Cardiology Flashcards
What 5 categories do you use to describe a murmur?
Intensity (grade 1-6, 5&6 without stethoscope)
Timing (systolic, diastolic, continuous)
Location (sternal edge)
Transmission (does it move when lying/sitting)
Quality (harsh/soft/whooshing)
What are the 8 ‘s’ of an innocent murmur?
Soft Single (no extra sounds) Systolic (systolic ejection) Short (ejection) Lower left sternal edge Small (no radiation) aSymptomatic Sensitive (changes w/position)
Name 5 innocent murmurs
Still (low frequency vibratory, lower left sternal edge, usually aged 3-6yrs) •Pulmonary ejection murmur •Pulmonary flow murmur of newborns •Venous hum (continuous) •Carotid bruit (systolic)
Name 3 L->R shunts
- PDA &VSD: infancy with faltering growth, L heart enlargement, transmits flow and pressure
- ASD: Childhood, exercise intolerance, R heart enlargement, transmits flow only
What happens when a L->R shunt is not corrected soon?
Long standing L->R shunt causes pulmonary hypertension and scarring, eventually shunt is reversed and it becomes R->L with cyanosis. The is irreversible and is called Eisenmenger syndrome.
Name 5 examples of R-> L shunts
- Truncus arteriosus
- Transposition of great arteries
- Tricuspid atresia (must have ASD and VSD for mixing blood)
- Tetralogy of fallot
- Total anomalous pulmonary venous connection (TAPVC)
What will happen with an untreated transposition of great arteries?
Die as soon as foramen ovale & ductus arteriosus shut
What type of heart shunt makes a baby cyanotic?
L->R shunt (breathless)
R->L shunt (cyanotic)
What is truncus arteriosus?
A single blood vessel (truncus arteriosus) comes out of the right and left ventricles, instead of the normal 2 vessels (pulmonary artery and aorta).
R->L shunt
What is tricuspid atresia?
The tricuspid heart valve is missing or abnormally developed. The defect blocks blood flow from the right atrium to the right ventricle
There must be ASD and VSD for mixing blood.
R->L shunt
What is the tetralogy of fallot?
R->L shunt
Overriding aorta
Pulmonic stenosis (R ventricular outflow tract obstruction due to deviation of outlet septum)
VSD (perimembranous due to deviation in outflow septum)
Right ventricular hypertrophy (due to systemic pressure from VSD)
What is TAPVC?
A defect in the veins leading from the lungs to the heart. (R->L shunt)
In TAPVC, the blood does not take the normal route from the lungs to the heart and out to the body. Instead, the veins from the lungs attach to the heart in abnormal positions and this problem means that oxygenated blood enters or leaks into the wrong chamber
What is coarctation of the aorta?
Aorta is narrow, usually in the area where the ductus arteriosus (ligamentum arteriosum after regression) inserts
What happens in a left heart outflow obstruction when the ductus arteriosus closes?
- When ductus arteriosus closes, blood can’t get through to body
- SHOCK
- Not cyanotic as blood is still being oxygenated
- ?sepsis
- ?bleed
- ?dehydration/metabolic
- If coarctation of the aorta-> give prostaglandins!
What happens in a right heart outflow obstruction when the ductus arteriosus closes?
- When duct closes-> CYANOTIC
- ?pneumothorax
- ?pulmonary hypertension
- ?opioid overdose
- Prostaglandins!
Describe VSD signs and treatment
- Pan systolic murmur, lower L sternal edge
- Only shows up when pulmonary pressures fall
- At its deadliest when heart is still small, hole still big and pulmonary pressures have just fallen
- Leads to heart failure, pulmonary oedema and hepatomegaly
- Give diuretics (furosemide, spironolactone) and high energy feeds
Describe an ASD, including presentation
- Ejection systolic murmur, upper L sternal edge
- Often not a disease of childhood
- Low pressure system
- Chronic R heart dilation
- Conduction problems
- Can present as a brain embolus after VTE going to brain instead of lungs
Where is a patent ductus arteriosus heard
Subclavicular
Treatment of left->right shunting in neonate
- ACEi, reduces afterload but doesn’t change pulmonary circulation
- Pulmonary artery band (increases pressure in R heart, reduces pressure of blood going to avoid pulmonary hypertension)
What happens to the baby’s circulation at birth?
- In fetus, PaRA > PaLA . R-L shunt through foramen ovale needed
- First few breaths -> pulmonary resistance ↓ + pulmonary blood flow ↑
- Foramen ovale functionally closes
- Ductus arteriosus closes within 1-2 days
Name 5 Predisposing conditions for congenital heart disease
- Down syndrome – AVSD, VSD
- Noonan’s syndrome – ASD, PS
- Turner syndrome – AS, Coarctation
- Fetal alcohol syndrome – ASD, VSD, Tetralogy
- Fetal rubella infection – PS, PDA
Describe a venous hum murmur
Innocent, continuous
Maximal at right supra/infraclavicular areas
Inaudible in supine position
Intensity changes with rotation of head and compression of jugular vein
Age 3-6yrs
What is a pulmonary flow murmur?
Heard in prem and full term neonates
Disappears by 3-6 months of age
Maximal at UL sternal edge
Transmits to L and R chest, axillae and back
How are femoral pulses different in PDA?
Bounding
What is a thrill?
A palpable murmur caused by turbulent flow from a structural heart lesion
Why would an infant present with shock and the only pulse palpable is right brachial?
Severe coarctation of aorta of interrupted arch
Blood to left arm and body is interrupted
How do you test whether cyanosis is resp or cardiac in origin?
Hyperoxia test
Resp cyanosis would be fixed, cardiac wouldn’t be
What 2 things cause the foramen ovale to close?
Raised left atrial pressure
Lowered right atrial pressure
How do you close a PDA?
Indomethacin in preterm infants
Older children-> surgery
Treatment of transposition of great arteries
Ballon atrial septostomy to keep foramen ovale patent and enlarge it
Prostin to keep ductus arteriosus patent, more blood flow to lung therefore higher pressure in LA to improve mixing of blood
Few weeks old can have surgery (arterial switch)
How does coarctation of the aorta present?
Either as a newborn (collapse, acidosis, no blood supply to lower body)
Or as a child if less severe narrowing (with hypertension, absent femorals & rib notching seen on CXR)
What investigations would point to coarctation of the aorta?
R arm BP > left and lower body
R arm O2 sats > lower body sats due to deoxy blood via PDA
Absent femorals
Hypertension
Rib notching on CXR due to collateral artery development
MRI scan
Define AVSD
Atrio ventricular defect
Seen in trisomy 21
Common valve instead of tricuspid and mitral w/5 bridging leaflets
How does tetralogy of fallot present? Treatment
Blue spells when there is muscular spasm stopping blood reaching lungs
Relieve spasm (morphine)
Increase pressure in aorta to force more blood to the lungs)
What mutation is associated with tetralogy of fallot
22q11 deletion
Describe a VSD
Blood shunted left to right Oxygen rich blood to lungs Pulmonary hypertension Presents with tachypnoea and poor feeding LV dilated due to increased volume (eventually Eisenmenger)
What is Eisenmenger?
Eventually L->R shunts reverse due to severe pulmonary hypertension
Child becomes cyanotic
