Cardiac exam Flashcards
Still’s mumur
prevalence: age 2-6yrs and resolves at adolescence
location: left lower sternal border
intensity: grade 1/2
quality: musical/vibratory
radiation: minimal
position: louder supine than sitting
Innocent mumurs
duration: short systolic
quality: musical or vibrational
radiation: minimal
intensity: grade 2 or less
position: louder supine than sitting
Pathological mumurs
intensity: grade 3 or higher with maximum at LUSB
timing: holosystolic or diastolic
quality: harsh or blowing, click
position: increased sitting
S2: abnormal with wide or fixed split
Systolic mumurs
early systolic: small muscular VSD
mid-systolic/ejection systolic: aortic stenosis
pansystolic: moderate/large VSD, mitral regurgitation
Diastolic mumurs
early distolic: aortic regurgitation, ASD with tricuspid stenosis
late diastolic: mitral stenosis
Mumurs
Right upper stenal border
pathogenesis: left ventricular outflow obstruction eg. aortic stenosis
radiation: usually to carotid region
Mumurs
Left upper sternal border
SYSTOLIC
cause: right ventricular outflow tract obstruction eg. pulmonary stenosis, benign flow mumurs
radiation: to axilla/back
DIASTOLIC
cause: aortic regurgitation or pulmonary regurgitation
radiation: left sternal border
CONTINUOUS
cause: PDA, cervical venous hum
Mumurs
Left lower sternal border
SYSTOLIC
cause: VSDs, tricuspid regurgitation, subvalvular AS, HCM, Still’s
DIASTOLIC
cause: semilunar valve regurgitation, tricuspid stenosis
Mumurs
Apex
SYSTOLIC
cause: mitral regurgitation
radiation: axilla
DIASTOLIC
cause: mitral stenosis
Cardiac failure
causes
congenital heart disease:
- volume overload: VSD, PDA, ASD, single ventricle
- pressure overload: AS, coarctation, PS
structurally normal heart:
- cardiomyopathy, myocarditis, MI, arrhythmias (CHB, SVT, VT), drugs/toxins
non-cardiac:
- sepsis, ESRF, HIV, SLE
Cardiac failure
clinical
cyanosis
tachycardia
hypertension
gallop rhythm (S3)
respiratory distress
hepatomegaly
jugular venous distension
Pulsus alternans
definition: varied pulse amplitude with alternate beats
causes:
- hypertrophic CM
- tachypnoea
- severe arotic regurgitation
Pulses paradoxus
definition: drop >10mmHg with inspiration
causes:
- cardiac tamponade
- restrictive CM/pericarditis
- hypovolaemic shock
Pulses bisferiens
definition: 2 systolic pulse peaks
causes:
- AR
- AS
- HCM
Water hammer pulse
definition: abrupt rapid upstroke of pulse with collapse
cause: rapid LV volume against low resistance system
- AR
Bounding pulse
definition: widened pulse pressue
cause: increased stroke volume
- PDA
- large AV fistula
- hyperkinetic state
- thyrotoxicosis
Chest wall scars
Fontan procedure
Single functional ventricles:
- HLHS
- tricuspid/mitral atresia
- complex CHD
Stage I (Norwood): BT shunt
- connecting brachiocephalic artery to right pulmonary artery
Stage II (Bidirectional Glenn): cavopulmonary shunt
- BT removed
- SVC anastomosed to PA
Stage III (Fontan): total cavopulmonary connection
- IVC joined to PA
Issues
- decreased exercise tolerance
- decreased neurodevelopmental outcome
- poor growth
- thromboses
- arrhythmias (SVT)
Post operative mumur
- AV regurgitation
- subaortic stenosis
- VSD
Associated conditions: PLE, plastic bronchitis
Continuous mumurs
Aneurysm
ASD
AV malformation
Blalock-Taussig Shunt
Collateral Vessels
pDA
vEnous hum
Mumur timing
Mumur site of intensity
Complex cyanotic heart disease
5 T’s
- Transposition Great Arteries (TGA)
- Truncus Arteriosus (TA)
- Tetralogy of Fallot (ToF)
- TAPVD
- Tricuspid valve anomalies
OTHER: HLHS, DORV, pulmonary atresia
Eisenmenger’s syndrome
Triad
- pulmonary to systemic shunt
- pulmonary artery disease
- cyanosis
associated defects: VSD 33%, ASD 30%, PDA 14%
clinical:
- cyanosis, clubbing
- RV impulse, palpable P2
- elevated JVP, oedema
- tricuspid/pulmonary regurgitation
Pulmonary flow mumur
prevalence: very common
timing: brief in mid-systole
position: loudest lying down
associated: hyperdynamic states
Venous hum
prevalence: ages 2-6yrs
timing: diastolic component loudest
location: supraclavicular fossa on the right and may radiate
quality: associated thrill
position: disappears when flat
VSDs
inspection: no cyanosis/clubbing
clinical:
- pansystolic mumur maximal at left sternal edge
- loud S2
- active praecordium
- thrill at left sternal edge
- no radiation but heard all over chest wall
- diastolic rumble at apex
haemodynamically significant if:
- symptoms including tachypnoea
- mumur may be softer
- hyperactive praecordium
- loud S2
- displaced apex
- diastolic mumur
- growth decreased
treatment:
- medical: diuretics, ACEi
- surgical (age 4yrs or shunt>2:1): pulmonary artery banding 1st if complication, VSD repair
ASD
haemodynamic: RV overload during diastole with an increased pulmonary blood flow secondary to shunt
complications: atrial arrhythmias, pulmonary HTN, heart failure
clinical:
- parasternal heave
- ejection systolic mumur left sternal edge
- S2 widely split
- diastolic mumur due to flow across tricuspid valve
ECG:
- ostium secundum: RAD, partial RBBB
- ostium primum: LAD, partial RBBB
treatment: surgical closure 4th/5th decade
AVSD
pathophysiology: left to right shunt through ASD/VSD
clinical: hyperdynamic apex beat, RV heave, palpable thrill LLSE
- loud pansystolic mumur LLSE, MR at apex
complications: atrial dilation, arrhythmias, volume loaded ventricles, pulmonary HTN
ECG: superior axis (-40 to -150), RVH
CXR: cardiomegaly, pulmonary plethora
Treatment: repair 4 to 6 months, diuretics
- delaying treatment increases the risk of pulmonary hypertension
Sign of cardiac failure
Cardiac lesions T21
Aortic regurgitation
congenital: Ehlers-Danlos, Marfan syndrome, Turner syndrome
acquired: rheumatic fever, post operative, infective endocarditis
pathophysiology: LV overload, pulmonary oedema
clinical:
- collapsing pulse
- decrescendo diastolic mumur LSE
- increased sitting forward in expiration
- associated thrill
ECG: LVH
CXR: cardiomegaly
Pulmonary stenosis
associated syndromes: Noonan’s, Williams
pathophysiology: RV overload
clinical:
- thrill over pulmonary area
- RV heave
- ejection systolic mumur LUSE
- radiation to back
- widely split S2
ECG: RVH, tall p waves
CXR: normal
treatment: surgery depending on pressure gradient
post repair: residual systolic and diastolic mumur
Aortic stenosis
associations: Turner syndrone, Williams (supravalvular), coarctation
pathophysiology: LV overload
symptoms: syncope, pain on exertion
clinical:
- collapsing pulse
- suprasternal/carotid thrill
- apex displaced
- ejection click LLSE
- ejection systolic mumur at LLSE radiating into the neck
ECG: LVH (tall R waves V5/V6, inverted T in 1, aVL, V5-6)
CXR: prominent LV
treatment: valve replacement if gradient >60mmHg
post repair: mumur of aortic stenosis and regurgitation
Coarctation of the aorta
associations: Turner’s, biscuspid valve (70%)
clinical:
- high BP arms, low in legs (20mmHg difference)
- radiofemoral delay
- systolic mumur loudest at left interscapular area
- ejection click LUSE if biscuspid aortic valve
ECG: LVH
CXR: cardiac enlargement, rib notching
treatment: end-end anastomoses via left thoracotomy
complications: residual HTN, recoarctation
Causes cardiac cyanosis
decreased pulmonary blood flow:
- tetralogy of fallot
- pulmonary atresia
- Ebstein’s
- tricuspid atresia
poor mixing:
- transposition great arteries
common mixing:
- truncus arteriosus
- DORV
- TAPVD
- univentricular heart
Tetralogy of Fallot
Tetrad:
- RVOT obstruction
- VSD
- Overiding aorta
- RVH
Variations: 25% Right sided AA
clinical:
- FTT, clubbing, cyanosis
- RV impulse
- systolic thrill ULSE
- systolic ejection mumur ULSE
CXR: prominent RV, small pulmonary arteries, oligaemia
ECG: RAD, RVH, tall p wave
treatment:
- modified BT Shunt
- corrective survery 4-12 months
complications:
- exertional dyspnoea
- cerebral thrombosis/brain abscess
- infective endocarditis
- arrhythmias
tx tet spells: morphine, beta blockers, vasoconstrictors
Hypertrophic cardiomyopathy
familial: AD 60%
HOCM: associated with septal hypertrophy or abnormal MV movement causing LVOTO
symptoms: angina, syncome, arrhythmias, sudden death
clinical:
- systolic ejection mumur from LVS hypertrophy or mitral regurgitation
treatment: beta blockers, endocarditis prophylaxis, myectomy
Dilated cardiomyopathy
most common cardiomyopathy
cause: usually idiopathic, toxic insult
pathophysiology: dilation 4 chambers
clinical:
- displaced apex
- MR or TR mumur
- 3rd heart sound
- left and right sided cardiac failure
symptoms: weakness, pulmonary oedema
treatment: medical, transplantation
Trisomy 21
cardiac
Turner syndrome
cardiac
Noonan syndrome
cardiac
William syndrome
cardiac
22q11
cardiac
CHARGE
cardiac
VACTERL
cardiac
Marfan
cardiac
Ehler Danlos
cardiac
Fetal alcohol syndrome
LEOPARD syndrome
Repair procedures
- VSD
- ASD
- TOF: BT shunt then definitive procedure at 1 year
- TGA: arterial switch
Pallative repairs
Can be temporary or permanent
- BT shunt
- Pulmonary banding
- Atrial septostomy
Timing of cardiac surgery
1st week:
- duct dependent
- severe obstructive lesion
First month:
- severe pulmonary pressure: PA banding or BT shunt
- obstructive lesions eg. TAPVD
Infants:
- left to right shunt to prevent pulmonary HTN
- RVOTO
Children:
- staged procedures
- asymptomatic lesions
Adolescence:
- surgery for acquired diseases
- stent procedure eg. non duct dependent CoA
- repeat procedures
Complications post cardiac surgery
- diaphragmatic palsy
- arrhythmias
- vocal cord palsy
- protein losing enteropathy (post Fontan)
- developmental problems
CXR in cardiac disease
