Cardiac disease Flashcards
What is the most common congenital heart disease?
VSD
What are the R-L shunts?
Tetralogy of Fallot (TOF)
Transposition of the Great Arteries (TGA)
What colour would you expect an infant with a R-L shunt to be?
Cyanosed - blue
What are the L-R shunts?
VSD
ASD
Patent/persistent ductus arteriosus (PDA)
How does heart failure tend to come about in neonates?
Obstructed systemic circulation
What are the causes of neonatal heart failure?
- Hypoplastic L heart syndrome
- Critical aortic valve stenosis
- Severe aortic coarctation
- Interruption of the aortic arch
How does heart failure tend to come about in infants?
High pulmonary blood flow
What are the causes of infant heart failure?
- VSD
- ASD
- Large PDA
How does heart failure tend to come about in older children/adolescence?
R or L sided heart failure
What are the causes of older children/adolescent heart failure?
- Eisenmenger
- Cardiomyopathy
- Rheumatic
When is a VSD considered small?
Smaller than the aortic valve (i.e.
When is a VSD considered large?
Larger than the aortic valve (i.e. >~3mm)
How does a small VSD present?
Asymptomatic
HS - PANSYSTOLIC, loud murmur at lower L sternal edge
What are the heart sounds (HS) for a small VSD?
PANSYSTOLIC, LOUD, at the lower L sternal edge
A loud murmur implies what?
A smaller defect (greater turbulance)
What is the management for a small VSD?
Advise will close spontaneously
F/U with paediatrician + discharge with normal ECG and Echo
How does a large VSD present?
After 1 week of age, the child’s growth begin to falter and becomes SOB + tachycardic. If a more subtle change in these signs, may present with recurrent chest infections. Child is in heart failure, hepatomegaly present as result of HF
HS - PANSYSTOLIC, soft murmur at lower L sternal edge, may be no murmur
What are the HS in a large VSD
PANSYSTOLIC, SOFT murmur at lower L sternal edge BIT may be NO MURMUR
In a child with a large VSD, what would you see on their CXR?
- Cardiomegaly
- Enlarged pulmonary arteries
- Increased pulmonary vascular markings
- Pulmonary oedema
By what age, in a child with a large VSD, would you see ECG changes, and what are those changes?
By 2 months you would expect to see biventricular hypertrophy
How is a child with a large VSD managed?
Management by paediatric MDT
Sx of heart failure treated with diuretic + captopril
Additional calorie intake - dietician input
Advise parents child will require surgery, usually at 3-6 months
What are the two types of ASD?
- Secundum ASD - 80%
2. Partial atrioventricular septal defect
What is a secundum ASD?
Involves centre of atrial septum, involving foramen ovale
What is different about the mitral (L AV) valve in partial atrioventricular septal defects?
It is tricuspid, where it is usually bicuspid
How do ASD’s present?
Usually asymptomatic
May have recurrent wheeze/chest infections
HS - ESM at UPPER L sternal edge
What are the HS in ASD?
ESM at UPPER L sternal edge (due to increased flow across the pulmonary valve from the L to R shunt)
How is an ASD managed?
If the ASD is large enough such that it is causing R ventricle dilatation intervention is required. This will usually take place between 3 and 5 y/o. A secundum ASD = insertion of an occlusion device in cath lab, a partial AVSD = surgical correction
Which children are at greater risk of TGA?
Those born to mothers with poorly controlled/uncontrolled diabetes during pregnancy
When does cyanosis become most pronounced in TGA + why?
2nd day of life - if these is no concurrent septal defect, closure of the DA on the 2nd day results in a loss of mixing, hence cyanosis. It is less pronounced if there is a concurrent VSD etc.
What are the HS in TGA?
II HS is LOUD and SINGLE
There isn’t necessarily a murmur, but if there is, it will be systolic + due to increased outflow into the L (in this case pulmonary) outflow tract
What is the classical appearance of TGA on CXR?
- Narrow upper mediastinum
- Egg-on-side appearance
- Increased pulmonary vascular markings
What is the management of TGA?
MUST FACILITATE MIXING
1. Prostaglandin-infusion - maintain DA patency
2. Atrial septostomy - essentially, tearing of the atrial septum via balloon catheter
(The above are ‘buying time’ procedures)
3. Definitively = arterial switch procedure
What are the features of TOF?
- Large VSD
- Overriding of the aorta
- Sub-pulmonary stenosis
- RV hypertrophy
What is the ‘classic’ presentation of TOF?
Severe cyanosis +
Hypercyanotic (Tett) spells +
Squatting on exercise +
Clubbing
How does TOF usually present now, in developed countries?
Dx from USS antenatally or cyanosis + murmur in first 2/12
What is the HS in TOF
LOUD, HARSH, ESM from first day of life at pulmonary listening point
What are the classical findings of TOF on CXR?
- ‘Boot-shaped’ heart
- Decreased pulmonary markings (due to decreased pulmonary flow)
- Pulmonary artery bay
When is definitive surgery performed for TOF, and what is done?
At 6 months
The VSD is closed and RV outflow tract obstruction is relieved
When is a hypercyanotic spell considered ‘prolonged’ and what is done about it?
Prolonged = beyond 15 mins
Sedation + pain relief; IV propranolol; IV fluids; bicarbonate for acidosis; muscle paralysis and ventilation to reduce O2 requirement
What does absent femoral pulses mean in the context of congenital heart disease?
Coarctation of the aorta
When does the DA usually close by?
Within 2 days of birth
What is the definition of PDA?
If the DA has remained patent for >1 month after the EDD
What are the signs in PDA?
- Continuous murmur, below the L clavicle, that continues into diastole
- Collapsing/bounding pulse
