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
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Transcript of Robosa, Dino Rodas, Francis Rodriguez, Shereen Rogelio, Ma. Gracella Salazar, Riccel Salcedo, Von.
CHD - ASDRobosa, Dino
Rodas, FrancisRodriguez, Shereen
Rogelio, Ma. GracellaSalazar, Riccel
Salcedo, Von
2. How do you explain the auscultatory findings?
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
What is your complete diagnosis?
2. How do you explain the auscultatory findings?
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
b. S2 is wide with fixed splitting
• 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)
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.
4a. What are the chest x-ray findings in a left to
right shunt?
Acyanotic Includes:
◦ Ventral septal defect◦ Atrial septal defect◦ Patent ductus arteriosus
Left-to-right shunts
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
Arteriosus
LA and LV
Yes Yes ↑
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
Arteriosus
LA and LV
Yes Yes ↑
Left-to-right shunts
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
Normal PA view PA view (ASD)
SVC
RV
IVC
Aortic knob
MPA
LV
Dilated MPA
Increased pulmonary vascularity
Right ventricular enlargement
2/31/3
Retrosternal space
Normal Lateral view Lateral view (ASD)
Retrosternal space
4a. What are the chest x-ray findings in a left to
right shunt?
Acyanotic Includes:
◦ Ventral septal defect◦ Atrial septal defect◦ Patent ductus arteriosus
Left-to-right shunts
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
Arteriosus
LA and LV
Yes Yes ↑
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
Arteriosus
LA and LV
Yes Yes ↑
Left-to-right shunts
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
Normal PA view PA view (ASD)
SVC
RV
IVC
Aortic knob
MPA
LV
Dilated MPA
Increased pulmonary vascularity
Right ventricular enlargement
2/31/3
Retrosternal space
Normal Lateral view Lateral view (ASD)
Retrosternal space
How do you manage this patient?
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.
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.
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
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
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
