Acyanotic Congenital Heart Disease Dr David Coleman Consultant Paediatric Cardiologist Our Lady’s Children’s Hospital, Crumlin Dublin

Common Shunt Lesions ♥ Ventricular septal defect (VSD) ♥ Atrial septal defect (ASD) ♥ Patent ductus arteriosus (PDA) * All 3 lesions can lead to Eisenmenger’s Syndrome if a large lesion is not detected and treated early enough

Common Stenotic Lesions ♥ Pulmonary stenosis (PS) ♥ Aortic stenosis (AS) ♥ Coarctation of the aorta (CoA)

VSD’s ♥ Commonest form of CHD ♥ Commonest types: membranous (perimembranous) ~75% muscular ♥ Can be single or multiple

VSD’s ♥ Symptoms relate to the degree of shunt (VSD size, pulmonary vascular resistance) if small: no symptoms if large (high pulmonary blood flow, CHF): tachypnoea dyspnoea slow feeding failure to thrive sweating

VSD’s ♥ Exam (smaller VSD): pink normal pulses normal S1 and S2 ± systolic thrill harsh pansystolic murmur LLSE ♥ ECG: normal (smaller VSD) or LVH ± RVH (larger VSD)

VSD’s ♥ Larger defect: MDM @ apex (mitral flow murmur) narrowly split S2 and loud P2 ± S3 CXR: cardiomegaly increased pulmonary vascularity

VSD’s ♥ Treatment options: Nil (spontaneous closure) Surgical closure Device closure

ASD’s ♥ Three types: secundum primum sinus venosus ♥ Commonest: secundum ♥ Primum: a form of atrioventricular septal (canal) defect

Secundum ASD ♥ Usually no symptoms in childhood ♥ Exam: pink normal pulses wide ± ‘fixed’ split S2 soft ESM @ ULSE ♥ ECG: incomplete RBBB (95%) ♥ CXR: often normal sometimes pulmonary plethora

Secundum ASD ♥ Haemodynamic significance of ASD is assessed to decide if closure appropriate ♥ Usually closed age 3-5 years (earlier if symptomatic) or when diagnosed if later ♥ Two options for closure: surgery - suture or patch interventional catheter - device

Amplatzer ASD Occluder

PDA ♥ CHF symptoms if large ductus in very young infant, otherwise often asymptomatic ♥ Exam: pink full volume pulses harsh systolic (1st few weeks) or continuous ‘machinery’ murmur loudest under left clavicle ♥ ECG: normal (small PDA) LVH ± RVH (large PDA)

PDA ♥ Options for closure: ♥ CXR: ± cardiomegaly, pulm plethora surgery - ligation interventional catheter - coil(s) or device

Pulmonary Stenosis ♥ Usually asymptomatic ♥ Exam: pink normal pulses ± systolic ejection click ESM loudest @ ULSE if severe, S2 widely split (not fixed)

Pulmonary Stenosis ♥ ECG: RAD, RVH ♥ CXR: normal ± prominent MPA (post-stenotic dilatation) ♥ Treatment of valvar PS (moderate/severe): balloon valvuloplasty preferred uncommonly surgical valvotomy

Aortic Stenosis ♥ Often asymptomatic; otherwise SOB, syncope or chest pain on exertion ♥ Exam: pink small volume pulse, small pulse pressure ± LV lift ± systolic thrill (suprasternal, URSE) ± systolic ejection click harsh ESM loudest @ URSE & radiating to carotids if severe, narrow split S2 (even reversed)

Aortic Stenosis ♥ ECG: normal (mild AS) LVH ± strain (more severe AS) ♥ CXR: often normal ± dilated ascending aorta ♥ Treatment of valvar AS (moderate/severe): balloon valvuloplasty surgical valvotomy

Coarctation of the Aorta ♥ CHF in neonate if severe CoA; often asymptomatic in older child ♥ Exam: pink reduced or absent femoral pulses soft systolic murmur mid LSE and/or mid left back ♥ ECG: RVH in 1st few months of life, LVH if older

Coarctation of the Aorta ♥ CXR: cardiomegaly evidence of CHF rib notching (older child) ♥ Treatment: surgery for ‘native’ CoA balloon angioplasty for re-CoA