congestive heart disease.power point presentation

congestive heart disease presentation

1. Congenital Heart disease
CHD

2. Definition
Congenital heart defect (CHD) or congenital
heart anomaly is a defect in the structure of
the heart and great vessels which is present
at birth.
CHD : Group of anatomic abnormalities of
the heart that are generally present at birth
or
Any abnormality in Cardio-Circulatory
structure or Function that is present at Birth.

3. Exact Etiology is unknown
Risk Factors: Maternal Infection: -
- Maternal rubella
- Viral infections – herpes simplex
- Maternal Medication – Thalidomide & Warfarin
- Women with poorly controlled - elevated phenylalanine
levels and folic acid deficiency
- Maternal smoking and Passive smoking
- Maternal DM-Type 1, & Gestational Diabetes
- Maternal Alcoholism
- Maternal age above 40 years

4. Conti....
Hereditary: Familial tendency
Genetic factors: Marfan Syndrome - an inherited disorder that affects
the connective tissue
Holt orem syndrome ( Heart - hand syndrome) Autosomal
dominant genetic condition characterized by the abnormalities of
the upper limbs and Heart
Ehler – Danlos syndrome A group of genetic connective tissue
disorders, that effect connective tissue .
Chromosomal defects:
Down Syndrome ( Atrio Ventricular septal defect)
Turners syndrome (Aortic valve stenosis, Coaractation of aorta)
Incidence: 8/1000live births
3-4/100 still born
2/100 premature infants excluding

5. Classification
Congenital heart defects are classified based on:
Direction and magnitude of
pulmonary blood flow
Distinction between cyanotic and
acynotic heart defects.

6. Classification of CHD
Classification of congenital Heart disorders
Acynotic Heart Disease
Cyanotic Heart Disease
(RT to LT Shunt)
LT to RT Shunt Outflow Obstruction
1. Atrial Septal Defect( ASD)
13%
2. Ventricular Septal Defect
(VSD)
3. Patent Ductus Arteriosus
(PDA
1. Coarctation of Aorta
(COA)
2. Pulmoanry Stenosis (PS)
3. Aortic Stenosis (AS)
1. Transposition of great Vessels
2. Tetralogy of Fallot (TOF)
3. Total anomalous pulmonary
venous connection (TAPVC )

7. Acyanotic heart diseases
Left to right shunt: 1.1 Atrial Septal defect
(ASD)
1.1 ASD: Failure of septal growth or excessive
reabsorption of tissue. Defect occur in any
portion of the atrium Resulting shunting of
blood between two arteries.
Types
1. Ostium primum : seen in Lower atrial septum
2. Ostium secundum : center of the atrial
septumat fossa ovalis
3. Sinus venosus : seen in upper atrial septum
associated with Partial Anomalous Pulmonary
Venous Connection
4. Coronary Sinus: Seen as a large opening
between the coronary sinus and left atrium

8. PATHOPHYSIOLOGY ASD
Blood leaks from Left atrium to Right atrium
Right atrium has increased blood volume

Right atrial Hypertrophy
Right sided Heart failure

9. Clinical manifestations

Mild ASD are usually asymptomatic
In severe cases :
 Atrial dysrrhythmias
 Wide & fixed split of 2
nd
heart sound
 Systolic ejection murmur over the pulm. area
 Mid diastolic murmur at left lower sternal border
(tricuspid area)
 Holosystolic murmur at mitral area
 Precordial bulge, a prominent right ventricular cardiac
impulse
 Frequent respiratory infections
 Rarely signs of CCF ,Poor weight gain

10. Acyanotic CHD
Diagnosis ASD
►ChestXray: Right Ventricle &Atria enlargement,Large
pulmonary artery, ↑ed pulm. vascularity
►ECG: volume overload,RT axis deviation,minor Right
ventricular conduction delay
►Echocardiography : Right atrium and Right Ventricular
hypertrophy
►Catheterization : O
2 Saturation in the Right atrium and
equal pressure in 2 atria
Prognosis - well tolerated
Complications : Pulm.Hypertension,Eisemenger syndrome

11. Complications of ASD
1.Congestive Cardiac Failure and Pulmonary artery
hypertension in later life
2. Risk for Bacterial endocarditis
3. Emboli formation from chronic increased pulmonary
blood flow
4. Pulmonary vascular obstructive disease

12. Management
Spontaneous closure occurs in 87% cases
ASD of size less than 3mm closes by 18 months
ASD between 3-8 mm in size 80% closes by 18 months
ASD more than 8mm Spontaneous closure is rare
The optimum age for closure is by approximately 5 years

13. Surgical Closure
Surgery for all symptomatic ASD
Asymptomatic patients with shunt ratio > 2:1
Surgical repair is under cardiopulmoanry bypass either a
simple suture or a patch (Dacron)
Catheter - delievered devices: Non surg ical closure by
clamshell button resembling umbrellas or double umbrella
linked in a dumbbell configuration
Secundum ASD by cardiac cathetrization with insertion of an
occlusion device
Treatment undertaken 3-4 years of age

14. 1.2 Ventricular Septal Defect 30%
The most common cardiac
malformation
It is an abnormal opening between
the right and left ventricles
Defect occur in any portion of the
ventricular septum - Majority
membranous, Muscular - Single or
Swiss-cheese defect

15. Classification
1. Muscular defects: muscular defects may be located
anywhere in the apical, mid, anterior,or posterior muscular
septum
2. Perimembranous defects: Seen in the upper portion of
the septum
3. Infundibular (Subpulmonary defects) : seen below
pulmonary valve
4. Endocardial cushion type defects ( Atrioventricular
canal defects): Located beneath the tricuspid valve

16. VSD Pathophysiology
Pressure in the left ventricle

Pulmonary vascular resistance

Pressure in the right Ventricle
Lt to RT shunt and pulmonary resistance
Rt.Atrium enlarge and incomplete Rt.Ventricular
emptying Cynosis

17. Clinical Manifestation
Small defects up to 3mm: with trivial LT to Rt shunt
Most common
Asymptomatic , Murmurs Normal growth
Loud, harsh holosystolic murmur
Large defects bigger than aortic valve: Excessive pulmonary blood
flow
Pulmonary hypertension, Dyspnea, feeding difficulties,poor
growth,prespiration,recurrent pulmonary infection, Heart failure
Less harsh but more blowing holosystolic murmur
Accentuated 2nd heart sound
Mid-diastolic apical murmur when shunt ratio > 2:1
Severe VSD: Frequent chest infections, Lt.to Rt. shunt leads to
Eisenmenger's Syndrome- Clubbing of fingers, Cynosis and
respiratory distress.

18. Ventricular Septal Defects
Diagnosis: Physical Examination- Clinical : thrill at lower sternal
edge, loud holosystolic murmur at lower sternal edge and 2nd Heart
sound is normal
CXR- Lt. atrial enlargement and pulmonary edema
Cardiomegaly,Plethoric lung
ECG- Lt Ventricular Hypertrophy, with or without left atrial
hypertrophy
Echocardiography - Determine size and location of VSD
Prognosis: 30-50% small defects close by 2yr of age

19. Complications - Ventricular Septal Defects
Congestive heart failure
Pulmonary vascular diseases
Aortic regurgitation
Infective endocardities
Growth retardation
Recurrent lung infection
Pulmonary HTN
Acquired Pulmonary Stenosis
AtrioVentricular Regurgitation

20. VSD - Management
Small defects: Reassurance,Prophylaxis against Infective
endocarditis
Large defects: Medical Mgmt.
Control Congestive heatr failure:
Diuretics - To relieve pulmoanary congestion Inj..Furosemide
1-3 mg/kg in divided in 2 or 3 doses
Angiotensine - converting enzme (ACE) inhibitors reduce
the pulmonary and systemic pressure > reduce the left -to-
right shunt
Digoxin if symptoms are severe Doses 5-10μg/kg/day

21. Conti....
Prompt treatment of respiratory infections
Infective endocarditis prophylaxis
Maintain good dental hygiene
Promoting normal growth
Fluid restruction and caloric restriction
prevent Infective Endocaritis
Prevent development of Pulm.HTN)

22. Conti....
Palliative care:- Banding of the pulmonary artery, a device,
known as the Amplatzer muscular procedure that causes
an increase in the resistance to bloodflow in the lungs, so
pulmonary artery pressure and volume of blood flow
returning to the left side of the heart are reduced
Corrective Surgical repair between 6-12 m
Intra cardic repair of VSD
1.Cardiopulmonary bypass is required
2. Sternotomy is needed
3.Small defects are repaired with a purse string suturing

23. Conti....
4.The moderate defect is corrected through a right atrial
incision
5. Large defects - a right or left ventriculotomy is necessary ,
Closure is corrected with pericardial patch or Dacron patch
Complications
Residual VSD
Conduction defects

24. Patent Ductus Arteriosus (PDA)
It is the failure of thefetal ductus arteriosus to close
within first week of life.
The continued patency of this vessel allows flowing
of blood from the high pressure aorta to low pulmonary
artery , causing left to right shunt.
Ductus arteriosus that connects the left pulmonary
artery with the descending aorta
Closure of ductus arteriosus is depends upon the
constrictor response of the ductus to the oxygen tension in
the blood

25. Patent Ductus Arteriosus (PDA)

26. Pathophysiology
Patend ductus arteriosus
Resistence in the aorta blood flows directly from the aorta in to
the pulmonary artery
LTto Rt shunt amount of oxygenated blood in the lungs

Increases the workload of the Left ventricle
Progressive dilation and left atrial hypertension

Pulmonary edema, characterized by hypoxia, Pulmonary
hypertension,and Right heart failure

27. Patent Ductus Arteriosus
Clinical Manifestation:
Manifestation are first evident in first 1-4 days of life
Asymptomatic in small ductus
Large PDA:-
Tachycardia and Tachypnea may be present
Persistent systolic murmur like “machine like”
Bounding peripheral pulses with Wide pulse pressure
Tachycardia with bounding pulse

28. Conti.....
Continuous or machinery murmur (beneath left clavicle)
Irritable, feed poorly, fail to gain weight and sweat
excessively
Increased respiratory effort and respiratory rates
Prone to develop upper respiratory tract infections and
pnuemonia
Signs of Congestive Heart Failure
Risk for bacterial endocarditis

29. Patent Ductus Arteriosus
Diagnosis:-
Electrocardiography: shows ventricular hypertrophy and
Pulmoary hypertension
Chest X-ray: The aorta, Left ventricle , left
atrium,Pulmonary vessels and main pulmonary artery
enlarged
Echocardiography: Ductus is easily visualized and shunting
is outlined with color mapping
Cardiac catheterization: It is used in very rare instance

31. Prognosis
Spontaneous closure occur in premature babies
Small PDA - Child can live normal Life
Large PDA- Congestive Heart Failure
If untreated, reversal of shunt takes place and pulmonary
hypertension develops
Result will be excellent if the child gets proper treated
Complications:
InfectiveEndocarditis/Endarteritis,
CHF
Embolization and Pulmonary Hyper Tension

32. Management
Medical : Oral or intravenous administration of a
prostaglandin (PGE inhibitor) synthase inhibitor
3 doses of indomethacin q12hours or ibuprofen q24
hours achieve ductal closure in greater than 80% of
premature infants.
Bacterial endocarditis prophylaxis for small PDA
Transcatheter closure: it is the standard therapy foe PDA-
in which occlusion of the ductus with catheter -
delievered spring wire coils covered with Thrombogenic
dacron strands (Gianturco coils ) has been the most
widely and successfully used nonsurgical technique.

33. Conti...
Amplatzer device is used to close PDA
during cardiac catheterization
Amplatzer septal occluder is a double
disk device constructed with 0.004"
to 0.007" Nitinol(nickle-titanium
compound) wire with shape memory.
A 4 mm wide waist connects the left
and right atrial disks and stents the
ASD.
Rashkind occlusion device consists of a
2 umbrella system delievered to the
ductus during cardiac catheterization

34. Surgical Management
Surgical closure: Ligation of the ductus arteriosus- It is
performed between 6 months and 2 years , in this left
lateral thoracotomy or Thorascopic (endoscopic) closure
of the ductus can be performed
In this does not need Cardiopulmonary Bypass,
Risk of ligation and division of patent ductus is extremely
small, the prognosis will be excellent

35. Pulmonary Stenosis( PS)
Acynotic Heart disease do to outflow obstruction
2.1 Pulmonary Stenosis (PS)
Narrowing at the entrance of the pulmonary artery
Mildely to moderately narrowed
Pulm. Stenosis 4 types
1.1 Valvular
1.2 Infundibular
1.3 Supra valvular
1.4 Peripheral

36. Acyanotic Heart Diseases - Outflow obstructions
2.1 Pulmonary Stenosis Pathophysiology:
Rt. outlet obstruction → pressure difference
↓
Rt. Ventricular hypertrophy

Right ventricular Failure , Rt.atrial pressure increase leads
to reopening of the foramen ovale
Systemic venous congestion , Congestive heart failure

37. Acyanotic CHD Pumonary stenosis
Clinical Manifestations
Mild to moderate - asymptomatic
Critical stenosis
Systolic ejection murmur
Heart failure in neonates & infants
Rarely cyanosis

38. Acyanotic CHD
Diagnosis: -Clinical, CXR- Rv hypertrophy & Reduced
pulm. blood flow, ECG, Echo
Prognosis: Good in mild to moderate
Complications : CHF in severe Pulmonary stenosis
Rarely IE
Treatment : Valvular Ps - Balloon Valvuloplasty
Surgical mgmt. TransventricularValvotomy (Brock
Procedure)

39. Acyanotic CHD Outflow obstruction
2.2 Aortic Stenosis (AS) : valve may have only two or one
leaflets, Leaflets that are partially fused together
2.1 Valvular - the commonest
2.2 Supra valvular
2.3 Subvalvular (Subaortic)
Clinical Manifestations
Mild Stenosis: Normal pulse & Apical pulse
Systolic ejections Murmor
Normal to enlarged heart size

40. 2.2 Aortic Stenosis
Clinical Manifestations
Critical Stenosis
LV failure
Pulm.edema,Cardiomrgaly
Weak peripheral pulses
Weak systolic M
Paradoxical split 2nd heart sound

41. 2.2 Aortic Stenosis Pathophysiology
Stenosis will leads to resistance to ejection of blood from the
left ventricle

LV Hypertrophy
LV pressure fails leads to left atrial pressure increase

Increased pressure in pulmonary veins
Pulmonary vascular congestion

42. Aortic Stenosis- Diagnosis
- Physical examination
Systolic ejection murmur best at right upper sternal
border, radiates to neck
Ejection click
S
2
splits normally or narrowly
- ECG- LV hypertrophy
- Chest X-ray - Increased pulmonary vascular markings
- Echocardiogram
Prognosis : good for mild to moderate
Treatment: Balloon valvuloplasty
Surgical repair : Aortic Valvotomy

43. Acyanotic CHD Coarctation of Aorta
2.3 Coarctation of the Aorta
(COA)
Occur at any site from the arch
of aorta to iliac bifurcation In
utero arch hypoplasia→Rt heart
output passes through the ductus
98% juxta ductal
It is a localized narrowing or
obstruction of the aorta just
adjacent to the site of insertion
of the ductus arteriosus
It is associated with nearly
30%patients with Turner
Syndrome

45. Coarctation of the Aorta
1. Preductal coarctation : The narrowing is seen proximal
to the ductus arteriosus, Blood flow to the aorta that is distal
to the narrowing is dependent on the ductus arteriosus - it is
commonly seen in Turner's syndrome.
2. Ductal coarctation : The narrowing occurs at the
insertion of the ductus arteriosus
3. Postductal coarctation : The narrowing is distal to the
insertion of the ductus arteriosus , blood flow to the lower
body can be impaired

46. Acyanotic CHD (COA)
Clinical Manifestations
Hypertension→Mechanical obstruction→Renal
Differential→Pink upper extr.& Cyanosed lower
extr.
Classixal signs: Disparity in pulse & BP
Radio-femoral delay
Systolic murmur at LM & inter-scapular area

47. 2.3 Coarctation of the Aorta Pathophysiology
Coarctation increases the pressure in the ascending aorta
Higher pressure to the cornary arteries that arises from the
aortic arch
Left ventricular hypertrophy and hypertension in the upper
part of the body including brain
Pressure decreased distal to the site of obstruction
hypoperfusion in lower part of the body including
abdominal organs and lower extremities
Condition left untreated may result LV failure, rupture of
aorta,Intra Cranial Haemorrhage etc.

48. 2.3 Coarctation of the Aorta Clinical Manifestations
Arterial Hypertension in arms with low BP in the lower
extremities, difference in BP between upper and lower
extremities is the classic sign of coarctation of aorta
High BP and bounding pulse in arms, Weak or absent
Femoral pulse
Cool lower extremities with prolonged capillary refill time
Dizziness , Headache, fainting and epistaxis due to
hypertension

50. Conti.....
Decreased ability to exercise
Shortness to breath
Failure to thrive
Poor growth
Complications
Hypertension
Cerebral aneurysm, Aortic aneurysm,Ruptured aorta
Intracranial haemorrhage, stroke, Paralysis
Cardiomyopathy, Infective endocarditis,Congestive heart
Failure

51. Diagnosis COA
Chest Xray - Cradiomegaly , Pulmonary congestion,
Prominant aortic knob, and Notching of ribs
ECG: Left ventricular hypertrophy, left sided changes in the
ST segment T wave in the chest leads
Cardiac Catheterization: Evaluates the severity of Coaractation
Echocardiography: The characteristic feature is indentation of
the posterior and lateral aspects of the aorta by a wedge
shaped shelf of tissue

52. Management
Stabilize the child
Control Hypertension
Ventilatory support in case of child with respiratory distress
Prostaglandin E1 (0.05 - 0.15mcg/kg/min) is infused
intravenously to open the ductus arteriosus
Manage congestive heart failure with the use of diuretics
and inotropic drugs - dopamine, dobutamine and
epinephrine
Non Surgical Management
Baloon angioplasty as a primary intervention for
coarctation of aorta

53. Baloon angioplasty

54. Surgical Management
Thoracotomy is performed and resection of coarcted
portion with an end to end anastomosis of the aorta or
enlargement of the constriction using a prosthetic material
or portion of left subclavian artery
Cardiopulmonary bypass is not required .
Postoperative Hypertension is the major complication - it is
treated by Sodium nitroprusside IV or amrione ,
Propranolol( Beta blocker) and Captopril (ACE inhibitor)

55. Ductal
segment

56. Complications
Recurrent Coarctation
Hemorrhage
Laryngeal nerve damage leading to stridor
Phrenic nerve damage leading to paralysis of the diaphragm
Chylothorax - Due to injury to the thoracic duct
Postcoarctectomy syndrome - Common in older children
with preoperative hypertension an additional effect of this
increased renin production might be the shunting of blood
from the mesenteric arteries in the GI system - child may
present with vomoting abdominal distention and fever

57. THANKS