Cardiac Tutorial Revisi 2 UNTUK PALANGKARAYA

7/27/2019 Cardiac Tutorial Revisi 2 UNTUK PALANGKARAYA

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CARDIAC IMAGING

Dr. Rahmad Mulyadi, SpRadRadiology Department

University of IndonesiaJakarta


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Atrium - Top two chambers

Right Atria - receive blood from body

Left Atria receive blood from lungs

Ventricles - Bottom two

chambers

Right ventricle pumps blood to lungs to

pick up oxygen

Left ventricle pumps blood to the rest of

the body

Anatomy of the Human Heart


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Coronary Arteries

Cells within the heart need

oxygen

Two CAs carry oxygen-rich blood

to heart muscle

Right Coronary artery

Left Main branches into two

narrower arteriesLeft Circumflex

Left Anterior Descending


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Diagnostic Studies

Invasive

Cardiac catheterization

Non Invasive

Chest X ray Echocardiography

Doppler Ultrasonography

Computed Tomography (CT) Magnetic Resonance Imaging (MRI)

Nuclear Medicine.


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Chest X-RayAnalysis of chest film for cardiac disease : Cardiac enlargement : shape and size

Overall : Cardiothoracic ratio (CTR) > 50% Selective chamber enlargement Pericardial effusions

Secondary/associated pulmonary changes

The mediastinum, for the size and location of the aortaand major systemic veins

Great vessels changes calcify, elongation, aneurysm

Position of pacemaker

Extracardial anomalies that may be associated with heartdiseaseThe plain film is virtually never relied upon for the diagnosisof the nature if the cardiac lesion it is valuable as anindicator of the severity of any haemodynamic disorder in

revealing cardiomegaly, state of the lungs, and to followprogress.


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Computed Tomography

Computed tomography is a digitally based x-ray

technique the resulting images arise fromdifferential x-ray absorption of tissue, a feature thatrests primarily on atomic weight (and thus theelectron density) of the various tissues.

The technique uses a narrowly collimatedx-raybeam to irradiate a slice of the body the amountof radiation transmitted is collected by photo-multiplier tubes and counted digitally.

By rapidly acquiring views from numerous different

projections, achieved by quickly rotating the tubeand detectors around the body.


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Once these transmission values are collected,they can be digitally filtered and back-projectedmathematically (by a technique known as

Fourier transformation) onto a matrix whichrepresents fine differentiation of tissue densities The Hounsfield scale (bone is +1000 and airis -1000) ,

CT : single slice/ multislices (MSCT), can bedisplayed as a 3-dimensional structure. MSCT : native/contrast CT,CT angiography,

perfusion CT. Computed tomography has the advantage of

rapid acquisition of images, but employs ionizingx-ray radiation which must be usedconservatively to avoid harmful cumulativebiologic effect.


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Noninvasive Diagnostic Studies

Echocardiography

Echocardiography has great value in

assessing congenital cardiac anomalies

and should usually be the first advanced

diagnostic study to be carried out if the

history, the physical examination, the

chest X ray, and the electrocardiogramsuggest the presence of congenital heart

disease.


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Echocardiography

The standard M-mode display and the

two-dimensional display provide such

information about cardiac anatomy as the

size of the cardiac chambers, the

connections of the great vessels,

abnormalities of the valves, andsubvalvular obstructions.


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Doppler ultrasonography

Doppler ultrasonography is useful indetecting septal defects and directly

assessing the amount of blood thatshunts through the defect.

The size of the shunt through a septaldefect can also be estimated from

Doppler ultrasound studies by comparingthe velocity of the blood flow through theaorta with velocity through the pulmonaryartery.


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Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging depends on immersing thebody in a steady, strong magnetic field, commonly up to1.5 Tesla (i.e. 15,000 Gauss for reference, the earth'smagnetic field is about 0.5 Gauss).

Some modern "whole-body" machines now operate at 4or more Tesla.

Hydrogen atoms, pervasive in the water which makes upabout 70% of the body's mass, have a dipole propertyby virtue of their characteristic spins.

Hydrogen spinning atoms, influenced by thepermeating magnetic field precess in alignment withthe dominant magnetic field Subjecting the bodytissues to an additional magnetic field gradient aspecific tissue slice of the body for imaging whileabsorbing this radiation in a resonant fashion.


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Hydrogen atoms alter their net magnetic axis directiontemporarily (excitation state) _rapidly decays to alower energy state while emitting its own unique radiofrequency signal detected by an external radio-frequency coil calculating images tissue-relatedimages.

Special pulse-echo sequences permit high level signals tobe detected from flowing blood images of thevasculature and it's blood velocity characteristics.

Functional MRI" detect differences oxygen-saturatedand de-saturated blood.

Brain processes of "thought" such as vision, motorcontrol and speech can be detected (though at lowspatial resolution) by virtue of their local oxygen

consumption when activated.


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To evaluate :

Cardiac structure Cardiac chamber

Valvular heart diseases

Pericardial diseases

Congenital heart diesases

Functional imaging in ischemic heart disease

Magnetic Resonance Coronary Arteriography coronary artery.


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Chest x ray


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Features that are typically examined on a chest X-ray

Every doctor will have a different approach to examining chest X-rays. A

commonly used mnemonic for what to look for on a chest X-ray is: It May Prove

Quite Right (but) Stop And Be Certain How Lungs Appear:

I = Identification (name, age, sex, indication for X-ray) by mas

M = Markers (differentiate left from right - diagnose dextrocardia)

P = Position - the spinous process ofT4 should be between the heads of the clavicle (if it isn't thebody is rotated)

Q = Quality - is the film penetrated properly. In a properly penetrated film the vertebral interspacesshould be visible behind the central (cardiac) shadow

R = Respiration - chest X-rays are typically done with full inspiration

(but) S = Soft tissue - look forsubcutaneous emphysema (suggestive of trauma), soft tissue swelling

A = Abdomen - look forfree abdominal air(suggests penetrating trauma, peritonitis, or recentsurgery)

B = Bone - look for fractures (these tend to be at the lateral aspects because of the mechanics -bending moment largest at lateral aspect)

C = Central shadow (cardiac silhouette) - greater than 50% of lateral distance in frontal view at thediaphragm suggests cardiac enlargement (usually secondary to heart failure) or a pericardialeffusion). A widened mediastinum may suggest aortic dissection.

H = Hila (of the lungs) - can be affected in lung disease, malignant processes and infection (hilarlymphadenopathy).

L = Lungs - for consolidation, interstitial lung disease (reticular, nodular or reticulonodular),honeycombing, miliary pattern, granulomas, lung masses

A = Absent structures/Apices of the lung (forpneumothorax
http://en.wikipedia.org/wiki/Mnemonichttp://en.wikipedia.org/wiki/Dextrocardiahttp://en.wikipedia.org/wiki/Spinous_processhttp://en.wikipedia.org/wiki/Claviclehttp://en.wikipedia.org/wiki/Subcutaneous_emphysemahttp://en.wikipedia.org/wiki/Pneumoperitoneumhttp://en.wikipedia.org/wiki/Bending_momenthttp://en.wikipedia.org/wiki/Pericardial_effusionhttp://en.wikipedia.org/wiki/Mediastinumhttp://en.wikipedia.org/wiki/Aortic_dissectionhttp://en.wikipedia.org/wiki/Pericardial_effusionhttp://en.wikipedia.org/wiki/Pericardial_effusionhttp://en.wikipedia.org/wiki/Mediastinumhttp://en.wikipedia.org/wiki/Aortic_dissectionhttp://en.wikipedia.org/wiki/Lymphadenopathyhttp://en.wikipedia.org/wiki/Lymphadenopathyhttp://en.wikipedia.org/wiki/Lymphadenopathyhttp://en.wikipedia.org/wiki/Lymphadenopathyhttp://en.wikipedia.org/wiki/Hilumhttp://en.wikipedia.org/wiki/Lymphadenopathyhttp://en.wikipedia.org/wiki/Pneumothoraxhttp://en.wikipedia.org/wiki/Pneumothoraxhttp://en.wikipedia.org/wiki/Lymphadenopathyhttp://en.wikipedia.org/wiki/Hilumhttp://en.wikipedia.org/wiki/Hilumhttp://en.wikipedia.org/wiki/Aortic_dissectionhttp://en.wikipedia.org/wiki/Mediastinumhttp://en.wikipedia.org/wiki/Pericardial_effusionhttp://en.wikipedia.org/wiki/Pericardial_effusionhttp://en.wikipedia.org/wiki/Bending_momenthttp://en.wikipedia.org/wiki/Pneumoperitoneumhttp://en.wikipedia.org/wiki/Subcutaneous_emphysemahttp://en.wikipedia.org/wiki/Claviclehttp://en.wikipedia.org/wiki/Spinous_processhttp://en.wikipedia.org/wiki/Dextrocardiahttp://en.wikipedia.org/wiki/Mnemonic


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Another approach is to examine first any major abnormality,

and then "review areas":

the apices,

the hila,

behind the heart (it must be rememberedthat lung can be seen through the heart),

the cardiophrenic angles,

the costophrenic angles,

beneath the diaphragm, and then

bone and soft tissues.


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Views

Typical views

PA (posterior-anterior) view - The patient faces away from X-ray source - X-rays pass from their source to patients back through the body to exit throughthe anterior body wall to expose the film

AP (anterior-posterior) view - The patient faces the X-ray source - these aretypically done in the ICU

Lateral view

The most common view is the PA (posterior-anterior) and is frequently donewith a left lateral view (so one can identify the location of abnormalities in 3-D space). PA views are preferred to AP views (which are often done withmobile/portable X-ray equipment), but much less convenient in the ICUsetting or when a patient cannot otherwise leave their bed. PA views arepreferred because the central shadow is better defined, the magnification ofthe heart is reduced, radiation to the breast tissue is reduced, and less ofthe lungs obscured by the heart/pericardial sac.
http://en.wikipedia.org/wiki/Human_anatomical_termshttp://en.wikipedia.org/wiki/Intensive_Care_Unithttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Pericardial_sachttp://en.wikipedia.org/wiki/Pericardial_sachttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Intensive_Care_Unithttp://en.wikipedia.org/wiki/Human_anatomical_terms


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Additional views

DecubitusDecubitus - useful for differentiating pleuraleffusions from consolidation (e.g. pneumonia)andLoculated effusions from free fluid in the pleura. if thethickness of linear fluid exeeds 1cm its mondatory to

pleural tap must be done "Tapping pluid"(N.A.Exeer,MD).In effusions, the fluid layers out(by comparison to an up-right view, when it often accumulates in the costophrenicangles).

Lordotic view - used to visualize the apex of the lung, to

pick-up abnormalities such as a Pancoast tumour. Expiratory view - helpful for the diagnosis of

pneumothorax

Oblique view Lordotic
http://en.wikipedia.org/wiki/Pleural_effusionhttp://en.wikipedia.org/wiki/Lordotichttp://en.wikipedia.org/wiki/Lordotichttp://en.wikipedia.org/wiki/Lordotichttp://en.wikipedia.org/wiki/Pleural_effusion


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Lateral viewThe cardiacsilhouette in this view isoval in shape and occupythe anterior half of thethoracic cage.

The ascending aorta andright ventricle form theanterior border, while theleft atrium and leftventricle form the

posterior border.


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The frontal film

Trachea

R main

bronchus

L main

bronchus

Pulmonary artery

Gastric air bubble

Blood-filled

pulmonary vesselscast soft gray

shadow and

typically taper out to

periphery, while

bronchi and

bronchioles are air

filled and do not cast

a shadow on the

image

Pleura not normally

visible


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Ascending

aorta

Aortic knob

Descending

aorta

RALA

RV

LV

The frontal chest film

may be acquired PA

or AP

View the film as

though the patient is

facing you with hisleft on your right

If the film is

unmarked, rememberyour anatomy (heart

and aortic arch are

left of midline)


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The diaphragm is a

musculotendinous

sheet separating the

thoracic and

abdominal cavities

The left and right

hemidiaphragms

are usually well

seen on PA and

lateral films

The plane of the right

diaphragmatic dome is

usually about half an

interspace higher than

the left

R

L

L

R

Look at the diaphragm and upper abdomen

~ interspace


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typically left chest is placed


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Normal lateral film

E

T

DA

typically left chest is placed

against detector to minimize

cardiac magnification


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Barium Swallow/ Cor analisa


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Normal Chest X-ray

Cardiac Structures

Position

More central in younger infants and children

More on the L side in older infants and teens

Size

In AP view if < 2 years take up to ~ 65%

If > 2 years - ~ 50%


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Mitral Stenosis (MS)

Definition :

Obstruction to left ventricular blood inflow atthe level of the mitral valve (MV)

Mit l t i


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Mitral stenosis

Mitral stenosis is a heart valvedisorder that narrows orobstructs the mitral valveopening. Narrowing of themitral valve prevents the valvefrom opening properly and

obstructs the blood flow fromthe left atrium to the leftventricle. This can reduce theamount of blood that flowsforward to the body. The mainrisk factor for mitral stenosis isa history of rheumatic fever but

it may also be triggered bypregnancy or other stress onthe body such as a respiratoryinfection, endocarditis, andother cardiac disorders


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Mitral Stenosis

Tests may include: Chest x-raya test that uses radiation to take pictures of structures inside

the chest

Electrocardiogram (ECG, EKG)a test that records the heart's activity bymeasuring electrical currents through the heart muscle

Echocardiograma test that uses high-frequency sound waves

(ultrasound) to examine the size, shape, and motion of the heart; in this test,the sound waves are passed through a transducer that is placed onto yourchest.

Transesophageal echocardiogramuses the same ultrasound techniquesto create an image of your heart, but gives a more detailed image. In thistest, the transducer is passed down your esophagus (the tube in your throatthat runs from your mouth into your stomach), to allow a better examination

of the mitral valve. Cardiac catheterizationan x-ray of the heart's circulation that is done after

injection of a contrast dye

Holter monitora portable EKG device that you wear for 24 or more hours,to detect heart rhythm abnormalities that often accompany mitral stenosis
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Mitral Stenosis


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Mit l St i l b bl d


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Mitral Stenosis - upper lobe blood

diversion. Trivial enlargement of the

transverse diameter of theheart. Left atrium causesdouble outline (opposite rightarrow) and is somewhatdilated. Left atrial appendageis dilated, causing aprominence of the left border(opposit left arrow). Upper lobevessels larger than lower lobevessels, that is, upper lobe

blood diversion. An arrowpoints to a dilated upper lobevein.


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MS


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MS

Mitral Regurgutation


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Mitral Regurgutation

(MR)/ Mitral Insufficiency (MI)

Definition:

Incomplete closure of mitral valve during left

ventricular systole leading to retrograde

blood flow into left atrium.


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Mitral regurgitation

Acute mitral regurgitation Chronic mitral regurgitation


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Mitral Regurgitation

Chest X-ray

Heart size may be normal in mild cases or

in acute regurgitation

Cardiomegaly (due to left atrial and left

ventricular enlargement in significant

chronic mitral regurgitation


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MI


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The echocardiogram is commonly used toconfirm the diagnosis of mitral regurgitation.Color doppler flow on the transthoracicechocardiogram (TTE) will reveal a jet ofblood flowing from the left ventricle into the

left atrium during ventricularsystole. Because of the inability in getting accurate

images of the left atrium and the pulmonaryveins on the transthoracic echocardiogram,a transesophageal echocardiogram may benecessary to determine the severity of themitral regurgitation in some cases.

Factors that suggest severe mitralregurgitation on echocardiography includesystolic reversal of flow in the pulmonaryveins and filling of the entire left atrial cavityby the regurgitant jet of MR.

Transesophageal echocardiogram of

mitral valve prolapse
http://en.wikipedia.org/wiki/File:Mitralinsuff_TEE.jpghttp://en.wikipedia.org/wiki/Echocardiogramhttp://en.wikipedia.org/wiki/Systolehttp://en.wikipedia.org/wiki/Transesophageal_echocardiogramhttp://en.wikipedia.org/wiki/Transesophageal_echocardiogramhttp://en.wikipedia.org/wiki/Transesophageal_echocardiogramhttp://en.wikipedia.org/wiki/Systolehttp://en.wikipedia.org/wiki/Echocardiogramhttp://en.wikipedia.org/wiki/File:Mitralinsuff_TEE.jpghttp://en.wikipedia.org/wiki/File:Mitralinsuff_TEE.jpg


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The Role of Imaging in Detection

Congenital Heart Disease


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For the fetus the placenta is the

oxygenator so the lungs do little

work

Shunts are necessary for survival

- Ductus venosus (by passes liver)

- Foramen ovale (RL atrial level shunt

- Ductus arteriosus (RL arterial

level shunt

With first few breaths lungs expand

and serve as the oxygenator (and

the placenta is removed from thecircuit)

Foramen ovale functionally closes

Ductus arteriosus usually closes

within first 1-2 days

Fetal Circulation


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Cardiac Position: Dextrocardia

Situs inversus Situs solitus


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Chest X-ray examination

Cardiac Size

To examine size and

shape of the cardiac

To examine the

enlargement of each

cardiac chamber


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Chest X-ray examination

Rule-out pulmonaryparenchymal disease

Evaluate pulmonary

blood flow

increased versus

decreased blood flow


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Computed tomography (CT)

CT provides a good display of the

anatomic abnormalities associated with

congenital heart disease and offers

advantages over echocardiography in

demonstrating anomalies involving the

great vessels.


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Indications: Cardiac CT

Detection of disease or pathology

i.e., diagnosis

Improve clinical decision making(Not first imaging)

No role in defining normal anatomy

No role in assessing function

Not a screening tool


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Mitral Regurgitation

Chest X-ray

Heart size may be normal in mild cases or

in acute regurgitation

Cardiomegaly (due to left atrial and left

ventricular enlargement in significant

chronic mitral regurgitation


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Other Indications

Extracardiac great vessel anomalies

Intracardiac shunt lesions

Diagnosis of cardiac congenital diseases

atrial septal defects

ventricular septal defects

Evaluate post-operative anatomyusually complex cyanotic heart disease

Pulmonary Sling:


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y gLeft pulmonary artery arises from right

pulmonary artery

Neonate

A ti C t ti


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Aortic Coarctation

10-day old girl with CHF; 8 cc contrast,

3D CTCT

Patent Ductus Arteriosus


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Patent Ductus Arteriosus

CT MR

In patent ductus arteriosus, pulmonary blood flow, LA and


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p , p y ,

LV volumes, and ascending AO volume are increased

AO = Aorta

LA = Left aorta

LV = Left Ventricle

PA = Pulmonary artery

Shunt Lesion: Septal Defects


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Shunt Lesion: Septal Defects

Post ASD repairASD/VSD

ASD

Post operative Evaluation:


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Post-operative Evaluation:

Graft right atrium

to pulmonary arteryGrafts subclavian arteries to

pulmonary arteries

N i i Di ti St di


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Magnetic resonance imaging (MRI)

MRI provides information similar to

that provided by CT. MRI offers better resolution than CT

without the disadvantages of the

radiopaquecontrast medium used inthat technique.


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I i Di ti St di


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Invasive Diagnostic Studies

Cardiac catheterization andselective angiocardiography

are the most definitive diagnostic

techniques currently available foruse in congenital heart disease.

Noninvasive studies often provide

information that is equivalent to that

obtained from cardiac catheterization and

is sufficient for planning surgical

treatment.


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Congenital Heart Disease (CHD)

Simple way to classify is:

Acyanotic CHD (LR shunts)

Cyanotic CHD (RL shunts) Obstructive lesions

CLASSIFICATION OF CHD


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L - R SHUNTS INCLUDE :

ASD 7.5% of CHD

VSD COMMONEST CHD 25%

PDA 7.5% of CHD



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R L SHUNTS

Defect between R and L heart

Resistance to pulmonary blood flow PBF

hypoxemia and cyanosis

INCLUDE :

TOF 10% of CHD, commonest R-L shunt

PULMONARY ATRESIA TRICUSPID ATRESIA

Ob t ti L i


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OBSTRUCTIVE LESIONS INCLUDE :

AORTIC STENOSIS

MITRAL STENOSIS

PULMONIC STENOSIS

COARCTATION OF AORTA 8% of CHD

80% have bicuspid aortic valve

Obstructive Lesions

ASD


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ASD

AP view The pressure in the left atrium is higher than the

right atrium. therefore, a defect in the atrialseptum will result in left to right shunting of

blood. The increased blood volume flowingthrough the right heart and pulmonaryvasculature will cause prominant pulmonaryvascular markings on chest X-Ray, and in

moderate to severe cases there will also becardiomegaly due to right atrial enlargementcausing prominance of the right heart border.

ASD


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ASD

Lateral View Prominant pulmonary vasculature is noted,

particularly in the hilar region. In severe

cases the right ventricle is dilated, this willbe manifested by fullness of the anteriorborder of the heart in the lateral viewsresulting in obliteration of lung tissue

normally noted in between the heart andsternum.

ASD


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ASD

PA VIEW

ASD


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ASD

Lateral View Prominant pulmonary

vasculature is noted,particularly in the hilarregion. In severe cases

the right ventricle isdilated, this will bemanifested by fullness ofthe anterior border of theheart in the lateral viewsresulting in obliteration oflung tissue normallynoted in between theheart and sternum.

Atrial Septal Defect


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Hole between the twoatria

Blood flows left to right

PFO Patent foramen

ovale fails to close

Right atrium and ventricle

becomes dilated

Too much blood to the

lungs

Patofisiologi


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Patofisiologi



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ASD with Eisenmenger syndrome

Chest X ray


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Chest X-ray

The pulmonary vascular markings increasedThe main pulmonary artery segment dilated

Cardiac enlargement (RV,RA)

Diameter of ascending aorta is small to normal

ASD

Ventricular Septal Defect


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Hole between the twoventricles

Left to right shunt majority

Dilated right ventricle too much blood tolungs increase inpulmonary pressure

Smaller defects canclose spontaneously

VSD


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VSD

VSD


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VSD

AP view The pressure in the left ventricle is higher than the right

during systole. This will result in left to right shuntingacross the VSD, throughout systole. The increasedpulmonary blood flow will cause prominent pulmonary

vasculature. The right ventricle will become hypertrophied with

moderate to large amount of shunt leading tocardiomegaly.

The left atrium will become dilated due to increase

pulmonary venous blood return. In the AP view, this willbe manifested by widening of the carinal angle since theleft atrium is situated just below the right and left mainbronchi as they bifurcate.

VSD


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VSD

PA VIEW


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Lateral view

This view best demonstrates the left atrial

dilatation. The dilated left atrium will cause

the esophagus to dilate, as noted in thisfigure with Barium swallow.

VSD


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VSD

LATERAL VIEW BARIUM SWALOW



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RA

RV

LA

LV

PicsofVSD


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Pics of VSD

PicsofVSD


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Pics of VSD

PicsofVSD


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Pics of VSD

PDA patent ductus arteriosus


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Connection LeftPulmonary Artery to

Aorta

PDA Problem : Too much blood goingto lungs

Increased PA pressure

Increase RV Long term damage to

lungs and birth



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RA

RV

LA

LV

RA

RV

LA

LV

AcuteChronic



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Tetralogy of Fallot (TOF)


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ventricular septal defect,

that allows blood to passfrom the right ventricle tothe left ventricle withoutgoing through the lungs

a narrowing (stenosis) ator just beneath the

pulmonary valve thatpartially blocks the flow ofblood from the right side ofthe heart to the lungs

the right ventricle is moremuscular than normal

(RVH)

the aorta lies directly overthe ventricular septaldefect (over-riding aorta)


Tetralogi


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Fallot

VSD Aorta di atas VSD

Obstruksi aliran

ventrikel kanan

Hipertrofi ventrik.Kanan

Cyanotic congenital

heart disease



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RA

RV

LA

LV

Tetralogy of Fallot


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Tetralogy of Fallot

Boot

shape

RVH liftingapex

loss of PA

knob

Conclusion


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Conclusion

Non Invasive imaging test is an evolvingand promising modality but its application

needs to validated with rigorous clinical

investigations. Ultimately, appropriate selection of a

noninvasive imaging test for a given

patient should be evidence-based.

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Cardiac Tutorial Revisi 2 UNTUK PALANGKARAYA

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