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1、Early management of congenital heart diseases,Jameel A. AL-Ata Consultant & assistant professor of pediatrics & pediatric cardiology.,Introduction,Outcome of CHD has improved mainly due to improved Surgical & Interventional care, specially for neonates. In KSA overall CHD surgical mortality in 4 lar
2、ge centers is 36 %.Pre-surgical morbidity & mortality remains high for many different reasons.,Introduction,Poor early recognition.( pre , natal & postnatal ). Delayed presentation. None familiarity of pathophysiology and natural history of CHD. Delayed initiation of treatment. Limited NICU / PICU f
3、acilities. Limited PGE availability . Limited medivac services. Others.,Pediatricians can make the difference by ;,Early recognition.Categorizing into type & severity.Timely initiation of proper medical treatment.Timely referral for interventional or surgical treatment. = EARLY MANAGEMENT,Early mana
4、gement of secondum Atrial Septal Defect ;,Confirm DX and size of ASD.Most pts will not need medical treatment.Assure parents and inform them of high likelihood of spontaneous closure.Watch for development of PHTN at F/U. Look for none cardiac associations.,ASD,No limitation of activity.SBE prophylax
5、is not usually recommended.Screen the family.Follow every 612 months.Refer for intervention or surgery at age 3-5 y. if size remains 5 mm.,Early management of VSD ;,Confirm DX , type of VSD & size.Examine for presence or development of coarctation or aortic insufficiency.Medical therapy ( diuretics
6、+/- ACE ) usually needed for 5mm defects. Digoxin not usually needed.Treat respiratory infections aggressively.,VSD,Ensure optimum caloric intake.High risk of development of PHTN.Large VSDs can be silent. ( PHTN )No limitation of activity.SBE prophylaxis is a must.,VSD,Follow monthly 4 m.o. Refer to
7、 surgery or intervention if ;1) FTT ,CHF 2) PHTN 3) AI 4) Endocarditis. ( usual age 612 months ) Small 2 mm.,PDA,Large PDA 3 mm act like large VSDs.Look for associations cardiac or non cardiac.Small PDAs can be referred for intervention if still patent at age 1 year whether symptomatic or not.,Early
8、 management of aortic stenosis ;,Confirm DX and severity.Look for aortic insufficiency and other associations.Mild to moderate AS. do not require medical therapy. Avoid hypotensive agents. Assure strict 6 m. f/u by echocardiography for grading of severity & LVH + function.Limit activity only if mode
9、rate to severe stenosis , no need to limit usual daily activity but only strenuous exercise and competitive sports.,AS . ;,Strict SBE prophylaxis & dental hygiene.Admit the child with AS. and chest pain & obtain urgent cardiac consultation.Refer for balloon valvuloplasty if severe except for sub aor
10、tic stenosis which should be referred earlier to prevent aortic insufficiency.Critical AS is an emergency that presents with CHF & may PDA dependant.,Early management of Pulmonary stenosis,Confirm DX & severity.Look for associations.Even severe PS usually does not require medical therapy.Limitation
11、of activity is usually not required.,PS . ;,SBE prophylaxis is controversial.Yearly F/U for mild to moderate PS & 6 m. for moderate to severe by echocardiography.Refer for balloon valvuloplasty if severe.Critical PS can present with RV failure & or cyanosis and may be PDA dependant.,Early management
12、 of Tetralogy of Fallot,A surgical cyanotic CHD where our role is to get the child to surgery safely at ag 6-9 m Excellent physical growth. CHF is rare. Accept saturation 70% in room air Prevent aneamia. Prevent dehydration. ( no LASIX ).,TOF,Prevent endocarditis.Advice to avoid high altitudePrevent
13、 and treat hypercyanotic spells.Refer to earlier than 6 m if developed spells.,Early management of PDA dependant CHD,Severe acute cyanosis 70 % or circulatory collapse in the 1st week of life indicate cyanotic or Lt sided obstruction PDA dependant CHD respectively.Examples are pulmonary atresia and
14、d-TGA for cyanotic and critical COA or IAA. For obstructive Lt sided CHD.The PDA provides the needed PBF, MIXING ,or SBF. for these lesions.,PDA dependant CHD,Our aims in these pts are ; 1) Keep ductal patency by PGE through a secure venous line.2) Maintane saturation 7580 % in RA even if ventilated
15、 to avoid induction of CHF 2nd to increased PBF with decreasing PVR.3) Avoid pulmonary vasodilation.,PDA dependant CHD,4) Avoid fluid overload .5) Avoid infection.6) Early intervention or surgery within 2-7 d.7) Provide a mixing or loading site.( d-TGA & HLHS ).8) Aggressive correction of metabolic
16、acidosis.,Conclusion,Knowing the pathophysiology and natural history of outcome is essential in the management of CHD.Most CHD pts can be managed as OPD in the community provided there is a clear plan set between the primary pediatrician and the cardiologist.More exposure of ped. Trainees to CHD medical therapy & surgery and to the ICU care these pts need will help in increasing the successful early management of CHD BY the pediatrician.,
