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179 the Pre-Operative Assessment of Acyanotic Pediatric Patients

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179 the Pre-Operative Assessment of Acyanotic Pediatric Patients 179 ORIGINAL ARTICLE Th e Pre-operative Assessment of Acyanotic Pediatric Patients Presented with Heart Murmur and Role of Surgry in congenital heart diseases, A retrospective analysis Dhafer O Alqahtani, Ali A. Alakfash, Omar R .Altamim Abstract Objectives: Th e aim of this study is to evaluate the incidence of congenital heart disease in patients referred solely because of heart murmur in pediatric age group and to assess the rule of medical and surgical management in patient with heart defects. Study design: It is retrospective analysis of all paediatric cases who presented with cardiac murmur. Materials and Methods:A retrospective database and echocardiographic review. All patients referred to King Abdulaziz Cardiac Center (KA CC) Riyadh, Kingdom of Saudi Arabia dur- ing the period from July 2007 till March 2009 for cardiovascular evaluation because of heart murmur detected during routine physical exam. We included any pediatric patient from the neonatal period till 14 years of age who had echocardiography in our center. Any patient with cyanosis, those with diff erence in the blood pressure between the upper limbs and lower limbs of more than 15 mmHg, preterm neonates, any acquired heart disease and syndromic and critically ill patients were excluded from the study. Results: A total of 245 patients met the inclusion criteria. Median age and weight is 7 months (one day – 12 years), 7.85 Kg (1.9 – 54 Kg) respectively. Normal echocardiography was pres- ent in 163 patients (66.5%). Th e most encountered anomaly found was patent ductus arte- riosious (PDA) which was diagnosed in 27 patients (11 %) followed by atrial septal defect (ASD) secundum in 26 patients (10.6%), then the VSD in 22 patients (9%), atrio-ventricular septal defect (AVSD) in 1 patient (0.4%), Coarctation of Aorta in 3 patients (1.2%), Tortuous of arch in 1 patients (0.4%), Pulmonary stenosis in 10 patients (4%), Mitral valve prolapse in 4 patients (1.6%) and the false tendon in 6 patients (2.4 %). Th e intervention by cardiac King Abdullah Hospital, catheterization was done for 10 patients (4%). Surgical repair done in fi ve patients (2%). Th e Bisha, Kingdom of Saudi spontaneous closure was observed in 31 patients (12.7%). Th ere was 7 patients (2.9%) missed Arabia follow up. DO Alqahtani Conclusions: Th e prevalence of congenital heart disease in acyanotic pediatric patients re- King Abdulaziz Cardiac ferred with Heart murmur is signifi cantly high in Saudi population. Center (KA CC) Riyadh, Kingdom of Saudi Arabia Key words: Acynotic heart disease, patent ductus arteriosious, atrial septal defect, ventricular AA Alakfash OR Altamim septal defect, mitral valve prolapse, coarctation of aorta. Corresopndence: Introduction: ological murmur. Sometimes the distinction is Dr Dhafer O Alqahtani, Consultant Paediatric Heart murmur is an abnormal Sound heard dur- not easy and the patient will be referred for evalu- Cardiologist, ing cardiovascular system( CVS) exam. It is a ation by a pediatric cardiologist, and very oft en an King Abdullah Hospital, Bisha, Kingdom of Saudi common fi nding in neonates and older children. echocardiographic exam will be requested, and Arabia Innocent murmurs are found in about 80% of some of general hospital no pediatric cardiologist Cell: 00966 504484494 normal hearts in pediatric age group. Th e treating or no near cardiac centre to them and need to de- email: drdhafer@hotmail. com physician should decide is it an innocent or path- cide is it pathological murmur need to be seen ur- Pak J Surg 2015; 31(3): 180 gently by cardiologist or reassure the parents, it is caused by the shunt at the atrial level. Because innocent murmur or minor congenital heart dis- the pressure gradient between the atria is so ease need to seen on regular follow up to release small and the shunt occurs throughout the cardi- their stress from the result of CVS exam. ac cycle, in both systole and diastole, the left -to- right shunt is silent. Th e heart murmur in ASD Cardiac murmurs are audible turbulent sound originates from the pulmonary valve because of waves through crossing the valves or shunts le- the increased blood fl ow passing through this sion emanating from the heart and vascular normal-sized valve, producing a relative stenosis system. in the range of 20 to 20,000 Hz. Heart of the pulmonary valve and this will not happen murmurs are common in neonates, infants, and before age of six months. Th e VSD murmur de- children. Where as only 0.8% to 1% of the popu- termined by the size and the level of pulmonary lation has structural congenital cardiac disease, vascular resistance (PVR). With a small defect as many as 80% of the population has a heart and lowPVR harsh murmur are audible and this murmur sometime during childhood. Most will not happen until the infant reaches 4 to 8 heart murmurs are innocent, and they must be weeks of age . Th e common congenital obstruc- distinguished from pathologic murmurs of con- tive lesions to ventricular output are AS, PS, and genital or acquired cardiac diseases. Th ere are COA. All these obstructive lesions produce the two types of murmur, Innocent murmur and an ejection systolic murmur it will heard aft er pathological murmur. birth. Th e innocent murmur or functional murmur During cardiac auscultation for murmur many arise from cardiovascular structure in absence factors aff ected the sound waves which have of anatomical abnormalities. All patient with three dimensions: intensity, frequency, and innocent murmur have no symptom or sign timbre or quality like thickness of chest wall, if of congestive heart failure , the intensity is less patient quit during exam, Size of diaphragm of than grade 3, normal ECG and cardiac size and stethoscope if small will mask the soft systolic shadow in chest X-ray. If the murmur associated murmur, and the experience of the physician, with symptoms or signs of congestive heart and the hyper dynamic circulation. failure, strong family history of CHD, dysmor- phic feature, cyanosis, diastolic murmur, loud Materials and Methods: systolic murmur and thrill, if no sign of hyper- A retrospective database and echocardiographic dynamic ( anemia or fever ), abnormal or weak review. All patients referred to King Abdulaziz peripheral pulse, or abnormal heart sound most Cardiac Center (KA CC) Riyadh, Kingdom of likely pathological murmur and need cardiology Saudi Arabia during the period from July 2007 consultation either urgently or routine follow up till March 2009 for cardiovascular evaluation according for the case situation. because of heart murmur detected during rou- tine physical examination. We included any pe- Th e causes of cardiac murmurs in pediatric diatric patient from the neonatal period till 14 group are related to the age of the patient at pre- years of age who had echocardiography in our sentation and the causes of congenital heart dis- center. Any patient with cyanosis, those with ease are varied and may include genetic (gene or diff erence in the blood pressure between the chromosomal) disorders, syndrome complexes, upper limbs and lower limbs of more than 15 metabolic disorders, or teratogenesis and the mmHg, preterm neonates, any acquired heart causes of acquired heart diseases in children in- disease and syndromic and critically ill patients clude rheumatic fever, endocarditis, and cardiac were excluded. injury caused by systemic illnesses. Results: Th e heart murmur with minor congenital heart A total of 245 patients met the inclusion crite- disease depend in the lesion like in ASD is not ria. Median age and weight is 7 months (one day Pak J Surg 2015; 31(3): 181 30 genital heart disease which diagnosed by echo- cardiography. 25 20 In our study, the percentage of innocent murmur to have CHD is low ( 60 % )compare to other 15 study ( 80%). Th e loudness grade of the systolic 10 murmur holds key information, but grading the 5 loudness might be physician-dependent. Th e strong predictive power of the murmur grade 0 PDA ASD VSD AVSD Coarctation Tortuous Pulmonary Mitral False and the good reproducibility make it a reliable of aorta of arch stenosis valve tendon prolapsed tool in the bedside decision whether a murmur needs further evaluation. Figure 1: In our study the false tendon of the cordi (cordi – 12 years), 7.85 Kg (1.9 – 54 Kg) respectively. tendni)which connect between papillary mus- Normal echocardiography was present in 163 cle and intraventricular septum and one of the patients (66.5%). Th e most encounted anomaly known cause of ejection systolic murmur at left found was PDA which was diagnosed in 27 pa- upper border of chest. It is a variant of normal tients (11 %) followed by ASD secundum in 26 heart structure patients (10.6%), then the VSD in 22 patients (9%), AVSD in 1 patient (0.4%), Coarctation Th e ductus arteriosus is a fetal vascular connec- of Aorta in 3 patients (1.2%), Tortuous of arch tion between the main pulmonary artery and the in 1 patients (0.4%), Pulmonary stenosis in 10 aorta that diverts blood away from the pulmo- patients (4%), Mitral valve prolapse in 4 patients nary bed. Aft er birth the DA undergoes active (1.6%) and the false tendon in 6 patients (2.4 constriction and eventual obliteration. A patient %). Th e intervention by cardiac catheterization ductus arteriosus (PDA) occurs when the DA was done for 10 patients (4%). Surgical repair fails to completely close postnataly. Most com- done in fi ve patients (2%). eTh spontaneous monly the DA arises from the left innominate closure was 31 patients (12.7%). Th ere was 7pa- artery and inserts into the region of the proximal tients (2.9%) missed follow up.
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