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Heart Diagrams by Dr. James L. Wilkinson MB. ChB.,FRCP, FRACP, FACC, FRCPCH. (Royal Childrens Hospital, Melbourne,
Australia)
(http://www.cc.umanitoba.ca/~soninr)
GENERAL PRINCIPLES
Pediatric Cardiology and Adult
Cardiology
Pediatric Cardiology :
1. Congenital Heart Disease (CHD)
Occurs since organogenesis
2. Acquired Heart Disease (AHD)
Disturbances occur after birth
INCIDENCE
CHD :
6-8/1000 live births
8 types of CHD (85%) :
VSD, ASD, PDA, PS, AS,
TF, TGA
AHD :
Neonatus : virus
5 - 15 yrs : RF
ETIOLOGY
CHD : 90% genetic environmental
factors
environment :
1st trimester pregnancy
organogenesis of the heart : radiation,
smoking, drugs (thalidomide), maternal
infection (rubella), mother age
high geografic location
(young/old),
AHD :
(less
O2), metabolic
disorders
(DM),
infection
(RF, diphtheriae)
Down syndrome (50% with CHD)
FETAL CIRCULATION
FETAL CIRCULATION
Signs :
Parallel systemic and pulmonary
circulations
Foramen ovale, ductus Botalli,
ductus venosus still open
RA : enlargement, cross circulation
Head, heart and upper extremities
are supplied by high O2 content
Cyanosis
Reduced Hb > 5 gr% (N=2,25
gr%)
2 types :
A. Central C :
arterial unsaturation
B. Peripheral C :
without arterial unsaturation
Distinction between A and B :
measurement of arterial O2
Central C :
Pulmonary C :
Lung disorders diffusion,
ventilation, perfusion
Cerebral C:
brain disorders center of
respiration
Cardial C:
R-L shunt
Hyperoxic (100% O2) test / Crying :
pulmonary C less / no C
intracardial C C still persist
Peripheral C
Heart Diseases in
Children
Classification
CHD
Cyanotic Type
Non cyanotic type
AHD
Rheumatic Heart Disease
Rheumatic Fever
Myocarditis
Endocarditis
Acyanotic Defect
PBF
Normal PBF
RVH
LVH or CVH
RVH
LVH
VSD
PDA
ECD
ASD
PAPVR
PVOD
AS or AR
COA
MR
PS
COA
MS
Cyanotic
PBF
LVH or CVH
Single Ventricel
TGA + VSD
PBF
RVH
TGA
HLHS
CVH
TGA + PS
LVH
AT
AP + Hypoplastic RV
RVH
TOF
PVOD
Etiology
Unknown
Mothers disease (TORCH)
Rubella
Medicine : fenitoin, Alcohol,
lithium
Radiation
Genetics (dominan
autosomal)
Diagnosis
Anamnesis and physical
examination
Simple investigation
Laboratory, ECG, X Ray
Echocardiography
Catheterization
Management
Spontaneous closure of ASD, 40% (4
years) or become small
ASD
VCS
VC I
RA
VP
LA
RV
LV
AP
AO
SIMPLE VSD
20 % of CHD, 25 % of VSD
Small 1-5 mm, Moderate 5-10
mm, RVH (-)
Asymptomatic : Rogers disease
,
Ausc ( murmur holosistolik)
MODERATE VSD
fatigue, intolerance activity,
dyspnea, recurrent respiratory
tract infection, CHF
Pansystolic (holosystolic) 3-4/6,
punctum maximum LSB 3-5, P2
intensity >
X-ray :
Increased PBF, LAH, LVH
ECG :
Small VSD
: normal
Catheterization : O2 in RV > RA
ECHO : 2D & Doppler: number, size,
location
Management :
Nonsurgical closure : Amplatzer septal
occluder
Surgical : infant with large VSD + CHF
Prognosis :
Perimembranous : surgical intervention
Muscular defect : spontaneous become
small/ prolaps aorta , Infundibulum Stenosis,
PH, CHF, Endocarditis
VSD
VCS
VC I
RA
VP
LA
RV
LV
AP
AO
Clinical
Manifestations :
Asymptomatic, recurrent
respiratory tract infection,
tachipneu
Continuous murmur at LSB2,
middiastolic murmur at apical
LVH, RVH
Echo : direction of
Management :
Surgical closure (ligation)
Nonsurgical closure : Amplatzer
Ductal Occluder
PDA
VCS
VC I
VP
RA
LA
RV
LV
AO
AP
DA
CoA
CONTINUED
CoA
CONTINUED
Hemodynamic :
Adequate O2 to distal of CoA :
(Adaptation mechanism)
Increased systolic pressure at
proximal of CoA
Increased diastolic pressure at
distal of CoA (arterioles
vasoconstriction)
Collateral circulation (a
subclavian, intercostal, etc)
POSTDUCTAL CoA
Clinical Manifestations
Pain of calves, headaches,
epistaxis
Hypertension (pathognomonic)
Brachial Femoral lag
Reduced / abcent lower
extremity pulses
POSTDUCTAL CoA
CONTINUED
X-ray :
Rib notching (collateral vessels)
E sign on barium meals
ECHO / Doppler :
Gradient and pattern of diastolic flow
Catheterization :
Confirmation of diagnosis
Management :
Surgery, balloon angioplasty
Clinical Manifestation :
Clubbing fingers, scoliosis,
squatting position
Ejection systolic murmur LSB3-4,
single HS 2nd
Lab : Hb, Ht, RBC levels increased
CONTINUED
X-Ray :
couer en sabot, RVH, PBF ,
concav pulmonary segment
Complication :
Cerebral Infarction (age < 2 yrs)
Cerebral Absces (age > 2 yrs)
Treatment :
Surgery : palliative / total
VCS
TOF
AO
VCS
VC I
RA
VP
AKA
LA
RV
LV
AP
AP AKI
AO
VKI
VKA
AO
AKa
VKA
AP
AKI
VKI
CONTINUED
DEXTROCARDIA
DEXTROCARDIA
CONTINUED
1. Visceroatrial relationship :
S (solitus), I (inversus) or A
(ambiguus)
2. Ventricular Loop : D (D-loop), L (Lloop) or
X (uncertain or undeterminate)
3. Great arteries (conotruncal) : S
DEXTROCARDIA
CONTINUED
DEXTROCARDIA
CONTINUED
Clinical Manifestations :
Loudest heart sound on the right
chest
IMID 50-80% without CHD
X-ray IMID: liver left, stomach
bubble- right
Echo : dextrocardia
Prognosis : depends on the lesions
Treatment : overcome the
associated lesions
ASD
VSD
PDA
SP
CoA
TF
TGA
DextrocardiaSolitus
DextrocardiaInversus
Dextrocardia