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Y4 Paeds > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What are the 3 foetal shunts ?

A

Ductus venosus - bypass liver
Foramen ovale - right atrium to left atrium
Ductus arteriosus - bypass pulmonary circulation

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2
Q

What happens to the foramen ovale at birth ?

A

The first breaths the baby takes expand the alveoli decreasing pulmonary vascular resistance. This causes a fall in right atrial pressure. This causes the left atria to have a higher pressure which causes the closure of the foramen ovale. This then becomes the fossa ovalis.

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3
Q

How does the ductus arteriosus close at birth ?

A

Prostaglandins are required to keep the ductus arteriosus open. Increased blood oxygenation causes a drop in circulating prostaglandins causing it to close. This then forms the ligamentum arteriosum.

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4
Q

How does the ductus venosus close at birth ?

A

Immediately after birth it stops functioning as the umbilical cord is clamped and 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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5
Q

What are some features indicating an innocent murmur ?

A

Soft
Short
Systolic
Symptomless
Situation dependent

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6
Q

what are some features of a murmur that would require a follow up from a paediatric cardiologist ?

A

Murmur louder than 2/6
Diastolic murmur
Louder on standing
Other symptoms - failure to thrive, cyanosis, feeding difficulty and shortness of breath

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7
Q

What investigations are required for a murmur ?

A

ECG
CXR
Echocardiology

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8
Q

What are some pan-systolic murmurs and where are they heard loudest ?

A

Mitral regurgitation - mitral valve ( fifth intercostal space, mid clavicular line )
Tricuspid regurgitation - tricuspid area ( fifth intercostal space, left sternal border )
Ventricular septal defect - left lower sternal border

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9
Q

What are some ejection-systolic murmurs and where are they heard loudest ?

A

Aortic stenosis - aortic area ( second intercostal space, right sternal border )
Pulmonary stenosis - pulmonary area ( second intercostal space, left sternal border )

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10
Q

What murmur is head in a an atrial septal defect ?

A

Mid systolic crescendo decrescendo murmur heard loudest at the upper left sternal border

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11
Q

Why is there a fixed split second heart sound ?

A

This occurs because blood is flowing from the left atrium into the right across the defect. This increases the volume of blood that the right ventricle has to empty before the pulmonary valve can close.

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12
Q

What causes splitting of the second heart sound ?

A

During inspiration the chest walls and diaphragm pull the lungs open. This also pulls the heart open. This is called negative intra-thoracic pressure. This causes the right side of the heart to fill faster as it pulls in blood from the venous system. The increased volume causes it to take longer to empty during systole. This causes the pulmonary valve to close slightly later than the aortic valve causing the split.

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13
Q

What murmur is heard in tetralogy of fallot ?

A

Ejection systolic murmur loudest at the pulmonary area
The murmur is due to the pulmonary stenosis

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14
Q

When does cyanosis occur in heart disease ?

A

When deoxygenated blood enters the systemic circulation. This occurs when the blood is able to bypass the pulmonary circulation and the lungs. - right to left shunt.

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15
Q

What heart defects cause a right to left shunt and therefore cyanosis ?

A

Ventricular septal defect
Atrial septal defect
Patent ductus arteriosus
Transposition of the great arteries

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16
Q

What is the pathophysiology of patent ductus arteriosus ?

A

The pressure in the aorta is higher than that in pulmonary vessels so blood flows from the aorta to the pulmonary artery. This creates a left to right shunt. This increases pressure in the pulmonary vessels causing hypertension. This increases the pressure for the right side of the heart causing right ventricular hypertrophy.

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17
Q

What is the presentation of patent ductus arteriosus ?

A

SOB
Difficulty feeding
Poor weight gain
Lower respiratory tract infections

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18
Q

When can patent ductus arteriosus be picked up ?

A

During the newborn examination if the murmur is heard.

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19
Q

What is the murmur heard in patent ductus arteriosus ?

A

Continuous crescendo - decrescendo ‘machinery’ murmur

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20
Q

What investigations are performed when suspecting patent ductus arteriosus ?

A

Echocardiogram
( Doppler flow )

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21
Q

What is the management of patent ductus arteriosus ?

A

Monitored until 1 years old using echo
Highly likely after 1 year it closes by itself
or
Trans-catheter or surgical closure

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22
Q

What is an atrial septal defect ?

A

A defect ( hole ) in the septum between the two atria. This connects the right and left atria allowing blood to flow between them.

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23
Q

How does an atrial septal defect occur ?

A

A defect in the development of the septum between the atria occurs causing a hole to develop connecting the left and right atria.

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24
Q

How does pulmonary hypertension occur from an atrial septal defect ?

A

An ASD leads to a shunt with blood moving between the two atria. Blood moves from the left atrium to the right. This means blood continues to flow to pulmonary vessels and lungs to get oxygenated and the patient does not become cyanotic. However the increased flow leads to right heart strain and overload. This strain can lead to right heart failure and pulmonary hypertension.

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25
Q

What are some types of atrial septal defect ?

A

Ostium secondum - the septum secondum fails to fully close
Patent foramen ovale ( not strictly an ASD )
Ostium primum ( septum primum fails to fully close - least common )

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26
Q

What are some complications of atrial septal defects ?

A

Stroke from VTE
Atrial fibrillation
Pulmonary hypertension
Right sided heart failure
Eisenmenger syndrome

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27
Q

How does atrial septal defect present ?

A

Mid-systolic crescendo-decrescendo murmur heard loudest at the upper left sternal border - split second heart sound
SOB
Difficulty feeding
Poor weight gain
LRTI
Asymptomatic

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28
Q

What is the management of atrial septal defect ?

A

Referred to paediatric cardiologist
Small and asymptomatic - watchful waiting
Transvenous catheter closure via femoral vein
Open heart surgery
Anticoagulants - aspirin, warfarin and NOAC - reduce risk of clots and strokes

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29
Q

What is a ventricular septal defect ?

A

A congenital hole in the septum between the 2 ventricles. This can vary in size from tiny to the entire septum.

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30
Q

What conditions are associated with VSD’s ?

A

Down’s syndrome
Turner’s syndrome

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31
Q

How does a VSD cause right sided heart failure ?

A

Due to the increased pressure in the left ventricle compared to the right, blood typically flows from left to right through the hole. This can cause right sided overload and right sided heart failure as the right side has to pump more blood.

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32
Q

How does a VSD present ?

A

Initially symptomless
Pansystolic murmur
Systolic thrill on palpation
Poor feeding
Dyspnoea
Tachypnoea
Failure to thrive

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33
Q

What is the management of a VSD ?

A

coordinated by a paediatric cardiologist
Small VSD - watched over time
Transvenous catheter closure
Open heart surgery
Antibiotic prophylaxis due to increased risk of infective endocarditis

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34
Q

What is Eisenmenger syndrome ?

A

Blood flow from right side of the heart to the left across a structural heart lesion bypassing the lungs

35
Q

what 3 underlying lesions can result in Eisenmenger’s syndrome ?

A

ASD
VSD
PDA

36
Q

Why does Eisenmenger’s syndrome occur ?

A

Over time, a left to right shunt causing pulmonary hypertension and when this exceeds the pressure of the systemic system blood flows from right to left. This causes deoxygenated blood to bypass the lungs causing cyanosis.

37
Q

What is cyanosis ?

A

The blue discolouration of skin relating to a low level of oxygen saturation in the blood.

38
Q

What happens when cyanosis occurs ?

A

The bone marrow will respond to low oxygen saturations by producing more red blood cells and Hb to increase the oxygen carrying capacity. This leads to polycythaemia. This makes the blood more viscous and more prone to develop clots.

39
Q

What is the management of Eisenmenger’s syndrome ?

A

It is not medically reverse the condition.
The only definitive treatment is a heart-lung transplant
Oxygen
Sildenafil - pulmonary hypertension
Polycythaemia - venesection
VTE prophylaxis

40
Q

What is coarctation of the aorta ?

A

A congenital condition where there is narrowing of the aortic arch usually around the ductus arteriosus.
Narrowing of the aorta reduces the pressure of blood flowing to the arteries that are distal to the narrowing. It increases the pressure in area proximal to the narrowing.

41
Q

What condition is coarctation of the aorta associated with ?

A

Turner’s syndrome

42
Q

How does the coarctation of the aorta present ?

A

In neonates - weak femoral pulses
Systolic murmur
Tachypnoea
Poor feeding
Grey and floppy baby
Left ventricular heave
Underdeveloped left arm or legs

43
Q

What is the management of coarctation of the aorta ?

A

Can live symptom free
Surgical input
Prostaglandin E is used to keep the ductus arteriosus open while awaiting surgery

44
Q

What is the management of coarctation of the aorta ?

A

Some can live symptom free
Prostaglandin E is used to keep the ductus arteriosus open before surgery

45
Q

What is aortic stenosis ?

A

Narrow aortic valve that restricts blood flow from the left ventricle into the aorta.

46
Q

What is the aortic valve ?

A

Normally made up of 3 leaflets called the aortic sinuses of valsalva which allow blood to flow from the left ventricle into the aorta and prevent blood flowing back into the left ventricle.

47
Q

What are the symptoms of aortic stenosis ?

A

Can be symptomless
Fatigue
SOB
Dizziness
Worse on exertion

48
Q

What are some signs of aortic stenosis ?

A

Ejection systolic murmur - loudest in aortic area
Radiates to carotids
Ejection click
Palpable thrill
Slow rising pulse
Narrow pulse pressure

49
Q

What is the management of aortic stenosis ?

A

Percutaneous balloon aortic valvuloplasty
Surgical aortic valvotomy
Valve replacement

50
Q

What investigations are required when suspecting aortic stenosis ?

A

Gold standard - echocardiogram
ECG
Exercise testing

51
Q

what are some complications of aortic stenosis ?

A

Left ventricular outflow tract obstruction
Heart failure
Ventricular arrhythmia
Bacterial endocarditis
Sudden death

52
Q

What is congenital pulmonary stenosis ?

A

The leaflets of the pulmonary valve develop abnormally becoming thickened and fused. This results in a narrow opening between the right ventricle and pulmonary artery.

53
Q

What are some conditions associated with pulmonary stenosis ?

A

Tetralogy of fallot
Congenital rubella syndrome

54
Q

What are some symptoms of pulmonary stenosis ?

A

Asymptomatic
Fatigue on exertion
SOB
Dizziness

55
Q

What are some signs of pulmonary stenosis ?

A

Ejection systolic murmur - heard loudest at the pulmonary area ( second intercostal space, left sternal border )
Palpable thrill in the pulmonary area
Right ventricular heave
Raised JVP

56
Q

What investigations are performed for pulmonary stenosis ?

A

Echocardiogram

57
Q

What is the management of pulmonary stenosis ?

A

Watching and waiting - symptomless
Balloon valvuloplasty via venous catheter
Open heart surgery

58
Q

How is a balloon valvuloplasty performed ?

A

Inserting a catheter under x ray guidance into the femoral vein through the inferior vena cava and right side of the heart to the pulmonary valve. The valve is then dilated by inflating the balloon.

59
Q

What are the 4 pathologies that cause tetralogy of fallot ?

A

Ventricular septal defect
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy

60
Q

How does cyanosis occur from tetralogy of fallot ?

A

The VSD allows blood to flow between the ventricles. The overriding aorta is placed further to the right above the VSD. This means that when the right ventricle contracts the aorta is in the direction of travel of that blood. Therefore a greater proportion of deoxygenated blood enters the aorta. Stenosis of the pulmonary valve also provides greater resistance in the RV causing blood to move into the LV. This causes deoxygenated blood to enter the systemic circulation causing cyanosis.

61
Q

What are some risk factors for tetralogy of fallot ?

A

Rubella infection
Increased age of mother
Alcohol consumption during pregnancy
Diabetic mother

62
Q

What investigations are performed when suspecting tetralogy of fallot ?

A

Echocardiogram - Doppler study
CXR

63
Q

What is seen on an CXR in tetralogy of fallot ?

A

Boot shaped heart due to right ventricular thickening

64
Q

When is tetralogy of fallot usually diagnosed in children ?

A

Antenatal scans
Newborn baby check - ejection systolic murmur

65
Q

What are the signs and symptoms of tetralogy of fallot ?

A

Cyanosis
Clubbing
Poor feeding
Poor weight gain
Ejection systolic murmur - heard loudest in the pulmonary area
Tet spells

66
Q

What is a tet spell ?

A

They are intermittent symptomatic periods where the right to left shunt becomes worse precipitating a cyanotic episode. This usually happens when the pulmonary vascular resistance increased - exercise.

67
Q

What is the management of a tet spell ?

A

Supplemental oxygen
Beta blockers
IV fluids
Morphine - decreases resp drive
Sodium bicarbonate
Phenylephrine infusion

68
Q

What may children do when having a tet spell ?

A

Older - They may squat as this increases systemic vascular resistance encouraging blood to enter the pulmonary vessels.

Younger - knees to their chest

69
Q

What is the management of tetralogy of fallot ?

A

In neonates - prostaglandin infusion to maintain the ductus arteriosus and allow blood flow back from the aorta to the pulmonary arteries.
Total surgical repair by open heart surgery

70
Q

What is Ebstein’s anomaly ?

A

It is a congenital heart condition where the tricuspid valve is set lower in the right side of the heart - towards the apex. This causes a larger atrium and smaller ventricle. Poor flow to the pulmonary vessels

71
Q

What is Ebstein’s anomaly associated with ?

A

Atrial septal defect
Wolff-Parkinson-white syndrome

72
Q

How does Ebstein’s anomaly present ?

A

Evidence of heart failure
Gallop rhythm heard on auscultation - addition of third and fourth heart sounds
Cyanosis
SOB
Tachypnoea
Poor feeding
Collapse or cardiac arrest

73
Q

When do patients with Ebstein’s anomaly and an ASD present ?

A

A few days after birth when the ductus arteriosus closes and the shunt closes. This causes the patient to become cyanotic and symptomatic

74
Q

What investigations should be performed for Ebstein’s anomaly ?

A

Echocardiogram

75
Q

what is the management of Ebstein’s anomaly ?

A

Surgical correction
Medical management for arrhythmias and heart failure
Prophylactic abx - prevent infective endocarditis

76
Q

What is transposition of the great arteries ?

A

A condition where the attachments of the aorta and the pulmonary trunk are swapped. This means the right ventricle pumps blood into the aorta and the left ventricle pumps blood into the pulmonary vessels. This means there are 2 separate systems where blood doesn’t mix.

77
Q

What conditions are associated with transposition of the great arteries ?

A

VSD
Coarctation of the aorta
Pulmonary stenosis

78
Q

Why is a foetus with transposition of the great arteries develop normally during pregnancy ?

A

The gas and nutrient exchange happens in the placenta therefore it is not necessary for blood to flow to the lungs

79
Q

What does immediate survival depend on in a baby with transposition of the great arteries ?

A

A shunt between the systemic circulation and pulmonary circulation - patent ductus arteriosus, ASD and VSD.

80
Q

When is transposition of the great arteries identified ?

A

Antenatal USS

81
Q

How does transposition of the great arteries present ?

A

Cyanosis
PDA and VSD initially compensate however after a few weeks the baby will develop :
Resp distress
Tachycardia
Poor feeding
Poor weight gain
Sweating

82
Q

What is the management of transposition of the great arteries ?

A

Prostaglandin infusion to maintain ductus arteriosus
Balloon septostomy
Open heart surgery - definitive

83
Q

What is a balloon septostomy ?

A

Inserting a catheter into the foramen ovale via the umbilicus and inflating a balloon to create a large ASD. This allows blood to return from the lungs to the right side of the heart.

Y4 Paeds (14 decks)

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