Heart disease diagnosis and treatment characteristics
1.Diagnostic features of adult precardiac disease
Under current medical conditions, the diagnosis of common precardiac diseases such as ventricular septal defect, patent ductus arteriosus and tetralogy of Fallot can be suggested by auscultation at birth. However, some precordial diseases with inconspicuous auscultatory murmurs are easily missed, such as atrial septal defect, aortic constriction, and diastolic aortic valve. Therefore, there is a need to raise awareness of the diagnosis of these precordial diseases during the clinical encounter to avoid missing the diagnosis. In some patients with murmurs detected at birth that disappear in adulthood, it is necessary to clarify whether the defect has closed or is complicated by severe pulmonary hypertension. In addition, some patients with precordial disease presenting with hypertension, heart failure, syncope, stroke, migraine and arrhythmia should be selected for appropriate investigations to exclude aortic constriction, atrial septal defect, patent foramen ovale and precordial disease combined with pulmonary hypertension. If ultrasound shows superior ventricular septal defect, it is important to exclude ectopic pulmonary venous drainage. In addition, if you encounter patients with frequent “colds” in the clinic, you should pay attention to exclude the possibility of infective endocarditis.
Patients who have been treated surgically are not completely cured, and the postoperative problems are more complicated, but there is a lack of specialists in adult precardiac disease in China, so there is less research on adult precardiac disease and post-surgical problems. The problems that need attention after surgery are arrhythmia, pulmonary hypertension, heart failure and infective endocarditis, etc.
2.Characteristics of adult precardiac disease treatment
Pulmonary hypertension in adults with precocious heart disease
The mechanism of the occurrence of pulmonary hypertension in adults with precardiac disease is complex, and there are many factors involved. However, the main mechanism of occurrence is the presence of left-to-right shunt, such as large VSD, and pulmonary hypertension can be avoided by performing pulmonary artery ligature surgery at an early stage. Therefore, the key to the prevention of pulmonary hypertension in precordial disease is early diagnosis and early treatment.
As to whether interventional treatment can be performed in adults with combined pulmonary hypertension, our experience is that patients with decreased pulmonary artery pressure after interventional treatment have good near-term efficacy, while the long-term efficacy is unknown at present; patients with increased pulmonary artery pressure after blocking the defect, if blocking treatment is performed, aggravate the patient’s symptoms and have poor prognosis.
Arrhythmia in adults with precordial disease
Arrhythmias can complicate the prognosis of adult patients with surgical and non-surgical preeclampsia at certain stages of the disease and are also closely associated with sudden death. Arrhythmias and conduction block can also occur after interventional placement of blockers due to direct compression of the atrial and ventricular muscles and conduction system by the blocker. Surgical procedures can directly cause damage to the sinus node, the atrioventricular conduction system, and scarring of the atria and ventricles can cause electrophysiological abnormalities and fatal arrhythmias.
Adult Precardiac Disease and Infective Endocarditis
In adult patients with precardiac disease, there is a pressure step difference in blood flow at the lesions with abnormal heart valves, vascular malformations, and abnormal shunts in the heart chambers, causing strong jets and eddies of blood. Under the impact of the jets of blood flow, the endothelium of the endocardium is damaged, collagen is exposed, and platelet-fibrin thrombi are formed. Endocarditis.
The indications for interventional treatment of precardiac disease are widening, and the prevention and treatment of post-interventional infective endocarditis are becoming more and more important. Cases of infective endocarditis associated with different types of precardiac interventions have been reported, suggesting that the awareness of late onset infective endocarditis should be further improved and long-term follow-up of such patients should be enhanced. In patients with larger blocking devices implanted with a long time to complete endothelialization, the duration of postoperative antiplatelet therapy should last longer. Patients with recent fever should be considered for intervention only after infective endocarditis has been excluded.
Several special types of interventions for adult precardiac disease
1. Porous atrial septal defect. One blocker can be used to seal multiple defects, and two blockers can be used to seal two defects. In China, up to four blockers can be used at the same time to seal mutually dispersed defect holes for porous atrial septal defects.
2. Sealing of septal tumor combined with precordial disease. The application of thin waist type atrial septal defect blocker can achieve complete blocking of atrial septal defect and make the atrial septum be clamped flat, that is, to achieve the effect of septal tumor forming.
3.Large atrial defects often have poor margins, and the incidence of dislocation of the blocker after blocking is high, so caution is needed.
Small atrial defects (<5mm) without right heart system enlargement can be left untreated and should be followed up regularly.
5. Interventional treatment of elderly patients with precordial disease. It has been demonstrated that surgical treatment of adult patients with preeclampsia over 40 years of age is superior to medical treatment in reducing cardiovascular events and overall mortality, and that age at repair of adult preeclampsia is not a risk factor for late death from arrhythmias and heart failure. We treated a 78-year-old patient with an atrial septal defect 8 years ago who required hospitalization almost monthly before surgery and once every 1-3 years after surgery and regained the ability to care for himself and is alive today. Therefore, advanced age is not a contraindication to the treatment of atrial septal defect occlusion.
Interventional treatment of several special adult ventricular septal defect precardiac diseases
1. Interventional treatment of large precordial disease with low success rate and high incidence of atrioventricular block should be done with caution. There are cases of successful blocking using PDA blocker.
2.Crestal type precordial disease, defect less than 5mm, defect more than 2mm from the attachment point of pulmonary artery, the application of zero eccentric precordial blocker, the success rate can reach more than 80%.
3.Interventional treatment of postoperative residual leakage of surgical preconditioning. Patients with indications for interventional treatment, interventional treatment is safer than surgical treatment and can avoid re-surgery.
4.The need for treatment of small ventricular septal defects (<3 mm) is still debated. Small ventricular defects generally do not have significant hemodynamic abnormalities and have a low chance of complicating infective endocarditis on long-term follow-up, but there are indeed clinical cases with complications of infective endocardium, and it is controversial whether interventional treatment should be performed.