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Normal Heart
Sign and Symptom of CHD
• Dyspneu
• Cyanosis
• Feeding problem
– Intermittent feeding
– Prolonged feeding
• Dyspneu de effort
• Orthpneu
• Recurrent respiratory tract infection
• Poor weight gain
• Asymptomatic murmur
• The presence of murmur does not mean that
there is CHD
• No murmur does not exclude CHD
Classification of CHD
– Acyanosis
• PDA
• ASD
• VSD
• PS
– Cyanosis
• ToF
• TGA
• Pulmonary atresia
• Truncus arteriosus
• Total anomaly pulmonary vein drainage
• Ticuspid atresia
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
Patent Ductus Arteriosus
LA LV
Lungs
PA AO
Systemic
RV RA
Qp > Qs
Patent Ductus Arteriosus
RA LA
RA LA
RV LV
RV LV
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 4th extremities
Patent Ductus Arteriosus
Diagnosis
Pulsus seler and continuous murmur heard
Patent Ductus Arteriosus
• Chest X- Ray
– Similar to VSD
Patent Ductus Arteriosus
Diagnosis Differential
AP-window
Arterio-venous fistulae
Management
premature: indometasin
PDA closure : surgery
transcatheter closure
PDA
Neonates/Infants Children/Adults
Fail Success
Success Fail Reactive Non
Age >12wks reactive
W >4kg
• 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
Atrial septal defect
LA LV
Lungs
PA AO
Systemic
RV RA
Qp > Qs
Atrial septal Defect
RA LA
RA LA
RV LV
RV LV
Atrial septal Defect
Clinical findings
Asymptomatic
Auscultation :
Normal 1st HS or loud
Widely split and fixed
2nd HS
Ejection systolic murmur
Atrial Septal Defect
Diagnosis Differential
Management
Surgery : Preschool age
Recent treatment: transcatheter closure using
ASO (Amplatzer septal occluder)
ASD
Infants Children/Adults
Observation
Heart Heart PH (-) PH (+)
Evaluation Failure (-) Failure (+)
At age 5-8 yrs PVD PVD
Anti failure (-) (+)
Cath Hyperoxia
Success Fail
During balloon
sizing
Atrial septal defect
LA LV
Lungs
PA AO
RV RA Systemic
Qp > Qs
Ventricular septal defect
RA
LA
RA LA
RV LV RV LV
Ventricular Septal Defect
Ventricular Septal Defect
• Clinical findings
Day 1st 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
Ventricular Septal Defect
Murmur: pansystolic
grade 3/6 or higher at
LSB 3 Small VSD
Large VSD
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:
Transcatheter closure
DSV
Anti failure
Aortic valve Infundibular PH Spontaneous Smaller
prolaps stenosis closure
Conservative
Surgical closure/Transcatheter closure
Ventricular septal defect
• 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 2nd HS
ejectiin click
Moderate: ejection systolic, early systolic click
Severe : ejecstion systolic, ejection click (-)
Stenosis infundibular
Ejection click ( - )
1st HS normal, 2nd HS weak, ejection systolic
Pulmonary stenosis periphery
1st & 2nd HS normal, ejection systolic
Pulmonary Stenosis
• Diagnosis
Asymptomatic patient:
click systolic (stenosis valvular)
systolic murmur
wide split 2nd HS vary with respiration
Poulmonary Stenosis
ECG : RAD
Echocardiograhhy : confirmation diagnosis
Catheterization: increased RV pressure
without increased oxygen saturation
Pulmonary Stenosis
• Management
Medicamentosa : useless
Mild stenosis: intervention (-)
Moderate stenosis: observation
Severe stenosis: balloon valvuloplasty
Pulmonary Stenosis
Pulmonary Stenosis
Before ballooning
Pulmonary Stenosis
During ballooning
Pulmonary Stenosis
After ballooning
Coarctation Aorta
Incidence
• In Western country 5 % of all CHD
• In Asian Country incidence lower
underdiagnosis ?
Anatomy
Stenosis at any where in the aorta
(from aortic valve to abdominalis aorta)
More frequent at ductus arteriosus Botalli and
pulmonary artery junction
Coarctation Aorta
Coarctation Aorta
• Clinical findings
Severe coarctation in neonates period can cause
heart failure in 1st weeks of life
• Diagnosis
Clinically : lower extremities pulses are weak
CXR : Mild cardiomegaly
Prominence of aortic knob
Normal pulmonary blood flow
ECG : normal or LVH
Echocardiography: a discrete shelf-like membrane
Cardiac catheterization and angiography: to confime
diagnosis
Coarctation Aorta
• Management
Neonates :
PGE1 to maintain PDA
Diuretic
Correction acid-base imbalance
Prepared to undergo surgery
Big children:
Surgery should be done as soon as diagnosis
made
Balloon angioplasty
Coarctation Aorta
Coarctation Aorta
Coarctation Aorta
Coarctation Aorta
Before ballooning
Coarctation Aorta
During ballooning
Coarctation Aorta
After ballooning
Tetralogy Fallot
Insidence
5-8% from all CHD
Anatomy
Cause: Left-anterior deviation of infundibular septum
• Diagnosis
Clinically : cyanosis
Single 2nd HS, ejection systolic murmur
Tetralogy Fallot
CXR :
Boot-shaped
Concave pulmonary
segment
Apex upturned
Decreased pulmonary
blood flow
“ Boot-shaped” appearance
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
• clinically • CXR
• ECG Tetralogy of Fallot • echo
< 1 yr > 1 yr
BTS
evaluation
total correction
Tetralogy Fallot
Tetralogy Fallot
Transposition of Great
Artery
Insidence
5% of CHD
Anatomy
Abnormality of formation of trunkal septum that cause
aorta arising from RV and PA arising from LV
Transposition of Great artery
Transposition of Great artery
• Clinical aspects
• Diagnosis
Clinically :
Suspicious if neonates presents with cyanotic
with birth weight normal or bigger
Murmur (-)
Single 2nd HS and loud
Transposition of Great artery
Murmur (-)
Single 2nd HS and loud
Transposition of Great artery
CXR :
Cardiomegaly
Egg-on-side heart
Increased
pulmonary
vascular
marking
“Egg on side” appearance
Transposition of Great artery
ECG :
RAD
RVH
Echocardiography : to confirm diagnosis
Cardiac catheterization: usually is not
needed
Transposition of Great artery
Diagnosis Differential
trunkus arteriosus
trikuspid atresia
pulmonary atresia
Management
Palliative: BAS
Surgery: arterial switch
Paliative : Blalock-Taussig shunt
Transposition of Great Artery
VSD(-) VSD(+)
LVOTO(-) LVOTO(+)
1mth > 1mth
3 mths >3 mths Dynamic & Un-
Cath resectable resectable
Cath
LV2/3 syst LV<2/3 syst BTS/
PARI<8 PARI8 PDA stent
Senning PAB
Cath
Arterial Switch Arterial Switch and Rastelli
Perforated VSD
Transposition of Great artery
Truncus Arteriosus
Insidence
around 1 % of CHD
Anatomy
Failure of septation of truncus arteriosus form aorta and
pulmonary artery
There are 3 type:
Type 1 : MPA arises from the truncus and then divides into
the RPA and LPA
Tipe 2 : The PAs arise from the posterior aspect of the
truncus
Tipe 3 : The PAs arise from the lateral aspects of the truncus
Tipe 4: Arteries arising from the descending aorta supply the
lungs
Truncus Arteriosus
Truncus Arteriosus
Truncus Arteriosus
Truncus Arteriosus
• Diagnosis
Clinically suspected if:
neonates present with cyanotic and single 2nd HS
murmur vary
CXR: cardiomegaly
increased pulmonary vascular marking
ECG: biventricular hypertrophy
Echocardiografhy: to confirm diagnosis
Catheterization: decreased oxygen saturation at right
heart and aorta
Truncus Arteriosus
Diagnosis Differential
Transposisi of great artery
Total anomalus pulmonary vein drainage
Management
Medicamentosa : temporary
Surgery: Rastelli
Palliative: pulmonary artery banding
Truncus Arteriosus
Tricuspid Atresia
• Incidence
– 1 % from all CHD
• Embriology
– Valve formed at 5th weeks
– Fussion of part of endocardial
cushion, ventricular septum and
miocardium
Tricuspid Atresia
• Anatomy
– Valve leaflet adhession one to another,
difficult to open
– ASD essentially required to drain blood
from RA to LA
– Classified into 2 group
• Normal related great artery
• Transposed grat artery
Tricuspid Atresia
• Manifestasi klinis
– Cyanosis early after birth
– Increased RV activity
– Increased LV activity
– Auscultation
• Single 1st and 2 nd HS
Tricuspid Atresia
• Clinical manifestation
– In almost all patients murmur is silent
– If murmur present
• Diastolic murmur due to relative MS
• Pansystolic murmur due to VSD
Tricuspid Atresia
Tricuspid Atresia
CXR:
Heart minimally
Enlarged
The PVMs are
Decreased
The MPA segment is
concave
Tricuspid Atresia
– ECG:
• LAD
• Left ventricular hypertrophy
• With or without LAE
Tricuspid Atresia
• Diagnosis differential
– Transposition of great artery
– Truncus arteriosus
– Tetralogy of Fallot
– Total Anomalous pulmonary vein
drainage
Tricuspid Atresia
• Management
– Fontan operation
Tricuspid Atresia
Tricuspid Atresia
Tricuspid Atresia
Tricuspid Atresia
Tricuspid Atresia
Tricuspid Atresia