interhospital echo conference - thai · pdf fileinterhospital echo conference thida...
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History
An 80-year-old Thai female
CC : progressive dyspnea for 1 month
PI : 3 months ago: She reported of dyspnea on
exertion and orthopnea but denied palpitation or
chest pain. She was admitted to private hospital
and diagnosed CHF. Her symptoms were slightly
improved after treatment.
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PI : 1 month later, She became worsening
dyspnea with generalized edema. She was
admitted at a private hospital for a few days and
referred to King Chulalongkorn Memorial Hospital.
History
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10 years PTA: Hypertension and dyslipidemia
1 months PTA: Hyperthyroidism
Current Medication:
1. Warfarin 2.5 mg/day
2. Digoxin 0.125 mg/day
3. Aspirin 81 mg/day
4. Bisoprolol 10 mg/day
5. Valsartan 160 mg/day
Past History
6. Furosemide 20 mg/day
7. Trimetazidime 70 mg/day
8. Isosorbide mononitrate
20 mg/day
9. PTU 100 mg/day
10. Addi-K 750 mg/day
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Physical examination An elderly Thai female, good consciousness, looked
chronically ill, no respiratory distress
• Vital signs:
BP 140/70 mmHg, PR 80 bpm (regular), RR 18/min
• HEENT : mild pale conjunctivae, anicteric sclerae
JVP 3 cm above sternal angle
• Heart : Apical impulse at left 5th ICS, MCL, no heave/thrill
normal S1, S2
Continuous murmur gr. III/VI at LUPSB
Pan systolic murmur gr. II/VI at apex radiate to axiila
• Lungs : no crepitation, no wheezing
• Extremities : no pitting edema
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CXR
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EKG
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Stress CMR
Negative stress inducible ischemia
No myocardial hyper-enhancement
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ALCAPA or Bland White Garlan syndrome
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Anomalous of Left Coronary Artery from Pulmonary Artery
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Incidence
• 1/250 – 1/400 of all congenital malformed hearts
• Overall incidence : 1/300,000 children • Frequency in boys (2.3 : 1)
Paediatric Cardiology, 3rd edition: Robert H. Anderson.
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Pathophysiology
• Fetus : diastolic PAP = systemic pressure : coronary a. perfusion same as in normal • After birth
: PAP -> coronary steal : LV ischemia : develop collateral connection from RCA
http://nursingcrib.com/nursing-notes-reviewer/fetal-circulation/ Paediatric Cardiology, 3rd edition: Robert H. Anderson.
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• Typically : RCA enlarge at its origin : LCA turn to be small, relative thin-walled : collateral may be diffusely large, well distributed
Pathophysiology
Paediatric Cardiology, 3rd edition: Robert H. Anderson.
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Presentation
• Majority present during infancy • Myocardial ischemia -> CHF • Anginal attack -> severe distress, grunting, or crying • Unexplained heart murmur • Myocardial ischemia in children/ young adult • May be sudden unexplained death • Progressive MR (fibrosis involve pappillary m, LV dilatation)
Paediatric Cardiology, 3rd edition: Robert H. Anderson.
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Clinical course and prognosis
• 10%–15% of patients survive to adulthood (extensive intercoronary collaterals)
• extent of collateral vascularisation -> clinical course • may present later in childhood, adolescence, or adulthood with
progressive MR, CHF, or myocardial ischaemia with exertion • Untreated -> prognosis is poor
Asian Cardiovasc Thorac Ann 2006;14:38-42
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Echocardiography : Vol 24, Issue 4 ,28-2-2007
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J Chin Med Assoc , September 2010: Vol 73, No 9
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MRI
• Described coronary a. anatomy and origin of LCA from PA • Assess venticular function and volume • Identify MR (secondary to ischemia) • RWMA/ myocardial ischemia • Retrograde/ bidirectional flow in proximal LCA • Post-repaired -> supravalve PS at site of PA patch
Cardiovascular MRI in Congenital Heart Diseas: Shankar Sriharan
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CLINICS 2010;65(11):1215-1216
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Managements
• Surgery • reimplantation of the left coronary artery into the aorta
Paediatric Cardiology, 3rd edition: Robert H. Anderson.
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Thank you for your attention