Cardio Flashcards
What are patients with VSD most at risk of
Endocarditis
What is transposition of the great arteries
Transposition of the great arteries (TGA) is a form of cyanotic congenital heart disease. It is caused by the failure of the aorticopulmonary septum to spiral during septation. Pulmonary artery is supplied by the LV and vice versa. Incompatible with life except for with PDA
How does transposition of the great arteries present
Cyanosis
Tachypnoea
What are prominent right ventricular impulse and loud single S2 seen in
transposition of the great arteries
Management of transposition of the great arteries
Maintain patent ductus arteriosus with prostaglandins
Balloon atrial septoplasty
Arterial switch surgical correction is definitive
What are the 4 features of tetralogy of fallot
Pulmonary stenosis
Leads to RV hypertrophy and right sided outflow obstructions
VSD which leads to eisenmenger syndrome as RV hypertrophy increases pressure to greater than LV
Overriding aorta
How dos tetralogy of fallot present
Typically around 2 months unlike other cyanotic heart conditions which present at birth
Tet spells where child is feeding/crying causes spasms of infundibular septum causing cyanosis and tachypnoea may even LOC
Squatting improves symptoms
What are the 3 cyanotic heart disease
Tetralogy of fallot
Tricuspid atresia
Transposition of great arteries
Pathophysiology of tricuspid atresia
Valve malformed or does not form at all
Incompatible with life unless ASD and VSD
What has egg on side X ray appearance
transposition of the great arteries
What determines the severity of tetralogy of fallot
Extent of pulmonary stenosis
Murmur in tetralogy of fallot
ESM louder on inspiration heard at left sternal edge- VSD tends to not present with murmur
CXR finding of tetralogy of fallot
ECG finding
CXR- boot shape
ECG- RVH
Management of tetralogy of fallot
Acutely prostaglandins to maintain PDA
If severe cyanotic episodes (over 15mins) where lose consciousness
- sutgical intervention where blood goes to lungs- BT shunt or RV balloon dilatation
- can use propanolol
Corrective surgery from 4 months onwards
Management of tricuspid atresia
Balock taussig shunt
Corrective surgery but is very difficult as only one functioning ventricle
Glenn operation then fontan
GF
Murmur in tricuspid atresia
ESM heard loudest at lower left sternal edge
What cardiac anomaly is downs associated with
ASVD
How is ASVD normally picked up
Routine echo for downs
Week 2-3 get cyanosis if not
Managment of ASVD
Treat heart failure and then corrective surgery at 3 months
What is point of balock taussig shunt
In cyanotic heart conditions like TOF and tricuspid atresia is lack of blood flow to lungs so this provides them with supply to oxygenate the blood
Murmur in ASD
Ejection systolic left sternal edge
Fixed splitting of S2
What are 2 types of ASD
Most common -Secundum where foramen ovale does not close
Primum- defect in AV septum
Management of the 2 types of ASD
Observation as will close spontaneously often
Manage if
- ratio of pulmonary to systemic blood flow ratio over 1.5
- right ventricular dilation
- symptomatic
Secundum- catheterisation and insertion of occlusive devise
Primum- corrective surgery
Presentation of ASD
Typically asymptomatic but can get recurrent infection, SOB
How are VSDs classified
Small (<3mm)
Large (>3mm)
How do small versus large VSD present
Small- SOB with normal saturations, abnormal feeding, tired
Large- HF, recurrent infections, hepatomegaly
Management of small versus large VSD
Small
- will correct naturally but monitor with echos
Large- need to prevent eisenmenger syndrome
- CDC
- increase calories, diuretics(furosemide) and catopril
- corrective surgery at 3-6 mths
Which type of VSD is endocarditis more common
Small
If have cyanosed baby what test determines if cyanotic HD
Hyperoxia test- give 10L for 10mins
Measure oxygen in blood gas of right arm, if stays below 15pa then cyanotic HD if have excluded lung disease and persistent pulomanry hypertension of the newborn
Complications of VSD
aortic regurgitation
infective endocarditis
Eisenmenger’s complex
right heart failure
Syndromes associated with VSD
Downs
Edward’s syndrome
Patau syndrome
cri-du-chat syndrome
What causes closure of ductus arteriosus
High oxygen
Risk factors for patent ductus arteriosus
Pre-term
Low oxygen ( born at high altitude, lung problems etc)
Maternal rubella infection during 1st trimester
Management of patent ductus arteriosus
Should close by 1 month
- indomethacin post natally
- surgical ligation at 1 year if indomethacin fails to close it
Signs and symptoms of PDA
Symptoms
- Often asymptomatic as should shut by 1 month post partum
- SOB, bradycardia and needs O2
Signs
- machine like murmur over ULSE
- heaving apex beat
- wide pulse pressure
- bounding pulse
What is the name of PDA murmur
Gibsons
What is eisenmenger syndrome and what causes it
Eisenmenger occurs in initial L->R shunts where the increased blood flow to pulmonary circulation results in vascular remodelling in the lungs. As such this causes pulmonary hypertensions which causes hypertrophy of RV- this then increases afterload of pulmonary circulation and can become greater than that of left side which reverses shunt. Then get cyanotic heart disease
Management of eisenmenger syndrome
Heart and lung transplant
How to distinguish innocent murmurs from pathological
InnoSent- 5 s’s
Asmypomatic
Silent
Left sternal edge
Soft blowing
Systolic only
Often occur in illness like infections when younger so check for fever etc
Also varies with posture
Symptoms of HF in infants
Breathless
Sweating
Feeding
Recurrent chest infections
Signs of HF
Poor weight gain
Tachypnoea
Tachycardia
Heart murmur
Enlarged heart
Hepatomegaly
Cool peripheries
Causes of HF in neonates
Typically from obstructed systemic circulation
- hypoplastic left heart syndrome
- critical aortic valve stenosis
- severe aortic coarctation
Causes of HF in infants
VSD
AVSD
Large PDA
Causes of HF in older children
Eisenmenger syndrome
Rheumatic fever
Cardiomyopathy
What causes cyanosis in an infant
Cyanotic heart disease
Respiratory disorders- surfactant deficiency, meconium aspiration, pulmonary hypoplasia
Peristent pulmonary hypertension of the newborn
Infection
Causes of outflow obstruction
Pulmonary stenosis
Aortic stenosis
Aortic coarctation- most common
How does aortic stenosis present
Moderate- SAD (syncope, angina, dyspnoea)
Severe- severe heart failure with shock in neonates
Signs of aortic stenosis
Carotid thrill
ESM radiating to the neck
Slow rising pulse
Management of aortic stenosis
Balloon valvulotomy
If needed transcatheter aortic valve replacement
What are the 2 types of aortic coarctation
Infantile- proximal to DA
Adult- distal to DA
Presentation of aortic coarcation
Asymptomatic could be
Infants- collapse on second day of life onwards when DA closes
Examination findings of aortic coarctation
High blood pressure in arms but low in legs
Systolic murmur heard loudest in the back
Management of aortic coarctation in infants
ABC and prostaglandin to open DA
Balloon repair or surgery
What is hypoplastic left syndrome
Underdevelopment of the whole left side of heart- present the sickedt of all congenital heart conditions
Difference between hypoplastic left heart syndrome and coarctation of aorta
Absent pulses in all peripheries- HLHD
Absent pulses in legs- CA
Management of PA
Prostaglandin ABC
Norword procedure OR BK shunt ASAP
What are 2 innocent murmurs
Venous hum- 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
Stills murmur- Low-pitched sound heard at the lower left sternal edge
What is most common childhood arrythmia
SVT
Sinus arrythmia common in children as detectable cyclical increase by 30bpm with inspiration
How does SVT present in utero
HF or hydrops fetalis
leads to reduced CO and pulmonary oedema
How does SVT show on ECG
Narrow complex tachycardia
Wolf parkinson white on ECG
Delta wave
Management guidelines for SVT
Circulation and resp support
Vagal manoevers
IV adenosine
DC cardioversion
Once sinus rythm restored maintenance with sotalol and flecainide
What is given for maintenance after SVT
Flecainide or sotalol
What is done if children relapse with SVT
Percutaneous radiofrequency ablation or cryoablation
Cause of rheumatic fever
Group A strep infection
Scarlet fever
Typically occurs 2-6 weeks after the pharyngitis
Signs and symptoms of rheumatic fever
J- polyarthritis
O- carditis (any)
N- subcut nodules
E- erythema marginatum
S- syndenhams chorea
What diagnoses rheumatic fever
Jones criteria- Strep throat and 2 majors or 1 major and 2 minors
Major
J- joints
O- carditis
N- subcut nodules
E- erythema marginatum
S- sydenhams chorea
Minor
F- fever
R- raised CRP or ESR
A- arthralgia
P- prolonged PR
P- previous RF
How can history of strep throat be shown
Group A strep on throat culture
Antistreptolysin titre
Acute management of rheumatic fever
Long term too
High dose aspirin as suppresses inflam in joints and heart
Amoxicillin if presence of current infection
Steroids if fever and inflammation does NOT respond rapidly
Valve replacement if needed
Prophylaxis for rheumatic fever
Monthly injections of benzathine penicillin for 10 years after or until age of 21
Lifelong if severe valve damage
Management of hyperyanotic attacks in tetralogy of fallot
Knee to chest position
Administer O2
IV morphine, adrenaline and propanolol
Potentially sodium bicarbonate
What do if at GP examine child and are absent femoral pulses
Same day consultation with paeds
What causes ebsteins anomaly
Lithium use during pregnancy
Pathophysiology of ebsteins anomaly
Posterior leaflets of tricuspid valve are displaced anteriorly causing stenosis and regurgutation
Murmur in ebsteins anomaly
Stenosis- mid-diastolic
Regurg- pansystolic
Presents as murmur during diastole and systole
CXR finding of ebsteins anomaly
Right atrial enlargement
CXR finding of ebsteins anomaly
Right atrial enlargement
Resp infection and then cardiac issues with cardiac enlargement
Viral myocarditis-> dilated cardiomyopathy
What typically presents with feeling faint and chest pain when exercising
Aortic stenosis
What syndrome is aortic stenosis associated with
Williams
How are hypercyanotic episodes managed in cyanotic babies with TOF
IV propanolol
Pain relief
Fluids
IV bicarbonate
Systolic murmur which radiates over the praecordium
VSD
Best way to assess venous congestion from RHF in a child
Hepatosplenmegaly as neck is short to assess neck veins
With congenital heart defects how do children appear during feeds
Breathless and sweaty
Which heart diseases worsen on closing of ductus arteriosus
Pulmonary stenosis
Tricuspid atresia
TOF
Transposition of the great arteries
On top of prostaglandins what else should be given to a child awaiting an echo
Abx to cover for sepsis
What is most common presentation of rheumatic fever
Polyarthritis
Murmur in VSD
Holosystolic (pansystolic) murmur heard over LLSE
Murmurs if ULSE
Pulmonary stenosis
PDA
ASD
Murmur in pulmonary stenosis
Starts at beginning of systole
Radiates to back
Thrill
Loudest at ULSE
If patient presents unwell with VSD what is first management
NG tube to promote calory intake
Cyanosis with left axis deviation and apical impulse
Tricuspid atresia
Which cyanotic condition at birth can present with no murmur
Transposition of great vessels as valves intact
What is eisenmenger most associated with
VSD
Cardiac anomaly associated with DiGeorge
Interruption of aortic arch
What can exacerbate innocent murmurs
Febrile illness
Complications of aortic coarctation affecting brain vessels
Cerebral aneurysms due to increased pressure pre coarctation due to activation of RAAS
What can cause delayed presentation of transposition of the great arteries
If VSD present
Systolic murmur heard loudest in the back
Aortic coarctation
Maternal risk factor for transposition of the great arteries
Uncontrolled DM
What is target sign
concentric alternating echogenic and hypoechoic bands
