Cardiac Flashcards
dDx breathless child
Left to right shunt
ASD
VSD
PDA
Features ASD
Secundum (most common, central defect) and partial AVSD- present similarly with different anatomy
Common asymptomatic
ASD secundum presentation
May present as recurrent chest infection/wheeze, arrythmias in 4th decade
Ix ASD secundum
Ejection systolic murmur best heard at upper left sternal edge
Fixed and widely split second heart sound
Xray showed cardiomegaly, enlarged pulmonary arteries, increased pulmonary vascular markings
ECG shows partial right BBB and right axis deviation
Mx ASD secundum
Treatment required if large enough to cause right ventricle dilation
Cardiac catheterization and insertion of an occlusion device
Ix partial AVSD
Asymptomatic pansystolic murmur from AV valve regurgitation
ECG shows QRS negative in AvF
Mx partial AVSD
Surgical correction between 3-5y
Features small VSD
<3mm and asymptomatic
Normal X Ray and ECG
Loud pansystolic murmur at left lower sternal edge
Usually self resolve
Require good dental hygiene prevent endocarditis
Features large VSD
More prominent presentation Heart failure with breathlessness and faltering growth after 1 week old Recurrent chest infection Soft pansystolic murmur Atypical mid-diastolic murmur Loud pulmonary second sound
Ix large VSD
Chest Xray shows cardiomegaly, enlarged pulmonary artery, increased pulmonary vascular markings and pulmonary edema
ECG shows ventricular hypertrophy by 2 months of age
Mx large VSD
Drug therapy for heart failure with diuretics combine with captopril
Additional calorie input required
Surgery performed at 3-6 months to prevent permanent lung damage from pulmonary hypertension and high blood flow
Cx VSD uncorrected
Eisenmenger syndrome
Features Eisenmenger syndrome
Long term complications of untreated left right shunting
Pulmonary arteries become thick walled with high resistance
Features develop after 1 year of uncorrected shunt defect
Progressive presentation and death by right sided failure
Palliation or full heart lung transplantation (rare)
Features PDA
PDA failure to close within first months due to a defect in the contractile mechanism
Resorts with continuous machinery murmur under the left clavicle continuing into diastole
Pulse pressure decreases with a collapsing bounding pulse
Large ducts exhibit heart failure and pulmonary hypotension
Ix PDA
Normal chest Xray and ECG uless duct is large
In large duct ECG and X Ray exhibit signs of VSD
Mx PDA
Closure to prevent endocarditis and pulmonary vascular disease
Closure with coil or occlusion device via a cardiac catheter 1 year of age
Prostaglandin inhibitors may be effective in term infants .e.g. Indomethacin
Preterm infants less responsive to prostaglandin inhibitors
dDx blue baby
Right to left shunt
Tetralogy of fallot
Transposition of the great arteries
Eisenmenger syndrome
Four features of tetralogy of fallot
Large VSD
Overriding of aorta with respect to ventricular septum
Subpulmonary stenosis causing right ventricular outflow obstruction
Right ventricular hypertrophy
Exam and Ix in tetralogy of fallot
Loud ejection systolic murmur
Clubbing of fingers and toes develops in older childhood
Chest Xray features: relatively small heart, uptilted apex, pulmonary artery bay, concavity of the left heart border, decreased pulmonary vascular markings
ECG develops signs of right ventricular hypertrophy
Mx tetralogy
Definitive correction at 6 months of age: closure of VSD, relieve RV outflow tract obstruction
Shunt via artificial tube between the subclavian and pulmonary OR balloon dilation of RV outflow obstruction
Hypercapnic episodes lasting >15 minutes related with analgesia, V propranolol, IV fluids, bicarbonate, artificial ventilation
Features transposition of great arteries
Aorta connect to the RV and pulmonary artery connected to the LV
Without mixing, this is fatal
Cyanosis is predominant feature; profound and life threatening
Presentation typically follows ductal closure
Second heartland is often loud and single- no murmur
Xray features transposition
egg on side appearance
increased vascular markings
Mx transposition
Maintain patency of ductus arteriosus with prostaglandin infusion
Balloon atrial septostomy via the atrial septum
All patients require surgery in the neonatal period to switch vessels
dDx blue and breathless
Common mixing
Complete AVSD
Tricuspid atresia
Features complete AVSD
Associated with down’s syndrome
Defect in the middle of the heart producing a small fine leaflet valve stretch across whole AV junction
Diagnosis by antenatal US
Cyanosis or heart failure at 2 weeks to 3 months
No associated murmur
Mx complete AVSD
Routine echo in all patients with down syndrome
Initially medical treatment with full repair at 3-6 months
Features tricuspid atresia
Only Left ventricle is effective: right ventricle is small and non-functional
Cyanosis in newborn which is duct dependant
Mx tricuspid atresia
Early palliation to maintain pulmonary blood supply low pressure: Blalock-Taussig shunt (subclavian to pulmonary artery)
Corrective surgery rarely possible due to single ventricle
Further palliative surgery: SVC to pulmonary at 6 months; IVC to pulmonary at 3-5 years
Features coarctation of the aorta
Collapsed child with shock
Outflow obstruction
Atrial duct tissue overrides the aorta at the point of insertion of duct
Present with collapse on day 2 when duct closes
Very sick baby with heart failure
Cardiomegaly
Severe metabolic acidosis
Features hypoplastic left heart
Underdevelopment of the entire left side of the heart: Mitral valve small and atretic
LV diminished
Small descending aorta
Antenatally detected
No flow in L side causing profound acidosis and cardiovascular collapse
Weakness or absence of peripheral pulses
Mx hypoplastic left heart syndrome
Norwood procedure
Features aortic stenosis
Aortic valve leaflets are partially fused giving restrictive outflow
Associated with mitral valve stenosis and coarctation of the aorta
Must have asymptomatic murmur: ejection systolic maximal in upper right sternal edge radiating to the neck
Reduced exercise tolerance, chest pain on exertion and syncope
Small volume, slow rising pulse, carotid thrill, apical ejection click, delayed soft aortic second sound
Ix Aortic stenosis
Prominent LV with post stenotic dilation of ascending aorta visible on chest X Ray
LV hypertrophy on ECG
Mx aortic stenosis
Regular clinic and echo assessment
Balloon valvotomy with symptoms on exercise, pressure gradient >64mmHg
Features pulmonary stenosis
Pulmonary valve leaflets are partially fused
Mostly asymptomatic
Ejection systolic murmur on left sternal edge
Ejection click on upper left sternal edge
Thrill and heave present in severe disease
Ix pulmonary stenosis
Post-stenotic dilation of pulmonary artery
ECG shows evidence of RV hypertrophy
Mx pulmonary stenosis
Transcatheter dilation once pressure gradient exceeds 64mmHg
Features supraventricular tachycardia
Rapid heart rate above 250-300 beats/min
Poor cardiac output
Pulmonary edema and heart failure
Hydrops fetalis and IUD if in utero
ECG shows narrow complex tachycardia with P wave following QRS
Wolff-Parkinson white accessory pathway associated with a delta wave
Mx supraventricular tachycardia
Restore sinus rhythm with PPV, vagal maneuvers, adenosine, electrical cardioversion
Features congenital complete heart block
Rare condition with anti-Rho and anti-La antibodies in maternal serum
Mother with connective tissue disorders: including latent and active
Antibody prevents normal electrical conduction development
Heart develops with atrophy and fibrosis of AVN
Can cause death in utero and neonatal heart failure
May be asymptomatic with some episodes of syncope or presyncope
Mx congenital complete heart block
Endocardial pacemaker in symptomatic children
