Cardiac Flashcards
CHD causes
alertation to develop fully in 2-8th weeks gestation; environmental, multifactorial, genetic. drugs (Lithium, retinoid acid, anti epileptics, ibuprofen/naproxen, ACE inhibitors, TCAs, sulfonamides, sulfasalazine, tobacco, alcohol, cocaine, marijuana). Maternal illness (DM, connective tissue, PKU, rubella, febrile illnesses).
CHD s/s
tachypnea, tachycardia, rales/wheezing, cardiomegaly, hepatomegaly, periorbital edema, poor feeding/tiring, poor weight gain, diaphoresis. children/teens: tachypnea, tachycardia, rales/wheezing, megaly, orthopnea, SOB with exertion, peripheral edema, poor g&d
CHD tx
treatment for HF d/t infections, obstruction, arrhythmias; tx fluid/electrolyte imbalances, increase contractility, decrease cardiac after load. elevated neurohormonal/inflammatory mediators: tx with Angiotensin and aldosterone inhibitors, b-blockers. diuretics, inotropes, after load reducers. pulmonary vasodilators. monitor BNP.
left to right shunting CHD (Acyanotic)
leads to increased pulmonary blood flow. ASD, VSD, PDA; obstruction to ventricular outflow = coarc, pull. stenosis, aortic stenosis.
ASD
most common, involves mid septum in area of foramen ovale (osmium secundum type). premium is lower portion of septum and common in Down children’s. often asymptomatic may fatigue, exertion dyspnea, be thin, history of frequent URI or pneumonia. murmur may not be heard until >2years old. possible mild left chest bulge or palpable lift. S2 often widely split and fixed. widely radiating, medium, not harsh, systolic crescendo-decrescendo murmur at pulmonic area. cardiac enlargement. ecg: right axis deviation with right atrial enlargement; lead V1 right bundle branch block with rSR’ pattern. tall P wave, may have prolonged PR interval. dx with echo. small may close spontaneously, large are treated after 1 year old, prior to school, or when identified in older kid. cardiac Cath surgery. SBE prophylaxis only after surgery; low dose aspirin for 6 months. small incidence of arrhythmia from scars, no exercise restriction
VSD
perimembranous (most common), supracristal, inlet, muscular. up to half are small and self-resolve by 4 years old. when pulmonary vascular resistance falls at 2-9weeks old, more blood shunts across VSD and loud murmur with early s/s CHF. small: harsh, high pitched, grade 2- IV/VI holosystolic murmur at LLSB. large: low pitched, grade 2 to V/VI holosystolic murmur at LLSB. if higher pitched over time, closing. thrill at LSB. diastolic rumble at apex. S3 or 4 gallop if CHF present. may have cardiac enlargement, ECG normal but with large may have LVH or BVH. echo diagnosis often. small defects/no CHF monitored in first year and then biannually to assess for closure. larger: Lanoxin, diuretics, ACE inhibitors, b-blockers, watching nutrition caloric intake, surgery if no improvement over months. SBE prophylaxis for 6 months post surgery.
Atrioventricular septal defect
complete: absence of endocardial cushion so basically makes a premium ASD, a single AV valve, and inlet VSD. partial: soft blowing murmur of mitral regurgitation. complete: low pitched grade 2 to V/VI holosystolic murmur at LLSB. diastolic rumble at apex, thrill LSB, S3/4, may manifest with signs of pHTN with loud single S2, precordial heave, minimal murmur, and desats with agitation. x-ray, ECG (superior axis -40 to -160, RVH, PR interval prolonged). echo diagnosis. tx: monitor q3-6mo first year then biannually; gain weight slowly. complete AV canal need surgery pre 6 months. digoxin, diuretics, ACE inhibitors, b-blockers. long term complications: regurgitant or stenotic AV valve, arrhythmias, pHTN. need SBE prophylaxis.
PDA
normal functional closure in 12-72hr after birth; permanent closure in 3 weeks. may not close hence PDA. CHF in first few weeks of life in larger, usually evident by 3 months. after first few weeks of life typical grade 2 to V/VI harsh rumbling continuous machinery murmur in left infraclavicular fossa and pulmonic area with thrill at base. CHF s/s. ECG: LVH, QRS axis normal or to right. Echo. tx: indomethacin or ibuprofen in preterm infants. asymptomatic infants followed for closure or trans catheter device closure <1 year old. large shunts or pHTN surgerically closed sooner. SBE prophylaxis.
Right to left shunting (cyanotic)
obstruction of pulmonary blood flow or mixing of oxygenated/unoxygenated blood. visible cyanosis when sats <85. more apparent with polycythemia and less so with anemia or fetal Hgb.
Tetralogy of fallot
pulmonary valve stenosis, Right ventricular hypertrophy, VSD, overriding aorta. cyanosis present by 6mo life. dyspnea/cyanosis with tet spells increase by 2-4 months. grade 3 to V/VI harsh systolic ejection murmur at left to mid upper sternal border, palpable thrill and holosystolic murmur at LLSB. sternal lift. boot shaped heart. ECG: RVH and right axis deviation with conduction delay in V1. cardiac Cath may be done. tx: PGE1 to maintain PDA until repair is possible. knee-chest position, O2 and sometimes morphine. open heart surgery. complications: arrhythmias, pulmonary valve regurgitation, lifelong cardiology follow-up. RVH > QRS prolongation. SBE prophylaxis.
TGA
dextro: aorta from right ventricle and pulmonic from left; aorta gets deoxygenated blood. cyanosis within 1hr of birth, sometimes as late as 3 months. CHF. S2 loud and single. ECG: right axis deviation and RVH. tx: immediate referral, PGE1, balloon a trial septostomy, arterial switch (Jatene procedure) in first few days of life. monitored closely. SBE for life. high mortality without treatment.
Tricuspid atresia
single ventricle system; passes through AD so mixed blood. cyanosis soon after birth. grade 1 to III/VI early systolic murmur, single S2, hepatomegaly. cardiomegaly. give PGE1, need shunts. at 4-6months, bidirectional anastomosis of SVC then at 2-4 years Fontan. SBE prophylaxis while cyanotic. Lifelong exercise restriction, may have arrhythmias, strokes, HF, enteropathy.
aortic stenosis
bicuspid rather than tricuspid > LVH > ventricular failure. can lead to arrhythmias. some need immediate surgery, some balloon valvuloplasty. activity intolerance, CHF, sudden death. narrow pulse pressure, grade 3 to IV/VI loud harsh systolic crescendo-decrescendo murmur at URSB with radiation to neck, LLSB, and apex; faint early systolic click at LLSB. early diastolic blowing murmur at LLSB to apex. in severe, S2 single or closely split, may have S3/4. ECG may be normal or have LVH/inverted T wave. Holter monitor may show ventricular arrhythmias. echo needed. Tx: valvuloplasty, may need division of fused valve. if mechanical valves, need anticoagulation with warfarin. need low-intensity sports.
pulmonic stenosis
RVH. exertion dyspnea, fatigue, cyanosis if critical. grade 2 to IV/VI harsh mid to late systolic ejection murmur at ULSB over pulmonic region with transmission along border, neck and back, into both lung fields. ECG: right axis deviation. needs balloon valvuloplasty if >50mmHG stenosis.
Coarc
narrowing of segment of aorta. most have bicuspid aortic valve. HTN in uppers, low BP in lowers. tachypnea, poor feeding, possibly cool lower extremities. bounding upper pulses. signs of CHF. systolic ejection murmur in left infraclavicular region with transmission to the back. ventricular heave at apex, gallop rhythm if CHF. echo. MRI can help. tx: PGE1 for critical. surgical resection. may need antihypertensives. avoid high intensity exercise in first year post surgery. lifelong follow up.
