valvular heart diseases

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(1).PRESENTATION

a.CC

asymptomatic

growth retardation

breathless ness

rest dyspnoea

recurrent respiratory tract infection

syncope (AS)

thromboembolic disorder(ref:http://www.hhrids.com/hr15050004/)

b.on examination

i.general

dyspnoec

JVP-not raised(raised when there is shunt reversal,raised/prominent a)

pulse-normal

BP-normal

ii.Precordium

. inspection-

.palpation

Apex-shifted to left(RVH)

Thrill-pulmonary

.auscultation

S1(N)+S2(wide fixed,wide due to more flow and delayed closure,fixed due to equilization of pressure)+extra0+added0+murmur(ESM @ 2nd -3rd ICS due to increased pulmonary flow,MDM @ tricuspid area due to increased flow through tricuspid valve,systolic murmur due to MR/TR if AV valve involved in osteum primum as it involves AV valve)

c.provisional diagnosis:ASD

/ASD with shunt reversal/Eisenmengers synrome

features of shunt reversal

i.recurrent RTI

ii.lower extrimity cyanosis and clubbing

iii.raised JVP

iv.absent diastolic murmur

v.oligaemic lung field

d.differentials

PS

.features of PS-

1.P2soft/absent,wide but non fixed S2

2.pulmonary thrill

3.ESM radiated to neck

(2).INVESTIGATIONS

a.For confirmation of diagnosis

CXray-

large transverse diameter of heart/cardiomegaly(RA,RV enlargement,small LA)

large/bulged pulmonary conus

normal aorta

large hilar artery

plethoric lung field/oligaemic lung field(if associated with eisenmengers syndrome)

ECG

osteum primum – RBBB+LAD

osteum secondum-RBBB+RAD

Echo with color doppler

cardiac catheterizaton

Fluoroscopic hilar dance

b.For detection of distant Extension
c.For diagnosis of Co morbidities/end organ damage

d.For Fitness

e.For follow up /prognosis

f.For planning

(3)CONFIRMATORY DIAGNOSIS

VSD(size anatomical type morphological type physiological type functional type grade )

a.symptomatic/asymptomatic

b.association

c. refractory to medical treatment

d.with or without shunt reversal/with eisenmenger’s syndrome

e.PHTN(RPA mm LPA mm MPA mm PPG mmHg PASP )
f.chember/structural status( LVIDd LVIDs RVIDd RVIDs IVS PWt RVOT LVOT Ma Mannu M ppg Aa Aan Appg sub aortic area TRa TRan TRppg Pa Pan Pppg )
g.any contrast/clot/vegetations/effusion
h.CVS( PLSVC APVD COA vascular rings PDA )
i.EF
j.conorbidities
k.previous surgery

(4)MANAGEMENT

pre operative planning
• record all relative informations
• optimise patient conditions
• choosing surgery with minimal risk and maximum benefit
• anticipate and plan for adverse events
pre operative management
• capacity-baseline organ function
• optimisation-lifestyle modification,medication,specialist referral
• alternative-minimal impacting procedure and appropriate post operative care
• theatre preparation-timing,team work,special instruments arrangements
PLAN:a. further investigations (Echo/markers/CT angiogram/angiogram/perfusion/lipid profile/diabetic profile)/b.clinical correlation neededc.follow up programmed.councelling and assurancee treatment(life style modification/medical/interventional/surgical)

i. general management
ii.symptom alleviation
iii.control of comorbidities
iv.definitive management plan and execution

a.plan of bypass b. plan for myocardial protection c.incision d.expected XCT

v.pre operative control of comorbidities
vi.plan proper with estimation of predictive risk
vii.back up plan with predictive risk
viii.intra operative precaution
viii.planning for post operative specific care
ix.revised risk assessed after control of co morbidities
x.consent taken after explanation assurance and alternative option discussion with back up plan and predictive risk

Rx protocol/operationName of operation (……………………………….)(cat of operation………) ASA (………………….) With preoperative control of co morbidities Preop control of HTN Preop control of DM Preop control of hypercholesterolemia With preoperative avoidence of smoking atleast 1 month prior(that decrease the risk by 30%) And avoidence of OHA and ASPIRIN With atleast 2 units fresh screened crossmatched human blood in hand And properplanning of specific post operative precaution and treatment plan
With proper risk assessment work out

1.perioperative risk of re infarction

2.with predictive risk of dying on waiting list(NZ score)

3. with predictive risk of dying in hospital(APACHE III)

4 with predictive risk of specific illness(Glasgow and Ranson criteria)

5. with predictive risk of operative severity score(POSSUM)

6. with predictive risk of operative mortality(Euro score)
7. with predictive cardiac risk of non cardiac surgery(RCRI)
8. with predictive risk of survival after noncardiac surgery in patient of IHD and CHD
9.with 30days post operative mortality prediction
10.CRASH
• a.general management
• b.control of symptom
• c.control of co morbidities
• d.definitive management planning and execution

small-FU

moderate to large-

Qp:Qs=/>2:1-transcatheter button/clam shell

eissenmengers syndrome-heart lung transplant/life long Digoxin/Diuretics+ follow up

best time for operation

after 1 year to before school going age

in adult as soon as detected if symptomatic

(as shunt reversal occurs at 3rd decade)

(5)FollowUP

(6)complications

pulmonary HTN with reversal of shunt

Arrhythmia (AF)

Embolus(pulmonary/systemic)/CVD

here it starts with sudden convulsion and may lead to hemi/para paresis/unconsciousness/cardiac arrest

Brain abscess

ASSOCIATIONS

coronary sinus variety

coronary sinus variety with LUPV draining into RA(

growth retardation and facial expression in a11 years old girl with ASD secondum(24 x26 mm ,deficit aortic ,postero superior and SVC rim with PASP 59 mm Hg)

tilted apex

POST OPERATIVE COMPLICATION AND MANAGEMENT:

if associated with COPD

expected to have high PCO2, low PO2,low % saturation

ensure low flow O2 to ensure continuous hypoxaemic respiratory drive

thromboembolism

here it starts with sudden convulsion and may lead to hemi/para paresis/unconsciousness/cardiac arrest

look for GCS,focal signs,pupil,temp(raised inhaemorrhagic shock)

start prophylactive inj. oradexon 1 amp IV stat

tab. clopid if not haemorrhagic

inj.solumedrol (500mg) iv BD

send for CT scan of Brain

1.how will you understand that AV valve is involved?

i.if there is systolic murmur @ tricuspid / mitral area(due to TR/MR)

ii.if it is osteum primum

iii.and if there is Down’s syndrome

2.How will you suspect reversal of shunt?

both murmur decreased in intensity

ii.P2 accentuated

iii.ESM-accentuated

iv.features of pulmonary HTN

3.what is LUTEMBACHER’s syndrome

ASD +MS

4.sign of severe PS?

i.left para sternal heave(RVH)

ii.P2 absent,wide split S2

iii.murmur prolonged loud and harsh

iv.ECG-RVH+RAH

v.xray-post stenotic dilation of pulmonary artery

bulged pulmonary conus

oligaemic lung field

5.what is Eissenmenger’s syndrome

pulmonary HTN with shunt reversal

6.what is Eissenmenger’s complex?

pulmonary HTN with shunt reversal due to VSD

7.features of shunt reversal

i.recurrent RTI

ii.lower extrimity cyanosis and clubbing

iii.raised JVP

iv.absent diastolic murmur

v.oligaemic lung field

8.natural history

8mm rarely close

reversal of shunt in 3rd decade

9.best time for surgery

i.after 1 year to before school going age

ii.in adult as soon as detected if symptomatic

(as shunt reversal occurs at 3rd decade)

10indication of ASD surgery?

i.anatomical

uncomplicated ASD(>3mm gap)

PAPVC(partial anomolous pulmonary venous connection) with RV volume overload

ii.haemodynamic

Qp:Qs ≥2

uncomplicated anomali Qp/Qs≥1.5

Qp:Qs ≤2 (if chance of bronchopulmonary sequestration)

iii.PAPVC

isolated PAPVC of whole lung

iv.no age factor

v.PVR

vi.association

MR/TR in old age

if moderate grade MR-MVR followed be ASD repair

11.contra indiction of ASD surgery

i. isolated PAPVC of a part of lung without ASD

ii. Qp:Qs ≤1.8

PVR>8-12unit/sq meter @ rest and not decreased

 

 

complication of a preoperative hypothyroid patient( although was euthyroid during MVR)

 

 

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