♥ Cardiac catheterization ♥

$ interpretation ‫ ﺑﯾﺟﻲ ﺳؤال وﻣطﻠوب ﺗﻌﻣل‬# ‫✍ ﻣوﺿوع ﻣﮭم‬

AKP ‫ و‬TAS ‫ﻓﻲ اﻣﺗﺣﺎن‬
&& % % simple ‫ ﺑﺷﻛل‬heart anatomy ‫ﻋﺷﺎن ﻧﻔﮭم اﻟﻣوﺿوع اﻷول ﻣراﺟﻌﺔ ﺳرﯾﻌﺔ ل‬

Right side Left side

1. Right atrium: 1. left atrium

4 ‫ﯾﻔﺗﺢ ﻓﯾﮫ‬
IVC & SVC ‫ﯾﻔﺗﺢ ﻓﯾﮫ‬ pulmonary veins
body ‫ﯾﺳﺗﻘﺑل اﻟدم ﻣن‬ lung ‫ﯾﺳﺗﻘﺑل اﻟدم ﻣن‬
Deoxygenated blood oxygenated blood

2. Right ventricle: 2. Left ventricle:

rt atrium ‫ﯾﺳﺗﻘﺑل اﻟدم ﻣن‬ left atrium ‫ﯾﺳﺗﻘﺑل اﻟدم ﻣن‬

tricuspid valve ‫ﻣن ﺧﻼل‬ mitral valve ‫ﻣن ﺧﻼل‬

3. Pulmonary artery: 3. Aorta:

Rt ventricle ‫ﯾﺳﺗﻘﺑل اﻟدم ﻣن ال‬ left ventricle ‫ﯾﺳﺗﻘﺑل اﻟدم ﻣن‬

pulmonary valve ‫ﻣن ﺧﻼل‬ Aortic valve ‫ﻣن ﺧﻼل‬

‫ ﻋﺑﺎرة ﻋن اﯾﮫ ؟؟؟‬catheter ‫◀ ال‬

‫ ﻟﻐﺎﯾﮫ ﻟﻣﺎ ﺗوﺻل‬blood vessels ‫ و ﺗﻣﺷﻲ ﻣﻊ‬-- eg femoral -- artery ‫ او‬vein ‫ ﺑﻧدﺧﻠﮭﺎ ﻓﻲ‬thin tube ‫ھﻲ‬
‫ﻟﻠﻘﻠب‬
‫؟؟؟‬catheter ‫ اﻟﻠﻲ ھﻌرﻓﮭﺎ ب ال‬data ‫◀ اﯾﮫ‬
1. pressure in the cardiac chambers & great vessels

2.O2 Saturation at different parts

3. Exercise stress with cardiac catheterization to evaluate overall cardiovascular

performance.

4. Angiocardiography to record of structural abnormalities.

 ‫اﻟﻠﻲ ﯾﮭﻣﻧﻲ دﻟوﻗﺗﻲ ﻧﻘطﺗﯾن ال ‪ O2 saturation‬و ال ‪pressure‬‬
‫دول اﻟﻠﻲ ھﺎﺑص ﻋﻠﯾﮭم ﻋﺷﺎن اﻋرف اﻟﻣﺷﻛﻠﮫ ﻓﯾن و اﻗدر أوﺻل ل ‪diagnosis‬‬

‫اﻟﻔﻛرة اﻧﻲ ﺑﺎﻣﺷﻲ ﻣﻊ ال ‪ pressure values‬و ‪saturation values‬‬

‫ﻓﻲ ال ‪ cardiac chambers‬و ال ‪great blood vessels‬‬
‫و اﺗﺎﻛد اﻧﮭﺎ ﻣﺎﺷﯾﮫ ﻣﻊ ‪normal‬‬
‫أي اﺧﺗﻼف ﻓﻲ ﻧﻘطﮫ ﻣﻧﮭم ﻋﻧد ﺟزء ﻣﻌﯾن ده اﻟﻠﻲ ھﯾﻘوﻟﻲ ان ﻓﯾﮫ ﻓﻲ اﻟﺣﺗﺔ دي ﻣﺷﻛﻠﮫ‬

‫اذن ﺑدﯾﮭﻲ ان اول ﺣﺎﺟﺔ ﻻزم اﻋرﻓﮭﺎ ھﻲ ‪:normal values‬‬

‫‪Cardiac catheter normal values‬‬

‫‪O2 saturation‬‬ ‫)‪Pressure (mmHg‬‬
‫)‪1.Vena cava (VC‬‬ ‫‪< 80 %‬‬
‫)‪2. Rt atrium (RA‬‬ ‫‪< 80 %‬‬ ‫‪0/4‬‬
‫)‪3. Rt ventricle (RV‬‬ ‫‪< 80 %‬‬ ‫‪20/4‬‬
‫)‪4.Pulmonary artery (PA‬‬ ‫‪< 80 %‬‬ ‫‪20/10‬‬
‫)‪5. left atrium (LA‬‬ ‫‪> 90 %‬‬ ‫‪0/7‬‬
‫)‪6. left ventricle (LV‬‬ ‫‪> 90 %‬‬ ‫‪100/10‬‬
‫‪7. Aorta‬‬ ‫‪> 90 %‬‬ ‫‪100/70‬‬

‫اﻷرﻗﺎم ﻣﻣﻛن ﺗﺧﺗﻠف ﺷوﯾﮫ ﺣﺳب اﻟﻣﺻدر اﻟﻠﻲ ﺑﺗﻘرأ ﻣﻧﮫ‬

‫اﻟﻣﮭم ﺗﻔﮭم ازاي ﺗﻘراھﺎ ﺻﺢ‬

‫ھﻧﻼﺣظ ھﻧﺎ ان‬

‫‪: saturation‬‬
‫ﺑﯾﻛون ﻗﻠﯾل ﻓﻲ ‪ rt side‬ﻻﻧﮫ ‪deoxygenated blood‬‬
‫و ﺑﯾﻛون اﻋﻠﻲ ﻓﻲ ‪ left side‬ﻻﻧﮫ ‪oxygenated blood‬‬

‫‪:pressure‬‬
‫ﺑﯾﻛون ﻗﻠﯾل ﻓﻲ ‪ rt side‬ﻻﻧﮫ ﺑس ﻣﺣﺗﺎج ﯾﺿﺦ اﻟدم ل ‪lung‬‬
‫ﻟﻛن ﺑﯾﻛون اﻋﻠﻲ ﻓﻲ ‪ left side‬ﻻﻧﮫ ﻣﺣﺗﺎج ﯾﺿﺦ اﻟدم ﻟﻠﺟﺳم ﻛﻠﮫ‬

‫◀ ازاي ﺑﻘﻲ اﻗرا ‪ data in cardiac catheterization‬؟؟؟‬

‫ﻣﻣﻛن اﻋﻣل رﺳﻣﮫ ﺑﺳﯾطﮫ ل ‪heart‬‬

‫او ارﺳم ‪ box‬ﻛﺎﻧﮫ ‪simplified heart‬‬
‫و اﻛﺗب ﻓﯾﮫ اﻷرﻗﺎم اﻟﻠﻲ ﻣدﯾﮭﺎﻧﻲ‬
 ‫( ﻧﺑدا ﺑﺎل ‪saturation‬‬
‫ھﺎﺷوف اﻻﺗﻲ ‪:‬‬
‫‪ .A‬ھل ال ‪ saturation‬ﻋﻠﻲ اﻟﺟﺎﻧب اﻟﯾﻣﯾن ﻛﻠﮫ اﻗل ﻣن ‪Normal -----٪80‬‬

‫ھل ال ‪ saturation‬ﻋﻠﻲ اﻟﺟﺎﻧب اﻟﺷﻣﺎل ﻛﻠﮫ اﻛﺗر ﻣن ‪Normal -----٪90‬‬ ‫‪.B‬‬

‫ھل ال ‪ saturation‬ﻣش ﺑﯾﺗﻐﯾر ﻟﻣﺎ اﻟدم ﺑﯾﺗﻧﻘل ﻣن ‪ chamber‬ﻟﻠﺗﺎﻧﯾﮫ ﻋﻠﻲ ﻧﻔس اﻟﺟﺎﻧب ‪normal ----‬‬ ‫‪.C‬‬

‫⬆ )‪ ( > 5%‬ﻟﻣﺎ اﺗﻧﻘﻠت ﻣن ‪ chamber‬ل اﻟﻠﻲ وراھﺎ ﻋﻠﻲ‬ ‫‪ .D‬طﯾب ﻟو ﻟﻘﯾت ان ال ‪ saturation‬زاد‬
‫اﻟﺟﺎﻧب اﻟﯾﻣﯾن‬
‫ده ﺑﺎﺳﻣﯾﮫ ‪step up in saturation ---‬‬
‫اذن ﻓﯾﮫ ﻣﺷﻛﻠﮫ ھﻲ اﻟﻠﻲ زودﺗﻠﻲ ال ‪saturation‬‬
‫ﻟو ﻓﻛرت ﻓﯾﮭﺎ ھﺗﻼﻗﻲ ان اﻟﺗﻔﺳﯾر اﻟﻣﻧطﻘﻲ اﻧﮫ ﺑﻘﻲ ﻓﯾﮫ‬
‫‪shunt‬‬
‫ﻣن اﻟﻧﺎﺣﯾﮫ اﻟﺷﻣﺎل ‪oxygenated‬‬
‫اﻟﻲ اﻟﻧﺎﺣﯾﮫ اﻟﯾﻣﯾن ‪deoxygenated‬‬
‫‪Left to rt shunt‬‬
‫ده اﻟﻠﻲ زودﻟﻲ ال ‪ saturation‬ﻓﻲ اﻟﻧﺎﺣﯾﮫ اﻟﯾﻣﯾن‬

‫⬇ )‪ ( 5%‬ﻟﻣﺎ اﺗﻧﻘﻠت ﻣن ‪ chamber‬ل اﻟﻠﻲ وراھﺎ ﻋﻠﻲ اﻟﺟﺎﻧب‬ ‫‪ .E‬طﯾب ﻟو ﻟﻘﯾت ان ال ‪ saturation‬ﻗل‬
‫اﻟﺷﻣﺎل‬
‫ده ﺑﺎﺳﻣﯾﮫ ‪step down in saturation ---‬‬
‫اذن ﻓﯾﮫ ﻣﺷﻛﻠﮫ ھﻲ اﻟﻠﻲ ﻗﻠﻠت ال ‪saturation‬‬
‫ﻟو ﻓﻛرت ﻓﯾﮭﺎ ھﺗﻼﻗﻲ ان اﻟﺗﻔﺳﯾر اﻟﻣﻧطﻘﻲ اﻧﮫ ﺑﻘﻲ ﻓﯾﮫ‬
‫‪shunt‬‬
‫ﻣن اﻟﻧﺎﺣﯾﮫ اﻟﯾﻣﯾن ‪deoxygenated‬‬
‫اﻟﻲ اﻟﻧﺎﺣﯾﮫ اﻟﺷﻣﺎل ‪oxygenated‬‬
‫‪RT to Left shunt‬‬

‫( ﺑﻌدﯾن اﺑص ﻋﻠﻲ ‪pressure‬‬

‫ھﺎﺷوف اﻻﺗﻲ‪:‬‬

‫‪ .A‬اﻟطﺑﯾﻌﻲ ان اﻟﺿﻐط ﻋﻠﻲ اﻟﺟﺎﻧب اﻟﯾﻣﯾن اﻗل ﻣن اﻟﺷﻣﺎل ﻋﻠﻲ ﻛل اﻟﻣﺳﺗوﯾﺎت‬

‫‪ .B‬ﻟو ﻟﻘﯾت اﻟﺿﻐط ﺗﺳﺎوي ﺑﯾﻧﮭم ﻋﻧد أي ﻣﺳﺗوي ﯾﺑﻘﻲ ﻏﺎﻟﺑﺎ ﻓﯾﮫ ﻓﺗﺣﮫ ﻣوﺻﻠﮫ ﺑﯾن اﻟﻧﺎﺣﯾﺗن ﻓﻲ اﻟﻧﻘطﮫ دي ﯾﻌﻧﻲ ﻓﯾﮫ‬
‫‪ shunt‬و دي ھﺗﺑﻘﻲ اﺗﻌرﻓت ﻣن ﻧﻘطﮫ ‪ saturation‬ﺑس ھﻧﺎ زﯾﺎده ﺗﺄﻛﯾد‬

‫‪ .C‬دي ﺑﻘﻲ اھم ﻧﻘطﮫ ﻓﻲ ‪pressure‬‬

‫ﻟو ﻟﻘﯾت اﻟﺿﻐط زاد ﻋن اﻟطﺑﯾﻌﻲ ﻓﻲ أي ‪step up in pressure ---- chamber‬‬
‫و ﻟﻘﯾﺗﮫ ﻗل ﻣﺑﺎﺷره ﺑﻌد ال ‪ valve‬اﻟﻠﻲ ال ‪ chamber‬دي ﺑﺗﻔﺿﻲ ﻣن ﺧﻼﻟﮫ‬
‫‪step down in pressure after the valve‬‬
‫اذن اﻻﻏﻠب ان ﻋﻧدي ‪stenosis‬‬
‫و اﻟﻧﻘطﮫ دي ھﺗوﺿﺢ اﻛﺗر ﻣﻊ اﻻﻣﺛﻠﺔ‬
 ‫♦ ﻣ ﺛﺎل ‪1‬‬

‫ﻟو ﻋﻧدي ‪ data‬ﻛﺎﻻﺗﻲ ‪:‬‬

‫‪0Saturation‬‬ ‫‪0Pressure‬‬
‫‪VC= 74‬‬
‫‪RA=74‬‬ ‫‪RA= -/4‬‬
‫‪RV= 74‬‬ ‫‪RV= 20/4‬‬
‫‪PA=74‬‬ ‫‪PA= 20/10‬‬
‫‪LA= 97‬‬ ‫‪LA= -/7‬‬
‫‪LV= 97‬‬ ‫‪LV= 100/10‬‬
‫‪Aorta= 97‬‬ ‫‪Aorta = 100/70‬‬

‫ھﻧﺎ طﺑﻌﺎ ﻛل ال ‪ values‬ﻣﺎﺷﯾﮫ ﻣﻊ ال ‪ normal‬ﻓﻛده‬

‫اﻗدر أﻗول ده ‪normal heart‬‬

‫♦ﻣ ﺛ ﺎ ل ‪: 2‬‬

‫‪0Saturation‬‬ ‫‪0Pressure‬‬
‫‪VC= 74‬‬
‫‪RA=88‬‬ ‫‪RA= -/7‬‬
‫‪RV= 88‬‬
‫‪PA=88‬‬
‫‪LA= 97‬‬ ‫‪LA= -/7‬‬
‫‪LV= 97‬‬
‫‪Aorta= 97‬‬

‫ھﻧﺎ ﻻﺣظﻧﺎ ‪Step up in saturation on the rt side‬‬

‫ﯾﻌﻧﻲ زي ﻣﺎ اﺗﻔﻘﻧﺎ ‪left to rt shunt -----‬‬
‫‪ ,‬دي اول ﻧﻘطﮫ ﻓﻲ اﻟﺗﺷﺧﯾص‬
‫اﻟﻧﻘطﮫ اﻟﺗﺎﻧﯾﮫ ﻻزم اﺣدد ﻣﻛﺎن ال ‪⁉ shunt‬‬
‫اﺑص ﻋﻠﻲ اﻷرﻗﺎم اﻟزﯾﺎده دي ﺣﺻﻠت ﺑداﯾﮫ ﻣن ﻓﯾن ﺑﺎﻟظﺑط‬
‫‪ VC‬ﻛﺎﻧت ﻧورﻣﺎل اﻧﻣﺎ ال ‪ rt atrium‬زاد‬
‫و ﻣن ﺑﻌدھﺎ ﺑﻘﻲ زاﯾد ﻓﻲ ﻛل اﻟﻠﻲ وراه ﺑﺎﻟﻧﺳﺑﮫ ل ‪rt side‬‬
‫اذن ‪shunt at the level of rt atrium‬‬

‫ﻟو ﺑﺻﯾﻧﺎ ﻋﻠﻲ ‪ pressure‬ھﻧﻼﻗﯾﮫ زاد ﻓﻲ ‪ rt atrium‬ﺑﻘﻲ ‪equal to left atrium‬‬

‫و ده ﺑﯾﺎﻛد و ﺟود ‪shunt‬‬

‫ﯾﺑﻘﻲ اﻟﺗﺷﺧﯾص ‪.‬؟؟؟؟ ‪/ ASD -------‬‬

 : 3 ‫♦ ﻣ ﺛﺎل‬

0Saturation 0Pressure
VC= 74
RA= 74
RV= 88 RV 100/12
PA=88 PA 100/12
LA= 97
LV= 97 LV 100/12
Aorta= 97 Aorta 100/70

shunt ‫ اذن ﻓﯾﮫ‬--- rt side ‫ﻋﻠﻲ‬saturation ‫ ﻓﻲ‬step up ‫ھﻧﺎ ﺑرده ﻻﺣظﻧﺎ‬

RT ventricle ‫ ﺑدا ﻋﻠﻲ ﻣﺳﺗوي ال‬step up ‫ال‬
pressure ‫و ﻟو ﺑﺻﯾﻧﺎ ﻋﻠﻲ‬
equal to left ventricle ‫ ﺑﻘﻲ‬rt ventricle ‫ھﻧﻼﻗﯾﮫ زاد ﻓﻲ‬
shunt between rt and left ventricles ‫ده ﺑﯾﺎﻛد اﻧﮫ ﻓﯾﮫ‬
/ VSD -----. ‫اذن دي ﺣﺎﻟﮫ‬

: 4 ‫♦ﻣ ﺛ ﺎ ل‬

‫ھﻧﺎ ھﻧﻼﺣظ‬
step up in saturation at level of PA
pulmonary ‫ ھﻧﺎ ﻋﻧد ﻣﺳﺗوي ال‬shunt ‫ﯾﺑﻘﻲ ال‬
artery

pressure at PA ‫و ﻛﻣﺎن ﻓﯾﮫ زﯾﺎده ﻓﻲ‬

‫ ﻧﺗﯾﺟﺔ ﻟزﯾﺎدﺗﮫ‬rt ventricle ‫و طﺑﻌﺎ اﻟﺿﻐط ھﯾزﯾد ﻓﻲ‬

pulmonary artery ‫ﻓﻲ‬

‫ ؟؟‬pressure‫ و ال‬saturation‫ ﺟﺎي ﻣﻧﯾن ﻋﺷﺎن ﯾﻌﻠﻲ ال‬PA ‫ﯾﺑﻘﻲ اﻟدم اﻟﻠﻲ ﺟﺎي ل‬
/ PDA ------. ‫ ﺗﺑﻘﻲ‬aorta ‫اﻛﯾد ﻣن‬
 : 5 ‫♦ ﻣ ﺛﺎل‬

0Saturation 0Pressure
VC= 74 %
RA=74 %
RV= 74 % RV 90/10
PA=74 % PA 100/60
LA= 97 %
LV= 82 % LV 100/12
Aorta= 82 % Aorta 100/55

step down in saturation ‫ ﺣﺻل ﻓﯾﮫ‬left side ‫ ھﻧﺎ ﻧﻼﺣظ ان ال‬,

‫ ﻓﯾن ﺑﺎﻟظﺑط‬shunt ‫ ال‬، ‫اﻟﻧﻘطﮫ اﻟﺗﺎﻧﯾﮫ ﻋﺷﺎن أوﺻل ﻟﻠﺗﺷﺧﯾص‬
left ventricle ‫ ﺣﺻل ﻋﻧد‬step down ‫ﻟو ﺑﺻﯾﻧﺎ ﻋﻠﻲ اﻷرﻗﺎم ھﻧﻼﻗﻲ ال‬
from rt ventricle to left ventricle -----shunt ‫اذن ال‬

:pressure ‫ ھﻧﺑص ﻋﻠﻲ‬,

pressure in LV ‫ ﻋﺎﻟﻲ ﺟدا ﻗرﯾب ل‬pressure in RV --- ‫ھﻧﻼﻗﻲ‬
opening between two ventricles ‫ ﻣن ﺧﻼل‬shunt ‫ده ﺑﯾﺎﻛد و ﺟود‬
VSD -----

‫ اﻋﻠﻲ ﻣن اﻟطﺑﯾﻌﻲ‬pulmonary artery ‫ھﻧﻼﻗﻲ ﻛﻣﺎن اﻟﺿﻐط ﻋﺎﻟﻲ ﻓﻲ‬

:‫ﻧﺟﻣﻊ اﻟﻣﻌﻠوﻣﺎت ﺑﻘﻲ‬

1. VSD
2. RT to left shunt
3. pulmonary hypertension
4.Rt ventricular hypertension

Eisenmenger syndrome ----reversal of shunt in VSD --- . ‫ﯾﺎ ﺗري دي ﺣﺎﻟﮫ اﯾﮫ ؟؟؟؟‬

reversal of shunt due to increased pulmonary vascular resistance

 : 6 ‫♦ ﻣ ﺛﺎل‬
0 Saturation
VC= 74
RA= 74
RV= 74
PA=97
LA= 97
LV= 97
Aorta= 74

heart ‫ ﻓﻲ‬saturation ‫ھﻧﺎ ھﻧﻼﺣظ ان‬

‫ و‬aorta ‫ طﺑﯾﻌﯾﮫ ﻟﻛن ﻟو ﺑﺻﯾﻧﺎ ﻋﻠﻲ‬chambers
‫ ھﺗﻼﻗﯾﮭم ﻣﻌﻛوﺳﯾن‬pulmonary
saturation in left side ‫ و ﻣﺎﺷﻲ ﻣﻊ‬pulmonary ‫زاﯾد ﻓﻲ‬
saturation in right side ‫ و ﻣﺎﺷﻲ ﻣﻊ‬aorta ‫ﻗﻠﯾل ﻓﻲ‬

TGA ‫ﯾﺑﻘﻲ دي ﺣﺎﻟﺔ اﯾﮫ ؟ ؟ ؟‬

7 ‫♦ﻣﺛﺎل‬
0 Pressure:
RA= 0/4
RV= 40/20
PA=20/10
LA= 0/7
LV= 100/10
Aorta= 100/70

‫ ﯾﺑﻘﻲ ﻣﻌﻧدﯾش ﻣﺷﻛﻠﮫ ﻓﯾﮭﺎ و‬saturation ‫ھﻧﺎ ﻣﺟﺎﺑش ال‬

shunt ‫ﻣﻔﯾش‬
RT ventricle ‫ﻟو ﺑﺻﯾﻧﺎ ﻋﻠﻲ اﻷرﻗﺎم ھﻧﻼﻗﻲ اﻧﮭﺎ طﺑﯾﻌﯾﮫ اﻻ ﻋﻧد ال‬
‫ زاد ﻋن اﻟطﺑﯾﻌﻲ‬presuure ‫ال‬
rt ventricle has to contract against obstruction ‫ده ﻣﻌﻧﺎه ان‬
((( ‫ﻋﺎدي )))ﻣﻣﻛن ﻛﻣﺎن ﺗﻼﻗﯾﮫ ﻗﻠﯾل‬pulmonary artery ‫ ﻓﻲ‬pr ‫ال‬
pulmonary hypertension ‫اذن ﻣﻔﯾش‬
. ‫؟؟؟‬obstruction ‫ﯾﺑﻘﻲ اﯾﮫ ﺳﺑب ال‬

Pulmonary stenosis
 8 ‫♦ ﻣ ﺛ ﺎل‬

0Saturation 0Pressure
RA=65 % RA -/4
RV= 65 % RV 95/6
PA=65 % PA 35/4
LA= 96 % LA -/6
LV= 84 % LV 95/6
Aorta= 84 % Aorta 95/55

saturation ‫ھﻧﺎ ال‬

step down at level of left ventricle
rt to left shunt ‫ﯾﻌﻧﻲ ﻓﯾﮫ‬

:pressure ‫و ال‬

‫ ﻋﺎﻟﻲ‬rt ventricle
‫ طﺑﯾﻌﻲ‬pulmonary

% ‫دي ﻣﻣﻛن ﺗﻛون ﺣﺎﻟﮫ اﯾﮫ ؟ ؟‬

rt sided out flow obstruction causing increase rt ventricular pressure rt to left shunt through
VSD
Tetralogy of Fallot --- ‫دي ﻣﺎﺷﯾﮫ ﻣﻊ‬

rt sided outflow obstruction ‫ ﻋﺎﻣل‬pulmonary stenosis ‫ﯾﺑﻘﻲ اﻧﺎ ﻋﻧدي‬

high pressure in rt ventricle ‫و ده اﻟﺳﺑب ﻓﻲ‬
rt to left shunt via VSD ‫ﻋﺎﻣل‬high pressure ‫و‬
step down in saturation in left ventricle ‫و ده ﺷوﻓﻧﺎه ﻓﻲ‬
low saturation in aorta ‫ و ده ﺑدره ﻣﺧﻠﻲ‬overriding aorta ‫ﻋﻧدي ھﻧﺎ ﻛﻣﺎن‬

11 Hint 11

TOF & Eisenmenger syndrome ✍

‫ا ﻻ ﺗ ﻧ ﯾ ن ﻓ ﯾ ﮭ م‬:
2 RT to Lt shunt
2 RT ventricular high pressure

‫اﻟﻔرق ﺑﯾﻧﮭم‬:
2 pulmonary artery pressure %
0 normal or low ----TOF
0 High --- Eisenmenger $
 9 ‫♦ ﻣ ﺛﺎل‬

Baby at day one:

0Saturation 0Pressure
RA=60 % RA -/7
RV RV
3 KEY – No reading PA=88 % PA 88/40
at RV Pulm. vein=96 % LA -/6
LA= 88 % LV 90/7
LV= 88 % Aorta 90/50
Aorta= 88 %

RT ventricle ‫اول ﺣﺎﺟﮫ ھﻧﻼﺣظﮭﺎ ھﻧﺎ ان ﻣﻔﯾش أي ﻗراﯾﮫ ﻓﻲ‬

pressure ‫ و ﻻ‬saturation ‫ﻻ‬
rt ventricle ‫ده ﻣﻌﻧﺎه ان اﻟﻘﺳطرة ﻣش ﻗﺎدره ﺗﻌدي ل‬
‫ﯾﻌﻧﻲ اﻟﺳﻛﮫ ﻣﻘﻔوﻟﮫ‬

Tricuspid atrasia ---- ‫ﻏﺎﻟﺑﺎ اﻟﺳﺑب‬

‫و دي اﻟﻠﻲ ﻋﻣﻠت اﻟﺗﻐﯾرات اﻟﻠﻲ ﺷﺎﯾﻔﻧﮭﺎ دي‬

to bypass the obstruction & maintain circulation
to left side from ASD ‫اﻟدم ﻻزم ﯾﻌدي‬
rt to left shunt
‫ ﻗﻠﯾل ﻋﻠﻲ ﻛل‬saturation ‫ ده ﯾﺧﻠﻲ‬mixing of blood ‫ھﯾﺣﺻل‬
left atrium ‫اﻟﺟﺎﻧب اﻟﺷﻣﺎل ﺑداﯾﮫ ﻣن‬

: ‫و ﻋﺷﺎن ﯾوﺻل ﻟﻠرﺋﮫ‬

(( Tricuspid atrasia with VSD)) VSD ‫اﻏﻠب اﻟﺣﺎﻻت ب ﯾﻛون ﻓﯾﮫ‬
pulmonary artery ‫ و ﻣﻧﮫ ل‬Rt ventricle ‫ ل‬Lt ventricle ‫ﺗﺳﻣﺢ ﺑﻣرور اﻟدم ﻣن ال‬

‫ ﻋﻠﻲ طول اﻟﻣﺳﺎر ده واﺣد‬saturation ‫ﻓﮭﺗﻼﻗﻲ ان‬

LT atrium ---- Lt ventricle --- ((rt ventricle though not measured)) – pulmonary artery
mixing ‫ ﺑﺳﺑب ال‬left side ‫و طﺑﻌﺎ ﺑﯾﻛون اﻗل ﻣن اﻟطﺑﯾﻌﻲ ﺑﺎﻟﻧﺳﺑﮫ ل‬

(( Tricuspid atrasia without VSD)) VSD ‫ﻟو ﻣﻔﯾش‬

PDA ‫ﻻزم ﯾﻛون ﻓﯾﮫ‬
aorta to pulmonary ---- ‫ﺗﺳﻣﺢ ﻟﻠدم ﯾﻌدي ﻟﻠرﺋﮫ‬
aortic pressure ‫ﻋﺎﻟﻲ ﻗرﯾب ﺟدا ل‬pulmonary ‫ ﻓﻲ‬pressure ‫و ھﻧﺎ ﺑﯾﻛون‬
‫زي اﻟﻣﺛﺎل ﺑﺗﺎﻋﻧﺎ ﻛده‬

normal ----pulmonary vein ‫ ﻓﻲ‬saturation ‫ﻟو ﻻﺣظﻧﺎ ﻛﻣﺎن ال‬

mixing with deoxgynated ‫ﻻن اﻟدم ﺟﺎي ﻣن اﻟرﺋﮫ ﻣؤﻛﺳد و ﺗﻣﺎم و ﻟﺳﮫ ﻣدﺧﻠش ﻋﻧد اﻟﻧﻘطﮫ اﻟﻠﻲ ﺑﯾﺣﺻل ﻓﯾﮭﺎ‬
blood
rt atrium ‫ﻋﻧد ال‬
 10 ‫♦ﻣﺛﺎل‬

0Saturation 0Pressure
SVC 88%
IVC 65% RV 30/6
RA = 83% PA 30/20
RV= 83%
PA=83 % LV 90/7
Pulm. vein=96 % Aorta 90/60
LA= 90 %
LV= 90 %
Aorta= 90 %

saturation ‫اول ﺣﺎﺟﺔ ﻧﺑص ﻋﻠﻲ‬

4 IVC ‫ و‬SVC ‫ ﺑﯾن‬saturation ‫ﻓﯾﮫ ﻓرق ﻛﺑﯾر ﻓﻲ‬

LA ‫ ﻓﻲ‬90 ‫ اﻟﻲ‬96 ‫ ﻣن‬pulmonary vein ‫ ﺑﻌد‬stepdown ‫و اﻧﮫ ﺣﺻل‬

‫ﯾﺑﻘﻲ اﯾﮫ اﻟﺳﺑب ؟ ؟ ؟‬

Partial anomalous pulmonary venous drainage ( PAPVD)

4 pulmonary veins ‫طﺑﻌﺎ اﺣﻧﺎ ﻋﻧدﻧﺎ‬

: ‫ﻣﻣﻛن ﯾﻔﺗﺢ‬ left atrium ‫ اﻟﻲ‬lung ‫ ﻣن ال‬oxygeated blood ‫دول ﺑﯾﺟﯾﺑوا ال‬
left atrium ‫ﯾﻌﻧﻲ اﻟطﺑﯾﻌﻲ ﺑﺗﺎﻋﮭم اﻧﮭم ﯾﻔﺗﺣوا ﻓﻲ‬
2 Supra cardiac e.g.
innominate vein or SVC left atrium ‫ﻟو واﺣد ﻣﻧﮭم او اﻛﺗر ﻓﺗﺢ ﻓﻲ ﻣﻛﺎن ﺗﺎﻧﻲ ﻏﯾر‬
2 Cardiac e.g. rt atrium PAPVD ‫ دي ﺑﺗﻛون‬systemic circulation ‫ﻏﺎﻟﺑﺎ ﻓﻲ‬
2 Infracardiac e.g. portal
‫ ﻓﻲ اﻟﻣﺛﺎل ﺑﺗﺎﻋﻧﺎ ﻻﻧﮫ ھﻲ اﻟﻠﻲ ﻓﺗﺢ ﻓﯾﮭﺎ‬SVC ‫ﻋﺎﻟﻲ ﻓﻲ‬saturation ‫و ده اﻟﺳﺑب ان‬
vein
pulmonary vein ‫ال‬

from Rt to Lt ‫ ﺗﺳﻣﺢ ﺑﻣرور اﻟدم‬ASD ‫ﻛﻣﺎن ﺑﯾﻛون ﻓﯾﮫ‬

mixing in left atrium ‫ﻓﺑﯾﺣﺻل‬
left side ‫ ﺑﯾﻘل ﻋﻠﻲ‬saturation ‫ﻋﺷﺎن ﻛده ال‬

‫ ﻻﻧﮫ اﻟﻣﺷﻛﻠﮫ ﻓﻲ واﺣد او اﻛﺗر ﻟﻛن ﻣش اﻻرﺑﻌﮫ ﻛﻠﮫ‬partial

‫ و دي اﺳﻣﮭﺎ‬left atrium ‫ ان اﻻرﺑﻌﮫ ﻣﻔﯾش وﻻ واﺣد ﯾوﺻل ل‬rare ‫ﻓﻲ ﺣﺎﻟﮫ‬

critical since birth ‫ دي ﺣﺎﻟﮫ‬total anomalous pulmonary venous drainage
 11 ‫♦ﻣﺛﺎل‬

0Saturation 0Pressure
RA = 60% RA -/4
RV= 80% RV 90/6
PA=80 % PA 90/50
LA= 96 % LA -/7
LV= 80 % LV 90/6
Aorta=80% Aorta 90/50

: ‫ھﻧﺎ ھﻧﻼﺣظ ان‬

RV , LV , Pulmonary & Aorta ‫ ﻣﺗﺳﺎوي ﻓﻲ‬Saturation
RV & LV ‫ ﻣﺗﺳﺎوي ﺑﯾن‬pressure ‫و ﻛﻣﺎن‬
Pulmonary & aorta ‫و ﺑﯾن‬
RV& LV ‫ ﺑﯾن‬connection ‫اذن اﻛﯾد ﻓﯾﮫ‬
Pulmonary & aorta ‫و ﺑﯾن‬
truncus arteriosus ---- ‫اﻟﺣﺎﻟﺔ دي ﺑﺗﺣﺻل ﻓﻲ‬

failure of separation between pulmonary & aorta ‫ھﻧﺎ ﻋﻧدي‬

so two ventricles connected as common trunk
‫ده ﯾﻔﺳر ﻟﯾﮫ‬
pressure & Saturation are equal between aorta & pulmonary
VSD ‫و ﻛﻣﺎن ﺑﯾﻛون ﻓﯾﮫ‬
‫ده ﯾﻔﺳر ﻟﯾﮫ‬
pressure & Saturation are equal between RV & LV
 12 ‫♦ ﻣﺛﺎل‬

0pressure:
Left ventricle : 155/30
Ascending aorta : 95/7
Descending aorta : 109/63

high pressure in left ventricle ‫ھﻧﺎ ﻋﻧدي‬

left sided out flow obstruction ‫ﯾﺑﻘﻲ ﻓﻲ‬
step down in pressure in ascending ‫و ﻛﻣﺎن ﺣﺻل‬
aorta
pressure gradient across the valve ‫ﯾﻌﻧﻲ ﻓﯾﮫ‬

Aortic Stenosis ----- ‫اﻟﺣﺎﻟﺔ‬

13 ‫♦ ﻣﺛﺎل‬

0pressure:
Left ventricle : 155/70
Ascending aorta : 155/70
Descending aorta : 70/30

high pressure in left ventricle ‫ھﻧﺎ ﻋﻧدي‬

left sided out flow obstruction ‫ﯾﺑﻘﻲ ﻓﻲ‬
ascending aorta ‫ ﻣﻛﻣل ﺑﻧﻔس اﻟرﻗم ﻓﻲ‬pressure ‫ﻟﻛن ال‬
pressure gradient across the valve ‫ﯾﺑﻘﻲ ﻣﻔﯾش‬
normal -----valve ‫اذن ال‬

step down in pressure in descending aorta ‫اﻧﻣﺎ ﺣﺻل‬

‫ ﺣﺻل ھﻧﺎ‬obstruction ‫ﯾﺑﻘﻲ ال‬
11 Hint 11
‫دي ﺣﺎﻟﮫ؟؟؟؟‬
Aortic stenosis & coarctation of aorta ✍ coarctation of aorta
‫اﻻﺗﻧﯾن ﻓﯾﮭم‬:
2 left ventricular outflow obstruction
2 high pressure in left ventricle
2 pressure gradient

‫اﻟﻔرق ﺑﯾﻧﮭم‬:
2 where is the lesion – where is the gradiant %
0 valve – drop in pr at ascending aorta ---AS
0 drop in pr at descending aorta --- coarctation
 14 ‫♦ﻣﺛﺎل‬
0 Saturation
RA=50
RV=50
PA=50
LA= 80
LV= 80
Aorta= 80

‫ ﻗﻠﯾل ﺟدا ﻓﻲ اﻟﻧﺎﺣﯾﺗﯾن اﻟﯾﻣﯾن و اﻟﺷﻣﺎل‬saturation ‫اول ﺣﺎﺟﺔ ھﻧﻼﺣظﮭﺎ ان‬

rt side ‫ﻋﻠﻲ ﻣﺳﺗوي‬step up ‫ﻣﻔﯾش‬
left side ‫ ﻋﻠﻲ ﻣﺳﺗوي‬step down ‫و ﻣﻔﯾش‬
‫ ﻗﻠﯾل ﺟدا و ﻛﻣل ﻛده ﻟﻐﺎﯾﮫ ﻟﻣﺎ ﺧرج ﻣﻧﮫ‬saturation ‫ ﻣن اﻟﺑداﯾﮫ‬rt side ‫ﺑﻣﻌﻧﻲ ان اﻟدم اﻟﻠﻲ دﺧل‬
‫ ﻗﻠﯾل و ﻣﻛﻣل ﺑﻧﻔس اﻟﻧﺳﺑﮫ ﻟﻐﺎﯾﮫ ﻟﻣﺎ ﺧرج‬saturation ‫ ﺑرده‬left side ‫و اﻟدم اﻟﻠﻲ ﺟﺎي ﻣن اﻟرﺋﮫ و دﺧل‬

❌ shunt ‫ﯾﻌﻧﻲ ﻣﻔﯾش‬

% heart ‫ ھﻧﺎ ﻣش ﺳﺑﺑﮭﺎ‬cyanosis ‫ ان اﻟﻣﺷﻛﻠﮫ ﺑﺗﺎع ال‬4 ‫ده ﯾﺧﻠﯾﻧﻲ اﻓﻛر‬

lung 6 ‫ دي ﻣﺷﻛﻠﮫ ﻓﻲ‬. ‫ھﺗﻛون اﯾﮫ ؟؟؟‬

chronic lung disease ----- ‫اﻟﺗﺷﺧﯾص‬

7897:7
2 Helpful points2
Step up in saturation (>5%) at the right side:
0 suggest left to right shunt
0 level?
1. in SVC compared to IVC --- PAPVD
2. in Right atrium --- ASD
3. in Right ventricle --- VSD
4. in pulmonary artery --- PDA

Step down in saturation (5%) at the left side:

0 suggest right to left shunt
0 level?
1. In left atrium --- via ASD
2. In left ventricle --- via VSD
Equal pressure between rt & left sides at any level
suggests an opening

A large pressure gradient across a valve suggests

setenosis.
For$each$scenario,$select$the$most$likely$from$the$following$list$(each$answer$may$
used$once,$more$than$once$or$not$at$all).$
A. Atrial$septal$defect$
B. Patent$ductus$arteriosus$
C. Tetralogy$of$Fallot$
D. Coarctation$of$the$aorta$
E. Transposition$of$the$great$arteries$
F. Ventricular$septal$defect$
'
Scenario'1:'
' Saturation' Pressure'(mmHg)'
Left'Atrium' 98%$ 10/5$
Left'Ventricle' 98%$ 152/60$
Aorta' 98%$ 90/50$
$
Answer:_____'
'
Scenario'2:'
' Saturation' Pressure'(mmHg)'
Right'Atrium' 88%$ 5$
Right'Ventricle' 87%$ 35/5$
Pulmonary'Artery' 87%$ 35/12$
Left'Atrium' 97%$ 6$
Left'Ventricle' 97%$ 100/8$
Aorta' 97%$ 100/58$
$
Answer:_____'
'
Scenario'3:'
' Saturation' Pressure'(mmHg)'
Vena'Cava' 30%$ N$
Right'Atrium' 32%$ N$
Right'Ventricle' 32%$ 90/10$
Pulmonary'Artery' 92%$ 60/7$
Left'Atrium' 93%$ 7$
Left'Ventricle' 94%$ 60/7$
Aorta' 35%$ 88/60$
$
Answer:_____'
' '
Scenario'4:'
' Saturation' Pressure'(mmHg)'
Superior'Vena'Cava' 75%$ N$
Right'Atrium' 75%$ 3$
Right'Ventricle' 75%$ 35/5$
Pulmonary'Artery' 88%$ 35/14$
Left'Atrium' 95%$ 8$
Left'Ventricle' 95%$ 100/8$
Aorta' 95%$ 100/55$
$
Answer:_____'
'
Scenario'5:'
' Saturation' Pressure'(mmHg)'
Right'Atrium' 65%$ N$
Right'Ventricle' 65%$ 90/10$
Pulmonary'Artery' 68%$ 100/60$
Left'Atrium' 95%$ N$
Left'Ventricle' 82%$ 100/12$
Aorta' 83%$ 100/55$
$
Answer:_____'
'
Scenario'6:'
' Saturation' Pressure'(mmHg)'
Superior'Vena'Cava' 68%$ N$
Inferior'Vena'Cava' 64%$ N$
Right'Atrium' 72%$ 12$
Right'Ventricle' 84%$ 85/7$
Pulmonary'Artery' 85%$ 20/8$
Left'Atrium' 98%$ 10/5$
Left'Ventricle' 91%$ 90/5$
Aorta' 88%$ 90/55$
$
Answer:_____'
' '
 '
'
'
'
'
Answers'
$ $
 $
D:'Coarctation'of'the'aorta'
'

'
A:'Atrial'septal'defect'
' '
 '

'
E:'Transposition'of'the'great'arteries'
' '
 '
B:'Patent'ductus'arteriosus'

'
F:'Ventricular'septal'defect'
' '
 '
C:'Tetralogy'of'Fallot'