Cardiology

Question 1

Name the main differences in foetal circulation as compared to adult circulation

Answer 1

1. Patent ductus arteriosus creates movement of blood from PA to aorta to bypass fluid filled lungs
2. IVC goes straight through R atrium and through foramen ovale to L atrium to again bypass pulmonary circulation.

Question 2

Left to right shunt complications

Answer 2

Abnormal mixing of blood from left side of the heart (red blood) to right side (blue blood)

Can lead to volume overload and heart failure. Pulmonary hypertension can develop/ hepatosplenomegaly. Eisenmengers is end-stage complication of this (pulmonary hypertension causing eventual right to left cyanotic shunt).

Often present breathless!

Question 3

What kind of shunt and murmur does a VSD cause?

Answer 3

Left to right shunt- can lead to heart failure. This is the most common CHD (15-20%)

LLSE murmur (might not be heard if VSD is very large)

Question 4

What is the most common CHD in Down’s?

Answer 4

AVSD. 50% of Down’s babies will have some form of heart defect.

Question 5

What is the most common CHD in Turner’s Syndrome and what clinical sign may they have?

Answer 5

Coarctation of the aorta
Absent femorals
Pre and post ductal sats are different

Question 6

What kind of murmur do you often see in PDA?

Answer 6

Machine hum murmur

Left to right shunt

Question 7

How do you treat a PDA?

Answer 7

It is abnormal over a month old.

Treat with NSAIDS e.g. indomethacin/ ibuprofen until ligation surgery.

Question 8

What clinical signs might you see in PDA?

Answer 8

Often asymptomatic
Bounding pulses
Poor weight gain
Breathlessness

Can cause HF as left of heart is receiving twice as much as it should.

Question 9

Name features of AVSD

Answer 9

• Left to right shunt
• Five leaflet AV valve
• Can be cyanosed
• More likely heart failure from overload

Question 10

Murmur and heart sounds heart in ASD

Answer 10

• Systolic murmur (ULSE) due to increased pulmonary blood flow.
• Fixed split S2 (S2 is closing of semilunar pulmonary and aortic valves). Sounds like Lub b’dub
• Left to right shunt

Question 11

Describe a right to left shunt and how do they present?

Answer 11

Deoxygenated blue blood is mixing from the right side of the heart is mixing with oxygenated red blood from the left side of the heart, decreasing it’s overall oxygen concentration.

The child therefore appears cyanosed!

Question 12

What happens in transposition of the great arteries (TGA)?

Answer 12

-Aorta attached to RV
-Pulmonary artery attached to LV
Blue blood returns from body and is pumped back around the body
Needs ‘abnormal’ connection between left and right to mix blood therefore often are duct-dependant

Question 13

How do you treat TGA?

Answer 13

Prostin needed to keep duct open until surgery. If this doesn’t work an atrial septostomy is performed to buy time before surgical repair.

Question 14

What congenital syndrome is associated with Tetralogy of fallot?

Answer 14

DiGeorge (2q11 deletion)

Question 15

Name the four abnormalities in tetralogy of fallot and what murmur do you get?

Answer 15

• VSD
• Overriding aorta
• Subpulmonary stenosis
• Right ventricular hypertrophy

Harsh murmur due to VSD

Question 16

What are duct dependent lesions?

Answer 16

Lesions that are dependant on the Ductus Arteriousus to maintain systemic perfusion eg due to outflow tract obstruction within the heart. Typically present cyanotic and shocked when the duct closes up hours to days after birth.

Question 17

Signs and features of coarctation of the aorta?

Answer 17

Outflow obstruction so may hear systolic murmur
Weak/ absent femorals
They depend on the PDA and so become shocked when the PDA closes.

Question 18

CHD causes of cyanosis:

Answer 18

Cyanosis can be caused by abnormal mixing of blue and red blood, or because the ductus arteriosus has closed and there is an obstructive lesion that was dependant on the blood flow through the ductus arteriousus into the pulmonary arteries.

Some causes of cyanosis (at least duct-dependant but may have e.g. VSD, ASD that enable right to left shunt also): Pulmonary atresia, Tricuspid atresia, Ebstein’s anomaly, hypoplastic left heart, interrupted aortic arch.

Question 19

Features of an innocent murmur (7 signs):

Answer 19

-Soft
-Short
-Symptom-free
-Systolic
-Site – heard over small area
-Sitting and standing – murmur changes with changes of
position (decreases in intensity when patient stands)
-Signs – none present

Special tests – radiograph, ECG normal

Question 20

Aortic region murmur (URSE):

Answer 20

Aortic stenosis: Ejection systolic

Question 21

Pulmonary region murmurs (ULSE):

Answer 21

• Pulmonary flow murmur (ESM)
• Pulmonary stenosis (ESM)
• ASD (actually murmur due to increased flow through pulmonary valve)
• PDA (Continuous)

Question 22

Tricuspid region murmurs:

Answer 22

• VSD (pan systolic murmur)
• Aortic regurgitation (early diastolic murmur)
• Tricuspid regurgitation (pansystolic murmur)
• Still’s murmur (musical/ vibratory innocent murmur)

Question 23

Mitral region murmurs:

Answer 23

Mitral regurgitation (Pansystolic murmur)
Mitral stenosis (Mid diastolic murmur)

Question 24

What are tet spells?

Answer 24

Peak incidence between 2-4 months of life with:

• Paroxysm of hypernoea= rapid, deep respiration. Due to increased R to L shunting, CO2 accumulates stimulating the central resp centre. This causes further R to L shunting perpetuating the hypoxia
• Irritability
• Increasing cyanosis

May be precipitated by dehydration, anaemia or prolonged crying induces tachycardia and reduced systemic vascular resistance.

Question 25

Describe the severities of TOF:

Answer 25

Mild: “pink TOF” often asymptomatic and present age 1-3 as heart gets bigger
Mod: Present in first few weeks of life with cyanosis and respiratory distress. Can develop recurrent chest infections and failure to thrive.
Severe: Present in first few hours of life with marked resp distress and cyanosis.

Question 26

What do you do if you think the murmur you hear could be pathological?

Answer 26

• Refer to cardiology for ECHO.

- ECG