Chd- Vsd & Asd

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2 populations in adult echo lab with CHD

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1. pts that have known CHD that have survive into adulthood. 2. pts that have undiagnosed or untreated CHD that is being discovered for the first as a adult.

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SHUNT LESION 4 types

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ASD, VSD, PDA, AV canal (ECD)

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what is a shunt

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abnormal communication between 2 chambers or 2 great arteries or 1 CH + 1 Vessel

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2 kinds of congenital shunts

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Patency of normal structures that fail to close spontaneously. Incomplete closure of septal structures during cardiac embryogenesis

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Blood flows through the SHUNT

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from higher pressure to lower pressure

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what is shunt going to do hemodynamically to whatever it is flowing

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this can cause volume overload and or pressure overload to the receiving chamber or vessel

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what determines how much flow goes across the defect

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amount of flow influence by anatomic resistance

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Qp:Qs

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how much blood flow is going to the lungs vs how much blood flow going to the body out of Aorta

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ONLY LT to RIGHT as long as the

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pulmonary vascular resistance is less than the systemic resistance

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4 types of ASD

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Ostium primum, ostium secundum, sinus venosus, coronary sinus.

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Ostium primum

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found at the bottom of the atrial septum, Found near the AV

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What is the 2nd most common CHD

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Ostium primum

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Ostium primum is associated with

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inlet VSD, Cleft ANterior Mitral Valve, Down syndrome

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Crux of the heart

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piece of atrial septum, piece of ventricular septum, piece of tricuspid valve, piece of mitral valve

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Ostium secundum found

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in the middle of the atrium septum, defect is in the area of fossa ovalis

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Most common type of ASD

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Ostium secundum 78%

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Ostium secundum accounts for---- of all cardiac anomalies

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6-10%

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Ostium secundum occurs 2X in

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Females

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Why do you think ASD might be at the middle of the atrium septum near fossa ovalis

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either deficiency in the growth of the septum secundum. excessive resorption of the septum primum

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Ostium secundum is associated with

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MVP

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Sinus Venousus accounts for, located at

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1-2% of all cardiac anomalies, at the top of atrial septum found at the junction of the RA and SVC, posterior to fossa ovalis

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Sinus venosus is associated with

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partial anomalius of pulmonary venous return PAPVR

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Cornary sinus (unroofed coronary sinus)

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RARE, persistent Left SVC,

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Clincial presentation of ASD

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murmur (asymptoic) . familial occurrence, mild heart failure, infants and fatigue in teenager.

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Physical exam ASD

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skinny, vey load heart sounds on the right side, splitting of S2, Diastolic rumble thorugh the tricuspid valve

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Echo to r/o ASD

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Subcostal 4CH, atrial septum, color flow/direction flow. spectral need to know the pressure gradient across the defect

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When will you see shunting?

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start mid systole when the pressure is the highest. Late diastole - 2nd shot increase blood flow bc of atrial contraction

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ALl these shints defects start out

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LT TO RIGHT shunts

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Eventually left to right shunt will cause

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volume/pressure overload on the right side

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if pt already have volume/pressure overload to the right side what will the heart look like on echo

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TR, D-SHAPED LV, flow velcoity throught he right side of the heart will be increase bc increase volume. higher velocity through TV & PV ]bc increase volume

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The hemodynamic signficant of shunt based on

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VOLUME CROSSING THE DEFECT not the size of the defect.

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Many pts develop

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RVH ( bc of the increase pulmonary vascular resistance) PHTN, TR dilated RV, PI

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If you see a pts with ASD

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identify where it is, measure it with calipers in 2D , measure in END DIASTOLE

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less than 3mm, 3-5mm, 5-8mm,

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less than 3mm= 100% closure, 5-8mm = 87% closure, 5-8mm=80%

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Qp:Qs if >2:1

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sign of elevated PA pressure, 2 or greater is having a negative hemodynamic effect on the heart.

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Qp/Qs

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VTI pulmonary X D2 pulmonic / VTI Aorta X D2 Aortic

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HOw can they repair ASD

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patch, amplatzer device occluer device ONLY FOR SECUNDUM

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Eisenmenger's Syndrome

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any left to right shunt that becomes right to left or bidirectional due to increase pulmonary vascular resistance

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Left to right shunt can cause

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RT side will have volume overload, pressure overload, Pressure goes up int he pulmonary vascular bed, pt develop PHTN can get bidirectional SHUNTING

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What happens when the pressure is higher on the right side of heart or equal to the left side of heart

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bidirectional shunting, right to left shunting.

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What is going to happen to pt fi there is right to left shunting

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cyanosis

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REVIEW what are things you need to document if pt ASD

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location, size direction, velocity of shunt, Qp:Qs, associated anomalies, RV systolic pressure, PA pressure,

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Bubble study

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agitated saline, Commercial contrast (microbubbles)

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VSD accounts for

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16-23% of all CHD

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Why does VSD Happen

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incomplete septation of the ventricles, VSD results from a delay closure of the IVS beyond the first 7wks of fetal life.

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VSD most common defect in

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Chromosomal syndromes

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Isolated VSD

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2nd most common type of CHD

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Most common type of CHD

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bicuspid AO VALVE

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VSD type is determined by location. 2 parts of ventricular septum

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membranous portion (fibrous) . musculature portion.

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musculature portion is divided into three portions

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INLET septum- seperates the ventricular inflows. TRABECULAR septum- Main body of the septum. OUTLET septum- most superior separates the outflow tracts.

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5 types of VSD

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perimembranous/membranous/infracristal. muscular. endcrdial custion type/AV canal defect/ Inlet VSD> Malignment. Outlet VSD/Infundibular/Suprcristal.

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Most common type of VSD

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perimembranous 75-80%

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where is perimembranous found

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Outflow Tract of LV, right below the AOrtic valve. infracristal.

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Small membranous VSD may close spontaneously during childbirth not bc of TISSUE GROWTH but bc

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Tricuspid septal leaflet bulging into the space to block up the hole

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Muscular VSD is found in the

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Body of the ventricular septum. bulk of ventricular septum. from tricuspid leaflet all the way to the Apex.

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Inlet VSD/Endocardial cushion/ AV Canal defect

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due to incomplete formation central fibrous body

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where is the defect Inlet VSD

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inferior to the AO valve plane, posterior or mitral annuls, below pulmonic valve anterior to membranous and trabecular septum

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Inlet VSD/Endocardial cushion/ AV Canal defect ASSOCIATED WITH

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Primum ASD, AV abnormalities, Complete AV defects

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Malignment of VSD

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Means that the ventricles are not align with the outflow tracts . They aren ot emptying equally in both ventricles can cause overriding.

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Malignment VSD where is the defect

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Defect between the outlet and the trabecular septum. The ao or pulmonary artery overrides the IVS

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MOST COMMON Scenarios of Malignment

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TOF, truncus arterious

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Outflow VSD/Supracristal VSD

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in the RVOT, Lateral and inferior to the AO valve

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What is unique characteristic about the defect outflow VSD

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More common in asians

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Outflow VSD is located

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anterior to the membranous septum,above the trabecular septum, Below the pulmonic valve

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What do we do to identify VSD on echo

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CW, Measure blod flow velocity across the defect, gradient 4V2 and estimate RV pressure.

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greatest volume of blood is through

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SYSTOLE, ventricles are contracting during systole.

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what happening to the shunt during systole

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blood goes tot he RV, no chamber dilatation because its going out the pulmonary artery bc systole and pulmonic valve is open

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BIGGEST EFFECT will be on the--- which side of the heart wll have volum overload

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Pulmonary artery/ left side of the heart/ increase LA &LV

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Long standing VSD --- will develop

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PHTN, RVH RV enlargement Eisenmenger's syndrome

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if pt has infundibular VSD that patient can develop

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AORTIC VALVE PROLAPSE

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VSD how are you gonna determine RV systolic pressure

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RV systolic pressure = systemic BP - VSD pressure gradient. You are doing to use CW through the VSD plug it into 4v2 systemic BP

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PT has a VSD

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localize defect, measure, CD, CW, evaluate direction of shunt, Qp:Qs

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Restrictive VSD, what type flow

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usually small, pressure RV is less than pressure LV, LT TO RIGHT FLOW

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Nonrestrictive VSD

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pressure RV is greater than to LV pressure, usually large. Birdirectional, RT to LT flow