congenital heart disease

1. Approach to a patient with
congenital heart disease
Guide : Dr.Vijay G.Somannavar

2. Introduction
• Congenital heart diseases or Congenital
heart anomalies are defects in the
structure of the heart and great vessels
which are present at birth.
• CHD are the leading cause of birth defect-
related deaths.
D E F I N I T I O N

3. When to suspect CHD
•-Cyanosis
-Respiratory distress
-Poor peripheral perfusion
-Decreased pulsations
-Difference in pulses (arm
vs. leg)
-Single 2nd heart sound
-Abnormally loud 2nd heart
sound
-Prominent heart murmur
-Hyperactive precordium
F I N D I N G S T H A T S H O U L D A L E R T O N E T O T H E P O S S I B I L I T Y O F C H D

4. Incidence
• 1 in 10 stillborn infants have a cardiac anomalies.
• 8 out of 1000 live born children have significant cardiac
malformations.
• Every year 1,80,000 children are born with heart defects in India.

5. Lesions % of all Lesions
- Ventricular septal defect 25-30
- Atrial septal defect (Secundum) 10
- Patent ductus arteriosus 10
- Coarctation of aorta 7
- Tetralogy of Fallot 6
- Pulmonary Valve Stenosis 5-7
- Aortic Valve Stenosis 4-7
- Transposition of great arteries 4
- 0thers 20

6. Classification
CHD
Acyanotic Cyanotic
Left-to-right
shunts
Outflow
obstruction
- Ventricular Septal
Defect (VSD)
- Patent Ductus
Arteriosus (PDA)
- Atrial Septal Defect
(ASD
- Pulmonary
Stenosis
- Aortic Stenosis
-Coarctation of
aorta
• Teralogy of fallot
• Tricuspid atresia
• Transposition of
great vessels
• Truncus arteriosus
• Total anomalous
pulmonary venous
return (TAPVR)
• Ebstein’s anomaly

7. Etiology
Maternal
disorders
• Rubella infection
(30-35%)
• PDA, pulmonary
stenosis
• DM (2%)
Maternal drugs
• Fetal alcohol
syndrome (25%)
• ASD, VSD,
tetralogy of
Fallot
• Anti seizure drugs
• Thalidomide
• isotretinoin
Chromosomal
abnormality
• Down’s syndrome
(30%)
• Atrioventricular
septal defect, VSD
• Turner’s syndrome
(15%)
• Aortic valve stenosis,
coarctation of the aorta
• Edward’s and
Patau’s syndrome
(60-80%)

8. Left to right shunts
• L to R shunts are characterised by RV
enlargement and RV failure.
• Usually present with recurrent chest
infections.
• They are not typically cyanotic.

9. Ventricular Septal Defect (VSD)
• Most common congenital cardiac lesion.
• Accounts for 25% of all CHDs.
• Defect may be –
perimembranous(adjacent to tricuspid
valve) or muscular(surrounded by muscle)
• Spontaneous closure occurs by 10 years.

10. Peri membranous
Muscular

11. Clinical features
• Children with small defects will remain asymptomatic .
• Infants with moderate to large defects will become
symptomatic within the first few weeks of life.
.
S I G N S A N D S Y M P T O M S V A R Y W I T H T H E S I Z E O F T H E D E F E C T

12. Small VSDs
– Symptoms
• Asymptomatic
– Physical signs
• Thrills at lower sternal edge
• Loud pansystolic murmur at lower left sternal edge
• Quiet second heart sound (P2)

13. Large VSDs
– Symptoms
• Breathlessness and failure to thrive.
• Recurrent chest infections
– Physical signs
• Prominence of the left precordium
• Soft pansystolic murmur
• Mid-diastolic murmur at the apex
• Loud pulmonary second sound (P2)

14. Investigations
– Chest X-ray
• Cardiomegaly
• Enlarged pulmonary arteries
• Pulmonary vascular
markings
• Pulmonary oedema
– ECG
• Biventricular hypertrophy and
signs of pulmonary HTN 
right ventricular enlargement
and hypertrophy
– Echocardiography
• Demonstrates the anatomical
defect, haemodynamic
effects and severity of
pulmonary HTN.

15. Atrial Septal Defect(ASD)
• Seen in 10% of all CHDs
• Females > males.
• It is an abnormal opening between
the atria
• Spontaneous closure ocurrs with in
1st year of life.

16. Clinical features
Symptoms :
• Fatigue and SOB
• Palpitations
• Recurrent respiratory infections
Physical signs :
• Ejection Systolic murmur
• Diastolic murmur (large
shunts).
• Wide fixed split S2
• Tachypnea, tachycardia and
enlarged liver from heart failure
M O S T I N F A N T S A N D C H I L D R E N A R E A S Y M P T O M A T I C .

17. Diagnostic tests
- CXR – enlarged
heart,increased
pulmonary vascular
markings
- ECG- Ostium
secundum:Right axis
deviation with Right
bundle branch block.
- 2D echo – show pattern
of blood flow through the
septal opening

18. Patent Ductus Arteriousus
(PDA)
• PDA occurs in 6-11 % of all children with
CHD
• It is a connection between the aorta and
the pulmonary artery
• Most babies have a closed ductus
arteriosus by 72 hours after birth.

20. Clinical features
• Fatigue
• Sweating
• Tachypnea
• Shortness of breath
Physical examination
• Widened pulse pressure
• Collapsing/ bounding pulse
• Left infraclvicular/upper left sternal edge continuos machinery murmur
• Differential cyanosis (cyanosis of lower limb but upper limb pink)

21. Coarctation of aorta
• Accounts for 7 % of all CHD.
• is narrowing of the aorta at varying points
anywhere from the transverse arch to the
iliac bifurcation.
• 98% of coarctations are juxtaductal.

23. Clinical presentation
• In older children:
– Leg discomfort with
exercise
– Headache
– Epistaxis
• Systolic hypertension of
upper extremities.
• Ejection systolic murmur
at upper sternal edge
• Diminished lower
extremity pulses
– Radio-femoral delay:
• blood bypassing the
obstruction via collateral
vessels in the chest wall

24. Right to Left Shunts
• R  L shunts cause hypoxia and central
cyanosis.
• Blood is shunted from the R to the L side
of the heart w/o passing through the
lungs for oxygenation.
• Unoxygenated blood circulates in
arteries  cyanosis

25. Tetrology of fallot
Components
• Ventricular septal defect
• Pulmonary stenosis
• Overriding of aorta
• RVH
M O S T C O M M O N C Y A N O T I C H E A R T D I S E A S E

26. Clinical features
– Cyanosis
– Shortness of breath
– Rapid breathing
– Loss of consciousness
– Clubbing of fingers and toes
– Restless and agitated
– Poor weight gain
S Y M P T O M A T I C A N Y T I M E A F T E R B I R T H

28. Posture
– It is a compensatory
mechanism
– Squatting increases the
peripheral vascular
resistance, diminishes the
right-to-left shunt and
increases pulmonary
blood flow.
S I T T I N G P O S T U R E O R S Q U A T T I N G

29. • Chest X-ray
– Normal sized, boot
shaped heart
– Concavity of Left heart
border
– Oligaemic lung fields
• ECG
– At birth normal
– Older: Right axis
deviation and RVH
• Echocardiography
– Degree of stenosis
– Coronary anomalies(5%
in TOF)

30. Thank You