Download Case report for V. grade students Cardiology Dr. Kemény Viktória

CASE REPORT FOR V. GRADE
STUDENTS
Cardiology
Dr. Kemény Viktória
M.D. – 6 MONTH OLD BOY
Was born on 40th week of gestational age – pvn
 Normal pregnancy
 Normal delivery
 Normal perinatal period
 Birth Weight: 3700 gr

Taken home from the Hospital on the third day
 General practitioner checked him on the fifth day
of his life – healthy newborn
 Mother had enough breast milk, the baby was
eating well, his weight was increasing



3 weeks later mother was complaining about
feeding difficulties (!!!) – got a prescription for
formula (not enough BM?!)
On the 4th week : recheck at the GP
same weight as a week ago
 tachydyspnea
 hepatomegaly
 holosystolic heart murmur

CARDIOLOGICAL EXAMINATION

Status:
clinical signs of congestive heart failure (CHF)
(tachydsypnea, hepatomegaly)
 4/6 holosystolic heart murmur
 palpable femoral pulses

•
Echocardiography:
-
-
-
-
8mm communication between the two ventricules on the
membranous part of the intraventricular septum (flow
velocity of the left-right shunt: 4,5 m/s)
Normal atrial septum
Normal left ventricular function, but the aorta/left atrium
ratio was 12/17 mm!!!
Normal flow in aorta and pulmonary trunk
Competent AV- and semilunar valves
Echocardiography

Diagnosis
Membranous VSD
 Congestive heart failure

VSD is the most common congenital heart
disease and accounts for 15% to 20% of
all such defects!
VSD
The ventricular septum can be devided into a
small membranous portion and a large muscular
portion. The muscular septum has three
component: the inlet, the trabecular and the
outlet (infundubular or conal) septum.
 Prevalence:

Perimembranous defects: 70%
 Outlet (infundibular or conal) defects: 5-7 %
 Inlet (or AV canal) defects: 5-8 %
 Trabecular (muscular) defects: 5-20 %

QUESTIONS
 What
happened to our baby during the
first weeks?!
 Why
did not hear the doctors the heart
murmur on the first week?
 What
was the first sign of the heart
failure?
POSTNATAL CHANGES IN THE PULMONARY
VASCULAR RESISTANCE
CHANGES IN CIRCULATION AFTER BIRTH



The PVR is as high as the SVR near or at term
Lung exspansion results reduction of PVR,
increase in pulmonary blood flow and fall in PA
pressure
Even in the presence of large VSD in a newborn,
the PVR remains elevated, and therefore a large
shunt does not occur, until the infant reaches 6 to
8 weeks of age when the PVR decreases, the
shunt increases and CHF may develope
THERAPY:


Loop diuretic (+ Potassium)
ACE inhibitors (afterload reducing med.)
/Some centers use digoxin too – our
patient didn’t get/
After a week of therapy the baby’s weight
increased, breathing became normal, the
hepatomegaly decreased.
MANAGEMENT





Infants with large VSD, CHF: if growth failure cannot
be improved by medical therapy, the VSD should be
operated on within the first 6 months of life
Surgery should be delayed for infants who respond to
medical therapy
If the PA pressure is more than 50% of systemic
pressure, surgical closure should be done by the end
of the first year
Older infants with large VSD and elevated PVR
should be operated on as soon as possible
Infants who have small VSD without CHF or
pulmonary hypertension are usually not candidate for
surgery
TAKE HOME MESSAGE
Even serious CHD-s can be „silent” in the first
days/weeks of life
 Causes, of this are the changes of circulation
after birth
 First clinical sign of the cardiological problems
can be the feeding difficulty, the growth
retardation
 CHF signs in infants: tachydyspnea +
hepatomegaly (right- and left sided failure)
 The management of the CHD depends on
different conditions/abnormalities/changes

THANK YOU FOR YOUR ATTENTION!