cardio Flashcards
What does left to right shunt present as?
give some causes
Breathlessness
ASD
VSD
Persistent duct
What does right to left shunt present as?
what are some causes?
BLUE
tetralogy of fallot
transposition of great arteries
What is the cause of a common mixing condition?
complete AVSD
What are the hallmarks of innocent ejetion murmur
innoSent Asymtpomatic Soft and blowing Left sternal edge systolic AND - No parasternal thrill no radiation no additional heart sounds
Symtpoms + signs of HF
symptoms: breathless, sweaty, recurrent chest infections, poor feding
signs: tachypnoea, gallop rhythm, murmur, enlarged heart
Causes of HF in neonates
caused by duct dependent circulation hypoplastic LH syndrome aortic valve stenosis coarctation of aorta interruption of aortic arch
Causes of HF in infants
caused by high pulmonary blood flow
VSD
ASD
large persistent DA
cause of HF in older children
caused by right/left heart failure
Eisenmeger syndrome (RHF only)
cardiomyopathy
rheumatic heart disease
What is eisenmeger syndrome
L –> R shunt is left untreated
leads to increased pulmonary blood flow
pulmonary hypertension
reversal to R –> L shunt causing cyanosis
Mx of HF
Reduce preload - diuretics (furosemide), venous dilators (nitroglycerin)
enhance contractility - IV dopamine, digoxin, dobutamine
reduce afterload - ACEi, IV hydralazine/nitroprusside
improve o2 delivery - beta blockers
enhance nutrition
If it’s due to circulation through malformation do prostaglandin infusion to keep duct open
- no tx
- ACEi/ARB
- ACEi + mineralocrticoid antagonist (+ diuretic + beta blocker)
- IV inotropes and diuretics
Causes of cyanosis in children
CARDIO: persistent cyanosis in healthy kid - structural heart defet persisten cyanosis + resp problems - congenital cardiac problem RESP: RDS, pulmonary hypoplasia, meconium aspiration persistent pulmonary hypertension OTHER: infection inborn error of metabolism
What are the 2 types of ASD
Secundum - problem in the middle of the atrial septum, this involves foramen ovale
primum (partial AVSD) - defect in the atrioventricular septum
Signs of ASD
Fixed splitting of 2nd heart sound
ejection systolic murmur heard best at left sternal edge (due to L to R shunt)
AVSD gets a pansystolic murmur
CXR features of ASD
cardiomegaly and enlarged pulmonary arteries and markings
ECG features of ASD
secundum - RBBB + RAD
primum - superior QRS as av node is displaced so conducts superiorly
Mx of ASD
measure pulmonary to systemic blood flow <1.5 nothing >1.5 it's big enough to damage RA so: secundum - catheter and correction primum - surgical
symptoms + signs of VSD
Small are asymptomatic
Large:
HF, breathlessness etc.
tachypnoea, tachycardia, hepatomegaly due to HF, large precordium
pansystolic murmur heard best at left lower sternal edge
loud murmur implies smaller defect
loud pulmonary second sound
ECG and CXR changes in VSD
Large:
CXR - cardiomegaly, pulmonary oedema (HF)
ECG - biventricular hypertrophy
Mx of VSD
small:
close spontaneously - ensure good dental hygiene so don’t get bacterial endocarditis (can give prophylactic amoxicillin to those at high risk)
Large-
treat HF
prevent eisenmeger
tx surgically at 3-6 months
Definitio of PDA
failure to close at 1 month after expected due date
Signs of PDA
Continuous murmur under left clavicle
High pulse pressure
bounding pulse (caused by high pulse pressure)
Can get left to right shunt causing vent. hypertrophy, pulmonary HTN etc.
Mx of PDA
Close it
- IV indomethacin
- prostacycin synthetase inhibitor
- ibuprofem
SURGICAL LIGATION
Components of tetralogy of fallot (TOF)
large VSD
overriding aorta (with respect to septum)
right outflow tract obstruction
right ventricular hypertrophy
Signs of TOF
Cyanosis
HYPERCYANOTIC SPELLS
squatting on exercise
What conditions do you have to exclude when doing nitrogen washout test
Persistent pulmonary HTN
lung disease
Mx of cyanosed infant
ABC
Prostaglandin infusion to maintain duct patency
Signs of TOF
harsh ejection systolic murmur on left sternal edge
CLUBBING
CXR signs of TOF
axis tilted to R
Pulmonary bay where pulmonary arteries should be
decreased pulmonary vasc. markings
Mx TOF
and mx of cyanotic spells
If bad cyanosis - PG infusion
surgery to repair
for hypercyanotic spells -
knee to chest position
administer o2
IV line and give morphine and a peripheral vasoconstrictor
Signs of transposition
Cyanosis on day 2 when duct closes
loud single 2nd heart sound
rarely a murmur
CXR signs of transposition
Increased pulmonary vasculature
Mx of transposition
PG E1 infusion
balloon atrial septostomy
What condition is complete AVSD associated with
Down’s syndrome
features of AVSD
pulmonary HTN
cyanosis at birth or HF at 2-3 weeks
ALWAYS have superior ECG axis
What happens in tricuspid atresia
RV doesn’t work, only left side of heart
Features of tricuspid atresia
CYANOTIC
Risk high pulmonary pressure
mx of tricuspid atresia
PG infusion
need to ensure blood flow to lungs at low pressure
3 stage surgical procedure at diff ages
4 examples of complex congenital heart disease
tricuspid atresia (most common)
mitral atresia
double inlet LV
common arterial trunk
What is aortic stenosis commonly associated with
mitral stenosis
coarctation of aorta
Signs and symptoms of aortic stenosis
Reduced exercise tolerance
chest pain
syncope (if severe)
Slow rising pulse
carotid thrill (ALWAYS)
EJECTION SYSTOLIC MURMUR at R sternal edge
Signs of pulmonary stenosis
Usually asymptomatic but can be a bit cyanotic
ejection systolic and CLICK murmur at L sternal edge
parasternal heave
Signs of adult type coarctation of aorta
Gets worse over time Hypertensio in right arm radio-femoral delay ejection systolic murmur (outflow obstruction) rib notching
How to manage outflow obstructions
Prostglandin infusions til you can operate
Signs of neonatal coarctation
Present with circulatory collapse at 2 days when ductus closes
absent femorals
severe metabolic acidosis
What is interruption of aortic arch
no connection between proximal aorta and distal to ductus arteriosus
Circulation through ductus arteriosus
associated with VSD
What is hypoplastic left heart associated with
Coarctation of aorta
get severe acidosis and complete circulatory collapse
no peripheral pulses
Why are arrhythmias in childhood normal
HR changes with breathing
inspiration - acceleration
expiration - decceleration
How does SVT present
HR can spike to 250-300bpm narrow complex tachy no P waves delta waves if WPW (can cause hydrops foetalis in utero)
Mx of SVT
If haemodynamically stable:
- vagal manoeuvres
- adenosine (50-100mcg) then increment dose
- choice of: DC cardioversion, fleicanide, amiodarone
If haemodynamically unstable:
try vagal manoeuvres and adenosine but do DC CARDIOVERSION ASAP
Cardiac ablation if recurrent/accessory pathways
How does long QT present
Syncope
often late childhood
mistaken for epilepsy
What causes syncope in children
Neural - certain stressors, standing up too quickly
get dizziness, pallor, abnormal vision
cardiac -
electrical - arrhythmia
structural - HOCM etc.
symptoms worse on exercise, breathlessness etc.
What is rheumatic fever
AI response to infection with group a b haemolysing strep
it is an acute disease but can progress to chronic in 80% of cases
Symptoms of rheumatic fever
Polyarthritis, myalgia, malaise
chronic sequelae - mitral stenosis leading to heart failure
How do you diagnose rheumatic fever
Jones criteria
Mx rheumatic fever
Acute: aspirin
Symptomatic HF: diuretics, ACE i
Prophylaxis: monthly injections of benzylpenicillin
Who should you suspect endocarditis in
Raised ESR, unexplained anaemia, sustained fever, haematuria
Signs of bacterial endocarditis
NEW MURMUR fever anemia splinter haemorrhages clubbing Pancarditis (valve problems, carditis, pericardial effusions)
Diagnosis of bacterial endocarditis
2 major criteria or 1 major and 2 minor (w/ evidence of preceding group a strep infection)
Major -
pancarditis
polyarthritis (ankle and knees)
sydenham chorea (jerky movements 2-6 months after)
erythema marginatum (on trunk and limbs)
subcutaneous nodules (extensor surfaces)
Minor- fever polyarthralgia Hx rheumatic fever raised APP prolonged PR on ECG
Causes of bacterial endocarditis
Staph a.
strep viridans (biggest cause - alpha haemolytic strep)
enterococcus
Ix bacterial endocarditis
Multiple blood cultures BEFORE ABx STARTED
detailed echo
mx bacterial endocarditis
Give Ab prophylaxis if at high risk (pt with prosthetic valve, patients with hx of infective endocarditis, patients with congenital heart disease)
MDT approach
Tx depending on native or prosthetic valves
if strep viridans - beta-lactam +/- gent
if staph a - beta-lactam
Surgery to remove infected prosthetic material
types of pulmonary HTN
arterial HTN - persistent shunt, persistent pulmonary infection of newborn
venous HTN - occlusion, LH failure
HTN w/ resp disease - chronic obstructive disease, bronchopulmonary dysplasia, interstitial lung disease
How do outflow obstructions present (what are the two kinds?)
And what causes them?
Outflow obstruction in well child - asymtpomatic w/ murmur
e.g. pulmonary stenosis, aortic stenosis
outflow obstruction in sick child - collapsed + shock
e.g. coarctation of aorta
