Download CARDIOVASCULAR CONFERENCE: Approach to a patient with

CARDIOVASCULAR CONFERENCE:
APPROACH TO A PATIENT WITH
CYANOTIC HEART DISEASE
General Data:
 Name: Baby Boy G
 Neonate
History of the Present
Illness
 Baby Boy Guadiz is born to 22-year old
primigravid 2nd year nursing student mother,
married to a 23-year old unemployed partner.
Initial pre-natal check up of the mother was
at 6 month at a local health center. CBC and
urinalysis results done revealed normal
results.
History of the Present
Illness
 UTZ done showed Single Live Intrauterine
pregnancy, cephalic, good cardiac and
somatic activity, 24-25 weeks AOG, to rule
out hypoplastic Right Ventricle. For further
evaluation, the mother consulted at our
institution and was advised fetal 2D echo.
History of the Present
Illness
 The fetal 2D echo revealed pertinent findings
of hypoplastic Left Ventricle, hypoplastiv
Mitral Valve, and a patent foramen ovale. At
26-27 weeks AOG, the mother had
trichomoniasis for which she was given
metronidazole tablet for 7 days. At 37-38
weeks, the mother developed UTI.
Cefuroxime 500mg BID was given for 7 days
that provided symptomatic relief.
History of the Present
Illness
 The mother denied any exposure to viral
exanthems and radiation. No illicit drugs and
abortifacients use. She is a non-smoker;
however, was a previous alcoholic beverage
drinker. Hep B screening was non-reactive
and OGCT was normal. No history of
hypertension, allergy, thyroid disease,
diabetes, asthma, or blood dyscrasia.
History of the Present
Illness
 Family history is negative for diabetes
mellitus, hypertension, and cardiovascular
disease. The mother came in our institution
for follow up but was 3cm dilatation, 70%
effacement intact BOW, there was
progression of labor alongside with
spontaneous rupture of BOW. Clear, non-foul
smelling amniotic fluid was observed. Repeat
fetal 2D echo was not done due to lack of
funds.
History of the Present
Illness
 Patient was born live, term, singleton, male,
delivered via normal spontaneous delivery,
BW 2.75 kg, BL 48 cm, AS 6 and 7, MT 38-39
weeks AOG, AGA.
Physical Examination on
Admission:
 HR 134, RR 58, T 37.2˚C
 BW 2.75 kg, BL 48 cm, HC 33 cm, CC 31 cm, AC 29




cm, AS 6 and 7, MT 38-39 weeks, AGA
Blue, pale; some flexion of extremities, good
respiratory effort, cyanotic
(-) Rash, (-) birth marks,
(+) Molding, (+) caput succedaneum (-)
cephalhematoma
(+) ROR OU, (-) eye discharge, normal set ears, () preauricular pits, patent nares, (-) Epstein’s
pearls
Physical Examination on
Admission:
 (-) Palpable neck masses, intact clavicle, no crepitations
 (-) Chest deformities, symmetrical chest expansion, (-)






retractions, clear and equal breath sounds
Adynamic precordium, regular heart rate and rhythm, S1
and S2 normal, (-) murmurs
Globular abdomen, (+) umbilical stump with 2 arteries and 1
vein, (-) organomegaly, (-) palpable masses
Grossly male, bilaterally descended testes, good rugae,
patent anus
Femoral pulses full and equal, (-) Barlow, (-) Ortolani
Straight spine, (-) sacral dimpling, (-) tuft of hair
(+) Moro, grasp, rooting, plantar, and sucking reflexes
APPROACH TO DIAGNOSIS OF A
PATIENT PRESENTING WITH
CYANOSIS AT BIRTH
Indicators that heart disease
may exist
 Cyanosis
 Cardiomegaly (Radiologic or Pericardial bulge)
 Pathologic heart murmur
 Tachypnea or overt respiratory distress
(dyspnea)
 Sweating especially during feeding
 Increased or decreased pulses
 Failure to thrive
Classification of
Congenital Heart Diseases
A) Acyanotic
B) Cyanotic
Major Considerations
 Is there a shunt (LR or RL)
 Is there obstruction to inflow or outflow
 Abnormal heart valves
 Abnormal connections of great vessels
 Combination
Subgroups of Acyanotic Diseases
 Shunt anomalies
 Valvular defects
 Obstructive lesions
 Inflow anomalies
 Primary myocardial diseases
Shunt Anomalies
 L  R shunt
 Increased pulmonary blood flow
 Increased pulmonary vascular arterial
markings on chest Xray
 ASD, VSD, PDA
Obstructive Lesion
 Discrepancy in amplitude of the peripheral
pulses
 Coarctation of the Aorta
Inflow Anomalies
 Increased pulmonary venous markings on
chest Xray
 No murmur
 Cor Triatriatum, Pulmonary vein stenosis
Valvular Defects
 Stenosis or regurgitant
 Characteristic murmur
 AS, AR, PS, PR, MS, MR, TS, TR
Primary Myocardial Diseases
 No murmur
 Disparity between cardiac size and
pulmonary vascular markings
 Glycogen storage disease
 Cardiomyopathy
Hemodynamic Consequences
A) Volume (Diastolic) overload
B) Pressure (Systolic) overload
ASD
Hemodynamic Consequence
Diastolic overload of RV
VSD
 Hemodynamic
Consequence
 MODERATE SIZE
 Volume overload of
LV
 LARGE SIZE
 Volume overload of
LV
 Pressure overload of
RV
Cyanotic Heart Disease
 Cyanotic heart disease exist when one defect
or association of defects allow the mixture of
saturated and de-saturated blood to reach
the systemic circulation
Do you suspect that patient is
Cyanotic?

When in doubt
A) Clubbing
B) CBC
C) Hyperoxia test
Hyperoxia Test
 Hyperoxia test is considered positive for
intracardiac shunting if PO2 < 150 mmHg
(torr) after 10 minutes of 100% fiO2
PVA / IVS
 Hemodynamic
Consequence
 Pressure overload
of RV
PVA / VSD
 Hemodynamic
Consequence
 Pressure overload
of RV
PDA Dependent Pulmonary
Circulation
 Pulmonary valve atresia (PVA) with intact
interventricular septum
 Other lesions with accompanying PVA
Approach to diagnosis
A) Chest Xray
Increased or decreased
pulmonary vascular
arterial markings
B) EKG
RVH, LVH, CVH
C) Character of second
S2 single, loud
S2 single, normal
Split S2
heart sound
CHEST X-RAY
Causes of Cyanosis
Noncardiac
Cardiac
•Pulmonary disorders (structural
abnormalities of the lung, ventilationperfusion mismatching, congenital or acquired
airway obstruction, pneumothorax,
hypoventilation)
•Abnormal forms of hemoglobin
(methemoglobin)
•Poor peripheral perfusion (sepsis,
hypoglycemia, dehydration, hypoadrenalism)
•primary or persistent pulmonary
hypertension
Increased pulmonary vascularity
•D-TGA
•TAPVR without obstruction
•PTA
•Single ventricle
•DORV w/o PS
•PPHN
Decreased pulmonary vascularity
•TOF
•Ebstein’s anomaly
•PS
•PA
•TA with PS
•DORV with PS
Pulmonary Vascular Markings
Decreased: Cyanotic
TOF
Tricuspid Atresia
Complex heart with PS
PVA / IVS
Second Heart Sound (S2)
Single Loud
Single Normal
Split S2
TGA
TOF
TAPVR without
obstruction
Aortic / Mitral
atresia
Tricuspid
atresia
Truncus
Arteriosus
PVA
Cardiac Work-Up
A) EKG
B) Chest Xray
C) 2D echocardiography
(TTE, TEE, ICE, IVUS)
D) Cardiac catheterization
E) CT angiography, cardiac MRI
 PLACE THE:
 ECG
 2-D ECHO
Modalities of Management
A) Pharmacologic
B) Catheter based therapy
C) Surgical
Pharmacologic
A) digoxin, diuretics, inotropes (pressor),
vasodilators
B) Prostaglandin
Catheter Based Therapy (DI KO
PA ALAM ITO, EXAMPLES LANG TO)
A) Balloon atrio septostomy (Rashkind)
B) Balloon valvuloplasty
C) Balloon angioplasty
D) Delivery of occlusion devices
E) Radio frequency ablation
Surgical (DI KO PA ALAM ITO,
EXAMPLES LANG TO)
A) Shunts like Modified Blalock-Taussig
B) PA band
C) Complete repair
D) Glenn, Fontan
E) Norwood
F) Jatene, Mustard, Senning