Cardio Flashcards
How common are congenital cardiac abnormalities?
1-2% of the population. 8:1000 are significant
What are the different ways congenital cardiac disease can present? What are some cardiac?
- Cyanotic (right to left shunt): Tetralogy of Fallot, TGA
- Acyanotic/breathless (left to right): VSD, PDA, ASD
- Outflow obstruction (asymp/collapse): PS, AS, coarctation
What are some causes of congenital cardiac disease? Which CHD they classically associated with?
Chromosomal abnormality:
- Down’s (30%): VSD, AVSD
- Edwards + Patau: complex
- Turner’s (15%): bicuspid aortic valve (AS), coarctation
- DiGeorge (80%): aortic arch anomaly, ToF
- Noonan: HOCM, ASD
Maternal factors:
- Rubella: PS, PDA
- SLE: complete heart block
- Warfarin, alcohol, DM
What is the common cardiac defect in Down’s?
VSD, AVSD
What is the common cardiac defect in Turners?
Bicuspid aortic valve causing AS, coarctation
Describe the changes that occur in the fetal circulation at birth
At birth, liquid out of lungs -> decreased intrathoracic pressure -> decreased resistance in pulmonary vessels -> increased blood flow
Decrease R sided pressures and increased left sided (due to return from pulmonary) -> closure of foramen ovale
After several days: PDA closes
What are some features of innocent murmurs?
- Soft, blowing
- Left sternal edge
- Systolic
- No systemic features (breathlessness, cyanosis)
- Normal pre and post-ductal sats
What are some causes of innocent murmurs?
- Anaemia
- Infection/illness
How does heart failure present in children?
SOB (worse on feeding/exertion), poor feeding, sweating
Poor weight gain, ^HR and RR, murmur, enlarged heart, hepatomegaly
What are some causes of heart failure in children?
Neonates- obstruction eg coarctation. Also AVSD
Infants- left-to-right shunt eg VSD, large PDA
Children- Eisenmenger, RHD, cardiomyopathy
Why can coarctation cause collapse in the first few days of life? What is the term that is used for this type of condition? What is the treatment?
Severe obstruction means arterial perfusion is supplied by the DA. Closure occurs in the first few days of life -> rapid worsening + decreased flow
This is called duct-dependent circulation, and treatment is to maintain the DA with prostaglandins
What is Eisenmenger syndrome? What causes it?
A complication of untreated left-to-right shunt, where high flow through the pulmonary vessels causes pulmonary hypertension -> eventual reversal of the shunt -> cyanosis.
Caused by VSD, ASD, PDA
A newborn boy becomes cyanotic after several hours. Saturations are 88%. What is the initial management?
ECG and CXR
What are the signs of ASD on examination and CXR?
Examination:
Ejection systolic murmur at upper left sternal edge (due to high flow across pulmonary valve)
Fixed and widely split S2
CXR:
Cardiomegaly
Pulmonary oedema, enlarged arteries
What is the best investigation for diagnosing CHD?
Echo
What are the types of ASD? How are they managed?
- Secundum (most): hole in middle of the septum. Cardiac catheterisation later in childhood
- Primum, part of partial AVSD: assoc with Down’s. Surgical correction later in childhood.
What is a small VSD?
<3mm
How does a VSD present?
Small: asymptomatic
- Pansystolic murmur, lower left sternal edge
- Quiet P2
Large: cause heart failure, recurrent chest infection
- Soft pansystolic murmur, apical mid-diastolic murmur
- Loud P2
- CXR shows cardiomegaly, pulm oedema, enlarged arteries
How is VSD managed?
Small: allow spontaneous closure
Large: surgical correction at 3-6 months. Treat heart failure with diuretics.
Define PDA. What is the main risk factor?
Failure of the DA to close after 1 month from the expected delivery date. Prematurity
What are the signs of PDA?
Bounding pulse
Continuous machine-like murmur
Possible heart failure in very severe cases
What is the management of PDA?
PG inhibitors eg. indomethacin
Cardiac catheterisation + occlusion at 1 year
How is cyanotic heart disease investigated?
- Hyperoxia test: place baby in chamber with 100% O2 for 15 mins. Cyanotic- still low saturation on ABG
- CXR: exclude lung disease
- ECG
- Echo
What is the acute management of cyanotic neonates?
A-E
Start prostaglandin infusion (keep DA open)
What are the morphological features of Tetralogy of Fallot?
- Large VSD
- Overriding aorta
- RV outflow tract obstruction eg. PS
- Right ventricular hypertrophy
How does Tetralogy of Fallot present?
- Cyanosis with hypercyanotic/’Tet’ spells (blue, crying, irritable, SOB with feeding)
- Squatting on exercise (to improve venous return)
What are the signs of Tetralogy on exam + CXR?
Exam:
- Loud ejection systolic murmur left sternal edge
- Single S2
CXR:
- ‘Boot’ shaped heart, small
- Pulmonary artery ‘bay’
Describe the management of Tetralogy
Surgery at 6 months to close VSD and open RVOT
- May need balloon dilatation in early life to relieve cyanosis
- Prolonged Tet spells may need propranolol
Describe the pathophysiology of TGA
The aorta arises from the RV and the pulmonary artery from the LV -> two separate circulations
Often co-existing defect eg. ASD, VSD that allows mixing
How does TGA present? What are the signs?
Early life with severe cyanosis (esp after DA closure)
Exam: Loud and single S2, no murmur
CXR: Egg on side heart, increased pulm vessels
What is the management of TGA?
- Improve mixing with prostaglandin infusion
- Balloon atrial septostomy (Rashkind) to allow mixing
- Surgery within several weeks of life
What is the pathophysiology of tricuspid atresia?
Complete absence of the tricuspid valve -> non-functioning RV
Cyanosis/SOB
What are some symptoms of aortic stenosis?
Reduced exercise tolerance
Syncope
Chest pain
What are some signs of aortic stenosis?
Ejection systolic murmur upper L sternal edge
Slow-rising pulse
Carotid thrill
Soft A2
What are some signs of pulmonary stenosis?
Widely split S2, soft P2
Systolic ejection click/murmur over upper L sternal edge
What are some signs/symptoms of coarctation?
Neonatal collapse (preductal)
Absent/weak femoral pulses
Hypertension in the R arm, ejection systolic murmur, continuous murmur on back
What is the most common type of arrhythmia in children?
SVT
What is the management of SVT?
1st: vagal manouvres eg. carotid massage
2nd: IV adenosine
3rd: cardioversion eg. DC, flecainide
In a child with syncope, what features from the history would make you worried about a cardiac cause?
- Not caused by an emotional stressor
- Exercise-induced
- Hx of palpitations
- FHx of sudden cardiac death
What are the features of acute rheumatic fever?
Major criteria: Polyarthritis Erythema marginatum Subcut nodules Pancarditis: endo, myo, peri Sydenham chorea
Minor: Fever Polyarthralgia Raised acute phase proteins Prolonged PR interval
What is the management of rheumatic fever?
Rest + high dose aspirin
Prevent recurrence with monthly IM benzathine penicillin for 10 years
Surgical repair of valves
Which CHD types predispose to infective endocarditis?
Tetralogy, TGA, VSD, PDA and bicuspid aortic valves. Also anything with prosthetic materials
How does infective endocarditis present?
High fever New/changed murmur Malaise Splinter haemorrhages Janeway lesions Roth's spots Neuro signs Splenomegaly
Anaemia
Raised ESR/CRP
Haematuria
What is the most common causative organism of infective endocarditis?
Most common: Strep viridans
What is the management of infective endocarditis?
Blood cultures!!!
Involve MDT of cardio, ID, neuro, surgeons
Initiate sepsis 6
IV broad spectrum antibiotics eg. beta-lactam +/- gent/vanc for 6 weeks
Describe BLS for children
- Check for safety, call for help
- Airway: head tilt chin lift
- Breathing: check for 10s. Give 5 rescue breaths
- Circulation: check for 10s. Start compressions 15:2