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Paediatrics > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What is the ductus arteriosus?

A

Connects the pulmonary artery to the aorta so that blood doesn’t flow to the lungs, closes within first few hours or days

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2
Q

What % of congenital heart defects are picked up antenatally? And when?

A

70% at 18-20 week anomaly scan

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3
Q

What is the most common presentation of congenital heart disease - complication of presentation?

A

A heart murmur - however 30% of children will have an innocent murmur at some point which is present in a normal heart

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4
Q

What are the hallmarks of an innocent ejection murmur?

A 
4 s's
aSymptomatic patient 
Soft blowing murmur 
Systolic murmur only - not diastolic
left Sternal edge - no radiation 
Also - normal heart sounds with no added sounds and no parasternal thrill
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5
Q

What can be causes of innocent murmur

A

Anaemia or febrile illness due to increased cardiac output

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6
Q

Main cause of heart failure in first week of life

A

Coarctation of the aorta

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7
Q

What can be important in maintaining arterial perfusion in coarctation of the aorta

A

Right to left flow of blood via the arterial duct = duct dependant systemic circulation
If the duct closes then severe acidosis, collapse and death

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8
Q

Main cause of heart failure after first week of life - mechanism and symptoms (when?)

A

Left to right shunt. As weeks go on, pulmonary vascular resistance falls, progressive increase in left to right shunt and increase pulmonary blood flow
Causes pulmonary oedema and breathlessness - about 3 months of life

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9
Q

What will happen if left to right shunt goes untreated

A

Children will develop Eisenmenger syndrome - irreversibly raised pulmonary vascular resistance as resistance rises in response to the left right shunt
Shunt is now from right to left due to raised pulmonary pressure and TEENAGER is blue

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10
Q

Treatment of Eisenmenger syndrome

A

Only really heart lung transplant - medication is available to palliate symptoms

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11
Q

Causes of neonatal heart failure other than coarctation of the aorta x3

A

Hypoplastic left heart syndrome
Critical aortic valve stenosis
Interruption of the aortic arch

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12
Q

Causes of heart failure in infants

A

Due to high pulmonary flow therefore ventricular septal defect, atrioventricular septal defect and large persistent ductus arteriosus

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13
Q

Causes of heart failure in older children

A

Rheumatic heart disease and cardiomyopathy

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14
Q

When can peripheral cyanosis occur? X3

A

If child is cold, unwell from any cause or due to polycytheamia

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15
Q

When does central cyanosis occur? What level of reduction needs to be present for its identification

A

Due to fall in arterial blood oxygen tension
Can only be recognised if concentration of reduced haemoglobin in blood exceeds 5g/dl
Therefore less pronounced if child is anaemic

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16
Q

What is persistent cyanosis in an otherwise well child a sign of?

A

Structural heart disease

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17
Q

Presentation of right to left shunt symptom wise

A

Blue child

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18
Q

Presentation of left to right shunt symptom wise

A

Breathlessness or asymptomatic

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19
Q

3 causes of left to right shunt

A

ASD, VSD, or persistent ductus arteriosus

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20
Q

Two types of ASD and incidence

A 
Secundum ASD (80%) 
Partial atrioventricular septal defect
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21
Q

What is Secundum ASD

A

Defect in centre of atria where foramen ovale is

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22
Q

What is partial AVSD?

A

Defect of AV septum involving atrial septum and av valves

Also 3 leaflet defect in left av valve with regurgitant leak

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23
Q

Symptoms of ASD

A

Asymptomatic or recurrent lung infections/wheeze

Arrhythmias from 4th decade onward

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24
Q

Physical signs of ASD on auscultation

A

Ejection systolic murmur best heard at left Sternal edge because increase blood flow over pulmonary valve

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25
Q

Physical sign of partial AVSD on auscultation

A

Apical pan systolic murmur due to regurgitation through AV valve

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26
Q

Signs of ASD and AVSD on chest X-ray x3

A

Cardiomegaly, increased pulmonary vascular markings, enlarged pulmonary arteries

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27
Q

ECG signs with Secundum ASD

A

Partial right bundle branch block is common

Right axis deviation due to right ventricle enlargement

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28
Q

ECG in partial AVSD

A

Superior QRS complex - mainly negative in avF - because defect is near av node therefore displaced node conducts to the ventricles superiorly

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29
Q

Management of Secundum ASD

A

Cardiac catheterisation with insertion of occlusion device usually done 3-5 years of age

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30
Q

Management of partial AVSD

A

Surgical correction. - usually done 3 years of age

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31
Q

What % of congenital heart disease is due to VSD

A

30%

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32
Q

Symptoms and signs of small VSD (what size?)

A

No symptoms and loud pan systolic murmur at lower left sternal edge (louder the murmur, smaller the defect)
Smaller than 3mm

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33
Q

Investigations in small VSD

A

Normal ecg normal X-ray - echo will show defect

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34
Q

Management of small VSD

A

They will close spontaneously

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35
Q

Symptoms of large VSD x4

A

Heart failure
Breathlessness and failure to thrive in 1 week old
Recurrent chest infections

36
Q

Signs of large VSD x 5

A

Tachycardia, tachypnoea and enlarged liver from heart failure
Active precordium
Soft pansystolic murmur or no murmur
Apical mid-diastolic murmur (increased flow across mitral valve with return of blood through lungs)
Loud pulmonary second sound from raised pulmonary arterial pressure

37
Q

Chest X-ray with large VSD

A

Cardiomegaly
Enlarged pulmonary arteries
Increased pulmonary vascular markings
Pulmonary oedema

38
Q

What is the foramen ovale?

A

Hole between the right and left atrium. As the lungs are not in use, pressure in them is high and blood flow is low, therefore pressure is low in the left atria…also pressure in the right atria is high as it receives all the blood flow from the placenta. Therefore hole stays open. When lungs start breathing, blood flow to lungs increases and pressure in right atria drops as no more placenta therefore pressure higher in left atria and foramen closes

39
Q

ECG in large VSD

A

Biventricular hypertrophy by 2 months of age

40
Q

Management of large VSD

A

Treat heart failure with diuretics and captopril
Additional calorie intake
Surgery at 3-6months to prevent Eisenmenger syndrome

41
Q

Two causes of patent ductus arteriosus

A

Congenital heart defect or prematurity (if in preterm infant)

42
Q

Clinical features of patent ductus arteriosus with additional features if it’s a large duct

A

Continuous murmur upper left sternal edge (always a murmur because pressure is lower in the pulmonary artery than in the aorta throughout the cardiac cycle)
Pulse pressure increased causing a bounding or collapsing pulse
Large duct - heart failure and pulmonary hyper tension

43
Q

Investigations in patent ductus arteriosus

A

X-ray and ECG usually normal

However if large the signs are the same as with large VSD

44
Q

Management of patent ductus arteriosus

A

Closure with coil or occlusion device via cardiac catheterisation at 1 year of age
Occasionally surgical ligation

45
Q

What sort of heart disease does right to left shunts cause

A

Cyanotic heart disease - present with cyanosis and O2 sats

46
Q

Diagnostic test of cyanotic heart disease

A

Hyperoxia (nitrogen washout) test
Place infant in 100% oxygen for 10min - if right radial artery pao2 from blood gas remains low diagnosis can be made (if lung disease and persistent pulmonary hypertension of newborn have been excluded)

47
Q

Management of neonatal cyanotic heart disease

A

Start prostaglandin infusion - maintain duct patency as they are duct dependant

48
Q

What is most common cause of cyanotic heart disease and features x4

A

Tetralogy of fallot

  • large VSD
  • overriding aorta with respect to ventricular septum
  • sub pulmonary stenosis causing right ventricular outflow tract obstruction
  • right ventricular hypertrophy as a result
49
Q

When are most tetralogy of fallot diagnosed?

A

Most are diagnosed antenatally or following identification of murmur in the first 2 months of life
Cyanosis may not be obvious at this stage - although a few present with severe cyanosis in first few days of life

50
Q

Classical description of symptoms of tetralogy of fallot

A

Severe cyanosis
Hypercyanotic spells (irrability, crying, breathlessness and pallor) and squatting on exercise
Developing late in infancy
- now rarely seen in developed countries

51
Q

Murmur in tetralogy of fallot

A

Loud harsh ejection systolic murmur at left Sternal edge from day 1 of life
With increasing outflow obstruction (due to muscular hypertrophy) murmur will shorten and cyanosis with increase

52
Q

Chest X-ray in tetralogy of fallot

A

May have pulmonary artery ‘bay’ - concavity on left heart border where artery and outflow tract would normally be
Decreased pulmonary vascular markings

53
Q

Management of tetralogy of fallot

A

Surgery to remove obstruction and close VSD at around 6 months of age
Very cyanosed infants may require shunt in the meantime eg. from subclavian artery to pulmonary artery

54
Q

What does transposition of the great arteries cause

A

Right to left shunt

55
Q

What is transposition of the arteries anatomically

A

Pulmonary artery is connected to the left ventricle and aorta to the right ventricle therefore oxygenated blood returns to the lungs and deoxygenated blood returns to the body
Unless there is a defect such as VSD, ASD or pda this is not compatible with life

56
Q

Symptoms/presentation of transposition of the great arteries

A

Cyanosis - usually at 2 days of life when closure of pda leads to decreased mixing

57
Q

Auscultation in transposition of great arteries

A

Usually no murmur but may be systolic murmur due to stenosis of left pulmonary outflow tract

58
Q

Management of transposition of great arteries

A

Maintain ductus arteriosus - prostaglandin infusion
Balloon atrial septostomy may be life saving
Most need surgery - arterial switch procedure within first few days of life
- transected above the valves and switched over
Transfer coronary arteries over to new aorta

59
Q

Which syndrome cause common mixing cardiac problems

A

Complete atrioventricular septal defect and complex congenital heart disease (such as mitral atresia, tricuspid atresia)
Breathless and blue

60
Q

When is complete AVSD commonly seen?

A

Down’s syndrome

61
Q

What are the defects present in complete AVSD

A

5 leaflet av valve - defect stretches all across the av junction and tends to leak

62
Q

Which lesions cause outflow obstruction in a well child x3

A

Aortic stenosis, pulmonary stenosis, adult-type coarctation of the aorta

63
Q

Features and symptoms of aortic stenosis

A

Can occur in association with mitral stenosis and coarctation of the aorta
Most have asymptomatic murmur but may present with chest pain on exertion, reduced exercise tolerance or syncope

64
Q

Signs of aortic stenosis

A

Ejection systolic murmur - maximal at left Sternal edge and radiating to neck
Small volume, slow rising pulses
Apical ejection click

65
Q

Features of pulmonary stenosis

A

Most are asymptomatic

Ejection systolic murmur best heard upper left Sternal edge
If severe might be right ventricular hypertrophy and heave

66
Q

Features of adult-type coarctation of the aorta

A

Not duct dependant - gradually becomes more severe over many years

67
Q

Features of coarctation of the aorta

A

Asymptomatic
Systemic hypertension in the right arm
Ejection systolic murmur at upper sternal edge
Collaterals heard with continuous murmur at the back
Radio femoral delay

68
Q

Adult type coarctation of the aorta on X-ray

A

Rib notching - due to development of large intercostal arteries running under ribs to bypass obstruction
‘3’ sign with visible notch in the descending aorta at site of coarctation

69
Q

Adult type coarctation of the aorta on ecg

A

Left ventricular hypertrophy

70
Q

Causes of outflow obstruction in a sick child

A

Coarctation of the aorta
Interruption of the aortic arch
Hypoplastic left heart syndrome

71
Q

How do sick children with outflow obstruction present?

A

Sick with heart failure and shock in neonatal period

Prostaglandin should be commenced straight away

72
Q

When do children with coarctation of the aorta present?

A

Usually at 2 days of age with acute circulatory collapse when the da closes

73
Q

Physical signs in children with coarctation of the aorta

A

Severe heart failure
Absent femoral pulses
Severe metabolic acidosis

74
Q

Management of coarctation of the aorta

A

Surgical repair

75
Q

What is interruption of aortic arch

A

Aorta does not continue to lower body - instead the connection to the pulmonary artery becomes the vessel and continues this way, there is also a VSD therefore cardiac output is maintained via left-to right flow across duct

76
Q

What is Hypoplastic left heart syndrome?

A

Underdevelopment of the left side of the heart - surgical treatment with complicated operation

77
Q

What is the most common childhood arrhythmia

A

Supra ventricular tachycardia

78
Q

Treatment of supraventricular tachycardia in neonate

A

Very fast heartbeat (250-300bpm) therefore need circulatory and respiratory support
Vagal stimulating manoeuvres (carotid sinus massage or cold ice pack to face) successful in 80%
IV adenosine or cardio version if that fails
Maintenance with flecainide or sotalol
Resting ECG will remain normal but 90% will have no further attacks after infancy therefore treatment can be stopped at age 1

79
Q

What mostly causes syncope in teenagers

A

Neurocardiogenic, situational, orthostatic or ischaemic causes

80
Q

Features of a cardiac cause of syncope

A

Symptoms on exercise
Family Hx of sudden unexplained death
Palpitations

81
Q

What age usually affected by rheumatic fever

A

5-15 years

Following group a b-haemolytic strep -2-6 weeks later

82
Q

Most common cardiac sequela of rheumatic fever

A

Mitral stenosis, can also get carditis, also less frequently aortic, tricuspid and rarely pulmonary disease

83
Q

Acute management of rheumatic fever heart disease

A

Aspirin for inflammation and bed rest
If aspirin doesn’t work then corticosteroids
Antibiotics if evidence of persisting infection

84
Q

Management following resolution of acute rheumatic fever episode

A

Prophylaxis with monthly penicillin injections
Up until the age of 18-21
Severity of episodes influences length of treatment

85
Q

What are all children with congenital heart disease (except for Secundum ASD) at high risk of

A

Infective endocarditis - highest risk with turbulent jet of blood - eg. VSD, coarctation of the aorta and persistent DA

86
Q

Most common organism for infective endocarditis

A

A-haemolytic strep

Treat with high dose penicillin + amino glycoside given IV for 6 weeks

Paediatrics (16 decks)

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