Cardiology Flashcards
What are the 3 fetal shunts
Ductus venosus
Foramen ovale
Ductus arteriosus
Where does blood get shunted through the ductus venosus
From umbilical vein to inferior vena cava
Blood bypasses liver
Where does blood get shunted through the foramen ovale
From right atrium to left atrium
Blood bypasses right ventricle and pulmonary circulation
Where does blood get shunted through the ductus arteriosus
From pulmonary artery to aorta
Blood bypasses pulmonary circulation
What happens with the first breath at birth
Expansion of alveoli
Decreased pulmonary vascular resistance
Fall in pressure in right atrium (now < left atrium)
Foramen ovale closes (takes a few weeks to seal)
What is the role of prostaglandins in fetal circulation
Keep ductus arteriosus open
Increased blood oxygenation at birth reduces prostaglandin levels
When does the ductus venosus stop functioning
When umbilical cord is clamped (no blood flow through umbilical vein)
What are innocent murmurs
Flow murmurs (due to fast blood flow through heart)
Often do not need investigation
What are the typical features of innocent murmurs
Soft
Short
Systolic
Symptomless
Situation dependent (quiet on standing, appear when unwell)
When do murmurs need to be referred to paediatric cardiologists
Louder than 2/6
Diastolic
Louder on standing
Symptomatic (failure to thrive, difficulty feeding, cyanosis, shortness of breath)
What investigations may be needed for murmurs in children
ECG
Chest X-ray
ECHO
What are the pan-systolic murmurs
Mitral regurgitation
Tricuspid regurgitation
Ventral septal defects
What are the ejection-systolic murmurs
Aortic stenosis
Pulmonary stenosis
Hypertrophic obstructive cardiomyopathy
What causes splitting of the 2nd heart sound
Pulmonary valve closing slightly later than aortic valve
Often normal with inspiration
Describe the murmur of atrial septal defect
Mid-systolic
Crescendo-decrescendo
Loudest at upper left sternal border
Fixed split second heart sound
Describe the murmur of patent ductus arteriosus
Normal first heart sound
Continuous crescendo-decrescendo murmur
Continuation during second heart sound
What is the murmur in tetralogy of Fallot
Ejection systolic murmur
Due to pulmonary stenosis
What are the potentially cyanotic heart diseases in babies
Due to blood bypassing lungs (right to left shunt)
Ventral septal defect (not cyanotic)
Atrial septal defect (not cyanotic)
Patent ductus arteriosus (not cyanotic)
Transposition of great arteries (cyanotic)
When does the ductus arteriosus normally close
Within 1-3 days of birth
Complete closure by 2-3 weeks
If missed in childhood, how may patients with patent ductus arteriosus present as adults
With heart failure
How might a patient with patent ductus arteriosus present
Murmur
Shortness of breath
Difficulty feeding
Poor weight pain
Lower respiratory tract infections
What investigation is needed for the diagnosis of patent ductus arteriosus
ECHO
What is the management for patent ductus arteriosus
ECHO monitoring (1 year, after this, unlikely to close spontaneously)
Closure (trans-catheter, surgical)
What are the indications for early treatment of patent ductus arteriosus
Evidence of heart failure
Symptomatic
What is the pathophysiology of atrial septal defects
Shunting of blood from left atrium to right atrium
Non-cyanotic
Right sided overload (get right heart failure and pulmonary hypertension)
Right heart strain
What are the types of atrial septal defects
Ostium primum (fails to close fully)
Ostium secundum (fails to close fully)
How might a patient with an atrial septal defect present
Murmur
Antenatal scanning/newborn examination
Symptomatic children (short of breath, difficulty feeding, poor weight gain, LRTIs)
Symptomatic adults (shortness of breath, heart failure, stroke)
What is the management of atrial septal defects
Watch and wait (if small and asymptomatic)
Surgery (femoral catheter,, open heart surgery)
Anticoagulation (aspirin, warfarin, NOACs)
What are the potential complications of atrial septal defects
Stroke
Atrial fibrillation
Atrial flutter
Pulmonary hypertension
Right sided heart failure
Eisenmenger syndrome
What conditions are ventricular septal defects often associated with
Down’s syndrome
Turner’s syndrome
How is the blood shunted in ventricular septal defects
Left to right
Patient not cyanotic
Right sided overload
Right heart failure
How might a patient with a ventricular septal defect present
Initially asymptomatic (some into adulthood)
Antenatal scanning
Murmur
Symptomatic (poor feeding, dyspnoea, tachypnoea, failure to thrive)
What would be found on examination of a patient with a ventricular septal defect
Pan-systolic murmur
Systolic thrill on palpation
What is the management of ventricular septal defects
Watch and wait (if small and asymptomatic)
Surgery (transvenous catheter, open heart surgery)
What is the main complication associated with ventricular septal defects
Increased risk of infective endocarditis
What is Eisenmenger syndrome
Due to: atrial septal defect, ventricular septal defect, patent ductus arteriosus
Right to left shunt
Develops at 1-2 years (if defect very small, in adulthood)
More likely in pregnant women
What would be found on examination of a patient with Eisenmenger syndrome that is associated with pulmonary hypertension
Right ventricular heave
Loud second heart sound
Raised JVP
Peripheral oedema
What would be found on examination of a patient with Eisenmenger syndrome that is associated with a septal defect
Atrial septal defect: mid-systolic, crescendo-decrescendo murmur
Ventricular septal defect: pan-systolic murmur
Patent ductus arteriosus: continuous crescendo-decrescendo ‘machinery’ murmur
Arrhythmias
What would be found on examination of a patient with Eisenmenger syndrome that is associated with chronic hypoxia
Cyanosis
Clubbing
Dyspnoea
Red complexion (due to polycythaemia)
What is the management for Eisenmenger syndrome
Heart-lung transplant (only definitive treatment)
Oxygen
Treat pulmonary hypertension (sildenafil)
Treat polycythaemia (venesection)
Anticoagulation
Prophylactic antibiotics (prophylactic antibiotics)
What is the prognosis for Eisenmenger syndrome
Reduced life expectancy (by 20 years)
Main causes of death: heart failure, infection, VTE, haemorrhage
What is coarctation of the aorta
Narrowing of aortic arch
Usually around ductus arteriosus
Increased pressure proximally, reduced pressure distally
What syndrome is coarctation of the aorta most commonly associated with
Turner’s syndrome
How may a patient with coarctation of the aorta present
Weak femoral pulses
Systolic murmur
Symptoms in infants (tachypnoea, poor feeding, grey and floppy baby)
Symptoms developing over time (left ventricular heave, underdeveloped left arm, underdeveloped legs)
What is the management for coarctation of the aorta
Mild cases often do not need management
Prostaglandin E (keep ductus arteriosus open until surgery)
Emergency surgical correction
What is aortic valve stenosis
Narrowing of aortic valve
Restricted blood flow from left ventricle to aorta
Valve can have 1-4 leaflets (normal is 3)
What are the symptoms associated with aortic valve stenosis
Mild disease may be asymptomatic (incidental murmur finding)
Fatigue
Shortness of breath
Dizziness
Heart failure
Fainting
Worse on exertion
What would be found on examination of a patient with aortic valve stenosis
Ejection systolic murmur (crescendo-decrescendo, radiation to carotids)
Ejection click
Palpable systolic thrill
Slow rising pulse
Narrow pulse pressure
What main investigation is needed in aortic valve stenosis
ECHO
What is the management for aortic valve stenosis
Regular monitoring (ECHO, ECG, exercise test)
Percutaneous balloon aortic valvuloplasty
Surgical aortic valvotomy
Valve replacement
What are the complications of aortic valve stenosis
Left ventricular outflow tract obstruction
Heart failure
Ventricular arrhythmia
Bacterial endocarditis
Sudden death (usually on exercise)
What conditions are associated with pulmonary valve stenosis
Tetralogy of Fallot
William syndrome
Noonan syndrome
Congenital rubella syndrome
How might a patient with pulmonary valve stenosis present
Often asymptomatic (incidental finding)
Fatigue on exertion
Shortness of breath
Dizziness
Fainting
What may be found on examination of a patient with pulmonary valve stenosis
Ejection systolic murmur
Palpable thrill
Right ventricular heave
Raised JVP
What is the main investigation needed in pulmonary valve stenosis
ECHO
What is the management for pulmonary valve stenosis
Watch and wait (if mild and asymptomatic)
Balloon valvuloplasty (femoral)
Open heart surgery
What are the 4 features of tetralogy of Fallot
Ventricular septal defect
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy
What happens in severe cases of tetralogy of Fallot
Heart failure before age 1
What are the risk factors for tetralogy of Fallot
Rubella infection
Maternal age > 40
Alcohol during pregnancy
Maternal diabetes
How might a patient with tetralogy of Fallot present
Cyanosis
Clubbing
Poor feeding
Poor weight gain
Ejection systolic murmur (pulmonary area)
Tet spells
What investigations are needed in tetralogy of Fallot
ECHO
Chest X-ray (boot shaped heart)
What are tet spells
Intermittent symptomatic episodes of tetralogy of Fallot
Right to left shunt temporarily worsens
Worsening cyanosis
Due to physical exertion
Reduced consciousness, seizures, death
What is the management for tet spells
Tell older children to squat, young children knees to chest
Oxygen
Beta blockers
IV fluids
Morphine (decreases respiratory drive)
Sodium bicarbonate (buffer metabolic acidosis)
Phenylephrine infusion (increase systemic vascular resistance)
What is the management of tetralogy of Fallot
Prostaglandin infusion (maintain ductus arteriosus)
Open heart surgery
What is Ebstein’s anomaly
Tricuspid valve set low (get big right atrium, small right ventricle)
Poor blood flow from right atrium to right ventricle
Poor blood flow to pulmonary vessels
Right to left shunt (get cyanosis)
Associated with Wolff-Parkinson-White syndrome
How might a patient with Ebstein’s anomaly present
Evidence of heart failure
Gallop rhythm (3rd and 4th heart sounds)
Cyanosis
Shortness of breath
Tachypnoea
Poor feeding
Collapse
Cardiac arrest
What investigation is needed for the diagnosis of Ebstein’s anomaly
ECHO
What is the management for Ebstein’s anomaly
Treat arrhythmia
Treat heart failure
Prophylactic antibiotics (infective endocarditis)
Surgical correction
What is transposition of the great arteries
Attachments of aorta and pulmonary trunk swapped
Get 2 separate circulations that do not mix
Immediate survival depends on a shunt being present
Often picked up in antenatal scans
What conditions are associated with transposition of the great arteries
Patent ductus arteriosus
Atrial septal defect
Ventricular septal defect
How might a patient with transposition of the great arteries present
Cyanosis
Respiratory distress
Tachycardia
Poor feeding
Poor weight gain
Sweating
What is the management of transposition of the great arteries
Prostaglandin infusion (maintain patent ductus arteriosus)
Balloon septostomy (catheter into foramen ovale, create a large atrial septal defect)
Open heart surgery
