cardiology

Question 1

what is patent ductus arteriosus

Answer 1

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

Question 2

features of patent ductus arteriosus

Answer 2

• 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

Question 3

Mx of patent ductus arteriosus

Answer 3

• > 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

Question 4

where can it go wrong in heart

Answer 4

genes
- trisomies 13/18/21, 22q11deletion
- cardiomyopathy genes, degeorges
williams syndrome

environment
- teratogens

Question 5

LR shunt

Answer 5

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

Question 6

RL shunt

Answer 6

• requires both a communication and distal obstruction

- blue blood goes to the systemic ventricle

Question 7

ASD patho

features

Mx

Answer 7

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.

Question 8

VSD patho
features
examination findings

Answer 8

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

Question 9

aortic stenosis

Answer 9

mild -> increased velocity, LV working a bit harder, may present when older, exercise tolerance, pain - hypertrophied and less perfused LV

Question 10

coarctation of aorta

Answer 10

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

Question 11

tetralogy of fallot
RFs
Ix
Sx and signs

Answer 11

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

Question 12

tricuspid atresia

Answer 12

R -> L atrial shunt if entire venous return

No RV inlet

Mx
palliation cant repair valve that is not formed

Question 13

pulmonary atresia

Answer 13

no RV outlet
R->L atrial shunt of entire venous return
blood flow lungs via PDA

Question 14

hypoplastic left heart

Answer 14

mixing of blood

norwood procedure

Question 15

transposition of great arteries

Answer 15

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

Question 16

adaptation at birth

Answer 16

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

Question 17

causes of resp disorders

Answer 17

resp distress (primary lung disease)
apnoea and bradycardia (immaturity or dysfunction of the resp centres in the brain)

stridor

Question 18

signs of resp distress in the newborn

Answer 18

floppy/sleepy
dusky around mouth

tachypnoea >60/min
expiratory grunt
chest recession (intecostal, sybcostal, tracheal tug)

nasal flaring
cyanosis

Question 19

History of

Answer 19

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

Question 20

Ix for resp distress

Answer 20

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

Question 21

pneumothorax

Answer 21

resus w positive pressure

Question 22

Risk of vsd

Answer 22

endocarditis

Question 23

types of ASD

complications

Answer 23

ostium secundum
foramen ovale
ostium primum - AV valve defects -> atrioventricular septal defect

stroke
AF/ Flutter
pulmonary HTN and RS HF
eisenmenger syndrome

Question 24

causes of pan systolic murmur

Answer 24

VSD
Mitral regurg
tricuspid regurg

Question 25

eisenmenger syndrome

Answer 25

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

Question 26

signs of aortic stenosis

Answer 26

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

Question 27

ass og pulmonary stenosis

Sx

Signs

Answer 27

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

Question 28

Mx of tet spells seen in tetralogy of fallot

Answer 28

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

Question 29

Ebstein’s anomaly

Answer 29

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