cardiology Flashcards
what is patent ductus arteriosus
failure of the ductus arteriosus (DA) to close after birth. This results in the flow of some oxygenated blood from the descending aorta to the pulmonary artery (a left-to-right shunt)
- pulmonayr hTN
- RV hypertrophy
- LV hypertrophy
more common in premature babies
born at high altitude
maternal rubella infection in the first trimester
features of patent ductus arteriosus
- left subclavicular thrill
- continuous ‘machinery’ murmur
- large volume, bounding, collapsing pulse
- wide pulse pressure
- heaving apex beat
- SOB
- difficulty feeding
- poor weight gain
- LRTI
Diagnosis
- echocardiogram
assess size
Mx of patent ductus arteriosus
- > indomethacin or ibuprofen
- given to the neonate
- inhibits prostaglandin synthesis
- closes the connection in the majority of cases
- > if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair
where can it go wrong in heart
genes
- trisomies 13/18/21, 22q11deletion
- cardiomyopathy genes, degeorges
williams syndrome
environment
- teratogens
LR shunt
L-R shunt
- requires a connection
- increased blood flow to the lungs - typically ventricular septal defect
- increased blood flow > pulmonary vascular
- remodelling > increased pulmonary pressures
RL shunt
- requires both a communication and distal obstruction
- blue blood goes to the systemic ventricle
ASD patho
features
Mx
shunt between the two atria therefore blood moves from left to right
leads to pulmonary hypertension as there is more pressure on the right side
lead to heart failure and the pulmonary HTN can lead to eisenmenger syndrome where the right is so high that the shunt is reversed meaning the blood goes from right to left BYPASSING THE LUNGS pt becomes cyanotic
mid systolic, crescendo decrescendo murmur loudest at the upper left sternal border
fixed spilt second heart sound
Shortness of breath
Difficulty feeding
Poor weight gain
Lower respiratory tract infections
transvenous catheter closure (via the femoral vein) or open heart surgery. Anticoagulants (such as aspirin, warfarin and NOACs) are used to reduce the risk of clots and stroke in adults.
VSD patho
features
examination findings
there is often an underlying genetic cond ->downs/turner
L->R shint
LV volume overload
pulmonary venous congestion
eventually pulmonary hypertension -> reverse the shunt CALLED EISENMENGER
features poor feeding child tachypnoeaic dyspnoea faltering growth sweaty
exam findings
pan systolic murmur - left lower sternal border 3rd/4th intercostal spaces
Mx
asymptomatic - watchful waiting
transvenous catheter closure via the femoral vein or open heart surgery.
increased risk of infective endocarditis -> ABx prophylaxis
aortic stenosis
mild -> increased velocity, LV working a bit harder, may present when older, exercise tolerance, pain - hypertrophied and less perfused LV
coarctation of aorta
narrowing of aortic arch around ductus arteriosus
ass w Turners
Presentation
- weak femoral pulses
- performing a four limb BP
—> high in the areas supplied before narrowing
adn low in the areas supplied after the narrowing
systolic murmur below left clavicle - tachupnoea - poor feeding - grey and floppy baby - LV heave - underdeveloped left arm reduced flow to the left subclavian artery underdevelopment of the legs
Mx
PGs to keep the ductus arteriosus open while awaiting for surgery
coarctation and to ligate the ductus arteriosus.
femoral delay
palpate R raidal artery
murmur that radiates posteriorly
between scapula
steroid to ope the valve
tetralogy of fallot
RFs
Ix
Sx and signs
VSD
RV hypertrophy
pulmonary valve stenosis
Overriding aorta
RFs Rubella infection Increased age of the mother (over 40 years) Alcohol consumption in pregnancy Diabetic mother
Ix
echo
doppler flow studies -> severity of the abnormality and shunt
xray boot shaped
Sx and signs
- Cyanosis (blue discolouration of the skin due to low oxygen saturations)
- Clubbing
- Poor feeding
- Poor weight gain
- Ejection systolic murmur heard loudest in the pulmonary area (second intercostal space, left sternal boarder)
“Tet spells” - irritable, cyanotic and SOB
6 months of age sats 85% monitor clinic they are gaining weight sats not gng too down no yercyanotic or tetroalogy spells
appro weight and 6 months of age we start to fix them patch on VSD and
tricuspid atresia
R -> L atrial shunt if entire venous return
No RV inlet
Mx
palliation cant repair valve that is not formed
pulmonary atresia
no RV outlet
R->L atrial shunt of entire venous return
blood flow lungs via PDA
hypoplastic left heart
mixing of blood
norwood procedure
transposition of great arteries
great arteries are transposed
aorta coming out of RV
parallel circuits
lungs into LA then back into lungs so body is getting deoxygenated blood
shock
high lactate
poor perfusion
hypotension
arterial switch in one week
adaptation at birth
lungs fill w air and replace fluid establish regular aspiration reduction in pulmonary vascular resistance increased pulmonary blood flow closure of shunts - ductus arteriosus - foramen ovale - ductus venosus
causes of resp disorders
resp distress (primary lung disease) apnoea and bradycardia (immaturity or dysfunction of the resp centres in the brain)
stridor
signs of resp distress in the newborn
floppy/sleepy
dusky around mouth
tachypnoea >60/min
expiratory grunt
chest recession (intecostal, sybcostal, tracheal tug)
nasal flaring
cyanosis
History of
gestational age
antenatal steroids <34 weeks
polyhydraminos - lung dev - swallow lycol, big baby or not swallowing signs of NM weakness, airway tone abnormal, physical blockage TOF w oesophageal atresia/oligohydraminos - potters syndrome pulmonary hypoplasia, ruptured membranes at 18 weeks
anomaly scans
sepsis RFs
method of birth and presence of meconium - emergency c section
resuscitation
Ix for resp distress
CXR - pneumothorax, pneumonia
infection screening - FBC, CRP, cultures
NPA/ET secretions (viral and bacterial
ureaplasma assay
transillumination - shine light on baby
NG tube - coanal atresia
effect of administering oxygen
pneumothorax
resus w positive pressure
Risk of vsd
endocarditis
types of ASD
complications
ostium secundum
foramen ovale
ostium primum - AV valve defects -> atrioventricular septal defect
stroke
AF/ Flutter
pulmonary HTN and RS HF
eisenmenger syndrome
causes of pan systolic murmur
VSD
Mitral regurg
tricuspid regurg
eisenmenger syndrome
when the shunts ie ASD/VSD/PDA reverses then blood bypasses the lungs and enter the body straight leading to cyanosis
bone marrow increases its prod of RBCs -> polycythaemia -> plethoric -> more viscous -> more prone to developing blood clots
Right ventricular heave: the right ventricle contracts forcefully against increased pressure in the lungs
Loud P2: loud second heart sound due to forceful shutting of the pulmonary valve
Raised JVP
Peripheral oedema
L->R shunt Cyanosis Clubbing Dyspnoea Plethoric complexion (a red complexion related to polycythaemia)
heart lung transplant
- > Oxygen can help manage symptoms
- > Treatment of pulmonary hypertension, for example using sildenafil
- > Treatment of arrhythmias
- > Treatment of polycythaemia with venesection
- > Prevention and treatment of thrombosis with anticoagulation
- > Prevention of infective endocarditis using prophylactic antibiotics
signs of aortic stenosis
ejection systolic murmur
loudest at the aortic area -> second intercostal space, right sternal border
radiates to carotids
Ejection click just before the murmur
Palpable thrill during systole
Slow rising pulse and narrow pulse pressure
gold standard Ix - echocardiogram
watching progression of the condition
surgical options
Percutaneous balloon aortic valvoplasty
Surgical aortic valvotomy
Valve replacement
complications Left ventricular outflow tract obstruction Heart failure Ventricular arrhythmia Bacterial endocarditis Sudden death, often on exertion
ass og pulmonary stenosis
Sx
Signs
Tetralogy of Fallot
William syndrome
Noonan syndrome
Congenital rubella syndrome
symptoms of fatigue on exertion, shortness of breath, dizziness and fainting.
Ejection systolic murmur heard loudest at the pulmonary area (second intercostal space, left sternal boarder)
Palpable thrill in the pulmonary area
Right ventricular heave due to right ventricular hypertrophy
Raised JVP with giant a waves
Mx
echocardiogram
watching and waiting
symptomatic or the valve is more significantly stenosed, balloon valvuloplasty via a venous catheter
Mx of tet spells seen in tetralogy of fallot
Mx of tet spells
older children - squat
knees to their chest
- Supplementary oxygen is essential in hypoxic children as hypoxia can be fatal.
- Beta blockers can relax the right ventricle and improve flow to the pulmonary vessels.
- IV fluids can increase pre-load, increasing the volume of blood flowing to the pulmonary vessels.
- Morphine can decrease respiratory drive, resulting in more effective breathing.
- Sodium bicarbonate can buffer any metabolic acidosis that occurs.
- Phenylephrine infusion can increase systemic vascular resistance.
In neonates, a prostaglandin infusion can be used to maintain the ductus arteriosus. This allows blood to flow from the aorta back to the pulmonary arteries.
Total surgical repair by open heart surgery is the definitive treatment
Ebstein’s anomaly
congenital heart defect characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle. It is sometimes referred to as ‘atrialisation’ of the right ventricle.
exposure to lithium in utero
ass PFO or ASD
WPW
cyanosis
prominent ‘a’ wave in the distended jugular venous pulse,
hepatomegaly
tricuspid regurgitation
pansystolic murmur, worse on inspiration
right bundle branch block → widely split S1 and S2
