acyanotic lesions Flashcards
VSD and ASD: pressure vs volume
VSD is pressure overload
ASD is volume overload (not as bad)
types of ASD - which is most common
1) secundum (60%) - anomalous pul return in 10%
2) primum (30%)
3) sinus venosus (10%) - anomalous drainage in SVC/IVC
4) coronary sinus - rare
ASD vs PFO shunts
PFO doesnt usually cause intra-cardiac shunts
T21 a/w which ASD
primum
which is closer to the AV node - primum or secundum ASD
primum
ASD vs VSD shunt magnitude determined by what two factors
ASD A) size of defect and B) compliance of ventricle
VSD A) size of defect and B) PVR (lower then PVR, more shunt)
why does CHD/pulmonary HTN develop so late in ASDs?
not pressure issue - there’s no direct transmission of systemic pressures
pulmonary arteries can handle the increased volume for quite some time, with normal PA pressures
classic murmur findings in ASD (3) vs VSD (4)
ASD:
- fixed split of S2 (more pulmonary flow)
- grade 2-3 ejection systolic at LUSE - get a RELATIVE pulmonary stenosis due to inc flow
- mid diastolic rumble sometimes - can be a/w tricuspid stenosis
VSD:
- holosystolic murmur LLSE +/- thrill (due to flow)
- Apical mid-diastolic rumble: relative mitral stenosis
- Early diastolic decrescendo murmur of AR (infundibular VSD)
- loud P2 (PHTN/Eisenmengers)
ecg findings of ASD
RBBB from RV dilation - not from actual block!
mild RVH
cxr findings of ASD vs VSD
ASD: RA enlargement, inc pulmonary vascular markings
VSD: LAH bc of inc volume return and RAH
- remember in Eisenmenger’s the LAH will improve bc now pul pressure > systemic
natural hx of ASD
<3mm - 100% spontaneously close
3-8mm - 80% by 1-2yo
>8mm - rare spont close
preferred way to close an ASD
non-surgical via catheter into IVC and expanding device!
conditions a/w VSD (3)
Turner
T21
DiGeorge
most common type of VSD
peri-membranous
why do we care about a outlet (infundibular or conal) VSD
aortic leaflet can prolapse through the VSD and cause aortic insufficiency or RVOT
which type of VSDs do not close spontaneously? which do?
Inlet and outlet (infundibular) VSDs do NOT
muscular > perimembranous DO close
ecg findings of VSD
dependent on size of VSD small = normal Moderate VSD = LVH and occasional LAH Large VSD = BVH with or without LAH If pulmonary obstructive disease = only RVH
indications for surgical repair of VSD
PHTN, shunt >2:1
impact on growth <6mo
frequent complication of surgical VSD repair
RBBB
when does Eisenmengers tend to happen in a VSD
teenage years
complete vs partial AVSD
complete = VSD + primum ASD + clefts in the mitral and tricuspid valve (single valve orifice, usually 5 leaftlets) partial = ostium primum type of ASD + cleft in the mitral valve
AVSD basically means what condition?
T21 (70% AVSD are T21)
partial AVSD vs just a primum ASD
partial AVSD - MR often trivial, but can have LA / LV enlargement if MR is significant, and CHF can therefore develop earlier
when to repair a partial AVSD
elective + asymptomatic -> 2-4yo
earlier in FTT, MR, or common atrium
how is the shunt of a complete AVSD different from a VSD?
it’s an obligatory shunt, determined by size of defect not PVR:
from LV > RA
heart sounds of complete AVSD (3)
- S1 is accentuated – due to abnormal AV valve
- S2 narrowly splits
- P2 increased in intensity – due to pulmonary HTN
classic exam findings for PDA (4)
bounding peripheral pulses, wide pulse pressure
hyperactive praecordium
continuous machinery murmur left infraclavicular/LUSE
apical diastolic rumble (mitral flow)
Eisenmenger’s in PDA - what is different about the cyanosis
LOWER half body cyanosis only
natural Hx of PDA in prem vs term
prem - PDA can spontaneously close
term - rare
what sided hypertrophy with PDA, and why?
Increased flow returning to the left heart results in increased left atrial and left ventricular end-diastolic pressures. The left ventricle compensates by increasing stroke volume and eventually may hypertrophy to normalize wall stress.
standard approach to fixing a PDA surgically
posterolateral thoracotomy
peripheral pulmonary stenosis - 3 major causes
a. Congenital rubella
b. Alagille syndrome
c. Williams syndrome
Peripheral or valvular peripheral stenosis:
- congenital rubella
- alagille
- williams
- noonan
Congenital rubella = BOTH
Alagille = peripheral
Williams = peripheral
Noonan = valvular with dysplastic pulmonary valves
murmur:
- PS
- peripheral PS
- AS
- MS
- MR
- AR
- PS: ejection systolic LUSE, click
- peripheral PS: mid systolic LUSE, axilla and back
- AS: ejection systolic RUSE, click
- MS: mid diastolic rumble, apex
- MR: regurgitant systolic, apex. S3 often present
- AR: High pitched diastolic decrescendo murmur with water hammer pulse
what happens to the vessel post a stenosis
dilation
ways to treat a PS vs AS
PS - PGE infusion - keep PDA open
balloon valvuloplasty - treatment choice for all ages
surgery - valve replacement
AS - keep PDA open, no competitive sport in severe AS
balloon valvuloplasty not as effective
surgical more common, less time to re-intervention
what does an ejection click mean on auscultation?
mid systolic click?
ejection: valvular stenosis of some kind!
mid systolic: MVP!!
types of AS
1) valvular (70%) - bicuspid v common
2) subvalvular (25%) - 2/3 have associated cardiac lesions
3) supravalvular (5%) - annular constriction at valsalva sinus
two conditions associated with supravalvular AS
- William syndrome
2. Familial hypercholesterolaemia
classic triad of AS presentation
- dyspnoea
- chest pain
- exertional syncope
signs of critical AS in a neonate
reduced peripheral perfusion (weak and thread pulse, pale cool skin, slow cap refill - from ductus closing
what other aortic conditions can result from AS?
post stenotic aortic dilatation
AR
what is the main surgery we use for AS?
Ross operation: patient’s own pulmonary valve replaces their shitty aortic one
then a homograft replaces the pulmonary valve- lasts longer as lower pressures, but will eventually need replacement
coarct - think what syndromic condition
Turners
coarct - think what associated defects
bicuspid aortic in 50-80%
berry aneurysm
CXR findings of coarct
1) rib notching between 4th-8th ribs in >8yo with large collateratls
2) post stenotic dilatation of aorta
ways a coarct can present
1) well neonate - differential cyanosis, absent femoral pulses
2) unwell neonate - shock in first 6 weeks, absent femoral pulses
3) older child - HTN (UL>LL), murmur
complications post coarct repair
coarct repair either - end to end anastamosis, subclavian flap, balloon
re-stenosis
aneurysm
HTN
what syndrome must always be thought of with interrupted aortic arch
DiGeorge - need to do workup e.g. Ca
what arrhythmia can result from MS
AF
most common valvular involvement in children with rheumatic heart disease
MR
causes of MR in children
- rheumatic fever
2. associated with AVSDs
MVP - a/w what syndromes
CT diseases: Marfan, EDS, osteogenesis imperfecta, Stickler syndrome, PCKD (adults)
MVP most commonly associated with what other cardiac defect
secundum ASD
what can cause an AR?
bicuspid aortic valve
dilated aortic root e.g. marfans, EDS
what is cor triatrium
Atrium divided into 3 parts by fibromuscular septum (usually two on left) –> like MS
