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cardio #4


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Atrial septal defect ASD
incomplete closure b/w the two upper chambers of the heart
*blood flow b/w atria causing some heart chambers to pump extra blood
ASD can cause Pulmonary HTN
What is that?
the heart can dialate, the muscle can become weak, and the pressures in the pulmonary arteries can increase due to increase in blood flow
Eisenmenger's syndrome
the pressures in the right side of the heart are high enough that blood may begin to flow from the right to the left side of the heart
Secundum atrial sepal defect
*most common 80%
*caused by failure of part of the atrial septum to close completely during development of the heart
*results in a "hole" b/w chambers
Sinus venosus artial septal defect:
assoc with-
-junction of the superior vena cava and right atrium
-anomalous drainage of the pulmonary v.
-one or more of the pulmonary vv carries oxygenated blood from the lungs to the right atrium instead of the left
ASD: blood can flow ("Shunt") across the hole from the left atrium to the right resulting in ...
enlargement of the right atrium and ventricle due to the extra blood ==
increasing pulmonary blood flow
shortness of breath
ASD findings:
*F:M= 3:1
****Systolic murmur with FIXED SPLIT S2*** heard best at the 2nd LICS
*will increase pulmonary flow across pulm. valve
*a lg ASD can cause MID-DIASTOLIC RUMBLE (increase flow across the AV valve
ASD can be differentiated from Pulmonary stenosis b/c
PS will have an ejection click

easily heart over left shoulder (back)
ASD is confirmed by:
echocardiogram- which visualizes the actual defect and estimates its size, as well as the conn. of the pulm. vv
Cardiac Catheterization is used for ASD when:
inconclusiive echocardiographic examination or associated anomalies, that req further eval.
ASD closure:
spontaneous closure within 1st yr-
by 18 months-
after 3 yrs-
lesions > 2.0 Qp:Qs occur at what age
-50%; 100% if <3mm if < 3 months
-80% if small 5-8 mm
-most won't close; >8mm=rare
-3-5 yrs
Why do you electively close ASD if not closed spontaneously by school-age?
b/c of pulmonary vascular obstructive disease
*the pulmonary arteries become thickened and obstructed due to increased flow, from left to right for many yeart
Therapy for sinuse venosus ASD:
Open heart surgery

*b/c there is no chance of spontaneous closure and these pt's are not candidates for transcatheter closure b/c of location of ASD
Surgical Treatment:
indications for surgical repair-
-right ventricular overload
a shunt fraction >2.0 as est. by echo
(amount of blood going in2 pulm
circulation/amount going out to
the systemic circulation)
elective closure prior to a child start
ing school
Surgical options for ASD closure:
*direct suture repair (small ASD)
*patch repair (more common)
-use pt's own pericardium, bovine periicardium, or synthetic mmaterial (Gore-Tex, Dacron)
Surgical (dr. Mann):
-infants/children who become symptomatic
-moderate-lg ASDs remaining at 4-5 y/o
-small ASD in an older child or adult
-heart lung bypass (patch repair)
-catheter reapair
Medication for ASD:
SBE prophylaxis
-d/c 6 months post-op
-not indicated for isolated ASDs
Septal Occluder for ASD:
not able to do in lg defects
*balloon catheter (use ultrasound) est. size
*fabric-covered wire frame over ASD
*wedges the ASD b/c the two parts
*6-8wks normal tissues grows in and over the defect
*90% success
*faster recovery, no thoracotomy
Tetralogy of fallot:
*Ventricular septal defect (SYSTOLIC murmur along LSB)
*Pulmonary Stenosis
*aorta "overrides" the ventricular septal defect
*right ventricular hypertropy

-Palliative: Blalock-Taussig (aortopulmonary shunt)
-Definitive: VSD patch repair and pulmonary valvulotomy
TOF effects:
*cyanosis dev. as ductus closes at birth (not able to circulate enough blood now)
*"Tet spells" (paroxysmal(sudden attacks) hypercyanotic episodes):
irritable to low 02 levels
sleepy or unresponsive
can be treated by comforting and
knee-ches position
TOF repair:
>95% infants successfully in 1st yr of life

*closure of VSD; augmentation of outflow tract

repaiir can lead to pulmonary insufficiency
TOF diagnostic eval:
*pediatric cardiology consult
*echoocardiograpy has replaced cath studies
*MRI occasionally
CXR heart configureations:
TAPVR (total anomalous pulm venous return)-
-"cuer en sabot" (wooden shoe)
-"backwards 3 sign" ( and rib notching)

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