Congenital Heart Defects and Mitral Valve Prolapse



The Medically Compromised Patient

Congenital Heart Defects and Mitral Valve Prolapse

Congenital Heart Defects

*Major developmental of fetal heart occurs between the fourth and seventh weeks of gestation.

*Most defects occur during this time.

*May be altered by : environmental, genetic, or chromosomal influences.

*Most are thought to be multifactorial in origin, resulting from an interaction between a genetic pre-disposition to develop a heart defect and and environmental influence.

*Infants born to parents with congenital heart defects or with siblings with defects are at higher risk.

*Chromosomal abnormalities associated with CHD: Down Syndrome and Turner's Syndrome.

*Intrauterine Factors include: maternal diabetes, congenital rubella, maternal alcohol ingestion, and treatment with anticonvulsant drugs.

Types of Defects

*Congenital defects of the heart can affect almost any of the cardiac structures or central blood vessels.

*There are currently at least 35 types of defects identified.

*Include: defects between heart chambers, interrupted development of the heart chambers or valve structures, malposition of the heart chambers and great vessels, and altered closure of fetal communication channels.

*Most common are: Patent Ductus Arteriosus, Arterial Septal Defects, and Ventral Septal Defects

Patent Ductus Arteriosus

*A shunt is opened in between the aorta and pulmonary artery.

*This normally closes with fibrous tissue within the first 2-3 weeks of life, one source stated the passage closed within the first 24-72 hours of life.

*The defect results in the heart overcompensating in an attempt to provide oxygenated blood to the body.

*Can be treated either pharmacologically or surgically.

Drugs that inhibit prostaglandin synthesis, such as indomethacin, may be used to induce closure of the defect.

Indomethacin is an NSAID, the oral implications of this drug include: ulcerative stomatitis, gingival ulcerations, and xerostomia.

Arterial Septal Defect

*In this defect, a hole in the atrial septum persists as a result of septal formation.

Partitioning of atria usually occurs during the fifth and sixth weeks of development and occurs in 2 stages.

*Defects may be small and asymptomatic or large and symptomatic.

*Most are small and discovered inadvertently during routine physical examinations.

Young children with this defect may be asymptomatic, then present with symptoms later in life.

*Surgical treatment is usually postponed until school age, as spontaneous closure is common.

Ventricular Septal Defects

*This defect is an opening in the ventricular septum that results from an imperfect separation of ventricles during early fetal development.

*This is the most common form among congenital heart defects at 20-30%, compared to the other 2 we discussed that were both only 6-8%.

*Can be the only heart defect or one of multiple cardiac anomalies.

*Left and right ventricles exchange blood through the opening in the septum.

*The severity of symptoms range from an asymptomatic murmur to CHF. These are all dependent on size of the defect, If the defect is small, it allows a small shunt and small increases in pulmonary blood flow. It produces few symptoms and approximately 1/3 closes spontaneously.

With medium size defects, a larger shunt occurs producing larger pulmonary blood flow, children with such defects are asymptomatic and have a low risk for development of pulmonary vascular disease.

Children with large defects have an increase in pulmonary blood flow, the pulmonary artery is put under high pressure and can produce pulmonary hypertension.

*Treatment is dependent on the severity of the defect. Surgical intervention is necessary in infants who do not respond to medical management.

Prevention

*Use of Rubella Vaccine, especially during childbearing age, if individual has not been previously vaccinated. This is not given during pregnancy due to potential risks to fetus.

*No medications are to be taken without consultation of a doctor.

*Appropriate radiologic equipment is to be used if x-rays are necessary.

*Cessation of tobacco, alcohol, and drugs.

*Genetic Counseling.

Clinical and Dental Hygiene Considerations

*Signs and Symptoms: Easy fatigue, exertional dyspnea, fainting, cyanosis of lips and nail beds, poor growth and development, chest deformity, heart murmur, CHF.

*Prevention of Infective Endocarditis: certain specific serious congenital heart conditions including unrepaired or incompletely repaired cyanotic congenital heart diseases are advised to have pre medication with antibiotics.

*For patients with CHD on therapy, keep in mind the increased risk of periodontitis, candidiasis, and caries due to xerostomia.

*Patients with CHD that have chromosomal disorders such as down syndrome may have other oral implications such as gingival and periodontal disease, hypodontia, abnormally shaped teeth and anomalies in eruption with malposition.

Mitral Valve Prolapse

*Occurs in 2.4%-7% of the general population, and occurs more in men than women. It may have a familial basis.

*The cause is usually unknown, but it has been linked to Marfan syndrome, osteogenisis imperfecta and other connective tissue disorders, as well as cardiac, hematologic, neuroendocrine, metabolic, and psychologic disorders.

Description

*Located between the left atrium and left ventricle. When the mitral valve leaflets are damaged, the closure is imperfect and oxygenated blood can backflow or regurgitate.

*Mitral valve is prolapsed into the atrium during systole.

Symptoms

*Most are asymptomatic and are discovered during routine physical examinations.

*Small % have symptoms including pain mimicking angina, dyspnea, fatigue, anxiety, palpitations, and light headedness. More severe involvement presents and increase of palpitations and progressive mitral regurgitation along with a systolic click and murmur.

*Rare cases of sudden death have been reported for persons with MVP , mainly those with a familial history.

Treatment

*Treatment focuses on the relief of symptoms and prevention of complications.

*B-adrenergic blocking drugs are used and are often beneficial in response to the previously listed symptoms. Some common B-adrenergic blocking drugs are: Atenolol, Motoprolol, Propranolol, and Nadolol.

*Be mindful these drugs may have interactions with epinephrine and local anesthetic should be used with caution, as well as gingival retraction cord with epinephrine.

*Encourage the cessation of stimulants: smoking, caffeine, alcohol.

Pre-Medication

*Prior thinking recommended antibiotic premedication therapy before dental treatment for MVP.

*Current recommendations from the AHA are that patients with or without symptoms of MVP no longer need antibiotic pre med prior to dental treatment.

Dental Hygiene Considerations

*Keep up to date records on patients medications and symptoms.

*Encourage meticulous home care regimen.

*Dental treatment is contraindicated for patients with unstable or recent onset of angina pectoris, or uncontrolled arrhythmias. MVP can present symptoms mimicking angina pectoris and palpitations, patients need to be current with their cardiologist if they have this condition and are having symptoms.

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