echocardiographic approach to congenital heart disease

approach to congenital heart disease

1. Approach to chd Dr Manish N Chokhandre Consultant Pediatric Cardiologist

2. Rule of commonness The uncommon manifestations of common diseases are much more common than the common manifestations of uncommon diseases

3. 5 BASIC QUESTIONS TO BE ANSWERED… 1. Is it a CHD?? 2. If yes: Cyanotic or acyanotic ?? 3. Pulmonary Blood flow: Increased? 4. PAH: +/-?? 5. Duct dependent lesion??

4. Approach History Examination Diagnostic Modalities ECG CXR ECHO

5. History • Newborns and Infants • Fast breathing • Difficult breathing • Grunting • Poor feeding – poor weight gain • Sweating – Suck – Rest – Suck – cycle • Reduced activities • Cyanosis – Central

6. History • Toddlers and Preschool • Previous + followings • Poor breathing and / or feeding • Limited activities on playground • Frequent illnesses – cough, cold , fever • Poor growth Older Children and Adolescents • All previous + extra • Chest pain • Syncope • Dizziness • Paroxysmal nocturnal dyspnea

7. History H/O frequent cough, cold and/or fever • H/O Hospital admission, H/O Surgery • Perinatal History – Maternal Infection, Maternal autoimmune diseases, Maternal medications • Family History – ho similar illness • Syndrome – Phenotype vs Genotype

8. Examination General Examination Head to toe- Syndromes

9. Head to toe Anthropometry Dysmorphism Clubbing Pallor Odema Chest/spine deformities

10. CVS exam VITALS: Pulse, BP, Temp, RR, SPO2 ◻ JVP ◻ Inspection of precordium ¤ Bony/Spine deformities ¤ Chest shape ¤ Trachea central/deviated ¤ Visible precordial bulge ¤ Visible pulsations ¤ Scars, dilated veins, sinuses.

11. Cvs exam Palpation ¤ Apex beat ¤ Parasternal Heave ¤ Thrills ¤ Any palpable pulsations in precordial region, back, neck, epigastric region ◻ Percussion: Heart borders, situs, 2nd left intercostal space dullness ◻ Auscultation: ◻ Heart sounds (HS1, HS2, HS3, HS4) ◻ Extra sounds (Clicks, opening snaps, tumour plop) ◻ Murmurs (Systolic, diastolic, continuous)

12. Ascultation

13. Second heart sound

14. Splitting of S2

15. Innocent murmur  Blood Pressure normal  Second sound is normal  No cyanosis  No Cardiomegaly  X Ray chest is normal  ECG is normal

16. 5 BASIC QUESTIONS TO BE ANSWERED… 1. Is it a CHD?? 2. If yes: Cyanotic or acyanotic ?? 3. Pulmonary Blood flow: Increased? 4. PAH: +/-?? 5. Duct dependent lesion??

17. CHD or not? NADA’S Criteria Major criteria Cyanosis CHF Systolic murmur Grade 3 or more Diastolic murmur Minor criteria Abnormal S2 Abnormal BP Abnormal ECG Abnormal CXR Systolic murmur Grade 1 or 2 Diastolic murmur 1 major or 2 minor indicates CHD

18. 2 nd question: Cyanotic or acyanotic Clinically: nail beds/lips/tongue blue But if saturation between 85-93% the human eye cannot detect cyanosis So, the gold standard of detection of cyanosis is PULSE OXIMETER Infact the pulse-ox is called the 5 TH VITAL SIGN

19. Pulse-oximeter

20. Classification of chd Acyanotic Increase PBF ASD VSD PDA AP window Combined Normal PBF AS/PS Cyanotic Decrease PBF TOF Pulm Atresia Increase PBF TGA TAPVC Truncus arteriosus Pulse-oximeter

21. Question: 3 Pulmonary Blood flow: Increased?

22. Classification of chd Acyanotic Increase PBF ASD VSD PDA AP window Combined Normal PBF AS/PS Cyanotic Decrease PBF TOF Pulm Atresia Increase PBF TGA TAPVC Truncus arteriosus

23. HOW TO ASSESS PBF ? Symptoms of incr PBF Inc RR, Retractions , Incr infections Sweating while feeding SOB Failure to thrive Harrisons sulcus

24. • objective method of assessing the PBF ?

25. CXR

26. CXR: Cardiac shadow •White arrow, right atrial border; •Purple arrow, right ventricular border; •red arrow, aortic notch; •yellow arrow, pulmonary artery; •blue arrow, left atrial border; •green arrow, left ventricular border.

27. ASD

28. Increase Pbf

29. Increase Pbf AV canal

30. Increase Pbf AV canal

31. Increase PBF Large vsd

32. TOF

33. ??? Eisenmenger

34. TGA

35. TGA

36. Rib notching

37. Classification of chd Acyanotic Increase PBF ASD VSD PDA AP window Combined Normal PBF AS/PS Cyanotic Decrease PBF TOF Pulm Atresia Increase PBF TGA TAPVC Truncus arteriosus

38. Acyanotic CHD

39. Large left to right shunt Atrial level shunt (ASD) Ventricular level shunt (VSD) Arterial level shunt (PDA/AP window)

40. Atrial level shunt ASD Secundum Primum Sinus venosus Coronary sinus Cardinal features Left parasternal impulse Wide, fixed split S2 Pulmonary ejection systolic murmur Tricuspid diastolic flow murmur rsR ‘ in V1 in ECG

41. AtriAl septal defect CLOSE by 3-4 YRS OR WHEN DIAGNOSED ELECTIVE DEVICE vs SURGERY BOTH HAVE EXCELLENT OUTCOME Normal QOL and life span

42. TRANSCATHETER ASD CLOSURE RAPID RECOVERY NO SCAR SUCCESS > 98% OF SELECTED CASES SELECTION IS THE KEY NO BLOOD TRANSFUSION Adv over SURGERY – neuro- developemental concern

43. Large left to right shunt Atrial level shunt (ASD) Ventricular level shunt (VSD) Arterial level shunt (PDA/AP window)

44. VSD Left ventricular type apial impulse Systolic thrill Pansystolic murmur Mitral diastolic flow murmur LV dominance in ECG

45. VSD: When to operate? LARGE VSD’s: 3 MONTHS; By 6 MONTHS – IF WEIGHT GAIN NOT APPR – AND/OR IF PULM HTN DEVELOPING MODERATE VSD’S INDIVIDUALIZED SMALL VSDS – AORTIC INSUFFICIENCY INFECTIVE ENDOCARDITIS Surgery vs transcatheter closure

46. Large left to right shunt Atrial level shunt (ASD) Ventricular level shunt (VSD) Arterial level shunt (PDA/AP window)

47. PDA Neonatal period All hemodynamically significant PDAs should be closed -Pharmacologic in preterm Neonates -Device closure or surgery

48. PDA BEYOND NEONATAL PERIOD ANY PDA THAT CAN BE AUSCULTATED NEEDS TO BE CLOSED ANY SYMPTOMAYTIC PDA NEEDS TO BE CLOSED SILENT PDA’S MAY/MAYNOT BE CLOSED IN POST NEONATAL PERIOD When to close? Large PDA- immediately Small- moderate - electively

49. Obstructive lesions Aortic stenosis Coarctation Pulmonary stenosis

50. PS Pulmonary stenosis Left parasternal heave Systolic thrill Ejection systolic murmur in upper left sternal border Wide split second sound, delayed, well heard P2

51. AS Aortic stenosis Narrow pulse pressure Systolic thrill Ejection systolic murmur radiating to neck Delayed A2

52. Coarctation of aorta Coarctation Absent or weak, delayed femorals compared to radials Arm blood pressure high Prominent carotids, palpable aorta in suprasternal notch Palpable collaterals\ Ejection murmur in inter-scapular region

53. Treatment for obstructive lesions AS/PS- early Balloon/surgical valvuloplasty Coarctation- Ballooning/surgery

54. Cyanotic heart disease Cyanotic Decrease PBF TOF Pulm Atresia Increase PBF TGA TAPVC Truncus arteriosus

55. Cyanotic chd

56. TOF

57. Presentation Cyanosis Slow weight gain Tet spell Complications- stroke, abscess Mild left parasternal impulse, thrill uncommon, S2 single, ejection murmur ends before S2 ECG: RAD, RVH CXR- no cardiomegaly, Ischemic lungs

58. When to operate? HYPERCYANOTIC SPELL-EVEN ONE IS ENOUGH TO INDICATE SURGERY Favourable anatomy, SpO2> 75%, no tet spell- complete repair at 6-9 months of age Before 6 months or unfavourable anatomy- BT shunt/ PDA stent

59. Mixing lesions TGA

60. Balloon septostomy

61. PDA stenting

62. TGA: when to operate: ALL TGA’s DIAGNOSED IN NEWBORN PERIOD: ARTERIAL SWITCH OPERATION IDEALLY IN SECOND WEEK CAN BE PERFORMED UPTO 4 WEEKS

63. Other lesions TAPVC and TRUNCUS ARTERIOSUS - as early as possible

64. Single ventricle PS or PA situation/TOF physiology Univentricular palliation BT shunt shunt Glenn shunt at 3 -6 months of age Fontan completion at 2-4 years of age Lifelong follow up Limited exercise capacity Surgery and anatomy related complications by age 35-40yrs Cardiac transplant

65. DIAGNOSING CARDIAC LESION IN THE CRITICALLY ILL NEWBORN

66. INDICATORS OF CARDIAC PROBLEM Primary Desaturation Shock Resp distress Secondary Murmur Cardiomegaly Abnormal peripheral pulse

67. Duct dependent lesion Pulmonary atreias /critical PS situation TOF PA PA IVS DORV PA TET AV canal Isolated critical PS TGA Cyanosed critically ill newborn - start prostin

68. Conclusion: How to reach a diagnosis? Suspect: Knowledge base is required Diagnostic modality: ECHOCARDIOGRAPHY High index of suspicion Shocky patient- Sepsis, sepsis, sepsis………keep CHD at back of mind When pulmonary think cardiac

69. Thank you