CONGENITALHEART

DISEASE

BY: DR.SHILPA F.Y. MPT

Classification:

Acyanotic congenital heart disease.

Cyanotic congenital heart disease. Patients become cyanosed very soon after birth

CYANOTIC CONGENTIAL HEART DISEASESA. Fallot’s Tetralogy:

Fallot’s Tetralogy:• Ventriculoseptal defect results in equal pressure

within both ventricles.

• As a result of the pulmonary stenosis, more blood is discharge into the aorta and cyanosis results.

• Lungs are only partially perfused and total oxygen is poor.

• Anomaly results in right to left interventricular shunt due to right outflow tract obstruction and high right ventricular pressure.

Fallot’s TetralogyCOMPLICATIONS•Lose of consciousness due to cerebral anorexia

•Polycythemia

•About 1/3 of patients are cyanotic at birth, these patients often do not survive infancy unless operation is performed quickly.

•Threat to life in the 1st year is cerebral infarction

•Brain abscess

Fallot’s TetralogySYMPTOMS:

•Asymptomatic at birth. soon after, infants become cyanosis.

•Systemic cyanosis

•Undersize child

•Clubbing of finger and toes

•Exertional dyspneoa and tiredness.

•After walking a short distance, body spontaneous desire to squat: increase systemic vascular resistance & blood is diverted into the pulmonary circulation with increase oxygenation.

Fallot’s TetralogyINVESTIGATION

•Heart of normal size

•A systolic murmur present at 3rd & 4th intercostal space.

•X-ray: Boot-shaped with poorly developed lung vasculature.

•ECG

•Cardiac catheterization

•Selective angiocardiography

Fallot’s Tetralogy Anastomotic palliative treatment:

1.Blalock’s anastomosis: performed on child of a few weeks to 5 years

Anastomosis of pulmonary artery to the left subclavian artery.

Incision: A left postero-lateral thoracotomy through the 4th intercostal space.

2.Waterston’s anastomosisAnastomosis of ascending aorta and right pulmonary artery.

Incision: A right antero-lateral thoracotomy through the 4th intercostal space.

3.Pott’s AnastomosisAnastomosis of ascending aorta to left pulmonary artery.

Fallot’s Tetralogy Total correction:

Technique: performed btw 5 and 10 years of child age

Operation carried out through median sternotomy with help of extracorporeal circulation

High vertical ventriculotomy perform which stop near the pulmonary annulus through this incision ventricular

septal defect closed with dacron patch

Pulmonary vulvular and infundibular obstruction is also widened with patch graft of dacron

Continue…

Fallot’s Tetralogy

Ventriculotomy closed with dacron patch, extracorporeal circulation is stopped

Measured intracardiac pressure to confirm the right ventricular systolic pressure reduced to less than 60 to

70% of that of left ventricle.

This operation risk is about 10% for small children, only 2 to 5% in older children

PHYSIOTHERAPY •After correction there may be alveolar edema.

•It may be necessary to prolong artificial ventilation with the use of PEEP.•And to wean the patient off the ventilator with the use of CPAP.

•Breathing exercise with emphasis on inspiration are particularly important.

•Fine shaking and percussion to be helpful in the resolution of the peripheral lung involvement.•Discharge is btw 2 & 3 weeks, total correction is preffered before school age.

B. TRANSPOSITION OF GREAT VESSELS•The Condition was first described by Morgagny.

•Aorta arises from Rt ventricle, pulmonary artery arises from Lt ventricle.

•The two circulations, pulmonary and systolic, instead of being in series are in parallel.

TRANSPOSITION OF GREAT VESSELS•The pulmonary and systemic circulations are separated.

•Venous blood circulate round the body while oxygenated blood circulate round the lungs.

•For the child be survive there must be a communication btw two circulation.

•Possible communications are persistent ductus arteriosus, arterial septal defect or ventricular septal defect.

TRANSPOSITION OF GREAT VESSELSSYMPTOMS:

•Deeply Cyanotic at birth(80%)

•Syncope

•Dyspneoa on exertion

•Cardiac failure

•Clubbing & Polycythemia

TRANSPOSITION OF GREAT VESSELS

Surgical procedure; palliative treatment:

1.Procedure is balloon septostomy

ruptured(Rashkind and Miller,1966) to create an atrial shunt.

2. Atrial septal is excised (Blalock and Hanlon,1950)

The Rt atrium and pulmonary vein are parallely incised.

A portion of the atrial septum is excised and two incisions are now anastomosed.

TRANSPOSITION OF GREAT VESSELSTotal anatomical correction:

Disconnecting the pulmonary artery from left ventricle and aorta from right ventricle

Coronary artery must be implanted onto the pulmonary artery, acting as major vessel from Lt

ventricle

C. TOTAL ANOMALOUS PULMONARY VENOUS DRAINAGE

•The pulmonary venous drainage has become disconnected from the left atrium

•And drains into the systemic venous circulation at some point

oInferior vena cava,oSuperior vena cava,oCoronary sinus,oRight atrium

•There is mixing of the pulmonary circulation though a patent foramen ovale.

D. Eisenmenger’s syndrome•Occurs in the reversal of the left-to-right shunt.

•Some of conditions are:oAtrial and ventricular septal defect,oPatent ductus arteriosus.

•But the Rt ventricle hypertrophies and the pressure in the pulmonary artery increases as a result of the increased flow.

•Increased pulmonary HT leads to equalization of pressure either side of shunt, but, at some point, the right-sided pressure will exceed and desaturated blood enters the Lt side of the circulation

Eisenmenger’s syndromeSymptoms:

oCyanosisoDyspneoa

•It is irreversible diseases

•Closer of the shunt is contraindicated if pulmonary HT is irreversible bcoz the Rt-to-Lt shunt now serves to decompress the pulmonary circulation

Physiotherapy Treatment :Pre-operative Treatment :•Infants with cardiac problem have pulmonary hypertension associated with excessive secretion leading to repeated chest infection.

•So chest physiotherapy important that the lung field are clear as possible prior to the surgery.

PercussionShaking and vibrations

Postural drainage

Post-operative Treatment :•Carefully watch the patient’s vital signs at all times.

•As soon as the child is stable, usually use the side lying position, with care not to disrupt line, wires or infusions.

•In some unit treatment will be on the day of operation, in others, day after.

•Depends on the type of operation the patient may or may not be ventilated.

•Patients should be assessed and physiotherapy given as necessary.

Post-operative Treatment•Percussion and vibrations should be avoided if post operative bleeding is persistent.

•Manual hyperinflation may enhance secretion clearance and negligible effect on oxygen saturation (Hussey et al,1996).

•Patient’s have small amount of secretions easily removed by suction alone.

•Early mobilization is important to stimulate deep breathing and coughing.

•Nasopharyngeal suction may be used in infants and children.

Post-operative TreatmentSpecific consideration:

•Pulmonary HT crises.Elevation of pulmonary artery pressure which restricts flow through the lungs.

Air way suction and chest physiotherapy is indicated, inspired oxygen should be increased & treatment time kept to a minimum.•Delayed sternal closure

Occasionally post operative closer of sternum is impended by pulmonary, myocardial or chest wall edema.

If child is stable and if the sternum edges feels, the child can turned into a side lying position

Manual hyperinflation is well tolerated and gentle posterior and posterolateral vibrations can be applied.

Post-operative Treatment•Phrenic nerve damage

oIt is a well-documented complication of pediatric cardiac surgery(Main,1995).oInability to wean from mechanical ventilation.oParadoxical movement is present.

Patient is positioned head up to relive the pressure from the abdominal viscera

References :1.) Textbook of surgery by, S.Das , 5th Edition.

2.) Bailey & Love’s Short practice of surgery , 22nd Edition.

3.) Davidson’s Principles & practice of medicine , 20th Edition.

4.) Cash’s Textbook of Chest , Heart and Vascular Disorders for Physiotherapists , 4th Edition.

5.) physiotherapy for respiratory and cardiac problems ( pryor and prasad) third edition

6.)Tidy’s Physiotherapy, Twelfth edition

THANK YOU