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Patent Ductus Arteriosus
- - Communication between the Aorta & Left pulmonary Artery
- - The shunt that is open in the fetus due to the collapsed lung causing higher resistance than systemic resistance.
- - Normally after birth (hours-weeks) the lumen starts to obliterate due to smooth muscle contraction and w/in 12days the Ligamentum Arteriosum forms.
- CLINICAL FEATURES:
- dyspnea, fatigue, diminished growth & cardiac failure (w/ Lg shunt)
- POSSIBLE FEATURES:
- subacute bacterial endocarditis, aneurysm, noninfectious thrombosis
- may eventually cause pulmonary hypertension & shunt reversal, surgical correction recommended early
- cyanosis & fatigue are main complaints, chest pain of pulmonary hypertension may be present
Ventricular Septal Defect
- Four Types:
- - Between the Crista Supraventricularis & Pulmonary Valve
- - Just caudal to the Crista Supraventricularis
- - Beneath the septal leaflet of the tricuspid valve in an area where the A-V conduction bundle is especially susceptable to injury
- - In the muscular septum near the apex of the right ventricle
- CLINICAL FEATURES:
- - defect size + pulmonary vascular resistance = volume of blood
- - increase pulmonary blood Q = increase pulmonary vascular R
- **if pulmonary vascular R increases to a level above systemic R, the shunt is reversed from left-to-right -- right-to-left, making surgical therapy uniformly unsuccessful.**
-surgical correction may be carried out with primary closure or, if the defect is large a patch is indicated
- - The name given to a defect which includes hypoplasia or absence of the main pulmonary artery.
- - Pulmonary circulation is dependent upon a patent ductus arteriosus and a ventricular septal defect
- - resemble those of tricuspid atresia
- - dyspnea, fatigability, frequent resp infections, cyanosis, hypoxia & cardiac failure are all common
- SURGICAL CORRECTION:
- - involves closing the ventricular septal defect, closing the patent ductus arteriosus and insertion of a dacrom graft betaeen the RV and left main pulmonary artery (RASTELLI PROCEDURE)
- - Extremely rare finding
- - congenital or rheumatic disease, trauma or endocarditis
- CLINICAL FEATURES:
- - edema and ascites are usually present, as may be hepatomegaly and splenomegaly
**Since it is usually caused by another cardiac defect, the primary defect must be repaired. Repair of the Tricuspid Valve is usually limited to valvuloplasty.
Pulmonary Congestion or Edema
- ACTIVE CONGESTION:
- - left-to-right shunt
- - increased speed of circulation
- - anemia / thyrotoxicosis / beriberi heart disease
- - increased blood volume
- - pregnancy
- PASSIVE CONGESTION:
- CHRONIC LV FAILURE:
- - severe systolic overload of LV
- - systemic hypertension / coarctation of aorta / aortic stenosis
- - severe diastolic overload of LV
- - mitral insufficiency / patent ductus arteriosus / aortic insufficiency
- - myocardial damage & failure
- - myocarditis / myocardial fibrosis / myocardial infarction
- - left ventricular aneurysm
- OBSTRUCTION TO FLOW:
- mitral stenosis / LA thrombosis / constrictive pericarditis / amyloidosis / endocardial fibroelastosis / compression of pulmonary veins
Beriberi Heart Disease
- Due to a dietary deficiency of Thiamine.
- CLINICAL FEATURES:
- - elevated BP
- - bounding pulse (extremely)
- - rapid circulation (extremely)
- COMMON OCCURRENCES:
- - increased venous pressure
- - ascites
- - edema
- - right heart failure
**Responds dramatically to Thiamine therapy.
Atrial Septal Defect
- 3 common types:
- 1. Ostium secudum: central portion of the atrial septum
- 2. Sinus Venosum: high in septum, near SVC
- 3. Ostium Primum: low in septum; close to medial leaflet of mitral valve
- Clinical: can cause upper respiratory infections and fatigue; no cyanosis, but can be mild dyspnea and fatigue
- -increased pulmonary flow resulting in pulmonary hypertension which can reverse shunt to become right to left
- -if it is a primum type defect then severe cardiac failure may be present; this defect should be corrected between the ages 3-5
- -the defect can be repaired by primary closure
- -in the ostium primum defect, the cleft in the mitral vlave is sutured; sometimes a pericardial graft is needed to the bridge the gap in the valve
Total Anomalous Pulmonary Venous Return
- -when 4 pulmonary veins return blood to the right side of the heart; most times atrial septal defects are present so blood can circulate to the left side of the heart
- Partial anomalous pulmonary venous return: pulmonary venous returns partially to the right side and partially to the left side
- 3 categories:
- Supracardiac (50%)- most common; pulmonary venous return empties into left SVC, then innominate vein, then SVC
- Cardiac (30%)- pulmonary venous return empties into coronary sinus; occasionally goes into right atrium
- Infracardiac (10%)- pulmonary veins drain into venous trunk that descends and enters IVC or portal vein below diaphragm
- Clinical: can cause cyanosis, cardiac failure, and pulmonary hypertension
- 75% of patients die before age 1
- Surgery tries to aim at rediverting the venous blood to the left side
- -ring of vessels surrounding the esophagus and trachea, most common being the double aortic arch.
- -defect causing the right and left (innominate) aortic arch to form descending aorta
- -another common vascular ring is formed round the right aortic arch joined by the ligamentum arteriosum on the left side; the ring circles the trachea and esophagus causing partial obstruction causing difficulty in respiration
- - surgical correction is directed towards relieving the constriction of the ring around the trachea and esophagus
- -narrowing of the mitral valve; most common valvular defect
- -can impede the flow of blood from the left atrium to the left ventricle during ventricular diastole causing a rise in left atrial pressure
- -this high pressure can cause increased pulmonary venous, pulmonary arteriolar, pulmonary artery pressures, and right ventricular systolic pressure
- -pulmonary arteriolar sclerosis or pulmonary fibrosis can occur
- Clinical: palpitations, weakness, orthopnea, dyspnea, pulmonary edema, and hemoptysis are symptoms. Edema and cyanosis appear in advanced stages
- -mitral commissurotomy can be done which opens the mitral valve along its fused commissures
- -acquired mitral stenosis, esp. calcific mitral stenosis requires valve replacement
- -acute pericarditis accompanied by severe chest pain; may cause pericardial effusion which can result in a cardiac tamponade
- -adhesive pericarditis is when the pericardium thickens and adheres to the heart itself which can be follow by constrictive pericarditis
- -constrictive pericarditis interferes with the normal function of the heart which may results in the pericardium being surgically removed
- -80-85% of cases
- -predisposing factors include heredity, vascular reactivity, renin-angiotensin-aldosterone , neurogenic factors (sympathetic stimuli causing constriction of renal blood vessels), physiology of circulation (vasoconstriction of efferent glomerular arterioles of kidney, vessels of skin and brain)
- -prolonged hypertension can result from stress (hereditary factor), prolonged emotional strain (physiological factor), acute nephritis, toxemia of pregnancy, etc.
- -secondary changes include renal ischemia and arteriosclerosis
- -a new equilibrium can be achieved once the pressure restores some disturbed aspect of renal function
ARTERIAL PULMONARY ATRESIA
- Is the Failure of Development of the MAIN PULMONARY ARTERY.
- Signs: RHF
- Complication: * Subacute Bacterial Endocarditis
- * Brain abcess
- * Cerebral Vascular Accidents
- Surgical Correction: depends on the right ventricle
- If the right ventricule chamber is NORMAL in size AS IS pulmonary artery simple pulmonary valvulotomy and a closure of the Ductus arterious.
- If the right ventricule is HYPOPLASTIC with a NORMAL pulmonary artery - Increase pulmonary flow or use the Rashkind procedure.
- If right ventricular is NORMAL and pulmonary artery is HYPOPLASTIC-- Rastelli procedure.
- If Main pulmonary artery is HYPOPLASTIC - Fontan procedure
TRANSPOSITION OF GREAT VESSELS
- It’s a complete transposition of the great vessels as the AORTA arises from RIGHT VENTRICLE (anterior to pulmonary artery) and the PULMONARY ARTERY arises from LEFT VENTRICLE (posterior to aorta).
- What happens?? Blood circulates around and around in the systemic circulation WITHOUT passing through the pulmonary circulation. Likewise,
- The pulmonary circulation is recirculated WITHOUT passing to systemic.
- How patient survive?
- INTRACARDIAL SHUNTS are presented which will permits mixing of both circulations.
- Patent foramen ovale and Ductus arteriosus are presented in most of the cases.
- Most commonly associated defect is the VENTRICULAR SEPTAL DEFECT.
- Symptoms: Cynosis, Respiratory Infection, Hypoxia, MI, pulmonary hypertention, CF.
- Surgical correction:
- Blalock Hanlon technique (DON’T NEED CPB) involves excising a portion of the ATRIAL SEPTUM.
- MUSTARD PROCEDURE which involves rearranging the arterial septum so that the blood in arterial chamber will empty into the ventricular pulmonary artery arise. The chamber receiving blood from pulmonary veins will empty into the ventricular aorta arises
SINUS OF VALSAVA ANEURYSM
- This type of Aneurysm develops in the SINUS VALSAVA IN THE AORTA at its junction with the annulus fibrosus.
- Right Coronary Sinus is the mostly involved.
- Rupture of this Aneurysm is into the RIGHT VENTRICLE, Occasionally into the RIGHT ATRIUM.
- An Aneurysm of the posterior cusp ruptures into the RIGHT ATRIUM.
- An Aneurysm of the left cusp ruptures the LEFT or RIGHT ATRIUM or into LEFT VENTRICLE (This type is rare).
- The cause of this defect is usually congenital. - There may be an associated VENTRICULAR SEPTAL DEFECT.
- Rupture of the Aneurysm may be marked by ACUTE ONSET OF LEFT VENTRICULAR FAIURE.
- Symptoms: Heart failure, Cardiomegaly ( Enlarged Heart)
- Surgical correction: Direct Suture of the Defect
- It occurs when the AORTIC VALVE fails to close completely immediately AFTER SYSTOL.
- There is an INCREASE in pulse pressure.
- LEFT VENTRICLE becomes Dilated and Hypertophied
- Pulmonary Congestion and Edema are common.
- Symptoms: Cerebral Insufficiency, Dizziness, Pulsating Headaches, Dyspnea, Increased Pulse Pressure, Pulmonary congestion and Edema.
- Coronary Insufficiency may occur. As well Left Heart Failure may occur followed by a Right Heart Failure.
- Treatments : Surgical replacement with a PROSTHETIC VALVE.
- Core pulmonale is a HEART DISEASE which is caused by HYPERTENTION in the PULMONARY CIRCULATION.
- HAPPENS DUE to abnormal resistance of blood flow from the RIGHT VENTRICLE.
- ACUTE COR PULMONALE is caused by PULMONARY EMBOLISM.
- CHRONIC COR PULMONALE is caused by one of the four general categories pulmonary disease:
- Chronic obstruction Lung Disease.
- Pulmoary Fibrosis.
- Musculoskeletal or Mechanica disorders or the Thoracic Cage.
- Primary Disease of the Pulmonary Vessels.
- In addition to one of the pulmonary manifestations for a Chronic Cor pulmonale RIGHT HEART FAILURE.
- Treatment: Is Directed toward the pulmonary component.
Hypertension is the elevation of the basal blood pressure above the normal limits of 145/90 mmHg.
Physiological Vasoconstriction or an increase of cardiac output due to Emotion, Cold or other causes that will give us a reading higher than 160/90mm.
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