Case Presentations: Congenital Heart Disease

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Case Presentations: Congenital Heart Disease

2 Feb, 1:30 PM

[Music] uh very good evening everyone i am dr vishali from netflix and i welcome you for this yet another amazing session by iraq kerala it's case presentations about congenital heart diseases uh we have with us as moderator dr nira jen and residents dr tanya and dr robin thank you good evening to all and today being venezuela actually we are entering the residence program so today the residents are the heroes and i it's my pleasure to welcome dr tanya and dr roby uh both these residents are actually from san diego uh institute of medical science like now and uh you are the heroes of today's program being the it is actually the residence program now so i welcome you both dr tanya and dr robin and this program is actually moderated but the session is moderated by doctor nina and his associate professor from the same institute sanjay gandhi institute like now and i welcome you sir and today the case presentation is on congenital heart disease i think we would be presenting uh they would be presenting two cases two cases and uh uh it will be very interesting to watch this program as we know that actually we come across very few cases in our residence program or even after that now this continues and many of actually we are eager [Music] and also i welcome dr gomez chapter dr amesh chennai is a program coordinator and dr anish is the sonal coordinator actually these people are the backbones of this program and i welcome all of you madam dr remington and dr and also i welcome all the attendees in this program and very warm good evening to everybody and now over to doctor gomez chapter for opening remarks thank you dr venu uh yeah i'm very happy that we are having a chairman like uh dr venu for uh giving this academic session and we are in the eighth program of academic session of kerala era 2020 and actually the congenital heart disease and the heart is actually missed by all our residents because this is not taken as important chapter in their pg study program so we wish that this content should be included in our program which is going this year so it will be very useful for all the residents so please be attentive throughout the session because this is kept as a squatter and sometimes as a shortcut is also for some faculty bring us cases so please be attentive to this session i request all the pgs residents and the faculty to be in online at least thank you thank you so much i'm dr anish uh the zone coordinator uh for ira pg program 2022 uh now i'm here to introduce our speaker is the doctor associate professor sanjay gandhi postgraduate institute lucknow one of the premier government set up institutes of our country is working there since 2017 as ap now he's associate he has very keen interest in academic activities and yes many publications uh more than 50 publications in this credit just presented many posters in uh national and international uh conferences so with that introduction uh i would like to hand over the mic to a doctor niraj afternoon you can proceed with the session so first of all thank you dr uh [Music] thank you dr venu and thank you dr anish for giving this opportunity to sanjay gandhi pgi so in next 30 to 40 minutes two of my resident dr tanya and dr robin will present one one case each and i have asked them to present within a span of 15-20 minutes just like the exam scenario and will be taking the question after the completion of the representation of the both both the cases so i'll end before i hand over to the dr tanya and dr robin i'll thank dr uh ayari kerala for giving this opportunity to the sanjay gandhi pga so good evening everyone and thank you kerala chapter for giving me this opportunity to present this case today i'm dr tanya a third year junior resident at sgpgims and today i'm going i've been provided with this case of a 36 year old man who was diagnosed with complex congenital heart anomaly as a child and was surgically operated for the same and this cardiac city of the patient has been done for evaluation of the cardiac defects and the post surgical anatomy of the patient and i've been provided with ecg gated uh cardiac ct images of the patient uh in 35 percent phase and i will now begin describing the case so uh i will begin determining the situs of the patient and this is a coronal uh hrct reformatted image that i'm describing uh i can see two fissures on the right side making this uh making this a tri-looped right lung while on the left side i can see a single fissure along with the two lobes making it a billowed left lung also looking at the anatomy of both the bronchi the right upper loop bronchus is an ep arterial bronchus that is the right upper low bronchus is seen passing above the descending right palm under the archery while on the left side the left upper loop bronchus is seen passing below the descending left pulmonary artery making it a high particle bronchus therefore the patient has got a normal bronchioles coming on to the axial soft tissue window i already checked for the visceral side of the patient since i i am only getting limited images to display over here uh the liver was located on the right side of the abdominal cavity with this plane and stomach on the left side making it normal visceral situs now we'll try and determine the morphology of the area so moving on from normal uh visceral situs now we'll try and determine the atrial situs so i can identify two atria this one and this one over here now if i trace the svc of from above so this is the svc and this is seen opening into this atrium uh which is located on the right side and further scrolling downwards so i can see two atria here and if i trace the svc from above this is the svc uh which i've traced which if i trace downwards is seen opening into this atrium uh also the ivc seen opening into this atrium uh further uh this atrium has got an appendage which appears triangular and shows pectinate muscles so i will label this as the morphological right atrium uh this one here the other atrium that i can see shows the openings of the pulmonary veins uh which can be seen here so this is the morphological left atrium therefore the patient has got a normal visceral atriositis moving on to the morphology of the atria as already described this is the right atrium showing the right atrial appendage which is directed anteriorly showing a triangular configuration with a wide opening and pectinate muscles with openings of the svc and the ivc the right atrium appears mildly dilated with the dilated ivc as well as dilated hepatic veins moving on to the morphology of the left atrium the left atrium appears enlarged with a membrane-like structure that can be seen dividing the left atrium into two parts a right part and a left part this membrane is seen to be incompletely dividing the left atrium suggestive of core triatrium further the opening of all the four punitive veins can be seen um uh this being the right inferior paranoid vein this being the right superior pulmonary vein the left inferior pulmonary vein and the left superior pulmonary vein all the four pulmonary veins are opening into the right side uh right side division of the left atrium further moving on to the morphology of the ventricle so these are the two ventricular cavities that i can identify the ventricular cavity on this side shows a smooth septal wall and fine trabeculations while this ventricular cavity uh so i will label this as the morphological left ventricle while uh the ventricular cavity which is located here shows uh coarse trabeculations along the free wall as well as the septum and also the presence of moderator band therefore i will label this as the morphological right ventricle therefore this is a loop configuration contrary to the normal d loop configuration that we uh get in patients uh moving on to the morphology of the great arteries so this is the uh arch of aorta uh the aortic arch is left sided and this is the aortic root which can be seen here this is the main pulmonary artery which is seen superiorly coursing and dividing into right and left branches talking about the orientation of the aortic root and the main pulmonary artery the uh the ascending aorta is located anteriorly and to the left of the main pulmonary artery therefore this is uh lever transposition of great arteries now we talk about the connections so beginning with the venus drainage i've we've already looked at the right spc i can also identify another left-sided spc in this patient which if i trace downwards is seen opening into the coronary sinus which i can see here and this coronary sinus is further seen opening into the right atrium uh this coronary sinus uh also shows uh an area of the essence with communication with the left atrium suggestive of partially unroofed coronary sinus further the ivc and the battery grains uh ivc is also seen opening into the right atrium uh for the other venous drainage the pulmonary veins as i've already described seemed uh are opening into the left atrium talking about the atrial ventricular connection the morphological right atrium is seen communicating with the morphological left ventricle while the morphological left atrium is seen communicating with the morphological right ventricle so there is discordant a2 ventricular connection further uh for uh as far as ventricular arterial connection is concerned the arch of iota is seen arising from the morphological right ventricle while the main pulmonary artery is seen arising from the morphological left ventricle further there is severe infundibular stenosis with those even arrowing of the infundibular stenosis with severe narrowing of the main pulmonary artery which is uh which appears narrowed uh superiorly tracing it uh it seems divide uh it is seen dividing into a right aneurysmially dilated right pulmonary artery and a relatively normal looking left pulmonary artery since this was a post-operative case there was a surgically created conduit in the patient and this is the conduit that we can see uh this is the conduit which is seen connecting the morphological left ventricle and superiorly it is seen connecting uh draining into the main pulmonary artery the conduit shows uh some mural calcifications at both the openings however there is normal contrast to pacification whether without evidence of any filling defect or stenosis within the uh within the convert uh apart from that there is uh a suspicious uh there is suspicious setting of the inter age uh sorry so this is us uh so this is uh the right atrium so the right atrium and the left ventricle show a patent foramen ovale there is no uh no evidence of any other ventricular septal defect or patent ductus arteriosus in the patient i cannot identify any other abnormal aortic pulmonary collaterals apart from that i've already looked so i could not find any other abnormality in the chest in the lung fields in the visualized bones or in the body wall or in any of the abdominal restroom so if i uh so to conclude my findings uh in a 36 year old male patient diagnosed with the complex congenital heart anomaly post surgery uh i would summarize my findings as corrected liver transposition of great arteries with severe pulmonary infundibular stenosis with a surgically created patent shunt connecting the morphological left ventricle with the main right pulmonary artery with findings of double svc partially unroofed coronary sinus and a patent form thank you good evening everyone i will be presenting the second case which is a 26 year old female who presented with the history of chess palpitation it is neon exertion and the clinician suspected suspected a heart disease for which an echocardiography was also done and a diagnosis of a congenital heart disease was made and then patient underwent the cardiac city and geography for further evaluation and the case is up for discussion starting with the slightest of the patient and as we can see here that the right loop of the liver majority of the liver is lying on the right side and the the stomach as well as steam is lying on the left side and in the coronal images we can see that the on the right side we can appreciate that there are three lobes and on on the left side we can appreciate that there are two loops making it a trilobe right lung and while uh left lung and we can also appreciate that the right upper bronchus right upper longest is passing above the inferior pulmonary artery descending pulmonary artery and on the left making it making it uh [Music] here you can see the the right bronchus is passing above this is this uh inferior division of the right right pulmonary artery and the right wing bronchus is passing above that so making it an ep arterial bronchus and on the left side we can see that the right left main bronchus is passing below the left left descending pulmonary artery making it a hyperterial bronchus so based on this the situs would be a cytoskeleton and as the bronchial site is normal so there are chances that the right atrium would be on the right side only with the non with normal connections now coming on to the axial images again and now we will try to identify the uh chair ventricular the cardiac chambers starting with the uh starting the atrium here we can appreciate a large dilated chamber which is a superiorly drain draining the svc and inferiorly we can appreciate that it is [Music] so this is the ivc and it is draining into this large dilated chamber and when we move cranially we can appreciate the svc which uh svc is being formed and then it is draining into this dilated chamber this one said and it is draining into this chamber ah and we also appreciate that this chamber has a finger like projections uh finger like projection with the uh contained pectin muscles then making it a morphological uh right atrium [Music] yes sir this is triangular with broad base complication it is connected connecting to the right sorry sir i just wanted and then we can appreciate a chamber behind this dilated uh chamber behind this which is which appears as small in comparison to the morphological right atrium and we can appreciate that there are no uh there are no any draining vein into this chamber and we can appreciate that there is a septal defect between these two chamber and and this and this chamber also shows some fingerlike projections over here making it a morphological left ventricle then coming on to the uh ventricles will i try to identify the morphological right and left ventricle uh here we can appreciate that uh a large dilated chamber uh which shows those tribulations as well as we can also appreciate a moderator band and the interventricular septum towards the this other side of this chamber shows uh it is rough making it a morphological right ventricle and the chamber and the chamber posterior to it uh has a smooth intraventricular septum and the tribulation are comparatively smooth and also we can appreciate that the so making it uh making it making it a morphologically left ventricle so as we can see the right right ventricle is is on his anterior and towards uh the left and the uh left ankle is towards the right ventricle is towards the right and uh and area towards the right and the left ventricle is towards the left making it a normal d loop configuration so and then moving on to the eighteen ventricle concordance as we can see that the morphological right atrium is draining properly into uh into the right ventricle as well as the and the left atrium is draining into the left ventricle so the atrial ventricle concordance is maintained so we have identified the morphological left atrium morphological morphology left atrium morphological right atrium morphological right ventricle and the morphological left ventricle i will try to identify and like try to identify and see the course of the inflowing tracks and then we'll discuss the outflowing tracks so as we can see uh the ivc appears to be obviously which is draining into the right atrium appears to be dilated and there is a channel which appears to be draining into the ivc which will discuss later now we can see that the ivc is coming and draining into the right atrium without any obstruction and then if we trace the ivc i uh sorry i was talking about the svc it was svc the svc is running draining properly into the right atrium and when we trace the ivc it appears to be draining into the uh into the morphological right atrium without any abstraction so the infra tract to the uh right atrium appears to be normal now coming on to the left morphological left atrium as we discussed earlier there is no and there is no draining vein into the right the left atrium and we know that the pulmonary remains drain into the right right atrium a left atrium so we will try to trace the course of the pulmonary remains so moving we'll try to go from the cranial to the uh according to the cranial direction as we here we can see that the pulmonary veins are being formed and then they are both the left and right corner veins are draining into a common horizontal channel this channel is lying here which we can appreciate between the morphological left and left atria and the descending thoracic this is the transverse channel into which the both of the parallel rays are draining and we can also appreciate that the lingua's vein from the lingual segment is also training but it is draining from us uh like separately into this transverse channel and this then this transfer common transfer channel when we trace it upward we can appreciate that it is traversing uh traversing upward and in vertically upward and in its vertical course we can appreciate that the superior branch of the uh superior pulmonary vein is draining into these so into this vertical segment and then if you trace the trace it further we can appreciate especially in this section i think everybody can appreciate that the this common word the common channel which is traversing upward it can be seen separately from uh the it is lying between the bifurcation of the right pulmonary artery and it is lying and we can see we can here we can appreciate that the common channel is totally separate from the ivc here is the ivc which is dilated here these are the common arteries which is again traversing upward and we can we can trace that it is then joining into the uh into the svc and then finally the channel is draining into the uh right atrium uh then we so now coming on to the outflow tracks as we can see the this is the morphological right ventricle and from right integral right ventricle uh the origin of the pulmonary artery should take place and here we can trace the right we can trace the pulmonary arteries which appears to be dilated uh here we can if we compare it to the iota we can see that the pulmonary arteries as well its branches are markedly dilated uh coming to the uh like location of the uh relations of the aorta and pulmonary artery we can appreciate that the pulmonary art main pulmonary artery is located anterior and towards the left of the left left to the aorta making it a normal anatomy when we look at the aorta we can appreciate that the arch of the aorta is passing [Music] the the the aorta is arching over the left main bronchus making it a normal left arch and in regulation that there are no there is no sign of any obstruction into the solubilities or aorta there are there is no uh unknown length window uh there are no evidence so there are no evidence of any collaterals in the chest wall and the bone bone window there is no obvious bony lesions so to summarize my uh also in negative findings there uh i just also want to put that there is no evidence of any uh intraventricular intervention septal defect and other uh other structures like the the the origin of the uh origin of the coronary arteries appears to be normal which are which we here we can see that they are originating the origin of the coronary arteries are normal as well as the drainage of the uh uh coronary sinus it appears to be normal so to summarize my finding uh in a patient 26 year old female who presented with the complaints of palpitation breathlessness and this neonation we can appreciate a non non-obstructive type of abnormal pulmonary venous drainage into the superior vena cava making it a totally a normal anonymous type of totally anomalous pulmonary venous connection uh type 1 or supracardiac type along with this we also have adreceptal defect and dilated pulmonary artery as well as branches for almost everything so just a minute i'll just clip the camera so how to differentiate what is the importance of recommending the bronchioles so the bronchitis is mostly uh concordant with the situs of uh the atria so if the right lung is tri-lobed and uh the right uh upper low bronchus is a particular then in almost all cases uh the the right atria the morphological right atrium will be located on the normal right side so we will also have [Music] in which we can have right-sided isomerism or left-sided isomerism so in right-sided isomerism if we have uh both trilobe lungs then we will have a right atrial morphology while if we have a left-sided uh heterotaxy syndrome the left-sided isomerism then we will have a bilob both the lungs as well as uh polysplenia and for the heart we'll have bilateral left atria while in other words [Music] drainage if the spc and the ivc are opening into the right atrium almost always it will be the right atrium further the morphology of the right oracle so the right atrial appendage so if the right atrial appendage is triangular wide open and shows the presence of pectinate muscles then that is indicator of a morphological right atrium while the morphological left atrium will have a pencil like appendage uh without and will have smooth walls [Music] said it could be because of the surgically created shunt because there was infundibular stenosis um and that is why we i could see that the main pulmonary artery was uh narrow however this shunt was connecting and uh shunting the blood from the left ventricle or the left sided heart system to the main pulmonary artery so and because of the direction of blood flow it could have led to dilatation of the main right pulmonary artery because of the direction of the jet dr robin [Music] um this is so there are four types of uh totally unknown venus connection type one is a supracardiac which is the most common type of tapvc then it's a type two is the cardiac tapvc and then type three is the yeah subcardi infra cardiac pta pvc and type four is our mixed type in this type four is the rate which is more likely to get obstructed [Music] it's a cardiac type because the vein is coming from the abdomen [Music] sir in that all four veins are not going to drain into the right sided circulation there might be like uh uh so few of the out of four panel events there like there might be only uh uh some of them in training into the like into right areas [Music] [Music] m arteries are located anterior and towards the left of the at which level we see this it was an added origin at the at the origin or even mean what wall or the sign is so we just [Music] and towards the left the origin is anterior and towards the left to the aorta and if it if it is located interior and to the right [Music] anterior to the aorta [Music] uh there's one question uh relationship of descending average to the left bronchus i think he needs to ask how to determine the is [Music] next question is how to identify infundibulum of rvot so anyone dr tanya dr robin you want to answer this question or that is situated just underneath the pulmonary valve so it's a thick muscular structure which separates the aortic valve from the uh the tricuspid valve or the miter wall so if if you see any muscular thick structure underneath the valve then then it is called infundibular septum and on the other side you you get informable ventricular reflection so both these structure makes makes the infundibular which is the common site of obstruction in cases of tetology or fellows so though it's it's it's it's very easy to uh though it may sound a little uh difficult to you like how to but it's very easy to describe it on the images but this is how the anatomy it's under just underneath the iot valve sub valvular label muscular structure this is the sign this is the feature of your pulmonary valve so it's indirect sign that pulmonary valve is situated at this dr level is asking uh what is what was the age of the patient in the first case that dr tanya had presented and this patient had surgery correct not a corrective surgery but a palliative surgery in the childhood so now this patient had a new symptoms and they wanted to actually they wanted to see the potency of [Music] between the right ventricle and the balloony artery but because this case has got so many interesting finding that's why we kept it for the discussion thank you uh so let me congratulate uh dr needed jane and the residents dr tanya and dr robin for their wonderful presentation and discussion of the cases dr nirei jain we are proud of you this year sanjay gandhi institute with which some of it with some of your faculties we had some sessions in the last year during the during the crest programs and we are happy to have you with us in ira kerala event uh i also wish to thank uh dr venugobal uh sir who is the academics chairman and also dr ani shema who is a coordinator from for the program today and also dr prime chennai who is the state coordinator for the academics program of ira kerala i wish to thank all the delegates who joined here and i hope you have enjoyed this case presentations because this residents have presented wonderful wonderful cases and their faculty has explained the details of the case and i must say that this knowledge of congenital cardiac disease in ct and mr is extremely important if at any point of time in your career if uh concentrate on fetal echoes and all it will give you a better insight to understand the anomalies at maybe at least 550 percent of the pgs right now who are listening to me will have to do the fetal radiology and fetal echoes in some point of their career and i am sure these insights that you have gained from the understanding of ct and mr of the congenital heart disease various congenital heart disease will be of great use to you


IRIA, Kerala presents 2 interesting cases on Congenital Heart Diseases presented by residents of SGPGIMS and moderated by Dr. Neeraj Jain, Associate Professor, SGPGIMS. This session will prove very useful for all radiology residents as well as the budding general physicians.


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