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suddendeath-1 - Coarctation of the Aorta Coarctation...

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Unformatted text preview: Coarctation of the Aorta Coarctation postoperative hypertension noted postoperative beyond the 10th postoperative yr: beyond -- alive and well and normotensive -70% at 10 yrs 70% 65% at 15 yrs 65% 20% at 25 yrs. 20% 3 arm leg gradient with exercise average arm is 80 mm Hg. is 3 SUDDEN DEATH in YOUNG ATHLETES ATHLETES Maron, et al, Circ 1980 Clinical Findings Clinical asymptomatic 3 syncope 3 presyncope 3 chest pain 3 mild fatigue 3 21/29 3/29 1/29 2/29 2/29 Circumstances of Death Circumstances death during or after severe exertion: death 22/29 22/29 3 death occurred during mild exertion: death 2/29 2/29 3 death occurred during sedentary death activity: 5/29 activity: 3 Causes of Sudden Death Causes 22 Unequivocal CV dis. 14 1 No CV disease 29 29 3 ALCAPA HOCM** 2 Atherosclero. CA Ruptured aorta 3 Probable CV Disease 6 5 1 Hypoplastic coronaries Idiopathic Concentric hypertrophy (no fiber disarray) Magnitude of the Problem Magnitude excluding trauma, cardiac death is the excluding most frequent cause of sports related death. death. 3 5/100,000 have a condition which 5/100,000 predisposes them to sudden death. predisposes 3 1/200,000 athletes per yr have sudden 1/200,000 death death 3 ~12 high school ath. die/yr in U.S. 3 Types of Sports Types 3 3 3 3 3 3 3 3 basketball football running swimming wrestling volleyball tennis baseball 33% 20% 16% 4.8% 3.8% 2.9% 2.9% 2.9% GOLF<1% Hypertrophic Cardiomyopathy and Sudden Death and Annual mortality rate 2-4% 3 Mechanism probably acute Mechanism dysrhythmia(v.tach, v.fib., asystole) dysrhythmia(v.tach, 3 Sudden death most common 10-25 yrs. 3 Peak age is 14 yrs. 3 Approx. 40% occur during ahtletics 3 If there is documented v. tach on If holter,death rate 8%. 3 HCM and Sudden Death HCM Increased risk of sudden death ass. with: Increased documented v. tach, family hx. of sudden death, young age of onset of symptoms. symptoms. Sudden death not related to presence or Sudden degree of outflow gradient. degree NO INTERVENTION(SURG,MEDICAL) HAS BEEN SHOWN TO DECREASE HAS RISK OF SUDDEN DEATH. RISK Abnormal Origin of CA’s and Sudden Death Sudden Left CA from right cusp is the most Left common cause of sudden death. common 3 Potential mechanisms: coronary comes Potential off tangentially from the aorta, ostium may be slit like,ostium may be partially covered by flap valve, initial few mm’m may be in wall of aorta. may 3 97% die at < 22 yrs of age 3 Rule out in pat with exercise chest pain Rule or syncope . Tx. surgical or 3 OTHER CAUSES of SUDDEN DEATH in ATHLETES DEATH Marfan Syndrome: related to aortic Marfan rupture. rupture. 3 Myocarditis: may be associated with Myocarditis: acute inflammation and chronic multifocal scarring-- arrthymias multifocal 3 Drugs: anabolic steroids predispose to Drugs: thrombotic MI, CVA, and cardiomyopathy. COCAINE COCAINE 3 Other Causes, Other 3 Primary dysrhythmias: a. sudden death reported with SVT,long QT, SSS. QT, b. exercise syncope most common presentation. presentation. SCREENING? SCREENING? 3 Scale: to identify 1000 atheletes at risk, Scale: 200,000 would have to be screened to prevent 1 death. death. 3 Routine screening by ECHO impractical 3 Routine EKG’s on all athletes probably Routine impractical. impractical. SCREENING? SCREENING? 3 SMA 1: history and PE focused hx of syncope, chest pain, or seizures in patient- always ask about sudden death in family members about focused PE looking for path. murmur, gallop, or S4, obvious ectopy murmur, LONG TERM EXPERIENCE AFTER CARDIAC SURGERY AFTER 3 60% of important CHD: VSD VSD ASD ASD PS PS PDA PDA CoA CoA Long Term Experience, Long Surgery for uncommon lesions- has Surgery been available for 25 yrs. been TGA TGA TA TA Single ventricle Single 3 These patients are now showing up in These adult clinics. adult 3 RESIDUAE & SEQUELAE of CONGENITAL HEART SURGERY SURGERY It ain’t over, til it’s over Surgical Residuae & Sequelae Surgical Obstructive lesions 3 Hypertension 3 Shunts 3 pulm. artery hypertension/ distortion 3 valve regurg 3 Surgical Residuae & Sequelae Surgical Arrhythmias 3 Systemic right ventricle- TGA Mustard or Senning Mustard 3 Fontan physiology- physiologic Fontan correction with single ventricle chamber correction 3 Coarction of the Aorta Coarction 50-85% incidence of bicuspid Ao valve. -- Late developement of stenosis/insuf-ficiency. ficiency. Associated with calcific changes Associated midlife event midlife -- infective endocarditis -3 >50% have mitral abnormalities 3 Coarctation of the Aorta Coarctation Associated abnormalities: -- intracranial aneurysms --- late aortic dissection --- intramural coronary artery disease -- Coarctation of the Aorta Coarctation Aortic aneurysms With dacron onlay patches -- 38% incidence of aneurysms -3 Aortic balloon angioplasty -- incidence of aneurysms unknown -native vs recoarc. For recoarctation, native balloon is procedure of choice balloon 3 Coarctation of the Aorta Coarctation Surgical results; aim for gradient < 10 30-40% have recurrent gradient when surgery done at less than 1yr. when 3 Significant late mortality--10-20% have resting hypertension --10-20% This is directly related to age at surgery.Exercise testing will provock gradient. gradient. 3 ...
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