Structures of the heart

Normal Heart

Atrial Septal defect

( ASD )
Insidence
: + 10 %
: ratio = 1,5 to 2 : 1
Anatomy :
Defect on foramen ovale : Secundum ASD
Defect at SVC and RA junction: sinus
venosus ASD
Defect at ostium primum : primum ASD

ASD

Atrial Septal Defect

Atrial Septal Defect

Diagram of ASD

Atrial septal defect

Lungs

LV

LA

AO

PA

RV

RA

Qp > Qs

Systemic

Atrial septal Defect

RA

RV

RA

LA

RV

LV

LA

LV

Atrial septal Defect

Clinical findings
Asymptomatic
Auscultation :
Normal 1st HS or loud Widely split and
fixed
2nd HS
Ejection systolic murmur

Atrial Septal Defect

Auscultation :1st HS N or loud

widely split and fixed 2nd HS
Ejection Sistolic Murmur

Atrial Septal Defect

ECG : IRBB , right ventricular hypertrophy

Atrial Septal Defect

Chest X-Ray

Right atrial enlargement

Prominence the MPA
segment
Increased pulmonary
vascular marking

Atrial Septal Defect

Diagnosis Differential
Primary Atrial Septal Defect
ECG : LAD
Partial Anomalous Pulmonary Vein
Drainage
Pulmonary Stenosis
Innocent Murmur

Atrial Septal defect

Management
Surgery : Preschool age
Recent treatment: transcatheter closure using
ASO (Amplatzer septal occluder)

ASD
Large Shunt

Small Shunt
Observation
Evaluation
At age 5-8 yrs
Cath
FR<1.5

Heart
Failure (-)

Children/Adults
PH (-)
Heart
Failure (+)
PVD
(-)
Anti failure

Success

FR>1.5

Conservative

Infants

Age >1yrs
W >10kg

PH (+)
PVD
(+)
Hyperoxia

Fail

Surgical
Closure

Reactive

Transcatheter closure (Secundum ASD) /

Surgical Closure(others)

Non
reactive

Conservative

Atrial septal defect

Atrial septal defect

ASD before occlusion

Atrial septal defect

During balloon
sizing

Atrial septal defect

ASD after occluded

using ASO

Ventricular septal defect

Insidence
20 % of all CHD
No sex influenced
Anatomy
Subarterial defect : below pulmonary and
aortic valve
Perimembranous defect: below aortic valve at pars
membranous septum
Muscular defect

VSD

Ventricular Septal Defect

Ventricular Septal defect

Lungs

LV

LA

AO

PA

RA

RV

Qp > Qs

Systemic

Ventricular septal defect

RA

RV

LA

LV

RA

LA

RV

LV

Ventricular Septal Defect

Ventricular Septal Defect

Clinical findings
Day 1st after birth: murmur (-)
After 2-6 weeks : murmur (+)
Murmur : pansystolic grade 3/6 or higher
at LSB 3
Small muscular defect: early systolic murmur
Significant defect: Mid diastolic murmur at apex

Ventricular Septal Defect

Murmur: pansystolic
grade 3/6 or higher at
LSB 3

Small VSD

Large VSD

Ventricular Septal Defect

Cardiomegaly
Apex down ward
Prominence pulmonary
artery segment
Increased pulmonary vascular
marking

Ventricular septal Defect

Diagnosis Differential

PDA with PH
Tetralogy Fallot non cyanotic
Inoscent murmur

Ventricular septal defect

Management:
Definitive : VSD closure
Surgery
Transcatheter closure

DSV
Heart failure (+)

Heart failure (-)

Anti failure
Aortic valve
prolaps
Fail

Infundibular
stenosis

PVD(-)

Success
PAB
Evaluate
in 6 mths

PH Spontaneous
closure

Cath

PVD(+)
Cath

Reactive

Smaller
Cath

FR<1.5 FR>1.5

Nonreactive
Conservative

Surgical closure/Transcatheter closure

Ventricular septal defect

VSD before occlusion

Ventricular septal defect

VSD during deploying

the device

Ventricular septal defect

VSD after occluded

using ASO

Patent Ductus Arteriosus

Insidence
+ 10%
Female : Male = 1.2 to 1.5 : 1
Premature and LBW higher

Anatomy
Fetus: ductus arteriosus connects PA and aorta.
If ductus does not closs Patent Ductus arteriosus

PDA

Patent Ductus Arteriosus

Lungs

LV

LA

AO

PA

RA

RV

Qp > Qs

Systemic

Patent Ductus Arteriosus

RA

RV

LA

LV

RA

LA

RV

LV

Patent Ductus Arteriosus

Clinical findings
Small defect:
Symptom (-)
Growth and development normal
Significant defect:
Decreased exercise tolerant
Weigh gained not good
Frequent URTI
Specific case: pulsus seler at 4th extremities

Patent Ductus Arteriosus

Diagnosis
Pulsus seler and continuous murmur heard

Patent Ductus Arteriosus

Chest X- Ray
Similar to VSD

Patent Ductus Arteriosus

Auscultation : continuosus murmur

at upper LSB 2

Patent Ductus Arteriosus

Diagnosis Differential
AP-window
Arterio-venous fistulae
Management
premature: indometasin
PDA closure : surgery
transcatheter closure

PDA
Neonates/Infants
Heart failure (+)

Heart failure (-)

Premature
Anti failure
Indometacin
Success

Children/Adults

Full term
Anti failure

Fail

Fail

Surgical
ligation

PH (+)
RL

LR

Hyperoxia
Success
Age >12wks
W >4kg

Spontaneous
closure

PH (-)

Reactive

Transcatheter closure

Non
reactive

Conservative

Patent Ductus Arteriosus

Patent Ductus Arteriosus

Patent Ductus Arteriosus

PDA before occluded

using ADO

Patent Ductus Arteriosus

PDA after occluded

using ADO

Patent Ductus Arteriosus

PDA before occluded

using coil

Patent Ductus Arteriosus

PDA after occluded

using coil

Pulmonary Stenosis
Incidence : 8-10%
Anatomy:
Pulmonary stenosis valvular :
Bicuspid pulmonary valve
Valve leaflet thickening and adhession
Pulmonary stenosis infundibular :
Hyperthropy infundibulum

Pulmonary Stenosis

Clinical findings
Valvular stenosis
Mild :
Ejection systolic
Wide 2nd HS
ejectiin click
Moderate: ejection systolic, early systolic click
Severe : ejecstion systolic, ejection click (-)
Stenosis infundibular
Ejection click ( - )
1st HS normal, 2nd HS weak, ejection systolic
Pulmonary stenosis periphery
1st & 2nd HS normal, ejection systolic

Pulmonary Stenosis

Mild

: ejection systolic
2nd HS wide split
ejection click
Moderate: ejecsi systolic , early ejection click
Severe : ejection systolic, click ejection (-)

Poulmonary Stenosis

Diagnosis
Asymptomatic patient:
click systolic (stenosis valvular)
systolic murmur
wide split 2nd HS vary with respiration

Poulmonary Stenosis

Normal or mild cardiomeg

Marked pulmonary valve
post stenotic dilatation
Normal pulmonary
vascularity

Pulmonary Stenosis

ECG : RAD
Echocardiograhhy : confirmation diagnosis
Catheterization: increased RV pressure
without increased oxygen saturation

Pulmonary Stenosis

Management
Medicamentosa : useless
Mild stenosis: intervention (-)
Moderate stenosis: observation
Severe stenosis: balloon valvuloplasty

Pulmonary Stenosis

Pulmonary Stenosis

Before ballooning

Pulmonary Stenosis

During ballooning

Pulmonary Stenosis

After ballooning

Coarctation Aorta
Incidence
In Western country 5 % of all CHD
In Asian Country incidence lower
underdiagnosis ?
Anatomy
Stenosis at any where in the aorta
(from aortic valve to abdominalis aorta)
More frequent at ductus arteriosus Botalli and
pulmonary artery junction

Coarctation Aorta

Coarctation Aorta

Clinical findings
Severe coarctation in neonates period can cause
heart failure in 1st weeks of life
Clinical manifestation in children:
arterial hypertension
commonly asymptomatic
Different pulses felt at upper and lower
extremities
Examination : increased left ventricular activity, thrill
systolic, 1st and 2nd HS normal, ejection systolic
murmur

Coarctation Aorta

Diagnosis
Clinically : lower extremities pulses are weak
CXR :
Mild cardiomegaly
Prominence of aortic knob
Normal pulmonary blood flow
ECG : normal or LVH
Echocardiography: a discrete shelf-like membrane
Cardiac catheterization and angiography: to confime
diagnosis

Coarctation Aorta

Management
Neonates :
PGE1 to maintain PDA
Diuretic
Correction acid-base imbalance
Prepared to undergo surgery
Big children:
Surgery should be done as soon as diagnosis
made
Balloon angioplasty

Coarctation Aorta

Coarctation Aorta

Coarctation Aorta

Coarctation Aorta

Before ballooning

Coarctation Aorta

During ballooning

Coarctation Aorta

After ballooning

Tetralogy Fallot
Insidence
5-8% from all CHD
Anatomy
Cause: Left-anterior deviation of infundibular septum
Sindroma consist of 4 items:
VSD
pulmonary stenosis
aortic over-riding
RVH

Tetralogy Fallot

Tetralogy Fallot

Hemodynamic acyanotic

Hemodynamic cyanotic

Tetralogy Fallot

Diagnosis
Clinically : cyanosis
Single 2nd HS, ejection systolic murmur

Tetralogy Fallot

Single 2nd HS, ejection systolic murmur

Tetralogi Fallot

Tetralogy Fallot

CXR :
Boot-shaped
Concave pulmonary
segment
Apex upturned
Decreased pulmonary
blood flow

Tetralogy Fallot

ECG : RAD
Echocardiography : to confirm diagnosis

Tetralogy Fallot

Diagnosis Differential
Pulmonary Atresia
Double outlet right ventricle and pulmonary stenosis
Transposisi of great arteri and pulmonary stenosis
Management
Paliative treatment: Blalock-Taussig shunt
Definitive: total correction

 clinically
ECG

Tetralogy of Fallot

< 1 yr

> 1 yr

spell (+)
propranolol

spell (-)
age 1 yr

failed

CXR
echo

succeed

cath

BTS
evaluation

cath

BTS/
PDA Stent

small PA

total correction

good sized PA

Tetralogy Fallot

Tetralogy Fallot

Transposition of Great
Artery
Insidence
5% of CHD
Anatomy
Abnormality of formation of trunkal septum that cause
aorta arising from RV and PA arising from LV

Transposition of Great artery

Transposition of Great artery

Hemodynamic normal
series

Hemodynamic of TGA
parallel

Transposition of Great artery

In adequate Mixing

TGA without VSD

Adequate Mixing

Transposition of Great artery

TGA with large VSD

TGA with VSD and PS

Transposition of Great artery

Clinical aspects

More frequent in male

Birth weight usually normal normal or bigger
Cyanotic vary from mild to severe
Auscultation : single 2nd HS and loud
Murmur vary from silent to pansystolic murmur or
continuous murmur

Transposition of Great artery

Diagnosis
Clinically :
Suspicious if neonates presents with cyanotic
with birth weight normal or bigger
Murmur (-)
Single 2nd HS and loud

Transposition of Great artery

Murmur (-)
Single 2nd HS and loud

Transposition of Great artery

CXR :
Cardiomegaly
Egg-on-side heart
Increased
pulmonary
vascular
marking

Transposition of Great artery

ECG :
RAD
RVH
Echocardiography : to confirm diagnosis
Cardiac catheterization: usually is not
needed

Transposition of Great artery

Diagnosis Differential
trunkus arteriosus
trikuspid atresia
pulmonary atresia
Management
Surgery: arterial switch
Paliative : Blalock-Taussig shunt

Transposition of Great Artery

PGE1

BAS/Blallock Hanlon

VSD(-)
1mth

VSD(+)
LVOTO(-)

> 1mth
Cath

LV2/3 syst

3 mths

LV<2/3 syst

Senning

LVOTO(+)

Un>3 mths Dynamic &

resectable resectable
Cath
BTS/
PARI<8 PARI8 PDA stent

PAB

Arterial Switch

Cath
Arterial Switch and
Perforated VSD

Rastelli

Transposition of Great artery

Truncus Arteriosus
Insidence
around 1 % of CHD
Anatomy
Failure of septation of truncus arteriosus form aorta and
pulmonary artery
There are 3 type:
Type 1 : MPA arises from the truncus and then divides into
the RPA and LPA
Tipe 2 : The PAs arise from the posterior aspect of the truncus
Tipe 3 : The PAs arise from the lateral aspects of the truncus
Tipe 4: Arteries arising from the descending aorta supply the
lungs

Truncus Arteriosus

Truncus Arteriosus

Truncus Arteriosus

Truncus Arteriosus
Diagnosis
Clinically suspected if:
neonates present with cyanotic and single 2nd HS
murmur vary
CXR:
cardiomegaly
increased pulmonary vascular marking
ECG: biventricular hypertrophy
Echocardiografhy: to confirm diagnosis
Catheterization: decreased oxygen saturation at right
heart and aorta

Truncus Arteriosus
Diagnosis Differential
Transposisi of great artery
Total anomalus pulmonary vein drainage
Management
Medicamentosa : temporary
Surgery: Rastelli
Palliative: pulmonary artery banding

Truncus Arteriosus

Tricuspid Atresia
Incidence
1 % from all CHD
Embriology
Valve formed at 5th weeks
Fussion of part of endocardial
cushion, ventricular septum and
miocardium

Tricuspid Atresia

Anatomy
Valve leaflet adhession one to another,
difficult to open
ASD essentially required to drain blood
from RA to LA
Classified into 2 group
Normal related great artery
Transposed grat artery

Tricuspid Atresia

Tricuspid Atresia with normal

related great artery

Tricuspid atresia with

transposed geat artery

Tricuspid Atresia

Manifestasi klinis
Cyanosis early after birth
Increased RV activity
Increased LV activity
Auscultation
Single 1st and 2 nd HS

Tricuspid Atresia

Clinical manifestation
In almost all patients murmur is silent
If murmur present
Diastolic murmur due to relative
MS
Pansystolic murmur due to VSD

Tricuspid Atresia

Tricuspid Atresia

Diagnosis and diagnosis differential

Clinically: Cyanosis with or without murmur

Tricuspid Atresia
CXR:
Heart minimally
Enlarged
The PVMs are
Decreased
The MPA segment is
concave

Tricuspid Atresia
ECG:
LAD
Left ventricular hypertrophy
With or without LAE

Tricuspid Atresia

Echocardiography: Essential to make

diagnosis
Catheterization
Catheter can not be passed from RA to RV
Increased RA and LA pressure
Decreased oxygen saturation in LA
Angiography: definitive diagnosis

Tricuspid Atresia

Diagnosis differential
Transposition of great artery
Truncus arteriosus
Tetralogy of Fallot
Total Anomalous pulmonary vein
drainage

Tricuspid Atresia

Management
Fontan operation

Tricuspid Atresia

Tricuspid Atresia

Tricuspid Atresia

Tricuspid Atresia

Tricuspid Atresia

Tricuspid Atresia

Modification of Fontan operation