Transcript ASD AND PS - Mike Poullis

ASD AND PS
PHYSIOLOGY
• ps reduces shunt
• shunt increases gradient on pulmonary
valve
Types of ASD according to
Edwards
• Secundum type-level of the fossa ovalis
• Sinus venosus type-associated with anomalous
return of right upper pulmonary vein
• Ostium primum ASD
• Raghib type-absent coronary sinus with Left SVC
connection to left atrium.
• Multiple coalescent defects-essentially forming
common atrium
Paradoxical embolism and Probe
patent ASD
ASD
Eisenmengers
ASD and VSD
Tests
• clinical
• Ecg p, pr, qrs
• cxr
Incidence, Age at Presentation, Clinical
• 10 percent CHD, 3:2 male:female
• Variable age, according to type. May be
asymptomatic into adulthood.
• Murmur on preschool physical exam.
• Cyanosis in the Raghib type.
• Adult with ASD and Rheumatic mitral valve
disease=Lutenbacher syndrome.
• Auscultation shows wide fixed splitting of the P2
sound with pulmonary flow murmur.
Radiology
• Prominent central PA's
• Peripheral pruning of vessels with pulmonary
hypertension
• Prominent RV outflow tract may encroach on the
retrosternal space
• Left atrium NOT enlarged because the LA can
decompress into RA via the defect.
• Angiography-presence of mixing at the atrial level
is inferred when an indistinct left atrial border is
observed on the levophase of a right ventricular
injection.
Other tests
• CT
– rt side heart
– pulmonary artery
– Contrast spiling into LA
• Rt heart cath sats pa pressure
• Lt heart cath indications for coronaries
Complications
• Eisenmenger
• Paradoxical embolism
Patent Foramen Ovale
• The defect in patent foramen ovale is not a result
of missing tissue; therefore, very specific
hemodynamics must be present (ie, right atrial
pressure exceeding left atrial pressure) for
shunting to occur.
• Patent foramen ovale is not associated with an
increased risk of endocarditis. Antibiotic
prophylaxis is not indicated.
CVA
• When patent foramen ovale & unexplained
neurologic event
Aspirin in low-risk patients or
combined with warfarin in high-risk.
• The recurrence rate of stroke or transient ischemic
attack has been reported to be as high as 3.4-3.9%
per year.
• In patients with atrial septal aneurysm and patent
foramen ovale, the risk of recurrent stroke within
2 years is ~9%,
How to calculate shunt
• How to do shunt calc
• Echo
• Pulmonary and Aortic valve areas and
flows
• (Pva * Pvf) /(Ava * Avf)
• Sats
• Shunt = (Smix-Sra)(Sart-Smix)
When to close ASD?
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Shunt >2:1
PA pressure
CVA/TIA
AF / arrthymias
Exercise tolerance
Occupation eg diver
When PV needs replacing
RV modelling
• In those with severe or long-standing valvular
obstruction, infundibular hypertrophy may cause
secondary obstruction when the pulmonary valve
is successfully dilated.
• This frequently regresses over time without
treatment.
• Some have advocated transient pharmacological
b-blockade, but there is insufficient information to
determine whether this is effective or necessary.
Doing the op
• Pledga, fibb for asd
• Beating heart for PV
Q’s
• Can do TV on beating heart why not ASD
• patch or not to patch ASD
• Why small aorta
• Why split sounds still present post op
Problems
• Low co post op
• Tamponade cxr echo clinical
• RCA air damage ecg echo
• Pulmonary hypertension take patch off