4. Cardiovascular pathology Flashcards
What is an innocent murmur?
-Increased flow in a normal heart
-Often more pronounced in minor illness (resolves when illness resolves 6-8 weeks later)
-No clinical significance and child is asymptomatic
What are the 7 S’s of an innocent murmur?
-Soft
-Short
-Systolic
-(L) Sternal edge
-Symptomless
-Sensitive (changes with position)
-Sweet (in pitch)
What features are present in a normal foetal and neonatal heart?
-Foramen oval (between atria)
-Ductus arteriosus (between pulmonary artery and aorta
What are the main types of paediatric cardiac pathology and how are they classified?
CYANOTIC
-Tetralogy of Fallot
-Transposition of the Great Arteries
NON-CYANOTIC
-Coarctation of the aorta
-ASD/AVSD/VSD
-Patent ductus arteriosus
What murmur can be heard at the L 2nd ICS?
-Pulmonary flow murmur
-Suggests turbulent flow
-Brief, high-pitched
What murmur can be heard below the clavicles?
-Venous hum (rare)
-Blowing continuous murmur in systole and diastole
-Disappears on lying down
What risk factors are associated with congenital heart disease?
-Family history
-Teratogens
-Maternal drug use
-Maternal diabetes
How does CHD tend to present?
-If severe can be detected antenatally
-Commonly presents at birth with:
–Cyanosis
–Shock
–Breathlessness
-Some may present with:
–Difficulty feeding
–Asymptomatic murmur
–Syncope
–Chest infections
–Oedema
How should you examine a child with ?CHD?
-RR, HR, pre- and post-ductal sats (legs = post-ductal)
-Lying and standing BP
-Feel pulses
–Easy to feel? Collapsing pulse?
-CRT
-?Clubbing in hands
-Auscultate chest for wheeze, crackles
-HS
-Assess for hepatomegaly + increased tone
How would you investigate a child with ?CHD?
-Routine bloods (septic screen if presenting with cyanosis / SOB)
-CXR (pulmonary oedema, consolidation, heart size)
-Blood gases (high lactate)
-Echo
-ECG
How are children with congenital heart disease managed?
-Many can be monitored for years and may not require surgical correction
-Medical control of heart failure pending any definitive repair
What is the order of foetal circulation?
1.Maternal blood received through umbilical vein
2.Umbilical vein – IVC – RA/LA (via foramen ovale)
3. RA – RV – PA – ductus arteriosus – aorta
OR
3. LA – LV – aorta
4. Aorta – body – umbilical arteries – placenta
What are the 4 features of Tetraology of Fallot?
- Large VSD
- Pulmonary stenosis
- Overriding aorta
- RV hypertrophy
Associated with DiGeorge syndrome
How do children with ToF present?
-Colouring depends on degree of pulmonary stenosis (blue = severe stenosis causing R-L shunt)
-Tet spells
= hyper-cyanotic episodes which are relieved by squatting down to reverse R-L shunt (increases LV pressure)
-Failure to thrive
-SOBOE
-Loud ESM due to pulmonary stenosis
-‘Boot-shaped heart’ on echo
How is ToF managed?
-Surgery - VT shunt
-Shunt placed between subclavian and pulmonary artery
-Done before 1y/o
What can be given to manage Tet spells?
-Propanolol
-Morphine
How does ASD present and what condition is it associated with?
-Associated with Downs Syndrome
-Usually asymptomatic / not detected until adolescence
-SOB
-Recurrent chest infections
-R heart failure
-Soft ESM at L 2nd ICS
How is ASD managed?
-Treated surgically if moderate or large
–Open heart surgery
–Catheterisation
What complications can arise from untreated ASD?
-Arrhythmias
–Ostrium Primum = defect in AV septum, RBBB, LAD and prolonged PR seen on ECG
–Ostrium Secondum = defect in FO and AS, RBBB + RAD seen on ECG
What occurs in VSD and what babies are most at risk of developing it?
-Hole in ventricular septal wall causing L-R shunt
–Excess blood to lungs – pulmonary oedema – SOB
-More common in:
–Trisomies
–Maternal diabetes
–Turner’s syndrome
–Foetal alcohol syndrome
How does VSD present?
-Signs of L heart failure eg tachypnoea, tachycardia, hepatomegaly
-SOB and sweating on feeding in large defects
-Pansystolic murmur heard at lower L sternal border radiating across chest
-Poor growth
-Recurrent chest infections
-Cardiomegaly
-Diagnosis confirmed on echo
How is VSD managed?
-Medical = diuretics, ACEis and high calorie feeds
-Surgical = wait til 3-6 months
-Aim to prevent endocarditis
-If small, often close before 2 y/o
Recognised complication = Eisenmengers
What causes a patent ductus arteriosus?
-Duct shunts blood from pulmonary artery to aorta during foetal life, closes within 2-3 days
-Duct remains patent in babies who are:
–Unwell (rubella, valproate withdrawal)
–Preterm
–Hypoxic
-Cardiac failure and pulmonary oedema caused by L-R shunt
How does PDA present?
-Machinery hum murmur heard over tricuspid area
-Collapsing pulse
-Chest infection
-SOB
-Eisenmenger syndrome (thickening of pulmonary arteries)
