Lancet 2005;365:891-900
REQUIREMENTS FOR MANAGING CHD
UNDERSTANDING OF :
Pathophysiology of the diseases
The Clinical symptoms & signs of the
disease
Natural history of the diseases
Initial treatment (incl.emergency case)
WHEN, WHERE and HOW to refer
The Role of Primary Physicians in
managing CHD in Children
Early detection
Initial treatment (if needed)
Decision when to be referred.
Follow up after intervention
(surgery OR catheter intervention)
Penyakit Jantung Bawaan (PJB)
RV is
larger
– 55%
RV pressure
= LV pressure
LV –
45%
Changes in Circulation after Birth
• Primary change :
a shift of blood flow for gas exchange from the
placenta to the lungs.
Changes in Circulation after Birth
• Direct transmission of LV
pressure to PA through the
Large defect delay fall in PVR
VSD high PA pressure CHF doesn’t
develop until 6 or 8 weeks of age
or older
• Asianosis/Tidak Biru/Non-Kompleks/Isolated
• Sianosis/Biru/Kompleks
– Aliran darah paru normal
• TGA tanpa PS
– Aliran darah paru meningkat
• TGA dengan VSD
• Truncus arteriosus
• Total anomaly pulmonary vein drainage
– Aliran darah paru berkurang
• ToF
• Pulmonary atresia
• Ticuspid atresia
PJB Kritis pada Neonatus
• Deteksi Dini
– Diagnosis prenatal
• Fetal ekokardiografi
Penyakit Jantung Bawaan (PJB)
Deteksi dini penting
• Tata laksana dan edukasi tergantung diagnosis pasti
• PJB tertentu umur optimal untuk koreksi
– HLHS : Minggu pertama lahir
– TGA : 2 minggu
– AVSD komplit : 3-6 bulan
– Trunkus arteriosus : < 6 bulan
• Sebagian PJB saat diagnosis belum perlu tindakan
– Intervensi non-bedah atau bedah dikerjakan pada
umur risiko rendah (1-2 tahun) tapi jangan terlambat
– Intervensi atau bedah segera dilakukan jika terapi
konservatif gagal
Penyakit Jantung Bawaan (PJB)
• Diagnosis
– Riwayat penyakit
– Pemeriksaan fisis
– Pemeriksaan penunjang
• Analisis gas darah DD/
• EKG
• Foto Rontgen toraks
• Ekokardiografi
• Kateterisasi
• Lain-lain: MS CT-scan, MRI
History taking
• Gestational and Natal History
- Infections
(Maternal Rubella, CMV, herpesvirus, coxsackievirus B)
- Medications
(Amphetamines, phenytoin, retinoic acid, valproic acid)
- Excessive alcohol intake
- Maternal conditions
(diabetic, lupus erythematosus)
• Postnatal History
Tanda dan Gejala PJB
• BB sulit naik
• Toleransi latihan berkurang
– Bayi Masalah minum
– Intermittent feeding
– Prolonged feeding
– Anak besar Dyspneu on exertion
• Takipnea
• Ortopneu
• Sianosis
• Perfusi sistemik menurun
• ISPA berulang
• Bising jantung
• Lain-lain: kejang
• Growth pattern in infants with CHD :
- cyanotic patients : disturbances in both height
and weight
- Acyanotic patients (particularly those with large
L R shunt) : more problems with weight gain
than linear growth
- Acyanotic with pressure overload lesions
without intracardiac shunt grow normally
Sianosis
• Sianosis
– Kebiruan pada kulit dan membran mukosa
– Hb-reduksi di atas 5 g/dL pada vena kulit (normal Hb-
reduksi 2 g/dL).
• Sianosis sentral
– Dihubungkan dengan desaturasi darah arteri
• Sianosis perifer
– Saturasi darah arteri normal
– Peningkatan ambilan oksigen pada jaringan
» Renjatan
» Hipovolume
» Vasokonstriksi akibat kedinginan
Sianosis Sentral vs Perifer
• Sentral
– Mukosa mulut
– lidah
• Perifer
– Akral
Lefkowitz B, 2000
Sianosis
Normal R L shunt
Megakaryocytes
Platelet are may enter
formed from the systemic
cytoplasm of circulation
megakaryocytes
by fragmentation
during their
passage through Trapped in
pulmonary capillaries of digits
circulation & release growth
factors clubbing
Clubbing Fingers
• Chest X-Ray
• ECG
• Arterial blood gases in room air
• Hyperoxitest
• Umbilical artery line
• Prostaglandin E1
Chest X Ray
Arterial blood gases in room air
confirm or reject central cyanosis
Normal
70% 100%
Penyakit Paru Sianosis Sentral
Kelainan Jantung
Sianosis
Perifer
70% 100%
80%
Udara Kamar
– 21% O2
Kelainan Paru 100% O2
70% 70%
100% 100%