Transcript 'Birth defect of Heart, its presentation and treatment'

Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow
Department of Cardiovascular & Thoracic Surgery
and
Telemedicine network at SGPGIMS
Welcomes participants in this presentation
"Birth defect of Heart, its
Presentation and Treatment"
Nirmal Gupta
Head
Department of Cardiovascular and Thoracic Surgery
SGPGIMS, Lucknow. U.P.
Magnitude: Birth defects of Heart in India
 Every year 2 lakh children are born with
congenital heart defects
 At least 60,000 of these need treatment in the
1st year of life
 Only 5000 get treatment because of lack of
awareness amongst public in general and
GP’s: delayed diagnosis
 Poor socio-economic status of families:
delayed treatment
Current facilities
 Requires highly trained and dedicated team
of diagnostic facilities, Surgeons and Nurses
 Poor availability of facilities even in best
hospitals
 Not a financially viable option for private
setups
 Lack of trained manpower in the country (only
5 dedicated units other than SGPGIMS)
SYMPTOMS
"Birth defects of Heart, its Presentation
and Treatment"
 Neonatal History
 Cyanosis
 Failure to thrive
 Exercise intolerance
 Shortness of breath
 Syncope
 Palpitation
 Chest pain
NEONATAL HISTORY
 Cyanosis, shortness of breath.
 Did the child need to stay in the hospital after
maternal discharge?
 Neonatal history
 Cyanosis
 Failure to thrive
 Exercise intolerance
 Shortness of breath
 Syncope
 Palpitation
 Chest pain
CYANOSIS
 > 5g/dl of deoxygenated Hb
 False positive........... polycythemia
 False negative...........anemia
 Pathophysiology leading to cyanosis:
 Obstruction of systemic venous blood flow to
the lungs
 Shunting of deoxygenated blood to left heart
 Desaturation of systemic arterial blood
 Neonatal history
 Cyanosis
 Failure to thrive
 Exercise intolerance
 Shortness of breath
 Syncope
 Palpitation
 Chest pain
FAILURE TO THRIVE
 Poor cardiac output and increased
myocardial energy consumption coupled with
poor feeding due to S.O.B.
 Neonatal history
 Cyanosis
 Failure to thrive
 Shortness of breath
 Exercise intolerance
 Syncope
 Palpitation
 Chest pain
EXERCISE INTOLERANCE
 Baby................ poor ability to suck and feed
 Child.................sedentary
 Pathophysiology leading to exercise
intolerance:
 Poor cardiac output.
 Increased energy consumption by an
overworked heart.
 Neonatal history
 Cyanosis
 Failure to thrive
 Exercise intolerance
 Shortness of breath
 Syncope
 Palpitation
 Chest pain
SHORTNESS OF BREATH
 Some children may be short of breath without
appearing in distress "Happily tachypnoec"
 Pathophysiology of S.O.B.:
 Increase pulmonary blood flow
 Interstitial edema
 Decreased oxygen diffusion
 Hypoxemia
 Neonatal history
 Cyanosis
 Failure to thrive
 Shortness of breath
 Exercise intolerance
 Syncope
 Palpitation
 Chest pain
SYNCOPE
 Pathophysiology:
 Inability to increase cardiac output suddenly
due to restricted left ventricular outflow, e.g.
severe aortic stenosis, IHSS.
 Abnormal vasomotor tone resulting in
vasodilatation when vasoconstriction is
needed to maintain adequate blood pressure.
 Neonatal history
 Cyanosis
 Failure to thrive
 Exercise intolerance
 Shortness of breath
 Syncope
 Palpitation
 Chest pain
PALPITATION
 Pathophysiology:
 Irregular rhythm
 Tachycardia
 Awareness of normal rate and rhythm.
 Neonatal history
 Cyanosis
 Failure to thrive
 Exercise intolerance
 Shortness of breath
 Syncope
 Palpitation
 Chest pain
CHEST PAIN
 Rarely cardiac in origin.
 Look for extra cardiac causes:
 Skin,
 Musculoskeletal,
 Costochondral joints,
 Pleural membranes,
 Pericardium,
 Referred pain
SIGNS
"Birth defects of Heart, its Presentation
and Treatment"
SIGNS
 Inspection
 Palpation
 Auscultation
INSPECTION
 Does the child appear ill?
 Decreased tissue oxygenation due to poor cardiac






output or severe cyanosis
Respiratory distress due to pulmonary edema or
hypoxemia.
Cyanosis
Edema
Distended neck veins due to increased right heart
pressure leading to systemic venous congestion
Clubbing of digits
Chronic peripheral tissue hypoxemia
SIGNS
 Inspection
 Palpation
 Auscultation
PALPATION
 Peripheral perfusion, normal 1-2 seconds.
 Reflection of cardiac output.
 FA=BA,
 Normal = full
 Diastolic runoff = bounding
 Poor stroke volume = thready
PALPATION ( Contd.)
 Precordium
 Increased cardiac output, ventricular
hypertrophy = hyperactive
 Highly turbulent blood flow = thrill
 Indicators of ventricular hypertrophy or
atrophy = RV, LV impulses
 Aortic stenosis, turbulent blood flow in
ascending aorta = Suprasternal notch: thrill?
 Hepatomegaly, check below right and left
costal margins.
SIGNS
 Inspection
 Palpation
 Auscultation
AUSCULTATION
 LUNGS
 Pulmonary edema = rales, crackles
 HEART
 First heart sound (S1):
 Closure of atrio-ventricular valves.
 Second heart sound (S2):
 A2: closure of aortic valve
 P2: closure of pulmonary valve
 Single S2 = absent pulmonary or aortic component or delayed
closure of A2 superimposing P2
 inaudible P2 in TGA
 Does the splitting of S2 vary with respiration?
 Added sounds:
 Gallop rhythm: S3, S4
AUSCULTATION (Contd.)
 Murmurs
 Grade: 1-6, one being the softest and six being the loudest.
 By definition grade four murmur is associated with a
palpable thrill.
 Systolic murmur:
 Holosystolic:
Shunting of blood between two structures , the pressure in one
structure is higher than the other throughout systole
 Harsh: VSD
 Soft: Atrio-ventricular valve regurgitation
 Ejection:
Increase in blood flow turbulence as systole progresses due to an
increasing amount of blood flow through a restricted orifice
 Aortic stenosis
 Pulmonary stenosis
 Small VSD
AUSCULTATION (Contd.)
 Mid-systolic:
Increase volume of blood flowing through normal valves
 ASD
 Anemia
 Diastolic murmur:
Early:
 Regurgitant blood flow from aorta or pulmonary artery into the ventricles
 Aortic insufficiency
 Pulmonary insufficiency
Late:
 Austin Flint murmur
 Aortic regurgitation blood flow causes vibration of left ventricular free wall

Systolic and diastolic murmur:
Pressure difference between two structures during systole and diastole.
 PDA & Shunts and collaterals
Congenital Heart Diseases
and their Treatment
"Birth defects of Heart, its presentation
and treatment"
Normal heart and its ECHO
Atrial Septal Defect: ASD
Coarctation of aorta
Ventricular Septal Defect: VSD
Patent Ductus Arteriosus: PDA
Pulmonary Stenosis: PS
Aortic Stenosis: AS
Atrio-Ventricular Canal: A-V Canal Defect
Tetralogy of Fallot: TOF
Transposition of Great Arteries: TGA
Transposition of Great Arteries: D-TGA
Truncus arteriosus: Truncus
Tricuspid Atresia: TA
Pulmonary Atresia: PA
Total Anomalous Pulmonary Venous Drainage: TAPVD
Hypoplastic Left Heart Syndrome: HLHS
Ebstein’s Malformation: Ebstein’s
General guidelines:
 At birth
 Blueness at birth or immediately after
 Murmur of the heart
 Rapid breathing
 Low blood pressure
General guidelines:
 At 2 – 6 months
 Difficulty in feeding- baby is unable to suck
properly, sweats or starts rapid breathing while
feeding
 Blue nails and toes and fainting spells
 Inadequate weight gain
 Recurrent chest infections
General guidelines:
 In first 3 years of life
 Fainting spells
 Abnormal heart beats
 Child avoids rigorous activities
 Unable to play with his mates
General guidelines for couples
 Drugs to avoid during pregnancy
 Strict “NO” to Isoretinoin, Thalidomide,
Estrogens, Oral contraceptives, ACE
inhibitors, Chloramphenicol, Chlorpropamide,
Erythromycin, Tetracycline and Haloperidol.
 Anti-cancer drugs and Phenytoin are harmful
but benefits outweigh the side effects.
 Epinephrine, Ephedrine, B-blockers and
Promethazine do not pose any significant risk,
though the research is inadequate
In the end…
“There are a million times more patients in India
with congenital heart diseases than polio, but
the government’s budget for the treatment of
congenital heart diseases is miniscule in
comparison”
….so the gap is of
more than billions
magnitude
Thanks for your attention friends
Can I have your questions, please.