Cardio Flashcards
1
Q
What is the hyperoxia / nitrogen wash out test?
A
Used to differentiate cardiac from non-cardiac causes of cyanosis
Process:
- Infant is given 100% O2 for 10 minutes
- ABG is taken
- A pO2 of <15 kPa = cyanotic congenital heart disease
2
Q
Is cyanosis always pathological?
A
Peripheral cyanosis is very common in the first 24 hours of life and may occur when the child is crying or unwell from any cause
3
Q
What type of CHD is tricuspid atresia?
A
RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE
4
Q
What is tricuspid atresia?
A
Absent tricuspid valve
- No connection between R atrium and R ventricle
- Small, non-functional RV (LAD)
- Only L ventricle effective
- Commonly have ASD + VSD
5
Q
What are the symptoms of tricuspid atresia?
A
- Central cyanosis (presents very early ~10mins)
- SOB
6
Q
What are the signs O/E of tricuspid atresia?
A
Murmur depends on associated abnormalities:
- Pan systolic - VSD
- ESM at left sternal edge - pulmonary stenosis
- Continuous murmur - PDA
7
Q
What is the management of tricuspid atresia?
A
1. ASAP PGE1 infusion
2. Surgery <2 weeks
(complete corrective surgery not possible in most cases bcos only one functioning ventricle)
1. Glenn operation (connect SVC to pulmonary artery)
2. Fontan operation (connect IVC to pulmonary artery)
8
Q
What type of CHD is TGA?
A
RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE
9
Q
What is TGA?
A
Anatomical reversal of the aorta and pulmonary artery
2 closed-loop systems (PA sends oxygenated blood to lungs and A sends deoxygenated blood to body)
Usually fatal immediately
10
Q
What is a RF for TGA?
A
Maternal diabetes
11
Q
What are the symptoms of TGA?
A
Postnatal cyanosis within a few hours (at rest)
Unaffected by supplemental O2
Tachypnoea
12
Q
What are the signs of TGA?
A
- Single loud second heart sound (S2)
- Prominent R ventricular impulse
- No murmur (ES murmur if VSD + pulmonary stenosis)
13
Q
What are the investigations for TGA?
A
CXR
- Egg-on-side / egg on a string (narrow upper mediastinum)
- Increased pulmonary markings
Echo
14
Q
What is the management of TGA?
A
- ASAP prostaglandin infusion e.g. alprostadil (maintain PDA)
- Balloon atrial septoplasty (tears atrial septum down to allow mixing)
- Arterial switch surgery (within 2wks)
15
Q
What type of CHD is AVSD?
A
RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE
16
Q
What is AVSD?
A
Single large defect connecting all 4 chambers (all blood mixes)
17
Q
What is AVSD commonly associated with?
A
Down Syndrome
18
Q
What are the S/S of AVSD?
A
Cyanosis at 2-3w of life
No murmur
Found on routine echo of Down’s
19
Q
What is the management of AVSD?
A
- Treat HF medically
- Surgery at 3m
20
Q
What type of CHD is ToF?
A
RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE
Most common cause of cyanotic heart disease
21
Q
What is the pathophysiology of ToF?
A
Simultaneous occurrence of 4 defects
- VSD (large)
- Overriding aorta
- R ventricular outflow tract obstruction (pulmonary stenosis)
- R ventricular hypertrophy
22
Q
What are the RFs for ToF?
A
Maternal diabetes
Maternal alcohol consumption
23
Q
What syndromes are associated with ToF?
A
DiGeorge Syndrome
Down Syndrome
24
Q
What are the symptoms of ToF?
A
Mild to severe cyanosis (depending on RVOTO extent)
Tet spells (crying > increased pulmonary resistance > R-L shunt > cyanosis)
Squatting relieves symptoms
Clubbing
25
What murmur is heard in ToF?
**Loud ESM at LUSB**
(from pulmonary stenosis)
26
What are the investigations for ToF?
**CXR** = large boot-shaped (due to RVH)
**ECG** = RVH / right axis deviation
**Echo**
27
What is the management of ToF?
Mild cyanosis (<15 mins) = self-limiting
**Initial Management**
**1.** Knee-chest position and high-flow O2
**2.** ASAP Prostaglandin e.g. alprostadil
If prolonged cyanosis:
**3.** Morphine (sedation and pain relief)
**4.** IV propranolol (peripheral vasoconstriction and relive sub-pulmonary muscle contraction)
**5.** IV fluids and bicarbonate (severe acidosis)
**6.** Muscle paralysis and artificial ventilation to reduce metabolic O2 demand
**Temporary Repairs:**
**1.** Shunt
**2.** Balloon dilation / stent
**Complete Repair:**
Surgery 6m later (within 1st year)
28
What type of CHD is Ebstein's Anomaly?
RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE
29
What is Ebstein's Anomaly?
Tricuspid Valve is displaced downwards
= small and hypocontractile RV
30
What is a RF for Ebstein's Anomaly?
Associated with in-utero lithium exposure (maternal BPD)
31
What are the S/S of Ebstein's Anomaly?
(Presentation depends on the degree of displacement)
Severe = in-utero hydrops fetalis
Mild = cyanosis
32
What murmur is heard in Ebstein's Anomaly?
**Pansystolic (tricuspid regurg)**
Mid-diastolic (tricuspid stenosis)
33
What are the investigations for Ebstein's Anomaly?
Echo = confirmatory
CXR = cardiomegaly (RA enlargement)
34
What is the management for Ebstein's Anomaly?
Surgery
35
What type of CHD is ASD?
LEFT-TO-RIGHT SHUNT
ACYANOTIC HEART DISEASE
36
What are the 2 types of ASD?
**Secundum (80%)**
- Defect in middle of atrial septum (foramen ovale does not close)
- Usually small
- Associated with Holt-Oram syndrome (tri-phalangeal thumbs)
**Partial/Primum (20%)**
- Defect of AV septum (lower)
- Usually large / presents earlier
- Associated with abnormal AV valves
37
What are the RFs for ASD?
Down Syndrome
Maternal alcohol consumption
38
What are the symptoms of ASD?
**Usually asymptomatic** (until Eisenmenger Syndrome)
- Shortness of breath, especially when exercising
- Fatigue
- Oedema
- Arrhythmias (from 40+)
- Palpitations
- Recurrent chest infections / wheeze
39
What are the signs of ASD?
- Ejection systolic murmur (loudest at LUSE)
- Fixed wide splitting of S2
*Not until a few weeks old*
40
What are the investigations for ASD?
**ECG**
Secundum = RBBB with RAD
Partial = RBBB with LAD, prolonged PR interval, ‘superior’ QRS axis
**Echo** = diagnostic
**CXR**
41
What is the management of ASD?
*Usually at 3yrs*
**Small** = heal spontaneously (monitor)
**Secundum** = cardiac catheterisation and insertion of occlusive device (percutaneous/endovascular closure)
**Partial** = surgical correction
42
What is the main complication of ASD?
Stroke (embolism may pass from venous system to L side of heart)
43
What type of CHD is VSD?
LEFT-TO-RIGHT SHUNT
ACYANOTIC HEART DISEASE
44
What are the RFs for VSD?
- Maternal alcohol consumption
- Maternal diabetes
- Congenital infection
- Chromosomal disorders - DS, ES, PS
- Post MI
45
How are VSDs classed?
Classification is based on size:
Small = <3mm
Large = >3mm
46
What are the symptoms of VSD?
**Small** = Asymptomatic (until Eisenmenger Syndrome)
**Large** = Heart failure, SOB, exertional dyspnoea, recurrent chest infections, struggling to feed, not gaining weight
47
What are the signs of a VSD?
**Small:**
- Loud pansystolic murmur at LLSE (intensifies with hand clenching)
- Soft pulmonary 2nd sound
**Large:**
- Soft pansystolic murmur (louder in small defects)
- Loud pulmonary 2nd sound
- Hepatomegaly
- Parasternal heave
- Systolic murmur at LLSE
48
What are the investigations for a VSD?
**Echo** = diagnostic
**Small** = all else normal
**Large** = CXR (HF), ECG (heart hypertrophy, R wave height >8mm)
49
What is the management for a small VSD?
Self-limited (close by themselves)
Close monitoring
After they close, no longer at risk of IE
50
What is the management for a large VSD?
*Usually result in a degree of heart failure in the first few months*
- Nutritional support
- Medication for heart failure e.g. diuretics
- Surgical closure of the defect
51
What are patients with small VSDs at risk of?
High risk of endocarditis
52
What type of CHD is PDA?
LEFT-TO-RIGHT SHUNT
ACYANOTIC HEART DISEASE
53
What is PDA?
Failure of the ductus arteriosus to close after birth
*(usually after day 1)*
Connects pulmonary artery to descending aorta
54
What are the RFs for PDA?
- Premature
- TORCH infections (Rubella 1st trimester)
- Maternal alcohol consumption
55
What are the symptoms of PDA?
**Small** = asymptomatic
**Large** = unspecific symptoms e.g. failure to thrive or resp symptoms (increased work e.g. apnoea, bradycardia, high O2 needs)
56
What are the signs of PDA?
- Continuous machine like / Gibson’s murmur at ULSE
- Large volume, bounding, collapsing pulse
- Heaving apex beat
- Left subclavicular thrill
- Wide PP
57
What are the investigations for PDA?
**Symptomatic** = echo at 1wk
58
What is the management for PDA?
**Medical**
- Indomethacin or ibuprofen given to neonate 1w after delivery (inhibits prostaglandin synthesis, promotes duct closure)
**Surgical**
- Coil/device closure at cardiac catheter at 1yr
- or surgical ligation
59
What is Eisenmenger Syndrome?
The progression of an untreated left-to-right shunt (acyanotic) to a right-to-left shunt (cyanotic)
60
What is the pathophysiology of Eisenmenger Syndrome?
- Uncorrected left-to-right shunt
- Chronically raised pulmonary arterial pressure
- Irreversibly raised pulmonary vascular resistance
- Eventually shunt decreases and child becomes less symptomatic
- At 10-15yrs, shunt reverses (right to left shunt)
- Teenager becomes blue and cyanotic (ES)
- >Death by right-sided heart failure (40-50yrs)
61
Which CHDs is Eisenmenger Syndrome associated with?
VSD, ASD, PDA
62
What are the S/S of Eisenmenger Syndrome?
- CYANOSIS (ASD/VSD = global, PDA = lower body only)
- Chest pain or tightness.
- Coughing up blood
- Dizziness or fainting.
- Easily tiring and SOB with activity
- Headaches
- Numbness or tingling in fingers or toes
- Original murmur may disappear
- Clubbing
- Right ventricular failure
63
What is the management of Eisenmenger Syndrome?
**>>Regular cardiology check-ups**
Goals of treatment are to control symptoms, improve quality of life and prevent serious complications.
**Medical:**
- Anti-arrythmics
- Iron supplements
- Aspirin
- Mx for pulmonary HTN
**Surgical:**
- Heart-lung transplantation
64
What is CoA?
Congenital narrowing of the descending aorta
65
What are the types of CoA?
**Preductal** = proximal to ductus arteriosus (most common)
**Post ductal** = distal to ductus arteriosus
66
What is associated with CoA?
- Turner’s Syndrome
- Bicuspid aortic valve
- More common in males
- Also - Berry aneurysms, Neurofibromatosis
67
What are the symptoms of CoA?
*3rd day of life > few weeks of life*
- Can be asymptomatic
- Leg pain
- Tiredness
- Headaches
- Dizziness
- Epistaxis
68
What are the signs of CoA?
- Brachio-femoral delay
- High BP in arms, low BP in legs
69
What are the investigations for CoA?
- **CXR** = ‘Rib notching’ (due to large collateral intercostal arteries forming)
- **Echo**
- **MRA** (magnetic resonance angiography)
70
What is the management for CoA?
**Initially** = Prostaglandin infusion
**Later** = Surgical repair or balloon angioplasty
71
What are complications of CoA?
- Secondary HTN
- Endocarditis
- Berry aneurysm > cerebral haemorrhage
72
What is aortic and pulmonary stenosis?
Abnormal development of the valves
73
What are the S/S of pulmonary stenosis?
Harsh ES murmur at LUSE
74
What are the signs of aortic stenosis?
Carotid thrill
75
What is the management of aortic/pulmonary stenosis?
**Transcatheter balloon dilation**
76
What is Hypoplastic Left Heart Syndrome?
Birth defect where L side of heart extremely underdeveloped > affects normal blood flow through the heart
77
What are the S/S of hypoplastic left heart syndrome?
*> Usually seriously ill soon after birth*
- Cyanosis of lips/gums
- Rapid, difficult breathing
- Poor feeding
- Cold hands/feet
- Weak pulse
- Unusually drowsy/inactive
78
What are the investigations of hypoplastic left heart syndrome?
**USS** = Possible to dx during second trimester
**Echo** = Can dx > small L ventricle and aorta
79
What is the management of hypoplastic left heart syndrome?
**Initial** = Prostaglandin
**Definitive** = Surgery
(3 separate operations: Norwood > Glenn > Fontan)
80
What are the S/S of an arrhythmia?
- HR 250-300bpm > poor CO, pulmonary oedema
**Neonatal** = HF, hydrops fetalis
**Foetus** = IUD
81
What are the investigations for an arrhythmia?
- **ECG** = narrow complex tachycardia (delta wave in WPW), T wave inversion due to ischaemia
- **Echo**
82
What is the management of an arrhythmia?
*> Prompt restoration of sinus rhythm is key to improvement*
**1. Circulatory and respiratory support**
- Tissue acidosis corrected
- Positive pressure ventilation if needed
**2. Vagal stimulating manoeuvres**
- Carotid sinus massage, cold icepack to face (80% success)
**3. IV adenosine**
- Tx of choice
- Induces AV lock after rapid bolus infusion > terminates tachycardia
**4. Electrical cardioversion with synchronised DC shock**
- If adenosine fails
- Once sinus rhythm restored, maintenance therapy required (e.g. flecainide or sotalol)
- 90% will have no further attacks after infancy
- Children who relapse or at risk > tx with percutaneous RFA or cryoablation of accessory pathway
83
What is Rheumatic Fever?
Inflammatory disease that can develop when strep throat / Scarlet Fever isn’t treated properly
84
What organism causes RF?
GAS
85
What age does RF present?
Children aged 5-15yrs
86
What can long-term damage from RF cause?
Mitral stenosis
87
What are the S/S of RF?
**Fever and tender joints**
>>Latent interval of 2-6w after pharyngeal infection
- **Polyarthritis** (tender joints, swelling)
- **Pancarditis** (endocarditis, myocarditis, pericarditis)
- **Erythema marginatum** (map-like outlines)
- **Sydenham’s chorea** 2-6m later (involuntary movements)
88
What is the diagnostic criteria for RF?
*Evidence of recent GAS infection with 2 major / 1 major + 2 minor criteria*
**Evidence of recent GAS:**
- Raised or rising streptococci antibodies
- Positive throat swab
- Positive rapid GAS antigen test
**Major criteria:** (CASES)
- Carditis (e.g. new murmur)
- Arthritis
- Subcutaneous nodules
- Erythema marginatum
- Sydenham’s chorea
**Minor criteria:** (FRAPP)
- Fever
- Raised ESR/CRP
- Arthralgia
- Prolonged PR interval
- Previous RF
89
What is the management of RF?
**Acute:**
- **1st line = single dose IM benzathine benzylpenicillin**
- *With arthritis* = NSAID (e.g. aspirin / naproxen)
- *With HF* = diuretic +/- ACEi
- *With AF* = Amiodarone or digoxin
- *With valve problem* = Assessment for emergency surgery
- *With severe chorea* = Consider anticonvulsant
- *With severe pain* = CS injections
**Prophylaxis: ALL PATIENTS FOLLOWING ACUTE TREATMENT**
- IM injection of long-acting benzathine benzylpenicillin every 3-4 weeks
- Until 10yrs after the last episode or until 21yrs old (lifelong if severe valve disease)
90
What is infective endocarditis?
Infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve, or a blood vessel
91
What are the RFs for IE?
- Strongest RF is previous episode of endocarditis
- Rhematic valve disease
- Congenital heart defects
92
What is the most common cause of IE?
Strep viridians
93
What are the S/S of IE?
- Pleuritic chest pain
- SOB
- Fever / chills
- Aching joints / muscles
- Anaemia / pallor
- Necrotic skin lesions (infected emboli)
- Splenomegaly
- Retinal infarcts
- Microscopic haematuria
- Clubbing
- Splinter haemorrhages
- Changing cardiac signs
- Neuro signs from cerebral infarct
94
What is the Modified Duke Criteria?
*IE diagnosis if pathological criteria / 2 major / 1 major + 3 minor / 5 minor*
**Pathological:**
- Positive histology / microbiology of pathological material obtained at autopsy or cardiac surgery
**Major:**
- 2 positive blood cultures
- Persistently positive blood culture - from 2 blood cultures taken >12hrs apart, or 3 or more positive blood cultures
- Positive culture for Coxiella
- Positive echo (vegetations)
- New valvular regurgitation
**Minor:**
- Predisposing heart condition / IVD use
- Fever >38
- Vascular phenomena (Janeway lesions, intracranial / conjunctival haemorrhage)
- Immunological phenomena (Osler's nodes, Roth Spots)
- Positive blood culture that doesn’t meet major criteria
95
What is the management for IE?
**Acute:**
- High dose IV penicillin + aminoglycoside e.g. gentamicin (or streptomycin) for 6w
**Prophylaxis:**
- Good dental hygiene
- Avoidance of body piercings or tattoos
**+/- Surgery**
- Removal of infected prosthetic material
96
What are the S/S of cardiac failure?
- SOB / respiratory distress
- Poor feeding / weight gain
- Recurrent chest infections
- Fatigue
- Increased RR + HR
- Murmur
- Gallop rhythm
- Signs of venous congestion
- Enlarged heart
- Hepatomegaly
- Cool peripheries
- Insufficient CO
- FTT
97
What are the causes of cardiac failure in a neonate?
- Hypoplastic L heart
- Aortic stenosis
- Severe coarctation of the aorta
- Interruption of the aortic arch
98
What are the causes of cardiac failure in an infant or older child?
**Infants:** (defect > high pulmonary blood flow > L-R shunt)
- Persistent VSA, ASD, PDA
**Older children:** (R- or L-HF)
- Eisenmenger Syndrome (RHF)
- Rheumatic HD
- Cardiomyopathy
99
What are the investigations for cardiac failure?
- Basic obs - O2 sats, BP, HR, RR
- Bloods - FBC, U&Es, Ca, BNP/ANP
- ECG
- CXR
- Echo
100
What is the management of cardiac failure?
- Diuretics (e.g. furosemide) or GTN (reduce preload)
- Dopamine or digoxin or adrenaline or dobutamine (enhance cardiac contractility)
- Oral ACE inhibitors e.g. hydralazine, nitroprusside, alprostadil (reduce afterload)
- Beta-blockers e.g. carvedilol (improve oxygen delivery)
- Enhance nutrition
- If cyanotic = prostaglandin infusion (alprostadil / prostaglandin E2)
101
What is a venous hum murmur?
Innocent murmur due to the turbulent blood flow in the great veins returning to the heart.
Heard as a continuous blowing noise heard just below the clavicles
102
What is Still's murmur?
Low-pitched sound at lower left sternal edge
103
What are the characteristics of an innocent ejection murmur?
- Soft-blowing murmur in the pulmonary area or short buzzing murmur in the aortic area
- May vary with posture
- Localised with no radiation
- No diastolic component
- No thrill
- No added sounds (e.g. clicks)
- Asymptomatic child
- No other abnormality
