ACYANOTIC HEART DISEASE

2. OBSTRUCTION OF BLOOD FLOW

 A vessel or valve is narrower than usual.
 Pressure from blood flow increases prior to the narrowing and decreases after the narrowing.
 They prohibit enough blood from reaching its intended size,the lungs or the rest of the body
 They threated or overwhelm the heart because of back pressure

a. PULMONARY STENOSIS
 Narrowing of the pulmonary valve or the pulmonary artery just distal to the valve
 10% of congenital anomalies
 Inability of the right ventricle to evacuate blood by way of the pulmonary artery because
of the obstruction leads to right ventricular hypertrophy.

Assessment:
 Cyanosis – if narrowing is severe
 Due to inability of the blood to reach the lungs for oxygenation or there is right-left shunting
across the foramen ovale-------this happens because of the increase pressure at the right side
of the heart
 Systolic ejection murmur ( grade IV or V crescendo-decresendo in quality) loudest at the
upper left sterna border radiating to the suprasternal border.
 Thrill- from the upper left sterna border or at suprasternal notch.
 Widely split of the 2nd heart sound ------because of late closure f the pulmonary valve.

Diagnosis:
 ECG/ echocardiography- reveal ventricular hypertrophy
 Cardiac catheterization – used for interventional enlargement of the stenosed valve

Therapeutic Management:
 Balloon angioplasty – procedure of choice
 A catheter with an uninflated balloon at its tip is inserted and passed through the heart into the
stenosed valve
 As the balloon is inflated, it breaks the valve adhesions and relieves the stenosis.
 Children may have residual heart murmur
 Can expect a normal life span

b. AORTIC STENOSIS
 Stenosis or stricture of the aortic valve prevents blood from passing freely from the left
ventricle of the heart into the aorta.
 Because the heart cannot force blood through the stricture valve
 increased pressure and hypertrophy of the left ventricle occur
 if the left ventricular pressure become acute----- increase
 pressure in the left atrium back pressure in pulmonary veins pulmonary edema
Assessment:
 Asymptomatic
 Murmur- can be transmitted to the right shoulder, clavicle and up the vessels of the neck, heart
apex
 Rough systolic sound heard loudest in the 2 nd right interspace ( aortic space)
 Thrill- at suprs sterna notch
 Decreased cardiac output - if severe
 Faint pulses
 Hypotension
 Tachycardia
 Inability to suck for long periods
 Chest pain similar to angina
 Because the coronary arteries receive inadequate amount of oxygen needed by the heart
muscle on exertion far exceeds what is available

Diagnosis
 ECG/echocardiography – reveal left ventricular hypertrophy

Therapeutic Management:
 Beta-blocker/calcium channel blocker---to reduce cardiac hypertrophy before the defect is
corrected
 Balloon valvuloplasty – treatment of choice
 Dividing the stenotic valve r dilating an accompanying constrictive aortic ring
 May lead to aortic valve insufficiency later in life—further surgery may be needed
 Some children will need artificial valve replacement for correction
 If prosthetic valve is used---- continue to receive anticoagulation or antiplatelet therapy and
antibiotic prophylaxis against endocarditis
 Children need exercise testing before participating in competitive sports if an artificial valve is
in place.

c. COARCTATION OF AORTA
 Narrowing of the lumen of the aorta due to constricting band
 Occurs most frequently in boys than in girls
 Leading cause of congestive heart failure in the first few months of life.

2 Locations:
 Preductal – the constriction occurs between the subclavian artery and the ductus arteriosus
 Postductal – constriction is distal to the ductus arteriosus

 Difficult for blood to pass through the narrowed lumen of the aorta
 Blood pressure increases proximal to the coarctation decreases distal
  Increased BP in the heart and upper portions of the body as pressure in the subclavian
artery increases
 headache, vertigo
 epistaxis (nose bleed)
 cerebrovascular accident

Assessment:
 Absence of palpable femoral pulses- slight coarctation
 Always include evaluation of femoral pulses in all initial newborn assessment and admission
inspections
 Absent brachial pulses – those with an obstruction proximal to the left subclavian artery
 Lower BP in the lower extremities
 Leg pain on exertion
 Because of diminished blood supply to the lower extremities
 Cold feet
 Muscle spasms
 Pulse is weak, delayed or even absent
 Collateral arteries enlargement
 Seen on the ribs as obvious nodules as the child grows older
 Soft, moderately loud systolic murmur – from the base of the heart and transmitted to the left
interscapular area
 BP is higher in upper extremities---because of the pull of gravity
 Headache
 Epistaxis
 Pulse in the upper extremities will be rapid and bounding

Diagnosis:
 BP in the arms will be at least 20mmHg higher than in the legs
 Echocardiography
 ECG – reveal left-sided heart enlargement from
 MRI – back pressure and also notching of the
 X-ray – ribs from the enlarge collateral vessels.

Therapeutic Management:
 Interventional angiography ( balloon catheter)/surgery
 The narrowed portion of the aorta is removed and the new ends of aorta are anastomosed
 A graft of transplanted subclavian artery may be necessary if the narrowed section is so
extensive than an anastomosis cannot be accomplished readily
 Digoxin – given before the time of surgery
 Diuretics – aims to reduce the severity of congestive heart failure
 from hypertension

PLANNING IS IMPORTANT:
 It would be ideal if children could achieve the greater part of their adult height before surgical
correction, preventing strain on the incision site as they grow
 In terms of self-image – correction is best done before children begin to think of themselves as
chronically ill or before they develop complications such as chronic hypertension.
 Girls must have the defect repaired before childbearing age –or the extra blood volume during
pregnancy can cause heart failure
 Surgical repair is scheduled by 2 years of age
 After operation – abdominal vessels receives more blood resulting to abdominal pain or
generalized abdominal discomfort
 Some may have elevated upper body hypertension after the repair
 Need continual treatment with antihypertensive agents
 Some may require repeat balloon angioplasty at adolescence to re-enlarge the aortic lumens
and help reduce this upper body hypertension.