blood
from aorta (AO) through PDA into PA
22
THE FETAL CIRCULATION
arrows indicate the directions of flow.
A fraction of umbilical venous blood enters the ductus venosus and bypasses the liver.
This relatively highly oxygenated blood flows across the foramen ovale to the left heart,
This blood preferentially perfuse the coronary arteries, head, and upper trunk.
The output of the right ventricle flows preferentially across the ductus arteriosus
This circulates to the placenta, as well as to the abdominal viscera and lower trunk.
23
Echocardiogram in PDA
Two-dimensional Doppler echocardiogram
left, parasternal short-axis view and right, suprasternal view.
24
Aortogram in PDA
Lateral aortogram from a 7-year-old girl with PDA measuring 2 mm at the narrowest point
A 5-cm coil was placed, with no residual flow evident by color Doppler imaging at 24 hours.
25
Acyanotic
Exertional dyspnoea and syncope
Normal or low systolic BP
Normally placed forceful or heaving apex
Systolic thrill and Ejection Systolic Murmur
Delayed component of second sound
ECG - Ventricular hypertrophy
Strain pattern in corresponding leads
ECHO & Catheterization diagnostic
AS•1-50 age•Male
PS•5-15 aged
•MaleCOA
•1-5 aged•child
OBSTRUCTIVE
26
ACYANOTIC OBSTRUCTIVE
Normal or slow peaking pulse
Low systolic normal diastolic BP
Normal JVP and waves
Heaving LV impulse Nil or minimal cardiomegaly
Systolic thrill and ESM in AA
Conduction of murmur to carotids Delayed and soft A2 ECG – LVH with
strain
27
A valvular heart disease caused by the incomplete opening of the aortic valve
RA
RV
LA
LV
VC PV
PA AO
LUNG
SVC
IVC
AORTIC STENOSIS
Aortic valve obstruction pressure gradient across AV LV Hypertrophy
28
ECG & CXR in Congenital AS
left ventricular hypertrophy
the typical left ventricular “strain”
AV ECHO in Congenital AS
a single closure line (arrow)
produced across the aorta
AV ECHO in Normal AV
Note the three cusps
"Mercedes Benz" configuration
29
Angiogram in Congenital AS
Angiocardiogram from a 13-year-old boy
He has a discrete subaortic stenosis
2D ECHO Parasternal long-axis a 27-year-old man
a non-obstructive sub-aortic membrane (open arrow)
It was relatively remote from the aortic valve
30
SV Aortic stenosis in Williams
Elfine Facies
a genetic disorder with autosomal dominant inheritance
2D ECHO in SV Aortic Stenosis
a single closure line (arrow) echogenic membrane is commonly observed above the sinuses of Valsalva
Aortogram in SV Aortic Stenosishourglass deformity diffuse hypoplasiadiameter of the ascending aorta is smaller than that of the aortic root
31
ACYANOTIC OBSTRUCTIVE
Normal pulse and BP
Normal or elevated JVP
a>v
Left Parasternal Heave
Systolic thrill 2nd left space
Ejection systolic murmur ULSB
Wide but not fixed S2
Well heard but delayed P2
ECG RVH with strain
CXR – RV Cardiomegaly Pul oligemia
32
A valvular heart disease in which outflow of blood from right ventricle is obstructed at the pulmonic valve
RA
RV
LA
LV
VC PV
PA AO
LUNG
SVC
IVC
PULMONARY STENOSIS
Pulmonary valve obstruction pressure gradient across PV
RV Hypertrophy
33
Valvular Pulmonary Stenosis
Peak gradient across the valve is more than 50 mmHg
Peak gradient across the valve is less than 50 mmHg
CXR in Valvular Pulmonary Stenosis
RAE RVH and prominent pulmonary bay
Decreased pulmonary blood flow - oligemia
34
ACYANOTIC OBSTRUCTIVE
Normal or high volume pulse
Radio-femoral delay
Arm BP > thigh BP
Prominent carotid and
palpable aorta
Palpable chest collaterals
ESM in the inter-scapular
area
Additional systolic and continuous
ECG LVH with strain
3 sign in the CXR
35
Patent foramen ovale - allows a continuation of the atrial shunting of blood, in 25% of people
RA
RV
LA
LV
VC PV
PA AO
LUNG
SVC
IVC
COARCTATION
Aortic Arch constriction pressure gradient across COA LV Hypertrophy
Bicuspid aortic valve
Obstruction to blood flow
Pre-ductal dilatation
Constriction of aorta
36
Better developed upper extremities in COA
Most commonly found distal to the left subclavian artery, opposite the point of entry of the ductus arteriosus (juxtaductal). CoA can occur in other locations along the aorta
37
Chest X-ray PARAA seen in up to 50% of patients
Cardiomegaly is present
Usually of left ventricular type
Rib notchingNotching of lower surface of ribs
Usually present bilaterally
Due to compression by collaterals
Barium Swallow "E" or "reversed 3" sign.
prestenotic dilatation of the aorta
Poststenotic dilatation of aorta
38
Aortogram in COA
with contrast medium injected into the ascending aorta
Contrast injection into the descending aorta (Dao)
Echocardiogram in COA
A, 2D echo of aortic coarctation
TAA = transverse aortic arch
39
ACYANOTIC L-R SHUNT
Sudden Chest pain
Bounding pulse
Wide pulse pressure
Normal JVP and waves
LV type apical impulse
continuous thrill LSB
Superficial continuous
murmur
Murmur peaks in diastole
LV dominance in ECG
40
RSOVAorta-RA Fistula in the same patient demonstrated at the time of surgery
Aortic Angiogram and echocardiography showing the leak from aortic root to RA
Non-coronary -RV
41
ACYANOTIC L-R SHUNT
8 month old infant
Sudden chest pain
wide pulse pressure
Normal JVP and waves
LV type apical impulse
continuous thrill LSB
Superficial continuous
murmur
Murmur peaks in diastole
Acute MI in ECG
42
Coronary Arteriovenous FistulaCoronary arteriovenous fistula between LAD
and pulmonary arteryThe leash of vessels arising from the LAD is
draining into the pulmonary artery
43
ACYANOTIC L-R SHUNT
Infant 6 months old
Chest pain unrecognised
unrelated to exertion
wide pulse pressure
Normal JVP and waves
LV type apical impulse
continuous thrill LSB
Superficial continuous
murmur
Murmur peaks in diastole
44
Anomalous origin of the left main coronary artery from the pulmonary artery
ALCAPA Natural History
A, In a fetus, both right and left coronary arteries receive
forward flow from their respective great arteries.
B, Soon after birth, before collaterals are well developed,
there may be an ALWMI and slight retrograde flow from
LCA to the pulmonary artery.
C, After collaterals have enlarged, there is high flow in
the enlarged RCA and the collaterals and significant
retrograde flow into the pulmonary artery
Typical electrocardiogram of an infant with
anomalous left coronary artery
before (above)
and after (below)
ligation of the anomalous left coronary artery. Note the abnormal Q waves in I, AVL, and V6.
45
CYANOSIS AND CLUBBING
Failure in Devpt
Failure in mentation
Exertional Cyanosis
Squatting episodes
Clubbing
Polycythemia
46
CYANOSIS AND CLUBBING
Normal pulse and BP
Normal JVP and waves
No cardiomegaly No thrill
Left Parasternal Heave
Second Heart sound single
ESM in Pulmonary Area
Murmur ends before A2
CXR MPA absent - Lung ischemic
47
CYANOSIS & CLUBBING
PS with shunt
Ventricular level
RAD + RVH
Tetralogy of Fallot
RAD +LVH
Hypoplastic Right Ventricle
LAD + RVH
Critical Pulmonic Stenosis
LAD + LVH
Tricuspid Atresia
48
Patent foramen ovale - allows a continuation of the atrial shunting of blood, in 25% of people
RA
RV
LA
LV
VC PV
PA AO
LUNG
SVC
IVC
TETRALOGY OF FALLOT
Infundibular stenosis
Over-riding of aorta
Rt Ventricular Hypertrophy
Ventricular septal defect
Patent foramen ovale - allows a continuation of the atrial shunting of blood, in 25% of people
49
Echocardiogram in COA
A, 2D echo of aortic coarctation
TAA = transverse aortic arch
Echocardiogram in COA
A, 2D echo of aortic coarctation
TAA = transverse aortic arch
50
Trans-thoracic Echocardiogram in COA
A, 2D echo of aortic coarctation
TAA = transverse aortic arch
51
CYANOSIS & CLUBBING
PS with shunt
Atrial level
Normal pulse and BP
Systolic thrill
Prominent a in JVP
TR may be present
Cardiomegaly
RVH late transition
PULMONARY ATRESIA
52
Pulonary Atresia
ostium secundum defect
endocardial
53
Diagramatic Representation of Pulmonary Atresia
A, 2D echo of aortic coarctation
TAA = transverse aortic arch
54
CYANOSIS & CLUBBING
PS with shuntAtrial level
As well as
Ventricular levelNormal pulse and BPSystolic thrill at LSB
Right atrial enlargement
Prominent a in JVPTR may be presentLeft Axis deviation
Cardio-megalyRVH late transition
Left Vent HypertrophyTRICUSPID ATRESIA
55
Tricuspid Atresia
RA
RV
LA
LV
VC PV
PA AO
LUNG
SVC
IVC
TRICUSPID ATRESIA
Ventricular septal defect
Blood mixture in pul artery
Atrial septal defect
Tricuspid Atresia
Patients with concordant ventriculo-arterial connection tend to be mre cyanosed than those with discordant connection
56
CYANOSIS & CLUBBING
Relatively older patient
Features of PAH
Short Systolic Murmur
MPA Prominent
Peripheral pruning
57
enlarged central pulmonary arteries
peripheral pruning of pulmonary vessels
CXR in Eisenmenger syndrome due to VSD
58
peaked P wave in lead II
right ventricular hypertrophy
right-axis deviation.
ECG in Eisenmenger syndrome due to VSD
59
CYANOSIS & CLUBBING
PS with shunt-Atrial level
Quiet precordium
Gallop rhythm
Cardiomegaly
Scratchy systolic murmur
Multiple sounds
Scratchy diastolic murmur
EBSTEIN’S ANOMALY
60
61
ECG in Ebstein’s Anomaly
Short PR, delta wave& wide QRS
Peaked P wave in V2 - RAE
ECG in Ebstein’s Anomaly
A, 2D echo of aortic coarctation
TAA = transverse aortic arch
62
2D ECHO 4C View
Septal attachment of TV
Massive RA dilatation
Necropsy specimen in EA
Septal attachment of TV
Massive RA dilatation
2D ECHO 4C View
Septal attachment of TV
Massive RA dilatation
63
CYANOSIS & CLUBBING
Neonate or infant
Failure to thrive
Cardiomegaly
Congestive Heart Failure
TRANSPOSITION OF GREAT VESSELS
64
Patent foramen ovale -
ostium secundum defect
endocardial cushion
65
CXR in CTGA
Vascular pedicle is narrow (paired white arrows)
Hump-shape caused by inverted infundibulum
ECG in CTGA
Atrial flutter at 200 beats/min
RAD, RVH and incidental VPC
66
CXR in CTGA
Vascular pedicle
Hump-shape
67
CYANOSIS & CLUBBING
InfantSevere Cyanosis
CV collapseIncreased Pul blood flowNormal Pul Artery PrLate onset PAHC/I for correctionECGRADRAERVH
Chest X-RayCardiomegalyPul PlethoraFigure of 8 heartTAPVCECHOCEMarkedly large RA RVSmall LACathNot neededMay be hazadousfor urgent septoplasty
68
PAPVC
Vascular pedicle
Hump-shape caused by inverted infundibulum
TAPVC
Atrial flutter at 200 beats/min
RAD, RVH and incidental VPC
69
enlarged central pulmonary arteries
peripheral pruning of the pulmonary vessels
TAPVC
70
CYANOSIS & CLUBBING
Infant
Increased blood flow
Normal PAP
Chest X-Ray
Without Cardiomegaly
No PAH
Peripheral pruning
Pulmonary AV Fistula
71
SUMMARY
CHD
Acyanotic
LR shunt
ASD
VSD
PDA
Ao-Rh shunt
RSOV
CAVF
ALCAPA
Obstructive
AS
PS
COA
Cyanotic
With PS
TOF
PA
TA
PA With PAH
Eisenmenger ASD
Eisenmenger VSD
Eisenmenger PDA
With Normal or ↑PAP
EA
cTGA
PAVF
72
THANK YOU FOR THE PATIENT LISTENING