Cardio Flashcards
To which group of mothers are infants with congenital heart block most commonly born to?
Those with connective tissue disorders
With anti-Ro, anti-La antibodies
Sudden loss of consciousness during exercise, stress or emotion
Long QT syndrome
What is the most common cause of cardiac problem in children?
Congenital lesion
What are the pressures in the sides of the heart in a fetus?
L pressure low (low lung return)
R pressure high (receiving systemic venous return)
What happens at birth in the heart?
Foramen ovale closes because pressure builds in L atrium, reduces in R atrium. FO has one way flap
DA also closes as pulmonary artery pressure increases
What is the most common symptom of a L to R shunt?
Breathlessness (or asymptomatic) because lungs become congested. Particularly in neonates who are trying to feed
What are three types of L to R shunts?
ASD
VSD
PDA
What are two types of ASD?
Secundum (80%) - patent foramen ovale
Partial atrioventricular
What are the symptoms of ASD?
Largely asymptomatic
Breathlessness
Recurrent infections/wheeze
Later arrhythmias
What are the clinical features of ASD?
Breathlessness
ESM (loudest at LUSE)
Split second heart sounds
What are the heart sounds in ASD?
ESM loudest at LUSE
Split second heart sound
What are the CXR features of ASD?
Enlarged heart
Increased pulmonary vasculature markings
Visible pulmonary arteries
What are the ECG features of ASD?
(Increased R sided pressure, RV enlargement)=
- RBBB
- RAD
What is the management for ASD?
Observation
If there is significant RV dilatation with raised pulmonary pressures, use an occlusive device to “close” the FO
What percentage of congenital heart disease cases are VSD?
30%
What are two types of VSD?
Small (<3mm e.g. smaller than aortic valve)
Large (>3mm)
What may be heard on auscultation of a child with a small VSD?
PSM at LLSE
Quiet P2
What management should be considered in a small VSD?
Bacterial endocarditis prevention
How does a large VSD present?
HEART FAILURE
SOB, FTT, recurrent chest infections
Tachypnoea, tachycardia,
Hepatomegaly
Auscultation large VSD
Soft PSM
Apical MDM
What will be heard on auscultation of a child with a huge VSD?
Nothing - no turbulent flow because valve so big
CXR and ECG features of VSD
CXR: enlarged heart, increased pulmonary vasculature, pulmonary oedema
ECG: Bilateral ventricular hypertrophy
What is the management for child with large VSD?
Management of heart failure: - Diuretics (furosemide) - Captopril - Digoxin Increased calories (if FTT)
What is a complication of a large VSD?
Eisenmenger’s syndrome
What is Eisenmenger’s syndrome?
L to R shunt causes pulmonary HTN. Eventually this pressure is raised above L side, and shunt switches to R to L = cyanosis
What are two (broad) causes of PDA?
Failure to close (congenital)
Prematurity
What is a persistent ductus arteriosus?
Failure of DA to close by 1 mo (generally a defect in constrictor mechanism)
Ausculation child with PDA
Continuous murmur loudest beneath L clavicle
What happens to the pulse pressure in PDA?
Increased
CXR/ECG features of PDA
CXR: often normal but with features of HF if large
ECG: often normal, but LVH, or RVH (if pHTN)
What are children with a PDA at increased risk of?
Bacterial endocarditis, pulmonary vascular disease (Eisenmenger’s)
How is a PDA managed?
MEDICAL (closure)
- Prostacyclin synthetase inhibtor
- IV Indomethacin
- Ibuprofen
When should a PDA be kept open? How?
If there is a duct dependent circulation (e.g. a R to L shunt additionally). Kept open using prostaglandin infusion until that anomaly is sorted
What is the commonest presentation of R to L shunts?
Cyanosis within the first week of life
What is the mainstay of treatment to keep ducts open?
Prostaglandin infusion
How is a cyanotic heart disease investigated?
Nitrogen washout test.
Measure R radial PaO2.
If <15 kPa, cyanotic heart disease
What are two examples of R to L shunts?
Tetralogy of Fallot
Transposition of the Great Arteries
What is the commonest cause of cyanotic heart disease?
Tetralogy of fallot
What are the four anatomical features of tetralogy of fallot?
Large VSD
Pulmonary stenosis
Aorta lies over ventricular septum
Resulting RVH
What are four physiological features of ToF?
Cyanosis
Hypercyanotic spells
Dyspnoea
Fainting
Two clinical features of ToF?
Clubbing
Loud ESM at LSE
CXR/ECG features of ToF
CXR: small heart, uplifted apex, pulmonary artery “bay”
ECG: RVH (no S wave)
Medical management of ToF
Hypercyanotic spells lasting >15 mins
- Knees to chest in parent’s arms
- Sedation/pain relief
- IV propranolol
- IVI
- HCO3- to correct acidosis
- Artifical ventilation to reduce metabolic demand
(With view to surgery at 6 mos)
Surgical management of ToF
Close VD, relieve obstruction
What happens in transposition of great arteries?
Essentially two parallel circulations (R-R and L-L).
Incompatible with life WITHOUT an open duct
Ausculation TOGA
Loud, single S2
CXR/ECG TOGA
CXR: egg shaped heart on side
ECG: normal
Management of TOGA
Improve mixing -
PROSTAGLANDIN INFUSION to keep ducts open
Ballon septostomy to keep ducts open
In what syndrome is AVSD quite common?
Down’s
What happens in tricuspid atresia?
Right ventricle is small and non function.
Mixing occurs through patient foramen ovale (in L ventricle) and patient VSD allows blood out pulmonary artery
What is the management for triscupid atresia?
KEEP DUCTS OPEN - prostaglandin infusion
Blalock Taussig - shunt insertion from subclavian to pulmonary
Clinical features of AS?
ESM radiating to carotid
Carotid thrills
Slow rising pulse
- Dyspnoea
- Syncope
- Chest pain
(All worse on exercise)
CXR/ECG features of AS
CXR: enlarged heart (LV). Dilatation of ascending aorta
ECG: LVH
Management for AS
Regular clinical/ECHO monitoring
Balloon valvulotomy (TAVR)
Antibiotic/anticoagulant prophylaxis
Ausculation PS
ESM UPLSE
Give three examples of outflow obstruction in sick infant
- Coarctation of aorta
- Interruption of aortic arch
- Hypoplastic L heart
What is the mainstay of treatment in outflow obstructions?
Prostaglandin infusions to keep ducts patent for mixing
When does coarctation of aorta present?
2 days (when DA closes)
Clinical features of coarctation of aorta?
Absent femoral pulse
Severe metabolic acidosis
Severe heart failure
Whcih syndrome is interruption of aortic arch associated with?
Di George
What is interruption of aortic arch codependent on?
PDA (R to L shunt)
Clinical features of hypoplastic left heart syndrome
All peripheral pulses absent
Commonest childhood arrhythmia
SVT
SVT acute management
Circ and resp support
Vasovagal manoevres - carotid sinus massage, cold ice pack on face, bear down
ADENOSINE (IV/IO)
Synchronised DC
SVT maintenance management
Fleicanide
Propranolol
Clinical features SVT
Reduced CO = pulmonary oedema
Hydrops fetalis
IUD
What symptoms are suggestive of a cardiac cause of syncope?
Arrythmias
Symptoms on exercise
FHx sudden unexplained death
How can vasovagal syncope be managed?
Look out for warning signs
Avoid triggers
Physical counter pressure manoeuvres, tilt training
May need to increased salt (consider furosemide) to improve volume
How long is the latent interval in RhF?
2-6 weeks
Which infection does RhF follow?
GA haemolytic strep
Age range of RhF?
5-15 years
Major criteria RhF
Carditis/murmur Arthritis S/c nodules Erythema marginatum (map-like) Sydenham's chorea (2-6mos after)
Minor criteria RhF
Arthralgia Fever Hx RhF Raised APPs (ESR/CRP) Prolonged PR interval
Acute management of RhF
Bed rest and anti-inflammatories (ASPIRIN)
How is RhF prevented from recurring?
Benzathine penicillin (monthly)
What might congenital heart disease raise the risk of?
Bacterial endocarditis
Features of bacterial endocarditis
- Fever (prolonged)
- Malaise
- New murmur
- Raised ESR
- Unexplained anaemia/haematuria
- Splinter haemorrhages, JWL, ON, clubbing
- Roth spots
Investigations fof suspected BE?
2 blood cultures BEFORE abx
Echo (vegetations)
Commonest causative organisms in BE?
Strep viridans
Management of BE?
Resuscitation
Abx (penicillin and gentamicin)
Commonest congenital heart defect
VSD
Second commonest congenital heart defect
PDA
