Cardiology

Question 1

What is an ASD?

Answer 1

ASD occurs when the septum between the left and right atrium is not formed properly - oxygenated blood from the left atrium goes into the right atrium

Question 2

What are some risk factors for ASD?

Answer 2

Maternal smoking in 1st trimester, maternal diabetes, maternal rubella, maternal drug use, Treacher Collins syndrome

Question 3

What is found on auscultation of an ASD?

Answer 3

Soft systolic ejection murmur best heard over pulmonary valve region (2nd ICS)

Wife, fixed split S2

Diastolic rumble in lower left sternal edge in patients with large ASD

Question 4

How is an ASD investigated?

Answer 4

ECG - tall P wave, right BBB, right axis deviation

Tranthoracic echocardiogram

Question 5

How is an ASD managed?

Answer 5

If ASD <5mm, spontaneous closure should occur within 12 months of birth

If ASD >1cm - surgery

Question 6

What are some complications of an untreated large ASD?

Answer 6

Arrhythmias, pulmonary hypertension, Eisenmenger syndrome, peripheral oedema, TIA/stroke

Question 7

What is Tetralogy of Fallot?

Answer 7

Cyanotic congenital heart disease - tetrad of:

• VSD
• Pulmonary stenosis
• Right ventricular hypertrophy
• Overriding aorta

Question 8

What are some risk factors for TOF?

Answer 8

Male
Family history
Teratogens (alcohol, warfarin, trimethadione)
CHARGE syndrome
Di George syndrome

Question 9

What can be seen on CXR for Tetralogy of Fallot?

Answer 9

Boot shaped heart and reduced pulmonary vascular marking

Question 10

What are the 3 categories of TOF?

Answer 10

1) Mild (Pink TOF) - mild PS/RVH and usually asymptomatic but disease progresses as the child grows so cyanotic by age 1-3 years
2) Moderate-severe (cyanotic TOF) - moderate-sever PS may present in the first few weeks of life with cyanosis and respiratory distress - prone to developing recurrent chest infections and or fail to thrive
3) Extreme - duct dependent lesions where the only way deoxygenated blood can flow to the lungs is through a PDA

Question 11

What are hypoxic (‘tet’) spells?

Answer 11

Paroxysm of hyperpnoea

Irritability

Increasing cyanosis

Question 12

What can be heard of auscultation of TOF?

Answer 12

Loud, single S2 (closure of aortic valve in diastole with absent/reduced pulmonary valve closure

Pansystolic murmur - best osculated either mid or upper left sternal edge (the smaller the VSD, the louder the murmur)

Ejection click - due to presence of dilated aorta

Continuous machinery murmur best heard at upper left sternal edge - occurs in the presence of PDA with extreme forms of TOF, especially those on prostaglandin infusion

Question 13

What is the management of TOF?

Answer 13

Medical

• Squatting
• Prostaglandin infusion - maintains PDA
• Beta blockers
• Morphine
• Saline 0.9% bolus

Surgical - definitive repair

Question 14

What are some complications of untreated TOF?

Answer 14

Polycythaemia, stroke, cerebral abscess, infective endocarditis, congestive cardiac failure, death

Question 15

What is transposition of the great arteries?

Answer 15

Ventriculoarterial discordance in which the aorta rises from the morphologic right ventricle and the pulmonary artery arises from the morphologic left ventricle

Question 16

What is the most common cause of cyanosis in the newborn?

Answer 16

Transposition of the great arteries

Question 17

What are the 3 common anatomical sites for mixing of oxygenated and deoxygenated blood in TGA to allow life to be sustained?

Answer 17

• Patent foramen ovale/ASD
• VSD
• PDA

Question 18

What are the clinical features of TGA?

Answer 18

Cyanosis appears in first 24 hours

Mild cyanosis particular when crying

Signs of CHF - tachypnoea, tachycardia, diaphoresis, failure to gain weight

Prominent right ventricular heave

Single second heart sound, loud A2

Systolic murmur potentially if VSD present

Question 19

What is the management of TGA?

Answer 19

Emergency prostaglandin E1 infusion to keep PDA patent

Correct metabolic acidosis

Atrial balloon septostomy

Surgical correction before the age of 4 weeks

Question 20

What are the long term consequences of TGA?

Answer 20

Neopulmonary stenosis
Neoaortic regurgitation
Neoaortic root dilatation
Coronary artery disease
Sudden cardiac death
Higher incidence of Neurodevelopmental abnormalities

Question 21

Which is the most common congenital heart defect?

Answer 21

VSD - hole in the septum separating the left and right ventricles

Question 22

What is Eisenmenger’s syndrome?

Answer 22

A condition where the pressure in the right ventricle exceeds that of the left and is caused by a significant gradual increase in the pulmonary vascular resistance

Results in a shunt reversal with deoxygenated blood flowing from the right ventricle into the left and entering the systemic circulation

This causes decreased systemic oxygen saturation and these patients become cyanotic

Question 23

What are some risk factors for VSD?

Answer 23

Maternal diabetes, maternal rubella, fetal alcohol syndrome, family history, Down’s syndrome, trisomy 13 and 18

Question 24

How would a baby with a moderate VSD present?

Answer 24

Excessive sweating, easily fatigued, tachypnoea

Usually obvious by 2-3 months of age

Question 25

How would a baby with a large VSD present?

Answer 25

Dyspnoea, problems with feeding, developmental issues, frequent chest infections

Question 26

Which is the most likely type of murmur to be heard with VSD?

Answer 26

Holosystolic (pan systolic) murmur - lower left sternal border

Question 27

What is the management of VSD?

Answer 27

Diuretics, ACE inhibitors, digoxin

Surgical repair

Question 28

What are the complications of untreated VSD?

Answer 28

CHF, growth failure, aortic valve regurgitation, pulmonary vascular disease, frequent chest infections, infective endocarditis, arrhythmias, sudden death