Sandbox: Ifeoma

Diseases	Clinical manifestations						Para-clinical findings			Gold standard	Additional findings
	Symptoms			Physical examination
							Imaging
	Exertional dyspnea	Failure to thrive	Recurrent respiratory infections	Murmur on auscultation	Peripheral edema	Clubbing	Echocardiography	Chest x-ray	Cardiac CT
Patent foramen ovale	−	−	−	−	−	−	Appearance of at least 3 micro-bubbles in the left atrium within three cardiac cycles after the complete opacification of the right atrium	Non specific	−	TEE	It is associated with migraine headache and decompression sickness in divers
Atrial septal defect	+/−	+/−	+/− (Right heart failure)	Systolic flow murmur in the upper left sternal border Wide, fixed splitting of S2 Diastolic flow rumble across the tricuspid valve			Hypermobile interatrial septum Abrupt septal irregularity Right atrial and ventricular volume overload Pulmonary artery dilatation	Cardiomegaly Pulmonary artery enlargement/increased pulmonary vascularity		TTE
Ventricular septal defect	-/+	-/+	After Eisenmenger syndrome	Holosystolic murmur May mimic aortic stenosis(mid/end dyastolic murmur due to increased pulmonary circulation)	-/+	-/+	Defect localization Direction of jet	Cardiomegaly in large VSD	Direct visualisation of murmur
Diseases	Exertional dyspnea	Failure to thrive	Recurrent respiratory infections	Murmur on auscultation	Peripheral edema	Clubbing	Echocardiography	Chest x-ray	Cardiac CT	Gold standard	Additional findings
Patent ductus arteriosus	Not at beginning May be produced during the course of disease	Depends on the size	-	Continuous machine-like murmur	-	May be present by progressing	Golden standard Used to classify the degree of the duct	Non specific	Used for Krichenko classification	Echocardiogram	Krichenko criteria for classification
Coarctation of the aorta
Aortic stenosis
Pulmonary stenosis	Depending on severity May be asymptomatic until increased pressure(pregnancy)	-	-	Continous systolic murmur	-	-/+	Right atrial hypertrophy	Non specific	Direct visualization of stenosis	Ecchocardiogram

Diseases	Pathophysiology	Shunt	Symptoms	Diagnosis	Echocardiography findings	Physical examination	Treatment	Complications
Patent foramen ovale	Failure of fusion of the septum primum and septum secundum leading to a flap valve opening.	Right-to-left shunt More prominent with increased right atrial pressure.	Majority of patients are asymptomatic	TEE (Gold standard) TTE TCD	Appearance of at least 3 micro-bubbles in the left atrium within three cardiac cycles after the complete opacification of the right atrium		Percutaneous closure Anticoagulants Antiplatelets	Paradoxical embolism Migraine with aura Decompression sickness in divers Platypnea-orthodeoxia syndrome
Atrial septal defect	Ostium secundum defect: Failure of the septum secundum to occlude the ostium secundum. Ostium primum defect: Failure of the ostium primum to fuse with the endocardial cushions. Superior sinus venosus defect: The orifice of the superior vena cava overrides the atrial septum above the fossa ovalis. Inferior sinus venosus defect: The orifice of the inferior vena cava overrides the left and right atrium. Coronary sinus defect: Absence of a portion of the common wall that separates the coronary sinus and the left atrium.	Continuous left-to-right shunt	Failure to thrive, tachypnea, recurrent respiratory infections, heart failure Commonly asymptomatic during childhood and adolescence Adults with large shunts may become symptomatic in the fourth decade presenting with fatigue, exercise intolerance, palpitations, syncope, and shortness of breath.	TTE (Gold standard) Cardiac CT Cardiac MRI	Hypermobile interatrial septum Abrupt septal irregularity Right atrial and ventricular volume overload Pulmonary artery dilation Coronary sinus defect: Enlarged ostium of the coronary sinus and unroofing of the terminal portion of the coronary sinus	Systolic flow murmur in the pulmonary valve region Wide, fixed splitting of S2 Diastolic flow rumble across the tricuspid valve Right ventricular heave	Spontaneous closure Percutaneous transcatheter closure Surgical closure	Right sided heart failure Peripheral edema Eisenmenger syndrome (cyanosis) Paradoxical emboli Pulmonary hypertension
Pulmonary ateriovenous fistula	Abnormal blood vessel(s) connecting the pulmonary arteries and veins directly without interposition of pulmonary capillaries	Right-to-left shunt between the pulmonary artery and pulmonary vein	Symptoms may occur only after the second decade Cyanosis Hemoptysis	Chest CT Pulmonary arteriogram	Appearance of contrast bubbles in the left atrium three to five cardiac cycles after appearance in the right atrium	Clubbing Systolic/continuous murmur	Embolization Surgical resection	Cerebral ischemia/abscess Hemothorax

• Patent foramen ovale may be classified anatomically according to the shape of the tunnel using a real time 3-dimensional transesophageal echocardiography (RT3D-TEE). It is classified based on the minimum overlap of the septum primum and septum secundum under valsalva maneuver.
• The table below shows the different tunnel types:

Patent Foramen Ovale Tunnel Type	Description
Type 1	Complete overlap
Type 2	Partial overlap (≧ 4 mm)
Type 3	Little or zero overlap (< 3 mm)

Diseases	Anatomy	Shunt	Symptoms	Physical Education	Diagnosis	Treatment	Complications
Type 1	Complete overlap
Type 2	Partial overlap (≧ 4 mm)
Type 3	Little or zero overlap (< 3 mm)