医学课件先心病室间隔缺损

AtrialSeptalDefect KendraMarsh MDDivisionofCardiology UICFellow Embryology GestationalWeek4GestationalWeek4 6 Athin crescentshapedwedgeoftissueof septumprimum growstowardsandfuseswithendocardialcushions Theremainingopeningiscalledtheostuimprimum Astheseptumprimumisgrowingdown theendocardialcushionsfuseandtheostiumprimumiseventuallyobliterated Embryology Theinteratrialseptumformsduringthefirstandsecondmonthsoffetaldevelopment StageIistheformationoftheseptumprimum Theseptumprimumwallsoffacrescent shapedportionoftheholebetweentherightandleftatria Foramenprimum alsocalledtheostiumprimum staysopenTheremainingpartoftheopeningbetweentherightandleftatriaisclosedbytheseptumsecundum The2tissuelayersoverlaplikeaflap allowingbloodflowtocontinueduringfetallife Changesincirculationatbirth closestheflappermanently AnatomyandPhysiology Extendsfromcavo atrialjunctionwithsuperiorandinferiorvenacavaeEndsneartheatrio ventricularcanalnearthetricuspidvalve OstiumSecundum MostcommontypeofASDCenteroftheseptumbetweentherightandleftatriumVariantofthistypeofASDiscalledaPatentForamenOvale PFO whichisverysmall OstiumPrimum NextmostcommontypeLocatedinthelowerportionoftheatrialseptum Willoftenhaveamitralvalvedefectassociatedwithitcalledamitralvalvecleft Amitralvalvecleftisaslit likeorelongatedholeusuallyinvolvestheanteriorleafletofthemitralvalve SinusVenosus LeastcommontypeofASDLocatedintheupperportionoftheatrialseptum AssociationwithanabnormalpulmonaryveinconnectionFourpulmonaryveins twofromtherightlungandtwofromtheleftlung normallyreturnredbloodtotheleftatrium UsuallywithasinusvenosusASD apulmonaryveinfromtherightlungwillbeabnormallyconnectedtotherightatriuminsteadoftheleftatrium Thisiscalledananomalouspulmonaryvein asd veno jpg ForamenOvale RemnantoffetalcirculationBehaveslikeflapvalveOpensduringincreasedintra thoracicpressure IncidenceandPrevalence oneofthemostcommoncongenitalheartdefectsseeninpediatriccardiology7 10 ofallpatientswithcongenitalheartdiseaseTwiceasfrequentinfemalesthanmales Presentation FatigueShortnessofBreathGrowthretardationFrequentrespiratoryinfectionsPersistentmurmur Diagnostics ECGX RAYECHOCARDIOGRAPHYSometimescardiaccatheterization ShuntDetermination Normally PulmonaryBloodFlow SystemicBloodFlowShuntSuspectedIf PulmonaryArterySaturation 80 Left Right UnexplainedArterialSaturationlessthan93 RighttoLeft mayalsoseeinPulmonaryEdema PulmonaryDisease oversedationandcardiogenicshockTypesofShuntsSystemicCirculationtoPulmonaryCirculationLefttorightPulmonaryCirculationtoSystemicCirculationRighttoLeft InvasiveMethodstoDiagnoseShunting OximetricMethodIndicatorDilutionMethod PrinciplesoftheOxymetricMethod BloodSamplingfromvariouschamberstodetermineOxygenSaturationLefttoRightShuntispresentwhenasignificantincreaseinbloodoxygensaturationisfoundbetween2rightsidedvesselsorchambers OximetricMethod ShuntRun isperformedifadifferenceof8 ormoreisnotedinbloodsamplingbetweenchambersBloodsamplestakenfromallrightsidedlocations IVC SVC RightAtrium RightVentricleandPulmonaryArteryIncaseofInter atrialshuntmultiplesamplesshouldbecollectedfromtheHigh middleandlowrightatrium SaturationRun ObtainSamplesfrom IVC HighandLowSVC HighandLowRightAtrium High MiddleandLowRightVentricle InflowandOutflowtracts mid cavityPulmonaryArtery Main LeftorRightLocalizingRighttoLeftShuntsoneshouldalsoobtain PulmonaryVeinLeftAtriumLeftVentricleDistalAorta FickEquationtoCalculateOxygenContent Assumesinsteadystatethat thatrateofsubstanceentering CinxQflow isequaltotherateofsubstanceleaving CoutxQflow therateatwhichindicator V isadded Flow Oxygenconsumption Arterial VenousoxygencontentdifferenceWhereoxygencontentisdeterminedbyautomatedmethodsoxygenconsumptionisassumedbasedonpatient sage genderandbodysurfaceareawhennotdirectlymeasured ShuntQuantification PulmonaryBloodFlowOxygenconsumption Differenceinoxygencontentacrosspulmonarybed PvO2 PaO2 SystemicBloodFlowOxygenConsumption Differenceinoxygencontentacrosssystemicbed SaO2 MvO2 EffectiveBloodFlow FractionofMixedVenousbloodreceivedbythelungswithoutcontaminationfromshuntOxygenConsumption PvO2 MvO2 FlammFormula AverageOxygenContentinChambersproximaltotheShuntMethodtocalculateMixedVenousOxygencontentNeedtofactorinContributionfromIVCandSVCwhichisnotequalFlammEquation 3xSVCOxygenContent IVCOxygenContent 4 IntheAbsenceofShunt PBF SBF EBF HowSignificantistheShunt FlowRatioPBF SBF2 0ormore LargeLefttoRightShunt1 0orless NetRighttoleftShuntNoneedtomeasureOxygenconsumptionSincethisnumberwillcanceloutoftheequation IndicatorDilutionMethod MoreSensitiveforsmallershuntsCannotlocalizetheleveloflefttorightshuntLefttoRight Dye indocyaninegreen isinjectedintopulmonaryarteryandasampleistakenfromthesystemicarteryRighttoLeft dyeinjectedjustproximaltothepresumedshuntandbloodsampleistakenfromsystemicartery InterpretationofIndicatorDilutionMethod EisenmengerSyndrome defectintheseptumbetweentheatriaincreasedflowthroughthelungsafterbirth eventuallyresultinpulmonaryhypertension Thefirstindicationofthismaybeareductioninheartsizeflowoverloadisconvertedtoapressureoverload towhichtheheartrespondswithhypertrophy ratherthandilatation Reductioninheart size Astheleft to rightshuntisconvertedbyreversalofflowacrosstheseptumtoright to leftshunt thepatientbecomescyanoticfrommixingofun oxygenatedblood CyanosisisthusalatefeatureofAtrialSeptaldefect Ifcyanosisispresentfrombirth ASDwillbecomplicatedbyoneormorecontributions PulmonaryStenosis PatentDuctus usuallycausesaverylargepulmonaryarteryandenlargementoftheaorta CommonAtrium allowingcompletemixingofoxygenatedandunoxygenatedblood Truncusarteriosus completemixingataorticlevel PregnancyandASD WelltoleratedafterclosureIncreasedriskofparadoxicalemboliperiandpostpartumContraindicatedinEisenmengerSyndromeMaternalmortality50 FetalMortality60 TTEandASD Transthoracicechocardiogramfourchamberviewtoevaluateatrialseptaldefect Notepresenceofinter atrialcommunicationbetweenleftandrightatrium IndicationsforIntervention AsymptomaticChildrenRightHeartdilationASD 5mmNosignsofSpontaneousClosure OlderPatientsHemodynamicallyinsignificantASDwithQp Qs2 3systemicarterialresistancePulmonaryarteryreactivitywithvasodilatorchallengeReversiblechangesonlungbiopsyNetL RShuntof1 5 1 TreatmentOptions 1976 KingetalpublishedthefirstattempttocloseanASDwithadoubleumbrelladeviceSizeofthesheathwas23FrPrimaryMethodoftodateforclosureissurgicalRecentadvancesininterventionalclosuretechniques Trans catheterClosureTechnique ImplantationofoneormoredevicesviacathetermethodEliminatesneedforcardio pulmonarybypassNoneedtostoptheheartwithcardioplegicagents PatientSelection StrictFoodandDrugAdministrationguidelinesEfficacymeasuredusingdatafromstrictfollowupFollow upatregularintervals 3 6 and12monthstheyearfollowingtheinitialprocedureAnyadverseeventsrequirefollowupfor5 7years PatientSelection Defectssmallerthan20 25mmindiameterShouldnothavedefectsintheveryupperorlowerportionsoftheseptumOstiumPrimumorSinusVenosus notgoodcandidatesbecausedefectusuallyinvolvesheartvalvesorabnormalvenousdrainagefromthelungsOnlybenefitOstiumSecundumdefectsNoloweragelimit butmustweighmorethan8 10kg Trans catheterApproach DeviceisadvancethroughanintroducersheathOne Halfofthedeviceisdeployedonleftsideofatrialseptum thesecondhalfisdeployedontherightsideA sandwich isformedoverthedefect6 8weeks deviceasaframeworkforscartissuetoformInchildrenthenewtissueformationwithcontinuetogrow TTEpostIntervention TransesophagealechocardiogramshowingAmplatzerdeviceplacedacrossthedefectforminga sandwich overtheatrialseptaldefect TTEafterintervention TransthoracicechocardiogramfourchamberviewonedayafterAmplatzerdeviceplacement Completeresolutionofshunt TransthoracicechocardiogramonedayafterAmplatzerdeviceplacedwithhighlightedareathatshowsnofurthershuntingofbloodacrossatrialseptum TissueformationoverHelexdeviceincaninemodel Invivotissueresponsedemonstratingflatprofile conformancetotheseptum andnonthrombogenicOccludermaterial topphotoshowsleftatrialview bottomphotoshowsrightatrialsideview Trans catheterDevices AmplitizerAtrialSeptalDefectOccluder AGAMedical GoldenValleyMn2001 FDAapprovedforSecundumlesionsNitinolmeshframeworkandleft rightatrialdisksFilledwithpoly fabrictopromotethrombosusCost 11K Surgery 21K Helexatrialseptaldefectdevice W L Gore AssociatesJuly1999Nitinol nickel titaniumalloyWireframeinshapeofcoilwithGore Tex9FrintroducersheathCost 6000 HelexSeptalOccluderDeliverySystemcomponents HelexSeptalOccluderDevicecomponents Outcomes Amplatzerstudy100childrenandadultsMeanage13 393patientssuccessfulimplantationOcclusionrateat3monthstotalocclusionImproveRVandLVfunctionanddecreasedLAvolumesPercutaneousClosureandFunctionalCapacity32adultsmeanage43yoQp Qs2 0 6months improvedO2uptakewithexerciseascomparedpre closurestatus ComparisontoSur