Structures of the heart

Normal Heart

Atrial Septal defect
( ASD )
Insidence : + 10 %
: ratio = 1,5 to 2 : 1
Anatomy :
Defect on foramen ovale : Secundum ASD
Defect at SVC and RA junction:
sinus venosus ASD
Defect at ostium primum : primum ASD

ASD
Atrial Septal Defect
Atrial Septal Defect
Diagram of ASD
LA
LV
RV RA
PA
AO
Systemic
Lungs
Qp > Qs
Atrial septal defect
RA
RV
LA
LV
RA
RV
LA
LV
Atrial septal Defect
Clinical findings
Asymptomatic
Auscultation :
Normal 1st HS or loud
Widely split and fixed
2
nd
HS
Ejection systolic murmur

Atrial septal Defect
Atrial Septal Defect
Auscultation :1
st
HS N or loud
widely split and fixed 2
nd
HS
Ejection Sistolic Murmur
ECG : IRBB , right ventricular hypertrophy

Atrial Septal Defect
Right atrial enlargement
Prominence the MPA
segment
Increased pulmonary
vascular marking
Atrial Septal Defect
Chest X-Ray
Atrial Septal Defect
Diagnosis Differential

Primary Atrial Septal Defect
ECG : LAD
Partial Anomalous Pulmonary Vein
Drainage
Pulmonary Stenosis
Innocent Murmur

Atrial Septal defect

Management
Surgery : Preschool age
Recent treatment: transcatheter closure using
ASO (Amplatzer septal occluder)

ASD
Small Shunt
Large Shunt
Observation
Evaluation
At age 5-8 yrs
Cath
FR<1.5 FR>1.5
Conservative
Infants
Children/Adults
Heart
Failure (-)
Heart
Failure (+)
Age >1yrs
W >10kg
Transcatheter closure (Secundum ASD) /
Surgical Closure(others)
Conservative
Anti failure
Fail Success
PH (-) PH (+)
PVD
(-)
PVD
(+)
Hyperoxia
Reac-
tive
Non
reactive
Surgical
Closure
Atrial septal defect
Ventricular septal defect
Insidence
20 % of all CHD
No sex influenced
Anatomy
Subarterial defect : below pulmonary and
aortic valve
Perimembranous defect: below aortic valve at pars
membranous septum
Muscular defect
VSD
Ventricular Septal Defect
LA
LV
RV
RA
PA
AO
Systemic
Lungs
Qp > Qs
Ventricular Septal defect
RA
RV
RA
LA
LA
RV LV LV
Ventricular septal defect
Ventricular Septal Defect
Ventricular Septal Defect
Clinical findings
Day 1
st
after birth: murmur (-)
After 2-6 weeks : murmur (+)
Murmur : pansystolic grade 3/6 or higher
at LSB 3
Small muscular defect: early systolic murmur
Significant defect: Mid diastolic murmur at apex
Small VSD
Large VSD
Ventricular Septal Defect
Murmur: pansystolic
grade 3/6 or higher at
LSB 3

Ventricular Septal Defect
Cardiomegaly
Apex down ward
Prominence pulmonary
artery segment
Increased pulmonary vascular
marking

Ventricular septal Defect
Diagnosis Differential

PDA with PH
Tetralogy Fallot non cyanotic
Inoscent murmur


Ventricular septal defect
Management:

Definitive : VSD closure
Surgery
Transcatheter closure

DSV
Heart failure (+) Heart failure (-)
Anti failure
Fail Success
PAB
Evaluate
in 6 mths
Surgical closure/Transcatheter closure
Aortic valve
prolaps
Infundibular
stenosis
PH Smaller Spontaneous
closure
Cath
PVD(-) PVD(+) Cath
Cath
Reactive Non-
reactive
Conservative
FR>1.5 FR<1.5
Patent Ductus Arteriosus
Insidence
+ 10%
Female : Male = 1.2 to 1.5 : 1
Premature and LBW higher

Anatomy
Fetus: ductus arteriosus connects PA and aorta.
If ductus does not closs Patent Ductus arteriosus

PDA

LA
LV
RV
RA
PA
AO
Systemic
Lungs
Qp > Qs
Patent Ductus Arteriosus
RA
RV
LA
LV
RA
LA
RV LV
Patent Ductus Arteriosus
Patent Ductus Arteriosus
Clinical findings

Small defect:
Symptom (-)
Growth and development normal
Significant defect:
Decreased exercise tolerant
Weigh gained not good
Frequent URTI
Specific case: pulsus seler at 4
th
extremities

Patent Ductus Arteriosus
Diagnosis
Pulsus seler and continuous murmur heard

Patent Ductus Arteriosus
Chest X- Ray
Similar to VSD
Patent Ductus Arteriosus
Auscultation : continuosus murmur
at upper LSB 2

Diagnosis Differential
AP-window
Arterio-venous fistulae

Management
premature: indometasin
PDA closure : surgery
transcatheter closure
Patent Ductus Arteriosus
PDA
Neonates/Infants Children/Adults
Heart failure (+) Heart failure (-)
Premature
Full term
Anti failure
Indometacin
Success Fail
Spontaneous
closure
Anti failure
Success Fail
Surgical
ligation
Transcatheter closure
PH (-) PH (+)
LR RL
Hyperoxia
Reactive
Non
reactive
Conservative
Age >12wks
W >4kg
Patent Ductus Arteriosus
Patent Ductus Arteriosus
Pulmonary Stenosis
Incidence : 8-10%

Anatomy:
Pulmonary stenosis valvular :
Bicuspid pulmonary valve
Valve leaflet thickening and adhession
Pulmonary stenosis infundibular :
Hyperthropy infundibulum

Pulmonary Stenosis
Clinical findings
Valvular stenosis
Mild : Ejection systolic
Wide 2
nd
HS
ejectiin click
Moderate: ejection systolic, early systolic click
Severe : ejecstion systolic, ejection click (-)
Stenosis infundibular
Ejection click ( - )
1
st
HS normal, 2
nd
HS weak, ejection systolic
Pulmonary stenosis periphery
1
st
& 2
nd
HS normal, ejection systolic
Pulmonary Stenosis
Mild : ejection systolic
2
nd
HS wide split
ejection click
Moderate: ejecsi systolic , early ejection click
Severe : ejection systolic, click ejection (-)
Poulmonary Stenosis
Diagnosis
Asymptomatic patient:
click systolic (stenosis valvular)
systolic murmur
wide split 2
nd
HS vary with respiration

Poulmonary Stenosis
Normal or mild cardiomegaly
Marked pulmonary valve
post stenotic dilatation
Normal pulmonary
vascularity
ECG : RAD
Echocardiograhhy : confirmation diagnosis
Catheterization: increased RV pressure
without increased oxygen saturation

Pulmonary Stenosis
Pulmonary Stenosis
Management

Medicamentosa : useless
Mild stenosis: intervention (-)
Moderate stenosis: observation
Severe stenosis: balloon valvuloplasty
Pulmonary Stenosis
Tetralogy Fallot
Insidence
5-8% from all CHD

Anatomy
Cause: Left-anterior deviation of infundibular septum

Sindroma consist of 4 items:
VSD
pulmonary stenosis
aortic over-riding
RVH
Tetralogy Fallot
Tetralogy Fallot
Hemodynamic acyanotic
Hemodynamic cyanotic
Tetralogy Fallot
Diagnosis

Clinically : cyanosis
Single 2
nd
HS, ejection systolic murmur

Tetralogy Fallot
Single 2
nd
HS, ejection systolic murmur
Tetralogi Fallot
CXR :
Boot-shaped
Concave pulmonary
segment
Apex upturned
Decreased pulmonary
blood flow

Tetralogy Fallot
Tetralogy Fallot
ECG : RAD
Echocardiography : to confirm diagnosis

Tetralogy Fallot
Diagnosis Differential
Pulmonary Atresia
Double outlet right ventricle and pulmonary stenosis
Transposisi of great arteri and pulmonary stenosis

Management
Paliative treatment: Blalock-Taussig shunt
Definitive: total correction


Tetralogy of Fallot
< 1 yr > 1 yr
spell (+)
spell (-)
propranolol
failed
succeed
BTS
total correction
cath
small PA good sized PA
clinically
ECG
CXR
echo
age 1 yr
cath
BTS/
PDA Stent
evaluation
Tetralogy Fallot
Tetralogy Fallot