Sanjay Gandhi Postgraduate Institute of Medical Sciences

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Sanjay Gandhi Postgraduate Institute of Medical
Sciences
Lucknow
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Department of Cardiovascular Thoracic
SurgeryandTelemedicine network at SGPGIMS
Welcomes participants in this presentation
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"Birth defect of Heart, its Presentation and
Treatment"

• Nirmal Gupta
• Head
• Department of Cardiovascular and Thoracic Surgery
• SGPGIMS, Lucknow. U.P.

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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 GPs
  delayed diagnosis
• Poor socio-economic status of families delayed
  treatment

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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)

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SYMPTOMS

• "Birth defects of Heart, its Presentation and
  Treatment"

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• Neonatal History
• Cyanosis
• Failure to thrive
• Exercise intolerance
• Shortness of breath
• Syncope
• Palpitation
• Chest pain

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NEONATAL HISTORY

• Cyanosis, shortness of breath.
• Did the child need to stay in the hospital after
  maternal discharge?

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• Neonatal history
• Cyanosis
• Failure to thrive
• Exercise intolerance
• Shortness of breath
• Syncope
• Palpitation
• Chest pain

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CYANOSIS

• gt 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

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• Neonatal history
• Cyanosis
• Failure to thrive
• Exercise intolerance
• Shortness of breath
• Syncope
• Palpitation
• Chest pain

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FAILURE TO THRIVE

• Poor cardiac output and increased myocardial
  energy consumption coupled with poor feeding due
  to S.O.B.

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• Neonatal history
• Cyanosis
• Failure to thrive
• Shortness of breath
• Exercise intolerance
• Syncope
• Palpitation
• Chest pain

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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.

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• Neonatal history
• Cyanosis
• Failure to thrive
• Exercise intolerance
• Shortness of breath
• Syncope
• Palpitation
• Chest pain

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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

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• Neonatal history
• Cyanosis
• Failure to thrive
• Shortness of breath
• Exercise intolerance
• Syncope
• Palpitation
• Chest pain

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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.

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• Neonatal history
• Cyanosis
• Failure to thrive
• Exercise intolerance
• Shortness of breath
• Syncope
• Palpitation
• Chest pain

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PALPITATION

• Pathophysiology
• Irregular rhythm
• Tachycardia
• Awareness of normal rate and rhythm.

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• Neonatal history
• Cyanosis
• Failure to thrive
• Exercise intolerance
• Shortness of breath
• Syncope
• Palpitation
• Chest pain

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CHEST PAIN

• Rarely cardiac in origin.
• Look for extra cardiac causes
• Skin,
• Musculoskeletal,
• Costochondral joints,
• Pleural membranes,
• Pericardium,
• Referred pain

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SIGNS

• "Birth defects of Heart, its Presentation and
  Treatment"

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SIGNS

• Inspection
• Palpation
• Auscultation

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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

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SIGNS

• Inspection
• Palpation
• Auscultation

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PALPATION

• Peripheral perfusion, normal 1-2 seconds.
• Reflection of cardiac output.
• FABA,
• Normal full
• Diastolic runoff bounding
• Poor stroke volume thready

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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.

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SIGNS

• Inspection
• Palpation
• Auscultation

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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

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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

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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

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Congenital Heart Diseases and their Treatment

• "Birth defects of Heart, its presentation and
  treatment"

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Normal heart and its ECHO
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Atrial Septal Defect ASD
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Coarctation of aorta
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Ventricular Septal Defect VSD
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Patent Ductus Arteriosus PDA
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Pulmonary Stenosis PS
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Aortic Stenosis AS
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Atrio-Ventricular Canal A-V Canal Defect
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Tetralogy of Fallot TOF
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Transposition of Great Arteries TGA
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Transposition of Great Arteries D-TGA
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Truncus arteriosus Truncus
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Tricuspid Atresia TA
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Pulmonary Atresia PA
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Total Anomalous Pulmonary Venous Drainage TAPVD
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Hypoplastic Left Heart Syndrome HLHS
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Ebsteins Malformation Ebsteins
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General guidelines

• At birth
• Blueness at birth or immediately after
• Murmur of the heart
• Rapid breathing
• Low blood pressure

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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

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General guidelines

• In first 3 years of life
• Fainting spells
• Abnormal heart beats
• Child avoids rigorous activities
• Unable to play with his mates

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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

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In the end

• There are a million times more patients in India
  with congenital heart diseases than polio, but
  the governments budget for the treatment of
  congenital heart diseases is miniscule in
  comparison

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• .so the gap is of more than billions magnitude

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Thanks for your attention friends
Can I have your questions, please.