CONGENITAL HEART DISEASE

Prepared By ,

Sonia Bhatia (F.Y. M.P.T)

Introduction
The primitive vascular tube apparent by the third week of fetal life. Over the next weeks it folds in on itself. By 12 weeks it has fully developed.

Classification:
Acyanotic congenital heart disease. Cyanotic congenital heart disease.

Acyanotic congenital heart diseases

Patent ductus arteriosus: This anomaly 5 to 10 percent of congenital heart disease.

Etiology :
A patent ductus arteriosus can be idiopathic. Some common contributing factors in humans include: Preterm Birth Congenital Rubella Syndrome Down Syndrome

Pathology:
As the higher pressure in the aorta then in the pulmonary artery Blood flow from aorta to pulmonary artery Pulmonary blood flow increase to the lungs, the pulmonary vessels dilated More blood to left side of heart Left ventricular hypertrophy

Signs and symptoms :

Tachycardia Shortness of breath Continuous machine-like murmur Enlarged heart Left subclavicular thrill Bounding pulse

Investigation:
Electrocardiogram show left ventricular hypertrophy. Cardiac catherisation Aortography

Operation:
Usually carried out in babies over 2-3 years of age.

Technique:
Operation performed through a left posterolateral thoracotomy through the 5th intercostals space. Lung retracted Mediastinal pleura incised over aortic arch So ductus arterious cleared Ligation of patent ductus with multiple non-absorbable ligatures Two transfixation ligatures one on either end of ductus and two in middle portion of the ductus. Temporary aortic shunt, usually left atriofemoral by pass used to temporary occlusion of aorta above or below the ductus.

COARCTATAION OF AORTA
5% common of congenital heart disease. Obstruction of the aorta in the region of the ductus arteriosus or ligamentum arteriosum just distal to the left subclavian artery.

There are three types:

Preductal coarctation:
The narrowing proximal to the ductus arteriosus.

Ductal coarctation:
The narrowing occurs at the insertion of the ductus arteriosus. This kind usually appears when the ductus arteriosus closes.

Postductal coarctation:
The narrowing is distal to the insertion of the ductus arteriosus.

Clinical features:
ypertension Hypotension

Investigation:
Chest radiographs Cardiac catheterisation Aortography

TREATMENT
Operative Technique: The coarctation of aorta is excised and end-end anastomosis of the aorta is performed usually with a graft. Left posterolateral thoracotomy through 4th intercostal space. Mediastinal pleura incised, after which vagus nerve is retracted medially. Aorta mobilized both above and below constriction take care not damage the intercostal vessels. Proximal and distal aorta occluded with vascular clamps.

Coarctation of aorta excised End to end anastomosis possible Continuous sutures with prolene After anastomosis, blood pressure measured proximal and distal to anastomosis Difference blood pressure more than 4 to 5 mm Hg Dacron patch inserted through short anterior arteriotomy Widen the lumen of the aorta Postoperatively antibiotics given for 3 to 4 days Patients are discharge in 7 to 10 days

ATRIAL SEPTAL DEFECT

This defects allows blood to flow from left to right atrium, so that right side of heart and lungs become overfilled, whereas left side heart receives less blood. Three types: 1. Fossa ovalis defect (Secundum defect): Commonest and lies in centre of the septum. Failure of development of septum secundum. Symptoms: Fatigue Palpitation Exertional dyspnoea Signs: Soft systolic murmur sound.

Treatment:
Incision:
Median sternotomy through 4th intercostal Space. Direct suturing and closure of defect by continuous suture with prolene. If direct suturing is not possible, prosthetic patch of knitted dacron may inserted with help of heart-lung machine.

Atrioventricular septal defect (ostium primum defect):

4 to 5% of patients with atrial septal defect, associated with incomplete formation of mitral and tricuspid valves.

Treatment:
Incision. Operative procedure: Operative is usually between 4 to 6 years of age. Operation performed with help of heart-lung machine. Initially cleft in mitral valve is closed with interrupted sutures placed from ventricular septum out to free margin of mitral orifice. After cleft repair, septal defect repaired with patch of pericardium inserted with interrupted sutures.

Anomalous drainage of pulmonary veins:

Right pulmonary veins usually enter the superior vena cava inferior to point of entry of azygos vein or enter into the right atrium or into inferior vena cava. Left pulmonary vein may also enter the superior vena cava.

Treatment:
Anomalous veins can be corrected by insertion of prosthetic patch Defect is closed Pulmonary veins are enter the left atrium

VENTRICULAR SEPTAL DEFECT

Common 20 to 30 % . Defect situated in muscular or membranous portions of the septum. Septum defect varies from 3 mm to more than 3 cm in size.

Clinical features:
Large septal defect-Dyspnoea on exertion Haemoptysis

Physical examination:
Loud pansystolic murmur in 3rd and 4th intercostal space. Thrill is palpable. Rales due to pulmonary congestion.

Treatment :
Operation : Technique:
Operation performed through a median sternotomy with help of extracorporeal circulation Longitudinal ventriculotomy performed usually in infundibular part of right Ventricle and near anterior descending coronary artery Defect usually closed with an oval patch of knitted dacron by mattress sutures posteriorly and continuous suture anteriorly

Pulmonary Stenosis:
In this incomplete obstruction to the flow from the right ventricle. Haemodynamics: Pulmonary circulation is decreased Work of right ventricle increased Right ventricular hypertrophy Diminished cardiac output Symptoms: Exertional dyspnoea Fatigue Systemic venous congestion Hypoxaemia Cardiac failure

Treatment :
Incision :
Median sternotomy

Open procedure:
Valve exposed via anterior aspect of pulmonary artery the commissures are cut. If annulus is constricted it is cut through vertically and dacron inserted. It may be necessary to replace the valve.

Aortic Stenosis :
Left ventricular outflow obstruction may be caused at three levels : Valvular Subvalvular Supravalvular The patients with valvular stenosis do not develop symptoms until the valve calcified around the age 40-50.

Haemodynamics:
The narrowed valve orifice subjects the left ventricle to a pressure overload. Left ventricle hypertrophy develops.

Symptoms :
Mild asymptomatic Severe Fatigue Syncope Dyspnoea

Treatment :
Incision : A median sternotomy. Open procedures : Valvular Stenosis : Valvotomy is performed by entering the ascending aorta and incising the commissures. Subvalvular Stenosis : It may approached through a low aortic incision and through valvular excision will be undertaken. Supravalvular Stenosis : Relieved by suturing an elliptical dacron into the vertical incision through the constricted portion of aorta.

Physiotherapy Treatment :
Pre-operative Treatment :
Infants with cardiac problem have pulmonary hypertension associated with excessive secretion leading to repeated chest infection. So chest physiotherapy important that the lung field are clear as possible prior to the surgery. Percussion Shaking and vibrations Postural drainage

Post-operative Treatment :
Chest PT will begin when patients condition stabilized. In some unit treatment will be on the day of operation , in others , day after. Depends on the type of operation the patient may or may not be ventilated. Patients should be assessed and physiotherapy given as necessary. Carefully watch the patient s vital signs at all times. Patient s have small amount of secretions easily removed by suction alone. Early mobilization is important to stimulate deep breathing and coughing. Nasopharyngeal suction may be used in infants and children.

References :
1.) Textbook of surgery by, S.Das , 5th Edition. 2.) Bailey & Love s Short practice of surgery , 22nd Edition. 3.) Davidson s Principles & practice of medicine , 20th Edition. 4.) Cash s Textbook of Chest , Heart and Vascular Disorders for Physiotherapists , 4th Edition.

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