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Zero to finals Paeds > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Why are their shunts that bypass the pulmonary circulation in fetal circulation?

A
  • blood needs to travel to the placenta and back to collect oxygen and nutrients and dispose of waste products such as CO2 and lactate
  • therefore no use for fetal lungs and so are not fully developed or functional so does not make sense for the blood to pass through pulmonary circulation
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2
Q

What are the 3 fetal shunts?

A
  • ductus venosus
  • foramen ovale
  • ductus arteriosus
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3
Q

What does the ductus venosus shunt connect together?

A

-connects the umbilical vein and inferior vena cava which allows blood to bypass the liver

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4
Q

What does the foramen ovale connect together?

A

-connects the two atria together and allows blood to bypass right ventricle and so pulmonary circulation

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5
Q

What does the ductus arteriosus connect together?

A

-connects the aorta and pulmonary artery and allows blood to bypass the pulmonary circulation

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6
Q

What effects do the first breaths a baby has have on their CV system?

A

-first breaths expand alveoli which decreases pulmonary vascular resistance –> this reduces the pressure of right atrium –> LA pressure is now greater which squashes atrial septum and causes funtional closure of foramen ovale which then gets sealed shut structurally after a few weeks and becomes the fossa ovalis

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7
Q

How is the ductus arteriosus closed?

A
  • prostaglandins are required to keep ductus arteriosus open
  • at birth there is increased oxygenation which leads to reduced circulating prostaglandins –> this causes closure of ductus arteriosus which then becomes the ligamentum arteriosum
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8
Q

How is the ductus venosus closed?

A
  • ductus venosus stops functioning immediately after birth as the umbilical cord is clamped and so there is no flow in the umbilical veins
  • it then structurally closes a few days later and becomes the ligamentum venosum
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9
Q

What are innocent murmurs?

A
  • also called flow murmurs
  • they are very common murmurs in children which are caused by fast blood flow through various areas of the heart during systole
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10
Q

What are the typical features of innocent murmurs?

A

all begin with S:

  • soft
  • short
  • systolic
  • symptomless
  • situation dependent (esp if murmur is quiter when standing or only heard when child is unwell or feverish)
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11
Q

Would clear innocent murmurs need any investigations?

A

No

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12
Q

What features in an innocent murmur would prompt further investigations and referral to cardiology?

A
  • murmur louder than 2/6
  • diastolic murmur
  • louder on standing
  • other symptoms such as failure to thrive, feeding difficulty, cyanosis or shortness of breath
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13
Q

What are the key investigations to establish the cause of a murmur?

A
  • ECG
  • CXR
  • Echocardigraphy
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14
Q

How would you differentiate between the causes of murmurs?

A

-by where they are heard loudest

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15
Q

What are the differentials of a pan-systolic murmur?

A
  • mitral regurgitation - heard at the mitral area (fifth intercostal space mid clavicular line)
  • tricuspid regurgitation - heard at the tricuspid area (fith intercostal space left sternal border)
  • VSD - heard at the left lower sternal border
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16
Q

What are the differentials for an ejection systolic murmur?

A
  • aortic stenosis -heard at the aortic area (second intercostal space right sternal border)
  • pulmonary stenosis -heard at the pulmonary area (second intercostal space left sternal border)
  • hypertophic obstructive cardiomyopathy - heard at fourth intercostal space on left sternal border
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17
Q

What can cause splitting of the second heart sound?

A
  • during inspiration the heart is pulled open due to negative intrathoracic pressure –> RHS of heart fills faster as it pulls blood from the venous system
  • this means RV has increased volume which means it takes longer to empty so there is a delay in the pulmonary valve closure -> closes sligjlty after aortic valve which causes second heart sound to sound split
  • Splitting of the second heart sound can be normal with inspiration
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18
Q

What kind of murmur may be found in ASDs?

A
  • mid-systolic crescendo-decrescendo murmur loudest at the upper left sternal border with a fixed split second heart sound
  • (a fixed split second heart sound means it does not change with inspiration and expiration)
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19
Q

Why does a fixed split second heart sound occur in ASD?

A

-as there is a hole between the two atria, blood flows from the left atria into the right atrium which then increases the volume in the right ventricle meaning it takes longer to empty –> delay in pulmonary valve closure

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20
Q

What kind of murmur may be found in PDA?

A

-continuous crescendo-decrescendo machinery murmur that may continue into the second heart sound making it harder to hear

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21
Q

What kind of murmur may be found in Tetrology of Fallot??

A

-the murmur in TOF arises from the pulmonary stenosis giving an ejection systolic murmur hear loudest at the pulmonary area

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22
Q

What defects can cause right-left shunts and thus cyanotic heart disease?

A
  • VSD
  • ASD
  • PDA
  • Transposition of the great arteries
  • TOF

*VSD, ASD and PDA are usually not cyanotic but if the pulmonary pressure increased beyond the systemic pressure shunt will be reversed to right-left –> Eisenmenger’s syndrome

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23
Q

When does the ductus arteriosus usually close after birth?

A

-stops functioning from 1-3 days after birth and usually closes completely within 2-3 weeks

24
Q

Why might a ductus arteriosus fail to close?

A
  • reasons as to why it fails to close id unclear
  • might be due to genetic or related to maternal infections such as rubella
  • prematurity is a key RF
25
Q

How might a small PDA present?

A
  • can be asymptomatic, cause no functional problems and close spontaneously
  • pts can remain asymptomatic throughout childhood then present at adulthood with signs of heart failure
26
Q

Describe the pathophysiology of a PDA

A
  • DA connects aorta and pulmonary artery
  • as pressure in aorta greater blood travels from aorta into pulmonary artery (left to right shunt)
  • this increases pulmonary pressure causing pulmonary hypertension which leads to strain on the RHS of heart as RV struggles to contract against increased resistance
  • this can lead to RVH and then the increasing blood flowing through the pulmonary vessels to the LHS can lead to LVH
27
Q

How might a PDA be picked up in a newborn examination?

A
  • if a murmur is heard -> murmur is a continuous crescendo-decrescendo machinery murmur that can continue into the second heart sound making it difficult to hear
  • small PDAs usually don’t have murmurs
28
Q

What other symptoms may a child with a PDA present with?

A
  • SOB
  • difficulty feeding
  • Poor weight gain
  • lower RTIs
29
Q

How can a diagnosis of a PDA be confirmed?

A
  • echocardiogram
  • use of doppler studies during echo can assess size and characteristics of shunt
  • also useful to assess effect on heart e.g R/LVH
30
Q

How are PDAs managed?

A
  • monitored until 1 year of age using echo
  • after 1 year it is unlikely that PDA will close spontaneously so trans-catheter or surgical closure can be performed
  • symptomatic pts may be treated earlier
31
Q

Describe the pathophysiology of ASDs

A
  • hole in atria leads to left-right shunt
  • blood flows into RA from LA which increases flow of the RHS leading to right sided overload and right heart strain -> this can lead to RHF and pulmonary hypertension
32
Q

What can pulmonary hypertension in ASD eventually lead to?

A

-Eisenmenger’s syndrome -> shunt is reversed due to pulmonary pressure becoming higher than systemic pressure –> cyanosis

33
Q

What are the types of ASD?

A
  • Ostium secondum (most common) - where septum secondum fails to fully close
  • Patient foramen ovale - where foramen ovale fails to close (not strictly classified as ASD)
  • Ostium primum - where the sptum primum fails to fully close (this often becomes AVSD)
34
Q

What are the complications of ASDs?

A
  • stroke
  • AF or atrial flutter
  • pulmonary hypertension and RHF
  • eisenmenger’s syndrome
35
Q

What can a DVT in a patient with an ASD lead to?

A

-stroke as the DVT clot can travel into the heart and across to the left side where then it can travel through the aorta and to the brain

36
Q

What murmur can be heard from an ASD?

A

-mid-systolic crescendo-decrescendo murmur heard loudest at the upper left sternal border with a fixed split second heart sound

37
Q

How are ASDs often diagnosed?

A

-often picked up on antenatal scans or newborn examinations

38
Q

How might ASDs present as?

A

-may be asymptomatic in childhood and present later in adulthood with dyspnoea, HF or stroke

symptoms in children:

  • SOB
  • Difficulty feeding
  • poor weight gain
  • Lower RTIs
39
Q

How should a child with ASD be managed?

A
  • should be referred to a paeds cardiologist
  • if ASD is small and asymptomatic, watchful waiting
  • if symptomatic can be corrected surgically using 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.
40
Q

What genetic conditions are commonly associated with VSDs?

A
  • downs syndrome

- turner’s syndrome

41
Q

Describe the pathophysiology of VSDs

A
  • hole between the ventricles leads to a left-right shunt
  • blood flows from LV into RV which leads to right side overload and right heart strain –> which eventually leads to RHF and pulmonary hypertension
  • if pulmonary hypertension continues it can lead to eisenmenger syndrome
42
Q

How can VSDs present in children?

A

-often initially asymptomatic and can present it late adulthood with HF

typical symptoms:

  • poor feeding
  • dyspnoea
  • failure to thrive
  • tachypnoea
43
Q

How can VSDs be diagnosed in children?

A

-can be picked up on antenatal scans or when a murmur is heard during NIPE

44
Q

What murmur can be heard in VSDs?

A
  • pan-systolic murmur hear loudest at the lower left sternal border in the 3/4th intercostal space
  • a systolic thrill may also be present
45
Q

How are VSDs managed in children?

A
  • referral to paeds cardiologist
  • small VSDs with no symptoms of PH/HF -> watchful waiting as often close spontaneously
  • If symptomatic can be corrected surgically using transvenous catheter closure or open heart surgery
46
Q

What are patients with VSDs at increased risk of?

A
  • infective endocarditis

- therefore antibiotic prophylaxis should be considered to reduce the risk of IE during surgery

47
Q

What defects can lead to Eisenmenger’s syndrome?

A
  • VSD
  • ASD
  • PDA
48
Q

How long would Eisenmenger’s syndrome take to develop?

A
  • 1-2 years in children with large shunts
  • in adulthood with small shunts
  • can develop more quickly during pregnancy so women with heart defect need monitoring with echo during pregnancy
49
Q

How does the body respond to the cyanosis caused by Eisenmenger syndrome?

A
  • bone marrow will respond by producing more RBC’s to increase oxygen carrying capacity
  • this leads to polycythaemia (high Hb) which gives pt a plethoric(RED) complexion and makes the blood more viscous and so more prone to clots
50
Q

What are examination findings associated with pulmonary hypertension?

A
  • RV heave (as RV contracts forcefully against increase in pulmonary pressure)
  • Loud P2 (second heart sound - due to forceful shutting of pulmonary valve)
  • Raised JVP
  • Peripheral oedema
51
Q

Can Eisenmenger syndrome be reversed?

A
  • once pulmonary pressure is high enough to cause it, it is not possible to medically reverse
  • only definitive treatment would be heart-lung transplant which has a high mortality
52
Q

How are patients with Eisenmenger syndrome managed?

A
  • Oxygen to manage symptoms (but does not affect overall outcomes)
  • treatment for PH, e.g using sildenafil
  • treatment for arrhythmias
  • treatment for polycythaemia with venesection
  • prevention and treatment of thrombosis with anticoagulation
  • prevention of IE using prophylactic antibiotics
53
Q

What is coarctation of the aorta?

A

-a congenital condition where there is narrowing of the aortic arch usually around the ductus arteriosus

54
Q

What genetic condition is associated with coarctation of the aorta?

A

-Turner’s syndrome

55
Q

Describe the pathophysiology of coarctation of the aorta

A

-the narrowing of the aorta reduces the pressure of the blood flowing to the arteries that are distal to the narrowing and also increased the pressure of the blood in areas proximal to the narrowing such as the heart and the first three branches of the aorta

56
Q

How might coarctation of the aorta present in children?

A
  • often only indication is weak femoral pulses in neonates
  • also doing a four limb blood pressure would reveal high blood pressure in the limbs supplied by arteries that come before the narrowing and low blood pressure in the limbs supplied by arteries after the narrowing

May have other signs in infancy:

  • tachypnoea of the newborn
  • poor feeding
  • grey and floppy baby

signs may develop later on:

  • LV heave due to LVH
  • underdeveloped left arm due to reduced flow to left subclavian artery
  • underdeveloped legs
57
Q

What murmur may be heard in coarctation of the aorta?

A

-may be a systolic murmur heard below the left clavicle and below the left scapula

Zero to finals Paeds (1 decks)

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