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Clinical case report
55-year-old male patient was detected a congenital heart disease because of cyanosis, dyspnea on
exertion in 2006 at Cho Ray hospital on regular Rx.
A few months ago, he has developed fatigue, dyspnea
on mild exertion. He went to Prof. HOA for examination, then he was referred to
Tam Duc hospital for
the further treatment.
His past medical history:
Gastrointestinal
hemorrhage (2006)
Type
2 Diabetes Mellitus (-)
Hypertension
(-)
Smoking
(+) 1/2 ppd 40 years
Dyslipidemia
Asthma
(-)
Family
history: unremarkable
On examination:
P: 52bpm, BP: 100/70mmHg, To:37oC,
RR: 18tpm
SpO2: 91% at rest (86% on exertion)
Digital
clubbing
Lower
extremities edema, jugular venous distension
HR
# 50 bpm, irregular, widely split and fixed S2, 3/6 holosystolic
murmur at apex and lower left sternal border. Crackle
at lower left lobe.
Hepatomegaly
Other
organs: unremarkable.
ECG:
Junctional rhythm # 53 bpm. cRBBB.
Chest X-Ray: Cardiomegaly, (Cardiothoracic ratio
of 0.7)
Increased pulmonary circulation
Echocardiography:
LA: 70mm
RA: 70mm
RV: 60mm
LV: 43mm
EF: 70%
ASDp: 34mm
ASDs : 17mm
inletVSD: 7mm
Blood tests:
Creat:
106 mmol/L (eGFR: 73mL/m/1.73m2 )
Fasting
glycemia: 5,06 mmol/L Total
Cholesterol 3.19mmol/L, LDLc 1.6mmol/L, HDLc 1.1mmol/L, TG 0.49mmol/L
RBC: 4.1 M, Hb: 12.7g/dL,
HCT: 37%, PLT: 93.6 K/uL
CRP:
0.5mg/L
Na:
126,8 mmol/L, K: 3,94 mmol/L
AST:
33 UI/L, ALT: 27 UI/L
Uric
acid: 580 umol/L
TSH:
1,819 uUI/mL
Congenital heart disease: Transitional
Atrioventricular septal defect - MR (3/4)- TR (4/4)- Pulmonary artery
hypertension (sPAP: 70mmHg)- Heart failure (NYHA II-III)
Atrioventricular Septal Defect
4%
of all congenital heart disease
Some
case may not be recognized until adulthood.
About
35% of AVSD patients have Down’s syndrome.
Among
children with Down’s syndrome, about 40–56% have CHD.
Heart
failure occurs in about 20% of unoperated incomplete AVSD.
Symptoms
Symptoms
of heart failure.
Symptoms
of pulmonary vascular disease.
Dyspnea,
exertional dyspnea.
Fatigability.
Palpitations.
Respiratory
tract infection.
Arrhythmias.
Complete
heart block
Physical examination
Prominent
and hyperactive precordium.
Palpable
S2 if pulmonary hypertension.
Systolic
thrill at the left lower sternal border.
Electrocardiogram (ECG)
QRS
wave with left-axis deviation (axis −30
to −180 degrees).
Prolonged AV conduction
Higher
degree AV block.
Right
ventricular hypertrophy
Incomplete
or complete right bundle branch block (particularly after surgery).
Chest X-ray
Cardiomegaly
in the presence of left and right ventricular dilatation or, possibly, left
atrial dilatation.
Enhanced
pulmonary vasculature, prominent pulmonary artery
Echocardiography
Ostium
primum defect, inlet ventricular septal defect, and direction of shunt at
atrial and ventricular levels
Morphology of AV valves, degree of
regurgitation at both AV valves
AV
valve ‘straddling’ (= attachment into an inappropriate ventricle)
Atrioventricular annulus ‘overriding’.
Subaortic
stenosis
Pulmonary
artery pressure
Size
of ventricles (balance) = the ratio of cavities of either ventricle.
Associated
CHD
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