Kuliah CHD
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Transcript of Kuliah CHD
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Burhanuddin IskandarPediatric CardiologyPediatric Department,Medical Faculty, Hasanuddin University/ WS Hospital Makassar
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Telur TGAManusia salju/angka 8 TAPVDKarpet Ebstein anomaliSepatu both TF
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Structures of the heart
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Normal Heart
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Atrial Septal defect( ASD )Insidence : + 10 % : ratio = 2 : 1Anatomy : Defect on foramen ovale : Secundum ASD Defect at SVC and RA junction: sinus venosus ASD Defect at ostium primum : primum ASD
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ASD
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Atrial Septal Defect
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LALVRVRAPAAOSystemicLungsQp > QsAtrial septal defect
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Atrial Septal DefectDiagram of ASD
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RARVLALVRARVLALVAtrial septal Defect
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Clinical findingsAsymptomaticAuscultation : Normal 1st HS or loudWidely split and fixed 2nd HSEjection systolic murmur Atrial septal Defect
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Atrial Septal DefectAuscultation :1st HS N or loudwidely split and fixed 2nd HS Ejection Sistolic Murmur
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ECG : IRBB , right ventricular hypertrophyAtrial Septal Defect
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Right atrial enlargementProminence the MPA segmentIncreased pulmonary vascular marking Atrial Septal DefectChest X-Ray
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Atrial Septal DefectDiagnosis Differential
Primary Atrial Septal DefectECG : LADPartial Anomalous Pulmonary Vein DrainagePulmonary StenosisInnocent Murmur
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Atrial Septal defect
ManagementSurgery : Preschool ageRecent treatment: transcatheter closure using ASO (Amplatzer septal occluder)
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ASDSmall ShuntLarge ShuntObservationEvaluationAt age 5-8 yrsCathFR1.5ConservativeInfantsChildren/AdultsHeart Failure (-)Heart Failure (+)Age >1yrsW >10kgTranscatheter closure (Secundum ASD) /Surgical Closure(others)ConservativeAnti failureFailSuccessPH (-)PH (+)PVD (-)PVD (+)HyperoxiaReac-tiveNonreactiveSurgicalClosure
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Atrial septal defect
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Atrial septal defectASD before occlusion
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During balloon sizingAtrial septal defect
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Atrial septal defectASD after occluded using ASO
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Ventricular septal defectInsidence 20 % of all CHD No sex influencedAnatomy Subarterial defect : below pulmonary andaortic valve Perimembranous defect: below aortic valve at pars membranous septum Muscular defect
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VSD
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Ventricular Septal Defect
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SystemicLungsQp > QsVentricular Septal defect
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LA
LV
RV
RA
PA
AO
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RARVRALALARVLVLVVentricular septal defect
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Ventricular Septal Defect
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Ventricular Septal DefectClinical findingsDay 1st after birth: murmur (-)After 2-6 weeks : murmur (+)Murmur : pansystolic grade 3/6 or higher at LSB 3 Small muscular defect: early systolic murmurSignificant defect: Mid diastolic murmur at apex
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Small VSD Large VSD Ventricular Septal DefectMurmur: pansystolic grade 3/6 or higher at LSB 3
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Ventricular Septal DefectCardiomegalyApex down wardProminence pulmonary artery segmentIncreased pulmonary vascular marking
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Ventricular septal DefectDiagnosis Differential
PDA with PHTetralogy Fallot non cyanoticInoscent murmur
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Ventricular septal defectManagement:
Definitive : VSD closure Surgery Transcatheter closure
- DSVHeart failure (+)Heart failure (-)Anti failureFailSuccessPABEvaluate in 6 mthsSurgical closure/Transcatheter closureAortic valve prolapsInfundibular stenosisPHSmallerSpontaneousclosureCathPVD(-)PVD(+)CathCathReactiveNon-reactiveConservativeFR>1.5FR
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Ventricular septal defectVSD before occlusion
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Ventricular septal defectVSD during deploying the device
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Ventricular septal defectVSD after occludedusing ASO
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Patent Ductus Arteriosus Insidence+ 10%Female : Male = 1.2 to 1.5 : 1Premature and LBW higherAnatomyFetus: ductus arteriosus connects PA and aorta. If ductus does not closs Patent Ductus arteriosus
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PDA
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LALVRVRAPAAOSystemicLungsQp > QsPatent Ductus Arteriosus
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RARVLALVRALARVLVPatent Ductus Arteriosus
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Patent Ductus ArteriosusClinical findings
Small defect: Symptom (-) Growth and development normalSignificant defect:Decreased exercise tolerantWeigh gained not goodFrequent URTISpecific case: pulsus seler at 4th extremities
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Patent Ductus Arteriosus DiagnosisPulsus seler and continuous murmur heard
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Patent Ductus ArteriosusChest X- RaySimilar to VSD
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Patent Ductus ArteriosusAuscultation : continuosus murmur at upper LSB 2
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Diagnosis DifferentialAP-windowArterio-venous fistulae
Management premature: indometasinPDA closure : surgery transcatheter closurePatent Ductus Arteriosus
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PDANeonates/InfantsChildren/AdultsHeart failure (+)Heart failure (-)PrematureFull termAnti failureIndometacinSuccessFailSpontaneous closureAnti failureSuccessFailSurgical ligationTranscatheter closurePH (-)PH (+)LRRLHyperoxiaReactiveNonreactiveConservativeAge >12wksW >4kg
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Patent Ductus Arteriosus
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Patent Ductus Arteriosus
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Patent Ductus ArteriosusPDA before occludedusing ADO
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Patent Ductus ArteriosusPDA after occludedusing ADO
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Patent Ductus ArteriosusPDA before occludedusing coil
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Patent Ductus ArteriosusPDA after occludedusing coil
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Pulmonary Stenosis Incidence : 8-10%
Anatomy:Pulmonary stenosis valvular : Bicuspid pulmonary valve Valve leaflet thickening and adhession Pulmonary stenosis infundibular : Hyperthropy infundibulum
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Pulmonary Stenosis Clinical findingsValvular stenosis Mild : Ejection systolic Wide 2nd HS ejectiin clickModerate: ejection systolic, early systolic clickSevere : ejecstion systolic, ejection click (-) Stenosis infundibular Ejection click ( - )1st HS normal, 2nd HS weak, ejection systolic Pulmonary stenosis periphery1st & 2nd HS normal, ejection systolic
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Pulmonary StenosisMild : ejection systolic 2nd HS wide split ejection clickModerate: ejecsi systolic , early ejection click Severe : ejection systolic, click ejection (-)
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Poulmonary StenosisDiagnosisAsymptomatic patient:click systolic (stenosis valvular)systolic murmurwide split 2nd HS vary with respiration
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Poulmonary StenosisNormal or mild cardiomegaly Marked pulmonary valve post stenotic dilatationNormal pulmonary vascularity
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ECG : RADEchocardiograhhy : confirmation diagnosisCatheterization: increased RV pressure without increased oxygen saturation
Pulmonary Stenosis
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Pulmonary StenosisManagement
Medicamentosa : uselessMild stenosis: intervention (-)Moderate stenosis: observationSevere stenosis: balloon valvuloplasty
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Pulmonary Stenosis
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Pulmonary StenosisBefore ballooning
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Pulmonary StenosisDuring ballooning
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Pulmonary StenosisAfter ballooning
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Coarctation AortaIncidenceIn Western country 5 % of all CHDIn Asian Country incidence lower underdiagnosis ?
AnatomyStenosis at any where in the aorta (from aortic valve to abdominalis aorta)More frequent at ductus arteriosus Botalli and pulmonary artery junction
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Coarctation Aorta
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Clinical findingsSevere coarctation in neonates period can cause heart failure in 1st weeks of life
Clinical manifestation in children: arterial hypertensioncommonly asymptomatic Different pulses felt at upper and lower extremities
Examination : increased left ventricular activity, thrill systolic, 1st and 2nd HS normal, ejection systolic murmurCoarctation Aorta
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Diagnosis Clinically : lower extremities pulses are weakCXR : Mild cardiomegalyProminence of aortic knob Normal pulmonary blood flowECG : normal or LVHEchocardiography: a discrete shelf-like membraneCardiac catheterization and angiography: to confime diagnosisCoarctation Aorta
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Management
Neonates : PGE1 to maintain PDA Diuretic Correction acid-base imbalance Prepared to undergo surgery
Big children:Surgery should be done as soon as diagnosis madeBalloon angioplastyCoarctation Aorta
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Coarctation Aorta
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Coarctation Aorta
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Coarctation Aorta
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Coarctation AortaBefore ballooning
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Coarctation AortaDuring ballooning
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Coarctation AortaAfter ballooning
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Tetralogy FallotInsidence5-8% from all CHD
AnatomyCause: Left-anterior deviation of infundibular septum
Sindroma consist of 4 items: VSD pulmonary stenosis aortic over-riding RVH
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Tetralogy Fallot
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Tetralogy FallotHemodynamic acyanoticHemodynamic cyanotic
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Tetralogy FallotDiagnosis
Clinically : cyanosis Single 2nd HS, ejection systolic murmur
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Tetralogy FallotSingle 2nd HS, ejection systolic murmur
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Tetralogi Fallot
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CXR : Boot-shapedConcave pulmonary segmentApex upturnedDecreased pulmonary blood flowTetralogy Fallot
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Tetralogy FallotECG : RADEchocardiography : to confirm diagnosis
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Tetralogy FallotDiagnosis Differential Pulmonary Atresia Double outlet right ventricle and pulmonary stenosis Transposisi of great arteri and pulmonary stenosis
Management Paliative treatment: Blalock-Taussig shunt Definitive: total correction
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Tetralogy of Fallot< 1 yr> 1 yrspell (+)spell (-)propranololfailedsucceedBTStotal correction cathsmall PAgood sized PA clinically ECG CXR echoage 1 yrcathBTS/PDA Stentevaluation
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Tetralogy Fallot
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Tetralogy Fallot
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Transposition of Great ArteryInsidence5% of CHDAnatomyAbnormality of formation of trunkal septum that cause aorta arising from RV and PA arising from LV
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Transposition of Great artery
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Fig. 7
Transposition of the great arteries.
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Hemodynamic normalHemodynamic of TGAseriesparallelTransposition of Great artery
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TGA without VSDIn adequate MixingAdequate Mixing Transposition of Great artery
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TGA with large VSDTGA with VSD and PSTransposition of Great artery
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Clinical aspects
More frequent in maleBirth weight usually normal or biggerCyanotic vary from mild to severeAuscultation : single 2nd HS and loudMurmur vary from silent to pansystolic murmur or continuous murmurTransposition of Great artery
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DiagnosisClinically : Suspicious if neonates presents with cyanotic with birth weight normal or biggerMurmur (-)Single 2nd HS and loudTransposition of Great artery
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Murmur (-)Single 2nd HS and loud
Transposition of Great artery
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Transposition of Great arteryCXR :CardiomegalyEgg-on-side heartIncreased pulmonary vascular marking
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Transposition of Great arteryECG :RADRVHBVH Echocardiography : to confirm diagnosisCardiac catheterization: usually is not needed
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Diagnosis Differential
trunkus arteriosus trikuspid atresia pulmonary atresia
Management
Surgery: arterial switchPaliative : Blalock-Taussig shuntTransposition of Great artery
- Transposition of Great ArteryPGE1VSD(-)VSD(+) 1mth> 1mthCathLV2/3 systLV3 mths3 mthsCathPARI
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Transposition of Great artery
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Truncus ArteriosusInsidencearound 1 % of CHDAnatomy Failure of septation of truncus arteriosus form aorta and pulmonary artery There are 3 type:Type 1 : MPA arises from the truncus and then divides into the RPA and LPATipe 2 : The PAs arise from the posterior aspect of the truncusTipe 3 : The PAs arise from the lateral aspects of the truncusTipe 4: Arteries arising from the descending aorta supply the lungs
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Truncus Arteriosus
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Truncus Arteriosus
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Truncus Arteriosus
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DiagnosisClinically suspected if:neonates present with cyanotic and single 2nd HSmurmur vary CXR:cardiomegaly increased pulmonary vascular markingECG: biventricular hypertrophyEchocardiografhy: to confirm diagnosisCatheterization: decreased oxygen saturation at right heart and aortaTruncus Arteriosus
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Diagnosis Differential Transposisi of great artery Total anomalus pulmonary vein drainage
Management
Medicamentosa : temporarySurgery: Rastelli Palliative: pulmonary artery bandingTruncus Arteriosus
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Truncus Arteriosus
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Tricuspid AtresiaIncidence1 % from all CHDEmbriologyValve formed at 5th weeksFussion of part of endocardial cushion, ventricular septum and miocardium
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AnatomyValve leaflet adhession one to another, difficult to openASD essentially required to drain blood from RA to LA Classified into 2 groupNormal related great arteryTransposed grat arteryTricuspid Atresia
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Tricuspid Atresia with normal related great artery
Tricuspid atresia with transposed geat artery
Tricuspid Atresia
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Manifestasi klinisCyanosis early after birthIncreased RV activityIncreased LV activityAuscultationSingle 1st and 2 nd HS
Tricuspid Atresia
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Clinical manifestationIn almost all patients murmur is silentIf murmur presentDiastolic murmur due to relative MSPansystolic murmur due to VSD
Tricuspid Atresia
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Tricuspid Atresia
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Diagnosis and diagnosis differentialClinically: Cyanosis with or without murmur
Tricuspid Atresia
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CXR: Heart minimally EnlargedThe PVMs are DecreasedThe MPA segment is concaveTricuspid Atresia
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ECG: LADLeft ventricular hypertrophyWith or without LAETricuspid Atresia
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Echocardiography: Essential to make diagnosisCatheterizationCatheter can not be passed from RA to RVIncreased RA and LA pressureDecreased oxygen saturation in LAAngiography: definitive diagnosisTricuspid Atresia
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Diagnosis differentialTransposition of great arteryTruncus arteriosusTetralogy of FallotTotal Anomalous pulmonary vein drainage
Tricuspid Atresia
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ManagementFontan operationTricuspid Atresia
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Tricuspid Atresia
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Tricuspid Atresia
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Tricuspid Atresia
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Tricuspid Atresia
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Tricuspid Atresia
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Modification of Fontan operationTricuspid Atresia
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