a simple approach to congenital heart diseases

1. Bedside Approach to
common
Congenital Heart Diseases

2. The rule of Commonness
The uncommon manifestations
of common diseases
are much more commoner
than the
common manifestations
of uncommon diseases

4. When to suspect CHD ?
• Presentation in childhood or adolescence
• H/O murmur detected in newborn nursery or
school health cell
• Family history of congenital heart diseases
• Symptoms specific to CHD: Cyanosis, Spells,
Squatting, Recurrent respiratory infections
• Dysmorphic features

5. Cardinal Symptoms
Dyspnea Fatigue
Angina Resp. infection
Palpitation Cyanosis
Syncope Stroke/Embolism
Edema Hemoptysis

6. CARDIAC DYSPNEA - MECHANISMS
• INCREASED PULMONARY VENOUS PRESSURE
Stimulation of J receptors > Hering Breur reflex
Altered Lung Compliance > Respiratory muscle
length – tension mismatch
↑ Airway resistance : reflex broncho constriction
peribronchial &mucosal edema, intraluminal fluid
• DECREASED CARDIAC OUTPUT :
Fatigue of Respiratory & Exercising muscles
Increased O2 Extraction > Widened A-V O2 diff
• HYPOXIA : Right to Left shunts

7. Recurrent Respiratory Infections
• Respiratory infections that
are too frequent, more
severe and longer lasting.
• Arbitrarily, if respiratory
infections occur for more
than 6 times a year or
more than once in a
month, lasting for more
than a week or requiring
either iv antiobiotics or
hospitalizations.

8. SIMPLE
COMMUNICATIONS +
RESISTANCE TO PBF
MIXING
SITUATIONS
VSD, ASD, PDA +
PULMONARY PULMONARY
STENOSIS HYPERTENSION
Complete : TAPVC, COMMON
ATRIUM, SINGLE VENTRICLE,
TRUNCUS ARTERIOSUS
Incomplete : TGA
RA
RV
PV Ao
LV
LA
RV
RA LA
LV
TA

9. • Is it cyanotic or acyanotic
• Is the situation one of
↑ Pulmonary Blood Flow: Neonatal HF, LRTI
↓ Pulmonary blood flow: Cyanosis, Spell,
Squatting
or one of obstructive lesion: DOE, Angina,
Syncope
• Is it right heart disease or left heart disease
• Has the patient developed pulmonary hypertension
Ask yourself the following …..

10. CCHD - Age at Presentation
Neonatal life (< 1month) : most severe disease;
sickest children; markedly hypoxemic;
many don’t survive to see their first birthday.
a) Severe Obstruction to PBF with R>L shunt :
Severe TOF, Pulmonary Atresia with IVS
b) Incomplete Mixing:
TGA + IVS + restrictive IAC
c) Complete mixing but with obstruction to PBF
SV + PS, TA + small VSD or severe PS,
Obstructed TAPVC

11. CCHD - Age at Presentation
Infancy ( 1m – 1yr) :
1) Moderate to severe PS + R>L shunt :
TOF, Pulm Atresia + VSD, DORV + PS, TA
2) Small ( hypoplastic ) RV – R>L @ IAC
Hypoplastic RV, Ebstein’s anomaly
3) Unobstructed TAPVC
Childhood (1-12 yrs) Eisenmenger syndrome

12. Mode of Presentation
• Neonatal Heart Failure (feeding difficulty,
intercostal indrawing, tachypnea, sweating,
restless / dyspnea in recumbency)
Obstructive lesion, myocardial disease
• Heart failure at 4-6 weeks (regressing PVR)
Post tricuspid shunts (VSD,PDA)
• Cyanosis at birth: Complex defects
TGA, Truncus, TAPVC, SV, TA,
• Cyanosis 3-6 months: TOF, DORV PS, TA
• Cyanosis in late childhood: Eisenmenger

13. Squatting relieves dyspnea inTOF
↑ SVR / Early reflected waves > Central AoP

14. Cyanotic (hypoxic) Spells
• TOF, Pulm Atresia with VSD, DORV PS
• 2 m – 2 yrs, early hours (activity, feeding,
defecation), worse in summer / during respiratory
infections, Cath may precipitate
Increased C.O / Lowered SVR > ↑ R-L shunt
Hyperpnea ↑Hypoxia
Tachycardia
Catecholamines R V contractility ↓RV size

15. General Examination
• ↓ weight + normal height - ↓ PBF
• ↓ weight + ↓ height - ↑ PBF
• Ellis van Creveld: Common atrium
• TOF : Down & Poland syndrome, CHARGE,
CATCH 22
• Trisomy 18 : DORV
• Cat eye syndrome : Tricuspid atresia

16. 6-10% of CHDs
1 out of 1500 live births
5-10%
15-20%
75%
ATRIAL SEPTAL DEFECT

17. E I

18. E I
Variable split of S2
Small ASD /PAPVC; Pulmonary Hypertension
Absent flow murmur
Pulmonary Hypertension/Small ASD

19. ASD - Differential Diagnosis
• MILD PULMONARY STENOSIS
No RV Volume overload features,
Ejection sound, Harsh MSM, S2 split
varies with respiration, P2 N, No MDM
• IDPA
Normal S2 split & P2, No MDM
• Straight back

21. A.S.D with Cyanosis
• PH with shunt
reversal
• Deroofed
Coronary sinus
• LSVC into LA
• Common Atrium
• TAPVC

22. A.S.D with Pulmonary Ejection Sound
• ASD with Pulmonary Hypertension
• ASD with Pulmonary Stenosis
• ASD with large L > R shunt

23. A.S.D with Mitral Regurgitation
• Cleft Mitral Valve in Primum ASD
• Mitral Valve Prolapse
• Rheumatic

24. A.S.D with systolic thrill in L II ICS
ATRIAL SEPTAL DEFECT
WITH PULMONARY STENOSIS
WITH MITRAL STENOSIS
LARGE L > R SHUNT

25. ECG in Atrial Septal Defect
• Left axis deviation of QRS: Primum ASD
• Left axis deviation of P: SVC ASD
• Left axis deviation of P & QRS: C.A

26. Ventricular Septal Defect

27. Ventricular Septal Defect
• Brisk upstroke of arterial pulse
• Hyperdynamic apex, RV impulse, Systolic thrill
• S2 split wide (L>R) Single (↑PVR), S3, MDM
• Restrictive VSD: High pitched, S2 normal
• Moderate sized VSD: Harsh, S2 wide
• Large VSD with ↑ PVR: Murmur shorter & fainter
S2 single & loud

28. What are the other two occasions
in which the murmur of VSD
is not holosystolic ?

29. What are the other two occasions
in which the murmur of VSD
is not holosystolic ?
• Muscular VSD
• Closing VSD

30. DD of Precordial Holo Systolic Murmur
VSD LV-RAF TR MR
Location L IV ICS RLSB LLSB APEX
Pulse Brisk Brisk Low Vol Brisk
JVP -- -- ↑v --
API RV
Precordium BiV BiV RV LV
Murmur Loud 3-4/6 2-3/6 3-4/6
harsh soft, high ptiched
Inspiration - - ↑ -

31. Patent Ductus Arteriosus
• Wide pulse pressure
• Hyperdynamic API
• S1 N; S2 paradoxical
• Continuous murmur
machinery, peaks around S2, eddy sounds
• S3, MDM at apex

32. DD of Continuous Murmur
• Patent Ductus
Arteriosus
• Coronary Arterial
Fistula
• Ruptured aneurysm
of sinus of Valsalva
• Anomalous origin of
LCA from from PA
• Venous hum, Mammary souffle, MS with PFO

33. SITE NATURE CONFIGURATION
PDA L II,I ICS Machinery
Eddies
CAF L II, III IS Soft high pitched
RSB, LLSB
RSOV L III ICS Loud, harsh, sawing
RSB, LSB Superficial
ALCOPA L II ICS Soft, high pitched
VENOUS NECK Soft / Rough
HUM URSB noisy

34. VALVULAR PULMONARY STENOSIS
• Prominent ‘a’ in neck
• ↑ RV Impulse, RV S4
• ESM L II ICS > LSB, Delayed soft P2

35. RV OUTFLOW OBSTRUCTION

36. Which right sided
auscultatory event
is prominent in expiration
& Why ?

37. Which right sided auscultatory event
is prominent in expiration & Why ?
Pulmonary Ejection sound of VPS

38. R II ICS
L III ICS
L III IV
ICS
L I ICS
LVOT OBSTRUCTION

39. How does the murmur of
Aortic stenosis
differ from that of
Pulmonary Stenosis ?

42. TETRALOGY OF FALLOT
Post VPD ↑↑ ---
Prominent ‘a’ JVP yes no
Parasternal impulse ++ no

43. VSD PS Physiology
• Tetralogy of Fallot 3-6 m, Rt Ao Arch, QRS 90-1500
• DORV with P.S Longer louder murmur, QRS > 1500,
Counterclockwise rotation
• CTGV with PS Pulsation L III ICS, Apical HSM
• Tricuspid atresia /VSD /PS ↑a JVP, ↓RV impulse,
LAD + LVH
• TGA PS Intense cyanosis from birth
• Single ventricle PS Precordial QRS

45. Eisenmenger Syndrome
ASD VSD PDA
• Age 4th decade 2nd decade
• Neonatal HF No +++ ++
• Effort syncope Yes Yes No
• Cyanosis Uniform Uniform Differential
• ‘a’ JVP No Yes Yes
• S2 split wide fixed Single Normal
• PR murmur ± ± ++
• ↑ CTR +++ No No
• Aorta -- -- ++

46. Be inquisitive !
Learn from
Textbooks / online
Teachers
Patients
Colleagues
Students
by yourself
Learning is a
life long commitment…

50. LVOT Obstruction – Causes & Differentials

53. `

54. Cyanosis in Congenital Heart Diseases
High resistance to PBF due
to PS / PH
R > L shunting across
ASD,VSD,PDA
Mixing of venous &
arterial blood
Adequate : TAPVC, T At, CA, SV, TA,
Inadquate: TGA

57. Atrial Septal Defect

60. Age at Presentation
1 month to 1 year :
TOF, VSD+PS, DORV+PS, PS + ASD,
Pulmonary Atresia + VSD + MAPCAs,
Pulmonary AV fistula, Mixing situations
with good mixing
1 year to 12 years :
Eisenmenger syndrome