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CHD - ASD Robosa, Dino Rodas, Francis Rodriguez, Shereen Rogelio, Ma. Gracella Salazar, Riccel Salcedo, Von

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CHD - ASD. Robosa , Dino Rodas , Francis Rodriguez, Shereen Rogelio, Ma. Gracella Salazar, Riccel Salcedo , Von. 2. How do you explain the auscultatory findings?. Etiology: Congenital Heart Disease - PowerPoint PPT Presentation

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Page 1: CHD - ASD

CHD - ASDRobosa, Dino

Rodas, FrancisRodriguez, Shereen

Rogelio, Ma. GracellaSalazar, Riccel

Salcedo, Von

Page 2: CHD - ASD

2. How do you explain the auscultatory findings?

Page 3: CHD - ASD

Etiology: Congenital Heart Disease Anatomy: atrial septal defect, ostium

secundum, dilated right atrium, markedly dilated and hypertrophied right ventricle, dilated main pulmonary artery, anterior mitral valve prolapse

Physiology: NSR, incomplete right bundle branch block, diffuse ST-T changes, moderate pulmonary hypertension, increased right ventricular pressure and overload

Functional Capacity: Class II Objective Assessment: C

Page 4: CHD - ASD

What is your complete diagnosis?

Page 5: CHD - ASD

2. How do you explain the auscultatory findings?

Page 6: CHD - ASD
Page 7: CHD - ASD
Page 8: CHD - ASD

a. At the base, S1 is normal followed by a grade 3/6cresendo-decresendo murmur– Increased flow across the pulmonic valve is

responsible for a midsystolic pulmonary outflow murmur

– Grade 2–3 mid-systolic murmur at the mid to upper left sternal border with fixed splitting of S2• Ostium secundum ASDs are most common

Page 9: CHD - ASD

b. S2 is wide with fixed splitting

Page 10: CHD - ASD

• Wide splitting– The split becomes wider when there is delayed

activation of contraction or emptying of the right ventricle resulting in a delay in pulmonic closure

• Fixed splitting– This occurs with delayed closure of the pulmonic

valve when output of the right ventricle is greater than that of the left ventricle (such as occurs in large atrial septal defects, a ventricular septal defect with left to right shunting, or right ventricular failure)

Page 11: CHD - ASD

c. At the apex, multiple clicks are heard◦ Midsystolic clicks, occurring with or without a

late systolic murmur, often denote prolapse of one or both leaflets of the mitral valve

Results from the chordae tendineae that are functionally unequal in length

Best heard along the lower left sternal border and at the left ventricular apex

◦ Systolic clicks usually occur later than the systolic ejection sound.

Page 12: CHD - ASD

4a. What are the chest x-ray findings in a left to

right shunt?

Page 13: CHD - ASD

Acyanotic Includes:

◦ Ventral septal defect◦ Atrial septal defect◦ Patent ductus arteriosus

Left-to-right shunts

Page 14: CHD - ASD

Left-to-right shuntsLeft-to-Right Shunt

Chambers Enlarged

Prominent aortic knob

Dilated MPA Pulmonary Vascularity

Ventral Septal Defect

LA and LV

No Yes ↑

Atrial Septal Defect

RA and RV

No Yes (convex)

Patent Ductus

ArteriosusLA and

LVYes Yes ↑

Page 15: CHD - ASD

Left-to-Right Shunt

Chambers Enlarged

Prominent aortic knob

Dilated MPA Pulmonary Vascularity

Ventral Septal Defect

LA and LV

No Yes ↑

Atrial Septal Defect

RA and RV

No Yes (convex)

Patent Ductus

ArteriosusLA and

LVYes Yes ↑

Left-to-right shunts

Page 16: CHD - ASD

RV Enlargement◦ PA view: lateral upward displacement of the

cardiac apex◦ Lateral view: fullness of retrosternal space

RA Enlargement◦ PA view: increased convexity of the lower right

cardiac border

Page 17: CHD - ASD

Normal PA view PA view (ASD)

SVC

RV

IVC

Aortic knob

MPA

LV

Dilated MPA

Increased pulmonary vascularity

Page 18: CHD - ASD

Right ventricular enlargement

2/31/3

Retrosternal space

Normal Lateral view Lateral view (ASD)

Retrosternal space

Page 19: CHD - ASD

4a. What are the chest x-ray findings in a left to

right shunt?

Page 20: CHD - ASD

Acyanotic Includes:

◦ Ventral septal defect◦ Atrial septal defect◦ Patent ductus arteriosus

Left-to-right shunts

Page 21: CHD - ASD

Left-to-right shuntsLeft-to-Right Shunt

Chambers Enlarged

Prominent aortic knob

Dilated MPA Pulmonary Vascularity

Ventral Septal Defect

LA and LV

No Yes ↑

Atrial Septal Defect

RA and RV

No Yes (convex)

Patent Ductus

ArteriosusLA and

LVYes Yes ↑

Page 22: CHD - ASD

Left-to-Right Shunt

Chambers Enlarged

Prominent aortic knob

Dilated MPA Pulmonary Vascularity

Ventral Septal Defect

LA and LV

No Yes ↑

Atrial Septal Defect

RA and RV

No Yes (convex)

Patent Ductus

ArteriosusLA and

LVYes Yes ↑

Left-to-right shunts

Page 23: CHD - ASD

RV Enlargement◦ PA view: lateral upward displacement of the

cardiac apex◦ Lateral view: fullness of retrosternal space

RA Enlargement◦ PA view: increased convexity of the lower right

cardiac border

Page 24: CHD - ASD

Normal PA view PA view (ASD)

SVC

RV

IVC

Aortic knob

MPA

LV

Dilated MPA

Increased pulmonary vascularity

Page 25: CHD - ASD

Right ventricular enlargement

2/31/3

Retrosternal space

Normal Lateral view Lateral view (ASD)

Retrosternal space

Page 26: CHD - ASD

How do you manage this patient?

Page 27: CHD - ASD

should include treatment of possible complications:◦ Respiratory tract infections◦ Arrhythmias, atrial fibrillation, supraventricular

tachycardia◦ Pulmonary hypertension, coronary artery disease,

heart failure◦ Infective endocarditis

Medical management

Harrison’s Principles of Internal Medicine 17th ed.

Page 28: CHD - ASD

Operative repair – definitive management with a patch of pericardium OR prosthetic material OR percutaneous transcatheter device closure

should be advised for all patients with uncomplicated secundum atrial septal defects with significant left-to-right shunting

Surgical management

Harrison’s Principles of Internal Medicine 17th ed.

Page 29: CHD - ASD

The mere presence of an ASD may warrant intervention especially if there is a significant shunt (> 2:1)

symptomatic pulmonary hypertension is present [pulmonary artery pressure

(PAP) > 2/3 systemic arterial blood pressure (SABP) or pulmonary arteriolar resistance > 2/3 systemic arteriolar

resistance net left-to-right shunt (Qp:Qs) of at least 1.5:1• RA or RV enlargement – radiographic, cardiac catheterization or there is evidence of pulmonary artery reactivity when

challenged with a pulmonary vasodilator (e.g. oxygen, nitric oxide and/or prostaglandins)

or lung biopsy evidence shows that pulmonary arterial changes are potentially reversible

Indications

Schwartz ‘s Principles of Surgery, 9th ed.http://www.achd-library.com/index.html

Page 30: CHD - ASD

Device closure may now be offered as an alternative to surgical closure to patients with secundum ASD of up to 36-38 mm in diameter

Surgical closure may also be offered, and may be especially attractive should the patient prefer the surgical approach, or especially if atrial arrhythmia surgery (atrial maze procedure for atrial fibrillation and radiofrequency or cryoablation for atrial flutter) may be offered concurrently

http://www.achd-library.com/index.html

Page 31: CHD - ASD

The following ASD patients require periodic follow up by an ACHD cardiologist

• Those repaired as adults• Elevated pulmonary artery pressures at the time of repair• Atrial arrhythmias pre- or post-operatively• Ventricular dysfunction pre-operatively• Co-existing heart disease (e.g. coronary artery disease,

valvular heart disease, hypertension) • Those with device closure need follow-up in specialized

centers with serial ECGs and echocardiograms to determine the late outcomes of these new techniques

• Endocarditis prophylaxis and aspirin are recommended for 6 months following device closure

http://www.achd-library.com/index.html