1. Sharqiyah Echo Club Anwar Jelani King Abdulaziz Hospital, Alhasa JelaniA@ngha.med.sa

2. 72 year lady known case of HTN, DM came to ER. S.O.B for 5 days.

3. Cough and sputum LL swelling worsening. Chest tightness, sputum,

4. Warfarin, Furosemide, Metoprolol, Lisinopril

5. O/E 104/59 110 bpm irregularly irregular 82% on RA 37.4 C.

6. Elevated JVP Resp Crept (loud) Ascites and LL edema up to the knees

9. Hb: 112 WBC: 13 Plt: 327 BUN: 23 Creat: 240 BNP: 140 Trop: 0.57

10. Echo?

16. What are your findings?

17. LVH Good LV systolic fx MR ++ LA enlargement

18. TR +++ RV dilated RV volume overload RV pressure overload

19. What do you think is going on? What would you like to know more? How would that affect your management?

24. Now, what is your working diagnosis at this moment? How would you mange the patient at this time? What will you plan?

26. Admitted. Lasix and Abx. TEE

37. ASD TR Pulm HTN (severe+)

38. Dx? Treatment? Intervention? Prognosis?

39. Consulted pulmonary IV diuresis. INR And discussed the further management.

40. endothelin receptor antagonist. competitive antagonist of endothelin-1, at ET-A and ET-B receptors.endothelin Bosentin.

43. Follow up in the OPD. Symptoms improved in sense of NYHA. Readmitted every few months when ran out of Bosentan.

44. Thank you for your attention.

45. Ostium Secundum True Defect in Fossa Ovalis. Ostium Primum Defect. Sinus venosus defect, at junction of RA/SVC ass with anomalous PV return. IVC form of Sinus venosus defect. CS septal defect ( bet CS/LA, L  R shunt due to unroofed CS.

46. Common. Present at any age. F:M 70:30 in secundum F:M 50:50 for Sin Venosus & Ost Primum. Down Syndrome  40% CHD  40% AV SD. DiGeorge / Ellis-Van Syndromes: Ost Primum.

47. Sinus Venosus ASD 5-10%. Post aspect: RA free wall Sup border Absent (SVC). Anomalous connection of Rt PVs to SVC or RA. TEE, MRI, CT. Should be looked for in any RA &/or RV unexplained dilatation. Surgical closure only possibility.

48. AtrioVentricular septal defects Common AV junction. Separate AV valves in partial form. Common AV valve in Complete form.

49. Secundum ASD with persistant L SVC  CS. Primum ASD  Rt heart dilataion. “Tri leaflet AV” valve –cleft MV-  regurgitation. Pachute or Double orifice MV. Surgical repair of ASD + restoration or preservation of competence. 96% 20 year survival. 7 late death, 15 reoperation for residual regurgitation, 3 for subaortic stenosis development.

50. Clinical features Asymptomatic initially. Not related to size exclusively! Exercise intolerance. A Fib/Flutter (increase Sx). Rt Heart Failure with severe TR. Pulm HTN (increased P flow). Cyanosis (inf sinus venosus)

51. Pink, unless advanced P HTN. RV lift on hel expiration. Palpable PA in 2 nd Lt IC. “wide, Fixed