Cardiac lecture Flashcards
Difficulty feeding
Increased RR
Sweating
Cyanosis
Syncope
Cardiac symptoms in newborns
Mainstay imaging?
Echocardiography
Defects that cause right to left shunting can cause…
Cyanosis
Will hypoxemia from HF respond to oxygen?
Will hypoexmia from R to L shunting respond to oxygen?
HF will respond to O2
R to L shunting will not repsond to O2
Hematocrit over 60 is common with R to L shunting and associated chronic hypoxemia
Polycythemia
Polycythemia from R-L shunting can lead to direct intracranial thrombosis.
Paradoxical embolus as noted
this can cause..?
Stroke
Retardation of growth can be a complication of…
congenital heart disease (CHD)
Pulmonary arterial hypertensions (PAH)
Pulmonary vascular obstructive disease (PVOD)
Major complications of congenital heart disease
Destruction of pulmonary vascular (arteriolar) bed in pressure of continous pressure overload (much less common with volume overload alone)
results in marked increase in PuVR and further elevation of PAP
Pulmonary vascular obstructive disease
An opening in part of the ventricular septum that separates the 2 ventricles
80% involve the thin membranous septum
20% involve the muscular septum
Ventricular septal defect
Associated with:
Coarctation of the aorta
ASD
PDA
sub-aortic/pulmonic stenosis
Ventricular septal defect
large resistance to flow through small hole
normal RVP and PAP
small L to R shunt
well tolerated.
*will often close on own. must monitor
Small “restrictive” ventricular septal defect (VSD)
allow varying transmission of LVP into the RV→PA.
PAH common and PVOD develops over time.
Large defects result in LV dilation and failure.
Moderate to large ventricular septal defects (VSDs)
When severe, CXR will show cardiomegaly, dialted pulmonary artery and HF
Ventricular septal defects (VSD)
Which image is diagnostic for ventral septal defect (VSD)
identifies the size and location of the defect and presence of shunting;
RV and pulmonary artery pressures can be estimated .
Echo-doppler
clinical manifestations:
no symptoms
harsh holosytolic murmur (best heard at LSB) appears within 36 hrs of birth
intensity may change with age.
Small VSD
HF signs and symptoms early in life; surgical repair indicated.
Large VSD
Possible systolic thrill at LLSB
nl S2
harsh holosystolic murmur along LSB.
Ventricular septal defect (VSD)
Are most of the ventricular septal defects small or large?
SMALL!
24% close spontaneously by 18 mos
50% by 4 years
even more by 10 years
HF occurs in ___% of infants with large VSD
80%
Risk of PVOD is high in….
moderate to large ventricular septal defects (VSD)
If the ventricular septal defect remains about, what is the pt at risk for?
Endocarditis
Do we still give antibiotics for prophylactic endocarditis?
NO
Timing of surgery is dependent on….
severity of shunt
LV function
Pulmonary artery pressure
if ______ continues overtime…. progressive, irreversible PVOD develops and surgery carries high mortality with little benefit
Pulmonary artery HTN
In presence of significant __________
PuVR and PAP rise dramatically.
This can lead to shunt reversal→R to L shunting→ hypoxemia and Rt sided heart failure (Eisenmenger’s physiology/complex).
Pulmonary vascular obstructive disease (PVOD)
A through and through communication between the atria at the septal level.
Pathology: Large enough defect to allow free communication between the atria.
Most common form (previously undetected) of CHD in adults;
female to male ratio is 2:1.
Atrial septal defect (ASD)
Atrial septum formed by fusion* of 2 overlapping planes of tissue during fetal development.
Most ASD’s occur in _____ septum due to lack of tissue for overlap.
Mid septum!
*Lack of atrial septal fusion occurs in up to ___% of adults leaving a “patent foramen ovale”,
a potential space/opening between the two atria.
25%
With this defect, it is possible for a clot to form between the flaps, causing a paradoxical embolus
Atrial septal defect (ASD)
defect in mid septum at the fossa ovalis (80%) from incomplete development
Ostium secundum
defect in lower atrial septum;
usually associated with additional defects.
Ostium primum
Which of the following is a defect in mid atrial septum? which one is a defect in lower atrial septum?:
Ostrium primum
Ostium secundum
Ostium primum= defect in lower septum
Ostium secundum= defect in mid septum
RA, RV and PA enlarge - volume overload
Pulmonary HTN usually occurs late (3rd or 4th decade) if lesion goes undetected up to that time in life
result of chronic volume overload x years.
Atrial septal defects
L to R shunting at atrial level due to:
Rt atrium more distensible than left
RV more compliant than LV
PuVR greater than SVR
LA pressure greater than RA pressure
Atrial septal defect (ASD)
RV volume overload and increased pulmonary blood flow;
well tolerated for many years.
Atrial septal defect
Majority of children are asymptomatic
Symptoms when present include fatigue, dyspnea, decreased stamina and usually begin in early 20’s.
Most adults become increasingly symptomatic by 3rd or 4th decade: fatigue, dyspnea and atrial arrhythmia’s (Afib).
paradoxical emboli can result in stroke!
Atrial septal defect
*Patent foramen ovale: incomplete fusion of atrial septum (tiny defect) allows
clot to pass from ______ to _______
right atrium –> left atrium
Hyperdynamic RV (lift): RV volume increase leads to ↑contraction via Starling mechanism.
S1 accentuated at LLSB
S2 widely split through inspiration/expiration: RV ejection is delayed from volume overload.
Atrial septal defect
Grade II-III midsystolic crescendo-decrescendo mumur, at upper LSB reflects increased blood flow across pulmonic valve.
Present during childhood.
Atrial septal defect
ECG shows:
rsR’ pattern in Rt precordial leads with mildly widened QRS (incomplete RBBB)
arrhythmias common in adults-Afib, Aflutter.
Atrial septal defect
Echo-Doppler shows: RV volume overload
enlarged RV, RA
2D echo and doppler identify the defect and semi quantitate the shunt.
Atrial septal defect
Cardiac cath shows:
Measurement of RV/PA pressures
quantification of shunting
identification of anomalous pulmonary veins if present.
Closure of ____ often performed percutaneously using catheters/devices.
atrial septal defects (ASD)
Is PVOD seen more with ventricular septal defect (VSD) or atrial septal defect (ASD)
VSD
(PVOD is uncommon ins ASD)
Harsh, holosytolic murmur at LSB
VSD or ASD?
large VSD
Grade II-III mid systolic crescendo-decrescendo murmur at upper LSB
VSD or ASD?
ASD
(reflects increased blood flow across pulmonic valve)
Undetected ASD can later lead to (right or left) sided HF?
Right
Once symptoms present (including paradoxical emboli), what do you do for ASD?
Surgical/catheter closure
For ASD, if there are NO SYMPTOMS but…
QP:QS ratio is greater than 1.5:1.0
OR
PAH is present
…what do you do?
Surgical/catheter closure
MC form of pulmonary stenosis= “dome shaped” stenosis of pulmonic valve
in pulmonic stenosis, the right ventricle develops _________ hypertrophy, and reflects the degree of obstruction at the valvular level
concentric!
Pulmonic valve must be obstructed by ___% or more to be hemodynamically significant
60%
Peak systolic gradient (pressure between RV and pulmonary artery) is
>40 mmHg
Moderate pulmonary stenosis
Peak systolic gradient (pressure gradient between RV and pulmonary artery) is
>75 mmHg
Severe pulmonic stenosis
RV failure occurs with severe obstruction due to pulmonic stenosis
this results in a decreased…
cardiac output
(and associated signs/symptoms)
Most infants/children are asymptomatic, unless severe
Sx include: DOE, fatigue
PE shows:
systolic thrill at suprasternal notch
early systolic click at upper LSB
murmur is LOUD! (grade 3-4)
harsh crescendo-decrescendo at upper LSB radiating towards clavicle and LOUDER WITH INSPIRATION
Pulmonic stenosis
Harsh crescendo-decrescendo murmur at upper LSB, radiating towards clavicle and louder with inspiration!!!
(usually grade 3-4)
Pulmonic stenosis
Image of choice for pulmonic stenosis
Identifies obstruction and estimates severity
Echo/doppler
Tx for pulmonic stenosis
Balloon valvuloplasty opens stenotic valve
Is intervention for pulmonic stenosis required if the gradient is <25 mmHg
NO!
but intervention is always required if gradient >75 mmHg
Persistent patency of the vessel that normally connects the pulmonary arterial system and the aorta in the fetus
Patent Ductus Arteriosus (PDA)
Normally, the patent ductus arteriosus (PDA) closes within _____ days after birth
2-3 days
Risk factors:
Maternal exposure to rubella
Pre-term deliveries
PDA
High resistance to flow
Well tolerated
Small L to R shunt
…small, moderate or large PDA?
Small
Aorta and pulmonary artery are in free communication, equal pressures
Marked L to R shunting
Pulmonary congestion
LV dysfunction and failure
PVOD
..small, moderate or large PDA?
Large
Elevated pulmonary artery pressure
Significant shunting
…small, moderate or large PDA?
Moderate
If there is a large PDA, what type of symptoms can you see within the first weeks of life?
CHF type symptoms
Systolic thrill over pulmonary artery in suprasternal notch and LSB
Apical and RV impulse increased
Murmur is continuous (thru systole and disatole)
“machinery murmur”
Grade 4 or louder at LSB and beow clavicle
Peaks near S2
PDA murmur
First line tx for PDA in premature infants
Indomethacin
..if ductus remains open, surgical or catheter closure!
(constriction of ductus)
8-9% of all infants presenting with CHD
discrete narrowing of distal segment of the aortic arch, just distal to the origin of the subclavian artery
Coarctation of the aorta
Systolic and diastolic pressures above coarctation are….
elevated!
(systolic and diastolic pressures below coarctation are reduced)
What 2 other cardiac abnormalities are often seen with coarctation of the aorta?
Ventricular Septal Defect
Bicuspid Aortic Valve
Prominent collateral circulation to lower body develops via internal mammary and subcostal arteries, causing what to be seen on CXR in coarcation?
Rib notching
Fatigue
Dyspnea
Fatigue in legs with exertion
Frank claudication
signs/symptoms of?
Coarctation of aorta
If a child has HTN, what 2 things should you consider?
Coarctation of aorta
Renal artery stenosis
(HTN secondary cause in kids)
In coarctation of the aorta, what does the BP look like in the legs compared to the arms?
>10 mmHg drop in leg BP compared to arms
(arm BP >10 mmHg higher than leg BP)
Mechanical obstruction of the coarct
PLUS
High renin HTN due to decreased perfusion of kidneys
…leads to what in coarctation pts?
Marked HTN in uper body
How does a pt with coarctation of the aorta appear?
Well developed upper body
Very thin legs
What will an ECG look like in a pt with coarctation of aorta?
LVH
With coarctation of aorta…
progressive HTN develops with age and often persists if surgical correction is performed after age…?
6
Biventricular origin of the aorta
Large VSD
Obstruction to pulmonary blood flow
RVH
Tetralogy of Fallot
MC cause of SCD in pts under 35 yo
HCM
