triple shunt

[drnono]

hi all
it is the 1st thread for me
we have an intereting cae in our unit
14 d old pt (1400 gm) with vsd, asd, ad pda
he tolerate full oral feedig now
already on lasix and capoten
stable general condition, normally thrivig despite of tachycardia
what about idomethacin for pda closure now?
any one has experience?
waiting for reply

[Stefan Johansson]

Well, I'd say it depends on the hemodynamic impact of the shunts.
From the clinical condition of the infants it appears that the volume load on the right ventricle (from the ASD/VSD) and lung circulation (from the ASD/VSD/PDA) is not very great.
If the PDA-shunt is significant, there seems to be nothing to lose with pharmacological treatment although it is a bit late to have good odds for closure.
If the child is well, and PDA is not very significant, you could probably just wait for spontaneous closure too.

[drnono]

thaks prof. alot but aother interestig thing in this case is that the presence of predominent right to left shunt at the ventricular level with no evidence of Rt ventricular outflow obstruction, there was also Lt to Rt shunt at PDA .
What is your explanation to this Rt to Lt shunt in this preterm 1400 gm baby .
Is less compliant Rt ventricle suggested to cause so ?

[Stefan Johansson]

...presence of predominent right to left shunt at the ventricular level with no evidence of Rt ventricular outflow obstruction, there was also Lt to Rt shunt at PDA .


This info makes the case more complicated than it appeared in your first post. Before you know more - you should probably leave the duct as it is, unless your pediatric cardiologist has another opinion!

A right TO left shunt at ventricular level is not normal and indicates increased pulmonary resistance (i.e. primary or second pulmonary hypertension), in the absence of an outflow obstruction. It is a bit odd though that the ductal shunt has the reverse direction, left TO right.

Is ductal flow only left TO right, or "predominantly" left-right (i.e. bidirectional)?
What are the shunt velocities through the VSD and the PDA?
What do the doppler profiles look like in the PDA and the main pulmonary artery?
If you have digital video clips from the ultrasound investigation, please email those to me and I could help you to upload them.

[drnono]

thanks again for interest
for sorry i dont have clip for the case but i can send you he images taken by echo
again my quesion about the less compliant RT venricle (the dominant and thicker one in fetal life), could this participate in this situation of the baby?

[Stefan Johansson]

Generally the right ventricle is more like the left ventricle (i.e. hypertrophic) due to increased work load, for whatever reason (for example increased volume, structural outflow obstruction, or increased resistance in the pulmonary vascular bed).
Unless there's any signs of generalized myocardial dysfunction or right ventricular outflow obstruction, I'd vote for increased pulmonary resistance as the underlying mechanism.

A video would say more than 1000 words, but to start with, please add the cardiology report to this discussion, and there may be clues there what's going on!

[drnono]

thanks alot ad very pleased for your reply
VD is muscular and 4.1 mm with predominent RT to LT hunt
ASD is about 5 mm with LT to RT shut
PDA is 3.7 mm with large LT to RT shunt
there is mild pulmonary stenosis
we have consulted a Prof. in pediatric cardiology
he sayed that the baby is stable and the PDA i not hemodynamically significant and the mild pulmonary stenosis i not relevent and is protective.
he advised for continuation of laix and captopril and weigt for some time to do another echo and reassess to take adecision
he also advised for increase caloric intake
the baby has gaied only 20 gm in the last week despite of 140 Kcal/Kg/day and er HR is always 150/min, not distressed

this is the situation now
we have no great experience in cases with triple shunt. she is the 1st case in our unit. if anyone has experience please to participae our plan for this case.
as i promied you i will send you the echo report but now the father has got it to consult another pediatric cardiologist. when he comes back i 'll sed it.

[Stefan Johansson]

Hmm, complicated hemodynamics!
The ASD and VSD seems pretty large from the measurements, given that the infant is rather small. The duct is clearly wide-open.
I speculate now... could it be so that the duct shunts lots of blood, leading to high atrial pressure, which is drained back to the right ventricle. Increased right ventricular pressure would be the result of the volume load from the ductal shunt/left atrium. Seems like a far-fetched explanation though.

The situation could be quite dynamic too, has shunt directions and velocities changed over time?

We would do echos at least 2-3 times weekly.