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LVH CoA MR
PS MS CoA Bayi
Common Mixing Atrial TAPVD Uniatrial Common mixing AV CAVSD Common Mixing Ventricle Single ventricle HLHS, TA, MA DORV, DILV Truncus (A-P Window) TGA + VSD
Common Mixing
Pressure & saturation of O2 in Aorta & pulmonal is the same
PDA
<10days
Mature
Medical th/
Failed reactive
Closed spontaneously
Conservative
HF :heart failure PH : Plumonary hipertension PVD : Pulmonary Vascular Diseases ASO tidak dapat dilakukan pada bayi < 8 Kg
ASD
Big Shunt
Adolescent Adult HF (+)
Medical th/ Failed Controlled > 1 yo
Observe
PH (-)
Cath
Immediately
FR < 1.5
FR > 1.5
Conservative
Conservative
HF :heart failure PH : Plumonary hipertension PVD : Pulmonary Vascular Diseases Reactive : PARI < 8 u/m2
VSD
HF (+)
Medical th/ Failed Controlled
HF (-)
Natural History
Closed Spontaneously
Smaller
PAB
If weight < 3kg
Cath
Cath
5 yo FR < 1.5 FR > 1.5
Cath
Evaluate 6 mo reactive Non reactive Conservative
VSD Closure
VSD + PH
Pulmonary Hypertension No or High Flow Yes High Flow Catheterization
PARI
Follow up Till Pre School < 8 u/m2 >8 u/m2
Flow ratio
< 1,5 > 1,5
VSD Closure
TOF
< 1 yo
Spell (+)
PROPANOLOL Failed Controlled
PA/RV graphy
Small PA
Spell : O2 100% > 1 yo Knee Chest Position MO 0,1 mg/kgbb Diazepam 0,1 mg/kgbb BicNat 3-5 meq/kgbb Propanolol 0,02-0,1 mg/kg Fenilefrine CI 2-5 mg/kgbb/mt Cath IV 0,02 mg/kg IM 0,1 mg/kg if not controlled Ventilation Good size PA BT Shunt,sat <30
BTS
evaluate 6 mo
Cath
BTS
PA/RV graphy
BCPS CRITERIA
1. 2. 3. 4. PAp < 18 mmHg PARI < 4 Um2 PA Confluence PA half size suitable (Kirklin)
CRITERIA FONTAN
1. 2. 3. 4. 5. 6. PAp < 15 mmHg PARI < 4 Um2 PA Confluence PA half size suitable (Kirklin) AV valve regurg. (-) LV dimension & function adequate for Systemic Pump 7. Arrhythmia (-) 8. Age over 2-3 yo.
TGA
Cath
Cath
LV > 2/3 LV < 2/3
BTS
PARI <8 PARI >8
Cath
PAB
ARTERIAL SWITCH
RASTELLI
SEQUENTIAL ANALYSIS
1. 2. 3. 4. Established Atrial Situs Ascertain Atrioventicular connexions Decide Ventriculo-Arterial Ascertain relationships
Right Left & Anterior Posterior relationship
SITUS
Established Atrial Situs Situs Solitus
Morphology right Atrium right side Morphology left Atrium on the left side
Situs Inversus
Morphology right Atrium left side Morphology left Atrium on the right side
Situs Ambigus
Not possible to separate right & left atria by morphological
Situs Solitus
By Plain Ro Right sided liver Means / Inference Right Sided Inferior vena cava & RA Sinus Node Tri-lobed, morphologically right Lung Echo
short axis Subxiphoid Thoracal X
V Spine
Bronchial Branches
Strong Xray Right side three lobed distance from bifurcatio shorter Left side two lobed distance from the bifurcatio shorter
IVC always to RA In LA isomerism, there must be an interrupted IVC. Azygos to SVC (Left) Hemiazygos to SVC (right) SVC doesnt always into RA, can be bilateral
SITUS AMBIGUS
By Plain Ro Liver both side, stomach in the middle Bilateral right lung type RA isomerism Asplenia Bilateral left lung type LA isomerism Polysplenia
AV connection
Discordant Ambigus Double inlet Single inlet (univentricular) Straddling,
insertion of papillary muscle MV in RV or insertion of papillary muscle TV in LV
Overriding
Insertion papillary of overriding mitral in the LV
VA c Ao onnection
Physical examination
2nd Heart sound single, not accentuated : PA 2nd Heart sound single, loud : TGA
Side by side Ao P Anterior (Ao) posterior (P)
Ao P
Normal
Ao
Hyperoxidation Test
O2 100% 10-20 minutes Lung problem
Saturation O2 increased to 100%
Cardiac problem
saturation O2 increased less than 30%
SITUS ATRIAL
PANDANGAN SUBCOSTAL ( SAGITAL KORONAL )
Situs solitus
RA
SITUS ATRIAL
PANDANGAN SUBCOSTAL ( SAGITAL KORONAL )
Situs ambigus :
RA isomerisme ( asplenia )
Keduanya morfologi RA IVS dan AOD satu sisi di kanan atau di kiri kolum vertebrae.
LA isomerisme ( polisplenia )
Keduanya morfologi LA IVS terputus melalui v. azygos / v.hemoazygos masuk ke VCS dan RA
L loop :
Morfologi RV di kiri Morfologi LV di kanan
Morfologi Ventrikel
PANDANGAN PARASTERNAL DAN PANDANGAN APIKAL 4 RUANG
Ventrikel kanan
Katup trikuspid : lebih dekat ke apex insersi khorda ke septum (+) Moderator band Trabekular kasar
Ventrikel kiri
Katup mitral ( bikuspid) : lebih jauh dari apex Insersi khorda ke septum (-) 2 muskulus papalaris besar ada di dinding ventrikel Trabekel halus
Koneksi Atroventrikuler
PANDANGAN APIKAL / SUBKOSTAL 4 RUANG
Konkordan :
Morfologi RA berhubungan dengan morfologi RV Morfologi LA berhubungan dengan morfologi LV
Diskordan :
Morfologi RA berhubungan dengan morfologi LV Morfologi LA berhubungan dengan morfologi RV
Koneksi Atroventrikuler
PANDANGAN APIKAL / SUBKOSTAL 4 RUANG
Ambigus :
Apa bila morfologi ke 2 atrium : RA atau LA (ambiogus)
Double inlet :
Kedua atrium berhubingan dengan satu ventrikel
A. Pulmonalis : bifucartio
bercabang dua
Relasi normal :
Aorta di posterior kanan PA
Malposisi
Aorta di : Anterior PA Anterior kiri PA Kiri dan kanan PA ( side by side )
Rongga atrium :
Septal atrium ASD Cor triatriatum
Atrioventrikular junction :
Katup AV : stenosis, atresia, cleft, regurgitasi, stradlling Septum : AVSD
KESIMPULAN
Ekokardiografi 2 dimensi paling penting untuk diagnosis PJB Diagnosis lengkap dan akurat bila dilakukan secara sistimatis ( analisa squensial ) Pemeriksa harus :
1.Mengerti anatomi dan morfologi jantung 2.Mengetahui gambaran karakteristik dari echo 2D 3.Trampil dan teliti
Hyperoxidation Test
O2 100% 10-20 minutes Lung problem
Saturation O2 increased to 100%
Cardiac problem
saturation O2 increased less than 30%
DORV : Double Outlet Right Vemtricle PAB : Pulmonary Artery Banding BTS : Blalock-Taussig Shunt BCPS : Bi Cavo-Pulmonary Shunt PS : Plumonary Stenosis TB : Taussig Bing
DORV
VSD SP (TB) PS (-) < 3 mo
VSD Subaortic
PS (+)
PAB TOF algorithm
PS (-)
BTS
> 3 mo
Cath
PAB
Cath
Cath
Cath
Cath
reactive Reactive
PAB
< 1 yo
INTRA VENTRICULAR TUNNELLING
Non PS Reactive resectable PS Non resectable CON SER VATIVE EXTRACARDIAC CONDUIT/ FONTAN
Non reactive
BCPS
BCPS
FONTAN TCPC
Taussig Bing
Echo
Great arteries side by side Conus between
MV & PV PV & Ao poss. Stenosis post arterial switch.
Often associated with Ao Arch Hypoplastic IN TGA there uss. Without Conus.
APVD : Anomaly Pulmonary Vein Drainage SVD : Sinus Venosus Defect BAS : Ballon Atrial Septostomy
APVD
Total
Obstruction (+)
Partial
PH (+) PH (-)
Obstruction (-)
PH (-)
PH (+)
BAS
Cath Cath
REACTIVE
NON REACTIVE
REACTIVE
TAPVD CORRECTION
CONSERVATIVE
PA + IVS
PGE1 Tricuspid Valve
Score 2 < - 4 Sinusoid RV Anomaly Coroner
BAS
Tricuspid Valve
Score 2 > - 4
< 6 mo BTS
> 6 mo
Cath
Small PA
BTS BCPS
Big PA
FONTAN /TCPC
PA + VSD
NEONATUS
PGE1
Cath Shunt
Cath
Selective Aortography MAPCA (+)
Univocalisasi + BTS
MAPCA (-)
RASTELLI OPERATION
TRICUSPID ATRESIA
PULMONARY FLOW
< 6 mo
PGE1 BAS/BH BTS
PULMONARY FLOW
> 6 mo
> 6 mo
BTS
PAB
Cath Cath
BCPS
Cath
Pap > 15 mmhg PARI < 4 HRU PAB < 15 mmhg < 4 HRU > 15 mmhg < 4 HRU
BCPS
< 2 yo
BCPS
> 2 yo
Cath
FONTAN TCPC
CONGENITAL AS
INFANT / BABY Severe
PG > 4.75 cm2/m2
CHILD / ADULT
PG > 60 mmhg PG < 60 mmhg LV strain Syncope Chest Pain BAV
Mild / Moderate
PG > 4.75 cm2/m2
BAV
NORWOOD
Cath
Cath
FONTAN
Ao Valvotomy
COARCTATIO AORTA
SIMPLE CoA
Ao Arch Normal
CoA + VSD
Ao Arch Hypoplastic
COMPLEX CoA
Hypoplastic LV & MV HLH
NORWOOD
Complete Repair In CPB
Multiple/Big VSD
HIGH RISK
Single VSD
FONTAN