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Overview of CongenitalOverview of CongenitalHeartHeart DiseasesDiseases
Dr. K. Vanderdonck
Charlotte Maxeke Johannesburg Academic Hospital
Universit of the !itwatersrand
"AHA #$%&'%#'&&
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Congenital Heart Disease (CHD) =
0.8% of all live births
12% of all infants with CHD have
chromosomal abnormalities
n c!rrent era" # 8$% of all chilren born withCHD sho!l reach a!lt life if treate
a&&ro&riatel' Correction re&air
ole of &alliation
nterventional cariolog'
Incidence
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n *+"
# 10 000 chilren born each 'ear with CHD
,0% of them are in nee of cariac s!rger'
CHD res&onsible for 1.2% of !ner $mortalit'
-nerestimate beca!se man' ie!niagnose
Incidence
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ormal l!ng mat!ration
/egins at en of ®nanc'
Contin!es for some time after birth
ormation of alveoli = a &ostnatal event
ith initiation of s&ontaneo!s ventilation
emoeling an mat!ration of &!lmonar'
vasc!lat!re
Dro& of + (&!lmonar' arter')&ress!re 3 4(&!lmonar' vasc!lar resistance)
rocess com&lete b' , months of age
Heart & Lungs
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Congenital heart efects have 5 ifferent effects on
the &!lmonar' circ!lation
ncrease &!lmonar' bloo flow
Decrease &!lmonar' bloo flow
ncrease &!lmonar' veno!s &ress!re
6ach t'&e &ro!ces a ifferent &attern of
im&aire growth an remoeling of the&!lmonar' vasc!lar be
Heart & Lungs
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ncrease &!lmonar' bloo flow (/)ormal remoeling of neonatal vasc!lat!re
oes not occ!r
7eas to &!lmonar' h'&ertension anincrease &!lmonar' vasc!lar resistance (4)
Develo&ment of &!lmonar' vasc!lar
obstr!ctive isease (4D)
4 initiall' reversible
-no&erate" 4 becomes irreversible
6isenmenger s'nrome
Heart & Lungs
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6isenmenger s'nrome9
*evere &!lmonar' vasc!lar obstr!ctive isease
which is irreversible
Have s!&ras'stemic + &ress!res an 4
with sh!nt reversal (t 7t sh!nt)
ncreasing c'anosis
Death
Heart & Lungs
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ncrease &!lmonar' bloo flow
Characteristic tria of s'm&toms
e&eate chest infectionsCongestive cariac fail!re
ail!re to thrive
resent in all &atients with increase /: ac'anotic an c'anotic
Heart & Lungs
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Decrease &!lmonar' bloo flow
+lveolar growth evelo&ment is im&aire
+ngiogenesis com&romise
+ll broncho;&!lmonar' segments &resent b!t
smaller
ncrease collateral &!lmonar' arterial bloo flow"
&rimaril' from bronchial arteriesC'anosis
Heart & Lungs
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Diagnosis
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6CH
ow the mainsta' of iagnosis
Done b' a &aeiatric cariologist
,,% rate of ma@or iagnostic errors when
&atient referre from a!lt 6cho lab
A66 gives aitional information abo!t
intracariac anatom' ntrao& A66
Diagnosis
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Cariac catheteriBation
*till stanar for9
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Diagnosis
Cariac CatheteriBation an +ngiogra&h'9
Ao efine anatom' es&eciall' in com&le lesions
Ao assess o&erabilit'
Ao assess + 4 an res&onse to o'gen on
&!lmonar' vasc!lat!re
4 # 8 oo !nits in 100% o'gen constit!tes a
contra;inication to s!rger'
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m&ortance of foetal echocariogra&h'an
&renatal iagnosis
Ao &re&are famil' for hos&ital amission
an &lan s!rgical intervention
Ao give the o&tion of terminating the
®nanc' if the &rognosis is &oor
Diagnosis
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Classification
Anomalies
Charateristic
s
Acanotic
&( )* "hunt+ncreased ,-.
/riad0
../
Chest infections
CC.
PDA
ASD
VSD
A-V Canal
#( Obstructive
1ormal ,-.
Often asmptomatic
Coarctation
Aortic stenosis
Pulmonary stenosis
Canotic
$( Decreased ,-.
Canosis
Child well2
asmptomatic
Tetralogy
Pulmonary atresia
Tricusp atresia a,b
TGV + PS
3( +ncreased ,-.
Canosis
/riad0.//Chest infections
CC.
Truncus
TAPVC
Tricuspid atresia c
TGV
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Treatment
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Ductus dependant lesions
rostaglanin 61 (+l&rostatil) o&ens an maintains&atenc' of the !ct!s arterios!s
or &!lmonar' bloo flow
!lmonar' atresia (4* : 4*D)
*evere tetralog'*ingle ventricle
or miing
A?4
or s'stemic bloo flowH7H* Critical +*
++ *evere coarctation
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Palliative Procedures
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Palliative Procedures
rovies s'm&tomatic relief (!s!all' tem&orar')b!t leaves the lesion !ncorrecte
+; sh!nts (arterial;&!lmonar' sh!nts)9
Designe to increase &!lmonar' bloo flow ina c'anotic chil with inaeE!ate &!lmonar'bloo flow
+trial se&tectom'
Designe to increase miing at atrial level!lmonar' arter' baning
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Palliative Procedures
*ight
-/
shunt
&433
)eft
-/
shunt
*ight
modified-/ shunt
&456 Central
"hunt
Aorto7pulmonar "hunts or Arterial "hunts
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!aterston shunt
&46#
,otts shunt &436
Palliative Procedures
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Palliative Procedures
,ulmonar Arter
-anding
+ ban9
Designe to limit/ in a chil
with ecessive&!lmonar' blooflow
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Closed Heart Surger
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remat!re infants9
*&ontaneo!s clos!re is common
Ar' nomethacine first if chil
s'm&tomatic*!rgical 7igation
Patent Ductus !rteriosus
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*!rgical Clos!re : 7igation or Division
*&ontaneo!s clos!re not common when
term infants is !n!s!al after the first few
months of life
f s'm&tomatic9 clos!re as soon as &ossible
*'m&toms = CC AA Chest
infections
Patent Ductus !rteriosus
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*!rgical Clos!re : 7igation or Division
f as'm&tomatic9 clos!re &lanne within
net 5 months
Ao &revent */6
f &resence of HA9 ma' have to be
catheteriBe
Patent Ductus !rteriosus
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PD! ligation " division
)eft thoracotom 3th+C"
)igation
Division
& #
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PD! transcat#eter closure
nterventional
Cariolog'9
m&lantation of
+m&latBer evice to
occl!e D+
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Coarctation
Coarctation of the +orta(Co+)
arrowing of the aortic l!menistal to the origin of the lefts!bclavian arter'
Have h'&ertension in the&roimal arterial tree (!&&erlimbs) an h'&otension anweaF &!lses in the lower limbs
n a!lthoo" !e to severe
s'stemic h'&ertension" will havecerebrovasc!lar accients
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+!lt t'&ecoarctation9
ftenas'm&tomatic
*!rger' inicateas soon as
iagnosis mae
Adult Coarctation or postductal
Coarctation
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eonatal coarctation9
Has a ifferent
&resentation9
Cariovasc!lar
colla&se
*evere metabolic
aciosis+t the time of !ctal
clos!re
+nfantile Coarctation orpreductal
Coarctation
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eonatal coarctation
revio!sl' associate with high mortalit'
-se of &rostaglanins has change o!tcome
*emi;!rgent s!rger' inicate once chil
res!scitate an stabilise
Coarctation
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*!rgical AechniE!es9
6n;to;en anastomosis
esection of coarctation an !ctal tiss!e
*!bclavian fla&
7eft s!bclavian arter' !se to &atch the
efect
atch angio&last'
Coarctation
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Surger Coarctation
*esection and end to endanastomosis
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Surger Coarctation
"ubclavian flap
,atch Angioplast
&
#
&
#
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nterventional Cariolog'9
/alloon ilatation an or stenting
6s&eciall' in rec!rrent Co+
*ometimes in native Co+
n oler &atients
f aortic arch is of aeE!ate siBe
Coarctation
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$pen Heart Surger& Cardiopulmonar %pass
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Cardiopulmonar %pass
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Cardiopulmonar %pass
Median sternotom
Arterial and venous
cannullas placed for
cardiopulmonar bpass
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!trial Septal Defect
+trial *e&tal Defect (+*D) Comm!nication between left
atri!m (7+) an right atri!m(+)
low is !s!all' from 7+ to +
res!lting in large &!lmonar'bloo flow
ften as'm&tomatic in chilhoob!t ma' have freE!entres&irator' infections
Can evelo& &!lmonar'h'&ertension in a!lthoo(!s!all' moerate)
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!trial Septal Defect
+natom'9 5 t'&es*ec!n!m = 80%*in!s 4enos!ssti!m rim!m
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Histor'
1stclos!re in 1G$2 (ohn 7ewis) !sing
h'&othermia inflow occl!sion
1stefect to be re&aire on C/ in 1G$5(ohn ?ibbon) !sing a &!m& o'genator
1stintracariac efect to be s!ccessf!ll' manage
with &erc!ataneo!s transcatheter techniE!es
!trial Septal Defect
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*!rger'
Done on C/
/' irect clos!re or &atch clos!re9
+!tologo!s &ericari!m
/ovine &ericari!m
nterventional Cariolog'
nl' +*D 2I" if small to moerate siBe" an
rim &resent
!trial Septal Defect
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Closure of !SD
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!trial Septal Defect
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4entric!lar *e&tal Defect +natom'9 , t'&es
Perimembranous(B)= 80%-nerneath antero;se&talcommiss!re of the tric!s&ivalve
Muscular (D)ften m!lti&le
Infundibular / Outlet (A)+ssociate aorticreg!rgitation
Inlet (C)solate or &art of +4 canal
Ventricular Septal Defect
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*mall 4*D
ormal + &ress!re normal 4
o s!rger' if &erimembrano!s or m!sc!lar
4*D : close s&ontaneo!sl'
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7arge 4*D
+ &ress!re = s'stemic &ress!re
*h!nt e&enent on egree of 4
Clos!re in infants9 f s'm&tomatic (CC AA Chest
infections)
f fail!re of meical treatmentf chil # 1 'ear9 nees cariac cath to
assess o&erabilit' (4 K 8 oo !nits + reactive to
2)
Ventricular Septal Defect
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+4 canal efects malaligne 4*DLs reE!ires!rgical clos!re (o not close s&ontaneo!sl')
Contra;inications to s!rger'9
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VSD Surger
&( *ight Atrium
opened
#( /ricuspid ;alve
retracted
$( ;"D exposed
3( Margins of ;"D
carefull assessed
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VSD Surger
,atch sutured in
place
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+trio;4entric!lar Canal +lso calle enocarial c!shion
efect
6ists as &artial or com&lete
+4 canal artial +4 canal9 &resenceof +*D 1I onl'
Com&lete +4 canal9&resence of +*D 1I an inlet4*D
arel' isolate inlet +4canal t'&e 4*D
!trioVentricular Canal
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+trio;4entric!lar Canal +lso have abnormal mitral an
tric!s&i valves an ma' havemitral anor tric!s&i
reg!rgitation Com&lete +4 canal !s!all' has
large 7t t sh!nt with severe&!lmonar' h'&ertension
reE!ent in DownLs s'nrome
!trioVentricular Canal
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!trioVentricular Canal
Com&lete +4 canal9
f &atient s'm&tomatic (CC AA Chest
infections)" s!rger' as soon as &ossible
f &atient as'm&tomatic96lective re&air one b' M months ol beca!se
of earl' evelo&mene of irreversible
&!lmonar' h'&ertension
f # M months ol" nee for cariac cath to
assess o&erabilit'
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*!rgical AechniE!e9
Com&lete correction = &roce!re of choice
Done on C/
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artial +4 canal or +*D 1I
7ess s'm&tomatic : re&air one later b!t
ieall' before 1 'ear
Done on C/
+lwa's &atch clos!re re&air left +4 valve
(mitral valve)
!trioVentricular Canal
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Partial !V Canal
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Complete !V canal
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'epair Complete !V canal&
#
Closure
+nlet ;"D Mitral
;alve*epair
$
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'epair Complete !V canal
/ricuspid
;alve
*epair
8
Closure
A"D &*A:
M; ); M,A
T+V Surger
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T+V Surger
Arterial "witch or Anatomical Correction
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Truncus !rteriosus
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Truncus !rteriosus
&( Closure ;"D
#( *astelli
procedure
$
3
8
Total !nomalous Pulmonar Venous
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Connection
Aotal +nomalo!s !lmonar' 4eno!sConnection (A+4C)
+ll &!lmonar' veins connect to a common
&!lmonar' veno!s chamber" which
em&ties into *4C or + or 4C
o &!lmonar' veins are connecte to 7+ /loo can onl' go into 7+ an 74 via
+*D
Com&lete miing of &!lmonar' an
s'stemic veno!s ret!rn with &ress!re an
vol!me overloa of the right heart
Corrective s!rger' is an emergenc'
Tpes of T!PVC
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Tpes of T!PVC
Total !nomalous Pulmonar Venous
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Connection
& #
$3
Interventional Cardiolog
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Interventional Cardiolog
Creation of +*D/alloon atrial se&tostom' (in A?4)
/lae atrial se&tostom'
/alloon valv!lo&last'Ao manage stenotic valves (+*;*;