Congenital Heart Disease &Surgically Corrected Cardiac & Vascular Disease &Prosthetic Implants

Congenital Heart Disease &Surgically Corrected Cardiac & Vascular Disease &Prosthetic Implants
DENTALMANAGEMENTOF THE MEDICALLYCOMPROMISED PATIENT
Dr. Ziad H. Delemi B.D.S, F.I.B.M.S (M.F.)

R.A. 5 mm Hg

L.A. 10 mm Hg
L.V. 125 mm Hg
R.V. 25 mm Hg

Pathophysiology

Normal fetal heart structures, allows blood to bypass circulation to the lungs (O2 provided by placenta)& to liver (nutrition also provided by placenta). PDA– patent ductus arteriosus(Connection LPA to Aorta)PDV- patent ductus venosus.PDA Normally closes 15hrs after birth (complete 3weeks).Foramen ovale ( closes 1-3 months). Right-to-Left shunting cause a recirculation of blood.Compensatory polycythemia.

Classification of Congenital Heart disease based on blood flow

Left-to-Right shunting lesions (acyanotic) Atrial septal defect Ventricular septal defect Patent ductus arteriosus Right-to-Left shunting lesions ( cyanotic) Transposition of great vessels Tetralogy of Fallot
Obstructing lesions Pulmonary stenosis Coarctation of aorta Other lesions Congenital complete heart block Cardiac malposition
Shunt : means communication between two sides of the heart



Multifactorial genetic & environmental causes: Familial Exposure of mother to teratogen (early pregnancy specially first 8 weeks) Mutant genes (e.g.: Down's syndrome) Hereditary disorder (e.g.: Ehlers- Danlos syndrome) Drugs (e.g.:phyenytoin, lithium) Infections (e.g.: Rubella) so every female should immunized against Rubella High altitude Excessive radiation
Causes of Congenital Heart disease

Complications

Infective endocarditis Pulmonary edema Cardiac failure Thrombosis Bleeding (thrombocytopenia, coagulation factors, anticoagulant drugs) Cyanosis Infection (leukopenia) Brain abscess Pulmonary arterial hypertension Growth retardation Exertinal intolerance

Signs & symptoms of Congenital Heart disease

1. Chest pain 2. Dyspnea 3. Cyanosis 4. palpitation 5. Syncope 6. Edema of ankles 7. Cold pale extremities

8. Clubbing fingers 9. Easy fatigue 10. Ruddy color polycythemia 11. Murmur 12. Distention of neck veins 13. Ascites 14. Congestive heart failure

Atrial Septal Defect

Hole between the two atriaBlood flows left to right PFO – Patent foramen ovale fails to closeRight heart becomes dilatedToo much blood to the lungs

Hole between the two ventriclesLeft to right shunt – majorityDilated right heart – too much blood to lungs – increase in pulmonary pressureSmaller defects can close spontaneously

Failure of D.A. to close or it re-opens Shunt is usually L- R but can be R- L if pulmonary artery pressure exceeds aorta pressure Treated with Oxygen, medicine and possibly surgery



Reduced blood flow to the lungs Low 02 blood pumped up Aorta (shunting)Reduced P02 in circulationCyanosis – baby appears blue (lips/skin)Increased RV pressure (RVH)squatting position

Pulmonary arteries supplied by left ventricle Aorta by right ventricle Not compatible with life Immediate survival dependant on shunt from left heart to right heart


Narrowing of the ascending aortaOften associated with other CHD-e.g. bicuspid AV,VSDLVH /congestive heart failureSevere Coarctation require immediate treatmentWeak femoral pulses – reduced blood flow to lower limbs

History Clinical examinations CXR ECG Echocardiography Doppler Echocardiography Cardiac catheterization

Observation (heal spontaneously) NSAIDs (Indomethacine or Ibuprofen) Surgical closure Ballon Treat complications transplantation

Dental management of the patient with C.H.D.

Medical consultation Prophylactic antibiotic coverage to prevent Infective endocarditis Most patients need standard regimen for rheumatic heart disease After healing (6months) by using synthetic material need prophylaxis After healing (6months) by using non-synthetic material not need prophylaxis Avoid dehydration in case of oral infection Bleeding time & prothrombine time tested before any procedures Antibiotic may be indicated due to leukopenia

Endocarditis Prophylactic Regimens for Dental & Oral Procedures

Amoxicillin Adults: 2 g Children: 50 mg per kg  Taken orally one hour before the procedure
Patient is unable to take oral medications
Patient is able to take oral medications
Ampicillin Adults: 2 g Children: 50 mg per kg  Given IM or IV within 30 minutes before the procedure

Patient is allergic to penicillin

Azithromycin or clarithromycin (Klaribac) Adults: 500 mg Children: 15 mg per kg  Taken orally one hour before the procedure

Clindamycin Adults: 600 mg Children: 20 mg per kg  Taken orally one hour before the procedure Cefadroxil or cephalexin ( Keflex) Adults: 2 g Children: 50 mg per kg  Taken orally one hour before the procedure
Patient is allergic to penicillin


Clindamycin Adults: 600 mg Children: 20 mg per kg  Given IV within 30 minutes before the procedure Cefazolin Adults: 1 g Children: 50 mg per kg  Given IM or IV within 30 minutes before the procedure

Atrial & ventricular septal defects (suturing, Dacron patch) Ductus arteriosus (suturing or resected) Coarctation of aorta (flap autoplasty, suturing or resected) Prosthetic heart valves (tissue or mechanical replacement) Coronary artery bypass graft Arterial graft ( autogenous , Dacron) splenectomy
surgically corrected cardiac & vascular disease

surgically corrected cardiac & vascular disease

surgically corrected cardiac & vascular disease

Antibiotic prophylaxis up to 6 months postoperatively to prevent infective endocarditis by using the regimen of rheumatic heart disease Patients with coronary bypass graft surgery usually are not considered susceptible 1-2 weeks after surgery . Patients with artificial heart valves very susceptible to infective endocarditis so coverage is need with antibiotic Surgical procedures avoided due to bleeding secondary to anticoagulant use.
Dental management of the patient with surgically corrected cardiac & vascular disease

No evidence supporting need for prophylaxis Breast implants Dental implants Implanted lenses Cochlear implants Vetriculoperitoneal CSF shunts Lumboperitoneal CSF shunts Pin, screws, plates used for fracture repair (till healing established) Little or No evidence supporting need for prophylaxis Prosthetic joints Transvenous pacemakers Central intravenous lines
Prosthetic Implants


Some evidence supporting need for prophylaxis Synthetic arterial grafts Synthetic cardiac patches Hickman catheter Ventriculoatrial CSF shunts Evidence supporting need for prophylaxis Prosthetic heart valves Mechanical Tissue
Prosthetic Implants

Prosthetic Implants

Dental implants

Prosthetic Implants

Implanted lenses

Prosthetic Implants

Ventriculo-Peritoneal Shunt
Lumboperitoneal CSF shunts

Prosthetic Implants

Cochlear implants
Prosthetic joints

Prosthetic Implants

Ventriculoatrial CSF shunts
Hickman catheter


Prosthetic Implants
Synthetic arterial grafts

Prosthetic Implants

Synthetic cardiac patches
Central intravenous lines