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BLUE BABIES BLUE BABIES AND PINK KIDSAND PINK KIDS
Dr Ravi NarayanDr Ravi NarayanSenior Consultant Ped.Cardiologist,& Senior Consultant Ped.Cardiologist,&
Assoc. Prof. CardiologyAssoc. Prof. CardiologyRAMAIAH NARAYANA HRUDAYALAYARAMAIAH NARAYANA HRUDAYALAYA
OVERVIEW OF MANAGEMENT IN OVERVIEW OF MANAGEMENT IN COMMON CHDCOMMON CHD
IntroductionIntroduction
CongenitalCongenital—means from birth—means from birth
Congenital heart defects (CHD) can Congenital heart defects (CHD) can vary from vary from small holessmall holes in the heart to in the heart to very very serious malformationsserious malformations
Some defects can manifest in Some defects can manifest in teenage or adults (GUCH)teenage or adults (GUCH)
Cyanosis)—Cyanosis)—note the nails are very blue note the nails are very blue because of deoxygenated blood entering the because of deoxygenated blood entering the
aortaaorta
Pink Kid!!!!Pink Kid!!!!IS HIS MURMUR INNOCENT???IS HIS MURMUR INNOCENT???
CLASSIFICATIONCLASSIFICATION
• ACYANOTIC//CYANOTIC• SHUNT LESIONS• ASD,VSD,PDA• STENOSIS-- AS, PS, • Narrowing of a pipe -- COA of aorta• Weak heart muscle Cardiomyopathy
CYANOTICCYANOTIC
• TOF,TGA, TAPVC, • Truncus,Tricuspid Atresia• E’S –EBSTEIN EISENMENGER• SINGLE ATRIUM
• SINGLE VENTRICLE
How big is the How big is the problem problem ???? CHD—1/1000 live birthsCHD—1/1000 live births India---180,000 babies/year India---180,000 babies/year KARNATAKA STATE—5-8,000KARNATAKA STATE—5-8,000 Estimated Estimated 5,000/year will have 5,000/year will have
shunt lesions(“Holes in heart”)shunt lesions(“Holes in heart”) Easy to diagnoseEasy to diagnose Reasonably easy to treat unlike Reasonably easy to treat unlike
complex heart diseasecomplex heart disease
HISTORY AND EXAMHISTORY AND EXAM CYANOSIS PRESENT OR NOTCYANOSIS PRESENT OR NOT DYSPNOEA//TACHPNEADYSPNOEA//TACHPNEA FAILURE TO THRIVEFAILURE TO THRIVE MURMUR, CREPS++MURMUR, CREPS++ CCFCCF CHEST XRAYCHEST XRAY
WHAT IS ECHO??WHAT IS ECHO??
ULTRASOUND OF ULTRASOUND OF HEART.HEART.
M MODE, 2D, M MODE, 2D, DOPPLER AND DOPPLER AND COLOUR COLOUR DOPPLERDOPPLER
3 D3 D TEETEE
EchocardiographyEchocardiography Second
Stethoscope * * Exquisite anatomy Exquisite anatomy
even in neonates even in neonates •••Structure and •••Structure and functionfunction
More than 95% of More than 95% of cases can be sent for cases can be sent for surgery without cath.surgery without cath.
MANAGEMENTMANAGEMENT
• MEDICAL• INTERVENTION• SURGERY
ASD--- left to right shuntASD--- left to right shunt
ASD
•TYPES•Secundum•Primum•Sinus venosus
•SIZE•PAH
ASD –ManagementASD –Management
• >> 10mm• Volume overload• 3-5 years—Device//surgery• 12-15 kg• Moderate ASD or large with good
rims >> Device
ASD—SPECIAL ASD—SPECIAL CIRCUMSTANCESCIRCUMSTANCES
SPECIAL CIRCUMSTANCES•SYMPTOMATIC IN INFANCY•PFO AND STROKE•AGE MORE THAN 50 YEARS
Pinhole surgery—another term for Pinhole surgery—another term for cardiac interventionscardiac interventions
• Key hole—laparoscopic surgery• Pin hole surgery--- like doing
angioplasty AND STENT in adults• Small tubes called catheters are passed
through the leg veins• A Device is then put into the catheter and
released in the heart to block the hole(ASD,VSD,PDA)
ASD Device PDA Device
© 2012 Vascular Innovations 22
ASD DEVICEASD DEVICE
Clockwise from above: Transcatheter delivery of Amplatzer device, which is positioned across the atrial septal defect
Left: Amplatzer device in place
ASD CASEASD CASE 10 YEAR OLD BOY10 YEAR OLD BOY 16 MM SECUNDUM ASD16 MM SECUNDUM ASD ALL RIMS (EXCEPT AORTIC RIM ) ALL RIMS (EXCEPT AORTIC RIM )
MORE THAN 5 MMMORE THAN 5 MM POST. AND INF RIMS SLIGHTLY POST. AND INF RIMS SLIGHTLY
FLOPPYFLOPPY
PLAN– 20 MM ASD DEVICEPLAN– 20 MM ASD DEVICE
ASD Device closureASD Device closure
Fluoroscopy showing ASD Fluoroscopy showing ASD devicedevice
Atrial Septal Defect
Patch Repair
VSDVSD
Large VSD
VSD --Doppler
VSD—ManagementVSD—Management
• Small to moderate VSD and no PAH• Wait upto 5-6 years• Moderate VSD, Mod PAH• Operate 1-2 years of age• Large VSD, severe PAH, preferably
4-5 kg. weight
VSD deviceVSD device
Ventricular Septal Defect RepairVentricular Septal Defect Repair
Patent Ductus Patent Ductus Arteriosus (PDA)Arteriosus (PDA) PDA(connection PDA(connection
between the 2 great between the 2 great arteries—aorta and arteries—aorta and pulmonary artery)pulmonary artery)
PDA -- ManagementPDA -- Management
• PDA preterm,Indomethacin//Ibugesic• Term neonate • Large << 5 Kg -- surgery,• >> 5 Kg -- device• Small and moderate –1-2 years,• Device// coil
COILING OF PDACOILING OF PDA
Left, top: Catheter crosses the PDA from the aortic side and delivers a coil.Left, bottom: Withdrawal of catheter, leaving coil in PDA
Amplatzer Ductal OccludersAmplatzer Ductal Occluders
Amplatzer ductal occluderIllustration courtesy AGA Medical Group
Aorta angiogram with device occlusion of PDA, lateral view
Note—dumbell device closing Note—dumbell device closing the PDAthe PDA
Cable has been detached—Cable has been detached—device in good positiondevice in good position
Hypertensive PDA – Closed with 16/18 Device
49© 2012 Vascular Innovations
50© 2012 Vascular Innovations
PS (pulmonary stenosis—narrowing of PS (pulmonary stenosis—narrowing of pulmonary valve)pulmonary valve)
ValvuloplastyPulmonary Balloon Valvuloplasty
Lateral angiograms
Aortic stenosis(AS– narrowing of aortic Aortic stenosis(AS– narrowing of aortic valve)valve)
Coarctation(narrowing of aorta)Coarctation(narrowing of aorta)
AngioplastyAortic Coarctation Angioplasty
Angiograms showing (left) post-surgical coarctation of the aorta and (right) angioplasty balloon inflated across coarctation site
Intravascular StentsCoarctation of the Aorta
Left: uninflated angioplasty balloon and stent within coarctation Middle: expansion of balloon and stent
Right: deflation of balloon leaving stent wide open
Advantages of InterventionsAdvantages of Interventions
• Short hospital stay• Child can start walking sam day or the
next day• Almost 95-99% success can be achieved
by interventions
Cardiac Surgery
Breakthroughs in Cardiac Breakthroughs in Cardiac SurgerySurgery
• Heart lung machine
• Cardioplegia
• Deep Hypothermia
• Circulatory arrest
Tetralogy of FallotTetralogy of Fallot
1 – ventricular septal defect (VSD), 2 –pulmonary stenosis2a – infundibular stenosis, 3 – enlarged aorta overriding
VSD4 – right ventricular hypertrophy
Tetralogy of Fallot Repair
(Above) With Transannular Patch
(Right) With Pulmonary annulus retained
In the “pink of health”In the “pink of health”
TGA “Switch operation”TGA “Switch operation”
How do we reach the How do we reach the common man?common man?
Take Diagnosis to the door stepTake Diagnosis to the door stepMobile Cardiac ClinicMobile Cardiac Clinic
INFECTIVE ENDOCARDITIS INFECTIVE ENDOCARDITIS PROPHYLAXISPROPHYLAXIS
• REQUIRED• CHD---VSD/PDA• VALVE—BICUSPID AV AND AS• RHD—MR• OPERATED AND DEVICE CLOSURE OF
ASD AND PDA ,• FIRST 6 MTHS• PROSTHETIC VALVE
IE PROPHYLAXIS NOT REQDIE PROPHYLAXIS NOT REQD
• ASD/ PS• MVP WITH NO MR• POST CABG OR STENTING• PACEMAKER
REGIMEREGIME
• AMPICILLIN OR AMOXYCILLIN• WITH OR WITHOUT GENTA• CEFATOXIME• 1 HR BEFOR PROCEDURE• 2 DOSES AFTER PROCEDURE
CONCLUSIONS•Early diagnosis•Intervention//surgery•Hybrid//minimally invasive
Team Effort
A parent’s dream---A parent’s dream---
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