Cardio Flashcards
How do left to right shunts present?
Breathless (left to right - think water on the lungs)
How do right to left shunts present?
Blue (right to left - think blood not being oxygenated)
How does common mixing present?
breathless and blue
How does outflow obstruction in a well child present?
asymptomatic with murmur
How does outflow obstruction in a sick neonate present?
collapsed with shock
Causes of left-to-right shunts
- VSD
- PDA
- ASD
Causes of right-to-left shunts
- TOF
- TGA
- Eisenmenger
- other ‘Ts’
Causes of outflow obstruction in a well child
- PS
- AS
- adult-type CoA
Causes of outflow obstruction in a sick neonate
- CoA
- HLHS
Features of an innocent murmur
InnoSent
- aSymptomatic
- Soft blowing murmur
- Systolic only (not diastolic)
- left Sternal edge
- no added sounds
- no radiation
- no thrill
- normal exam inc. femoral pulses
- normal sats
- normal ECG
When to refer day 1 murmurs
- symptomatic
- loud (esp. day 2 of life)
- abnormal exam (inc. syndromic)
- sats <94%
- abnormal ECG
What is heart failure in the first few weeks of life normally due to?
left heart obstruction
What is heart failure in infants normally due to?
left to right shunt
When can cyanosis be missed?
anaemia (central cyanosis will not be visible)
Ix for suspected congenital heart disease
Echo + Doppler US (+ ECG + CXR)
Presentation/examination of ASD
- usually asymptomatic
- soft ESM at ULSE (over pulmonary valve) due to increased flow through PV from left-to-right shunt
- fixed and widely split S2
With primum ASD (partial AVSD): apical pansystolic murmur from AV regurg
What is a partial AVSD the same as?
primum ASD
Management of ASD
secundum: cardiac catherization + occlusion device
primum (partial AVSD): surgical correction at 3-5yrs
Presentation and exam of VSD
Small:
- asymptomatic
- loud pansystolic murmur
- soft P2
Large:
- heart failure (SOB, faltering growth) from 1 weeks
- recurrent chest infections
- soft pansystolic murmur
- loud P2
- thrill
- apical mid-diastolic murmur
Management of VSD
Small: close spontaneously
Large: diuretics ± captopril (ACEi), additional calorie input, surgery at 3-6 months
When is a ductus arteriosus ‘persistent’?
failure to close by 1 month of EDD
Presentation and exam of PDA
- usually asymptomatic
- if large: pulmonary HTN, heart failure
- most have continuous ‘machinery murmur’ below left clavicle at ULSE
- increased pulse pressure, collapsing or bounding pulse
Management of PDA
- close with coil or occlusion device via cardiac catheter at 1yr
- occasionally surgical ligation needed
What test should be performed in cyanotic neonates?
hyperoxia (nitrogen washout test) - place infant in 100% O2 for 10mins
- if right radial artery PaO2 remains low - diagnose cyanotic congenital heart disease (if lung disease/persistent pulmonary HTN ruled out)
Management of a cyanosed neonate
- ABCDE
2. prostaglandin infusion to keep DA patent
4 features of Tetralogy of Fallot
- large VSD
- over-riding aorta (lies over VSD)
- (sub)pulmonary stenosis
- RV hypertrophy
Presentation features (not really presentation) of TOF
usually detected antenatally, or following detection of murmur in first 2 months of life +/- cyanosis
- ‘Tet’ spells (hypercyanotic spells)
- loud, harsh ESM at left sternal edge from day 1 of life
- boot-shaped heart on CXR
Management of TOF
- surgical repair around 6months
- treatment of prolonged (>15mins) tet spells
Treatment of prolonged (>15mins) tet spells
- hold knees up/let them squat
- sedation, analgesia
- IV propranolol
- IV fluids
- bicarbonate to correct acidosis
- muscle paralysis + artificial ventilation to reduce metabolic demand
Presentation of TOF
- usually day 2 of life when DA closes
- severe cyanosis (less severe if more mixing of blood from associated anomalies)
- usually no murmur
Management of TOF
- prostaglandin infusion to keep DA parent
- balloon atrial septostomy
- surgery (arterial switch procedure) in neonatal period (first few days of life)
What is Eisenmenger syndrome
right to left shunt secondary to high pulmonary blood flow and hypertension, cause by left to right shunt/common mixing (if not treated early enough)
Presentation of Eisenmenger syndrome
- 10-15yrs
- LESS symptomatic of original problem (left-to-right/common mixing)
- cyanosis
- progressive, will die of right heart failure if untreated
Management of Eisenmenger syndrome
- palliative medication
- heart-lung transplant
Presentation of complete AVSD
- cyanosis at birth or heart failure at 2-3 weeks of life
- no murmur
- most commonly seen in Down’s syndrome
Management of complete AVSD
- treat heart failure medically
- surgical repair at 3-6 months
Presentation of aortic stenosis
- asymptomatic
- ESM at URSE, radiating to the neck
- always also a carotid thrill
- if severe: reduced exercise tolerance, chest pain on exertion, syncope
- if critical: heart failure and shock as neonate
Management of aortic stenosis
- regular assessment and echo to decide when to intervene (safer in older children)
- balloon dilatation (valvotomy) when severe
- may eventually need valve replacement
Presentation of pulmonary stenosis
- asymptomatic
- ESM at ULSE
- may have a thrill
Management of pulmonary stenosis
- regular assessment and echo to decide when to intervene (safer in older children)
- balloon dilatation (valvotomy) when severe
- may eventually need valve replacement
What does a boot-shaped heart on CXR suggest?
Tetralogy of Fallot (TOF)
What does an egg-on-string heart on CXR suggest?
Transposition of the great arteries (TGA)
What is seen on ECG in WPW
- short PR interval
- delta wave
What should you advise patients with congenital heart disease/prostheses?
And which is the exception
- risk of IE
- good dental hygiene
- avoidance of tattoos and piercings
Exception is secundum ASD
What age does Kawasaki disease affect
any age, predominantly 6m-5y, peak onset 1st year of life
Diagnosis of Kawasaki disease
Fever >5 days plus 4 of:
- lymphadenopathy
- rash
- mucositis (strawberry tongue, cracked lips)
- conjunctivitis (non-purulent)
- extremity involvement (red, peeling finger tips)
Management of Kawasaki disease
- ECHO
- 10mg/kg/6hr (high dose) aspirin until fever subsides
- IV Ig 2g/kg
- low dose aspirin when fever abates (around day 10)
- echo at 6 weeks
- if giant coronary aneurysm: may need long-term warfarin and close F/U
What does a machinery murmur at the ULSE suggest?
PDA
