Understanding Atrial Septal Defects and Related Cardiac Conditions
Atrial Septal Defect (ASD)
Definition: An opening in the interatrial septum causing a left-to-right shunt and overload of the right atrium (RA) and right ventricle (RV).
Classification and Prognosis
| Classification: | Prognosis: |
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Diagnosis
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I-Symptoms: < 5 mm → asymptomatic > 5 mm:
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III-ECG:
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V-XRAY:
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II-Auscultation:
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IV-Echo:
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Treatment
- I-Percutaneous Defect Closure:
- Indication: Qp/Qs >1.5+RV overload
- Contraindication: irreversible pulmonary hypertension
- Heart & Lung Transplant: Eisenmenger syndrome
- Follow-up valve surgery
- Vitamin K Antagonist
Infective Endocarditis (IE)
| Major | Minor |
I-(+) Blood Culture:
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Treatment
Empirical:
- Streptococci:
- Penicillin + Gentamicin
- Amoxicillin
- Ceftriaxone
- Staphylococci:
- Oxacillin
- Clindamycin
- Vancomycin
- Enterococci:
- Amoxicillin
- Ampicillin + Gentamicin
Antibiotic therapy for 4-6 weeks
Atrial Fibrillation / Atrial Flutter
| Atrial Fibrillation | Atrial Flutter |
Classification:
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Classification:
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Anticoagulation
| Risk assessment (CHA2DS2-VASc Score) | Treatment |
The higher the score, the higher the risk of developing stroke. |
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Rate and Rhythm Control
| Acute: | Long-term |
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Acute Coronary Syndrome (ACS)
| NSTEMI (Non-ST Elevation Myocardial Infarction) like Unstable Angina (NOT TOTAL occlusion) | STEMI (ST Elevation Myocardial Infarction) |
(no fibrinolytics) Catheterization for angiography If Catheterized: Clopidogrel & Glycoprotein IIb/IIIa inhibitor If symptoms >12 hours, PCI fails → CABG!!! |
(No heparin because clot is complete, too big by now) Supportive Care (Oxygen, Nitrates + Morphine) Catheterized for angiography: Clopidogrel & Glycoprotein IIb/IIIa inhibitor If tPA works, do PCI (within 24 hours) If tPA doesn’t work or contraindicated → do PCI immediately If PCI fails → Do CABG!!! |
Congestive Heart Failure (CHF)
Definition: Structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood adequately to meet the body’s needs.
Etiology
↓ EF <40% (Systolic failure)
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Preserved EF
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Classification
| Severity (NYHA) Classes: | Progression (ACC/AHA) Stages |
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Clinical Features
Course: acute/chronic
Cardiac Output: Low/High
Location: Left/ right/biventricular
Impaired function: Systolic / Diastolic
Left Ventricular Failure Symptoms:
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Left Ventricular Failure signs:
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Right Heart Failure Symptoms:
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Right Heart Failure signs:
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Diagnosis
Echocardiography:
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X-ray:
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| Coronary angiography |
ECG:
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LAB:
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Treatment
General:
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Medications:
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Surgical approach:
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Implantable defibrillator:
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Heart Transplant
| Indication | Contraindication: |
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Cardiosurgery
Tetralogy of Fallot
Surgical treatment:
- Widening of the narrowed pulmonary blood vessels
- Pulmonary valve is widened or replaced
- Passage from Right Ventricle to Pulmonary artery is enlarged
- It is done to increase blood flow to the lungs to bring oxygen
- Repair the Ventricular Septal Defect
- A patch is used to cover the hole in the septum
- The patch stops oxygen-rich and oxygen-poor blood from mixing
Characteristics:
- VSD
- Overriding aorta
- RVH
- Pulmonary infundibular stenosis
Transposition of Great Vessels
I-Temporary:
- Atrial Septal Defect & Ventricular Septal Defect allow blood to circulate between 2 sides of the heart (Septostomy)
II-Permanent: Switch the arteries to their proper places
Radical and Palliative Heart Surgeries
Palliative heart surgeries:
- Type I: Increase Pulmonary Flow (Aortopulmonary Junction)
- Type II: Decrease Pulmonary flow & Hypertension
- Type III: Improve Mixture of arterial and Venous Blood
- Type IV: Decrease the load of the Right Ventricle
Heart Transplant Procedure:
- Performed on patients with End-Stage Heart Failure or Severe Coronary Artery Disease when other measures failed.
Procedure:
- I-Orthotopic transplant: Removal & Replacement of the patient’s heart with a donor’s heart
- II-Heterotopic Transplant: Implant donor heart with the patient’s heart left in place
In Orthotopic Transplant:
- The native heart is removed
- Leaving Superior Vena Cava, Inferior Vena Cava, the left Atrial cuff, the aorta, and pulmonary artery in situ
- The left Atrial cuff is anastomosed first, to provide heart inflow
- Right heart inflow is achieved by using the bicaval technique
- Donor main pulmonary artery is connected to the recipient’s pulmonary artery
- The final aortic anastomosis is completed
- 3-5 days of inotropic support to recover from cold ischemia
Nonruptured Abdominal Aortic Aneurysm
Indications for surgery:
- Abdominal Aortic Aneurysm >5.5cm
- Asymptomatic Abdominal Aortic Aneurysm
Treatment:
- Elective surgery
- Endovascular aneurysm Repair:
Indications for Endovascular Aneurysm Repair:
- Symptomatic + expanding aneurysm (due to the high risk of rupture)
- Open repair: young patients
- Endovascular repair (older and high-risk patients)
- Asymptomatic: but aneurysm >4 cm
- Complicated aneurysm (embolism, thrombosis, fistulization)
Treatment:
- I-Monitoring: To check whether or not the aneurysm is growing
- II-Prevention: Healthy food/exercise/ avoid Cardiovascular Disease risk such as smoking, control blood pressure
- III-Surgery:
- Open abdominal surgery
- Endovascular surgery to repair an abdominal aortic aneurysm
- Remove damaged section
- 1 month to recover
- Less invasive
- Groin incision
- X-ray guided
- Synthetic graft to the end of the catheter
- Insert it through an artery
- Graft placed at the site of the aneurysm
- Held in place by a metal mesh
- Reinforces the weakened section
- Shorter recovery time
Autogenous Vein in Vascular Bypass Surgery
Advantages:
- Decreased Infection
- Decreased rejection
- No anticoagulation
- No thromboembolism
Disadvantages:
- Structural Deterioration
- Limited Quantity
- Not as Strong