Cardiology Flashcards
What is the most common cause of heart disease in children?
Congenital
How do left-to-right shunts present?
Breathlessness
What are the common causes of left to right shunts?
Ventricular septal defect - VSD
Persistent arterial duct - PDA
Atrial septal defect - ASD
How to right-to-left shunts present?
Blue Examples - AVSD, complex congenital heart disease
What is a common mixing congenital heart lesion?
Atrioventricular defect
How does an outflow obstruction present in a well child?
Asymptomatic with a murmur
What are examples of outflow obstructions (well child)?
pulmonary stenosis
aortic stenosis
How does an outflow obstruction present in a sick neonate?
What is the cause?
Collapsed with shock
Coarctation of the aorta
Where does the foramen ovale lie?
Between the left and right atrium
Where is the ductus arteriosus?
connects the pulmonary artery to the aorta
Describe fetal circulation (long)
the left atrial pressure is low as little blood returns from the lungs, right atrial pressure is high as it receives all systemic venous return
blood flows across the foramen ovale from the right atrium to the left atrium
Describe the changes to circulation at birth
LONGG
With the first breaths, resistance to pulmonary blood falls and the volume of blood flowing through the lungs increases six fold
RISE IN LEFT ATRIAL PRESSURE
Volume of blood returning to right atrium falls
Pressure difference causes foramen ovale close
When does the ductus arteriosus normally close?
within the first few hours or days
What happens when ducts in babies who rely on duct-dependent circulation close?
They rapidly deteriorate
How does congenital heart disease present?
antenatal cardiac ultrasound diagnosis
detection of a heart murmur
shock
cyanosis
When is the fetal heart checked?
Between 18/20 weeks gestation - cardiac anomaly can then be identified and surgery booked antenatally
Most common presentation of congenital heart disease?
heart murmur
What are the hallmarks of an innocent heart murmur (30%) ?5 S’s
aSympotomatic patient Soft blowing murmur Systolic murmur only, not diastolic left Sternal edge no Signs
Also:
Normal heart sounds with no added sounds
No parasternal thrill
No radiation
What conditions mean innocent murmurs are more likely to be heard?
anaemia
febrile illness
Which tests can help distinguish between innocent and pathological murmur?
ECG
Chest radiograph
get paediatric cardiology review
What are the symptoms of heart failure?
breathlessness (particularly on feeding and exertion)
sweating
poor feeding
recurrent chest infections
What are the signs of heart failure?
Poor weight gain Tachypnoea Tachycardia Heart murmur - gallop rhythm Enlarged heart Hepatomegaly Cool peripheries
What are the main causes of heart failure in neonates?
Hypoplastic left heart syndrome
Critical aortic valve stenosis
Severe coarctation of the aorta
Interruption of the aortic arch
What are the main causes of heart failure in infants?
ventricular septal defect
atrioventricular septal defect
large persistent ductus arteriosus
What are the main causes of heart failure in older children and adolscents?
Eisenmenger syndrome (right heart failure only)
Rheumatic heart disease
Cardiomyopathy
When are foetus’s especially at risk of developing an AVSD?
Down’s syndrome
Previous child with heart disease
Mother with congenital heart disease
Why might heart murmurs present late in neonates?
pulmonary resistance is still high therefore VSD or PDS may only become apparent with pulmonary resistance falls a few weeks after birth
What happens when the duct closes in duct dependent circulation?
severe acidosis
collapse
death unless ductal patency is restored
What cause heart failure in the first weeks of life?
left to right shunt
pulmonary vascular resistance falls and there is an increased in left to right shunt and increasing pulmonary flow
What is Eisenmenger syndrome?
irreversibly raised pulmonary vascular resistance resulting from chronically raised pulmonary arterial pressure
What is central cyanosis a sign of?
fall in arterial blood oxygen tension
What are the causes of cyanosis in a newborn infant?
cardiac disorders - congenital heart disease
respiratory disorders - respiratory distress syndrome
persistent pulmonary HTN of the newborn infection - septicaemia from group B inborn error of metabolism
What is the key for early survival in neonates with duct dependent circulation?
maintaining ductal patency
What are the causes of cyanosis in infants (high pulmonary flow)?
ventricular septal defect
atrioventricular septal defect
large persistent ductus arteriosis
What are the causes of cyanosis in older children and adolescents (right or left heart failure)?
Eisenmenger syndrome
Rheumatic heart disease
Cardiomyopathy
What are the left to right shunts?
atrial septal defects (ASDs)
VSDs
persistent ductus arteriosus (PDA)
What are the two different types of ASD?
secundum ASD - 80%
partial atrioventricular septal defect (AVSD)
What are the symptoms of ASD?
none - commonly recurrent chest infections/wheeze arrhythmias - fourth decade onwards
What are the physical signs of ASD?
Ejection systolic murmur heard at ULSE A fixed split second heart sound
What would be seen on a chest radiograph in ASD?
cardiomegaly
pulmonary arteries and increased pulmonary vascular markings
What would be seen on an ECG in secundum ASD?
partial RBBB
right axis deviation
right ventricular enlargement
What would be seen on an ECG in partial AVSD?
superior QRS axis
What is the management for ASD?
Secundum ASDs - cardiac catheterization with insertion of occlusion device partial AVSD - surgical correction is required treatment takes place 3-5 years
What are the symptoms of small VSDs?
aSymptomatic
What are the physical signs of small VSDs?
Loud pansystolic murmur at lower left sternal edge Quiet pulmonary second sound
What are the investigation results in a small VSD?
Chest radiograph - normal ECG - normal Echo - demonstrates precise anatomy of the defect
What is the management of a small VSD?
lesions will close spontaneously
What makes a VSD ‘large’?
defects are the same size or bigger
What are the symptoms of large VSDs?
heart failure with breathless and faltering growth after 1 week old recurrent chest infections
What are the physical signs of a VSD?
Tachypnoea Tachycardia Enlarged liver from heart failure Active precordium Soft pansystolic murmur or no murmur Apical mid-diastolic murmur Loud pulmonary second sound
What would be seen on a chest radiograph with a large VSD?
cardiomegaly
enlarged pulmonary arteries
increased pulmonary vascular markings
pulmonary oedema
What would be seen on an ECG in a large VSD?
Biventricular hypertrophy by 2 months of age
What would be seen on an echocardiogram in a patient with a large VSD?
demonstrates the anatomy of the defect haemodynamic effects and pulmonary hypertension
How is a large VSD managed?
Diuretics
Captopril
Calories (high energy intake via NG tube) Surgery at 3-6 months of age
What are the symptoms of a PDA?
None
What are the signs of PDA?
continuous murmur at ULSE +/- bounding pulses
How is PDA managed?
Coil or device closure at cardiac catheter at 1 year of age or ligation
What are the right to left shunts that occur?
tetralogy of fallot
transposition of great arteries
How do these right to left shunts present?
CYANOSIS (blue)
What are the 4 cardinal features of tetralogy of fallot?
a large VSD
overriding aorta with respect to ventricular septum
subpulmonary stenosis
RVH
What are the clinical features of tetralogy of fallot?
Cyanosis
Loud ejection systolic murmur at ULSE
Clubbing of fingers and toes
Hypercyanotic spells
What is the management of tetralogy of fallot?
Surgery at 6-9 months
What would the investigations show in tetralogy of fallot?
Chest radiograph - small heart, uptilted apex due to RVH, ECG - normal at birth , RVH when older
What are the clinical features of transposition of the great arteries?
Cyanosis
Usually no murmur
What does a chest radiograph in transposition of the great arteries?
classical finding - “egg on side” appearance
increased pulmonary vascular markings are common
ECG = normal
How of children with transposition of the great arteries managed?
prostaglandin infusion
balloon arterial septostomy
arterial switch operation in neonatal period
What is Eisenmenger syndrome?
high pulmonary blood flow due to large left to right shunt or common mixing is not treated at an early stage, then the pulmonary arteries become thick walled and the resistance to flow increases. At 10-15 years the shunt reverses and teenager becomes blue. Situation is progressive and adults die of right sided heart failure.
What are the two common mixing lesions?
AVSD (complete)
Complex disease - e.g. tricuspid atresia
What are the clinical features of AVSD?
Downs syndrome (VSD more common than AVSD) Cyanosis at birth No murmur Superior axis on ECG Presentation at antenatal US screening
What are the clinical features of complex diseases like tricuspid atresia?
Cyanosis
Breathless
How are complex diseases like tricuspid atresia managed?
Shunt (Blalock-Taussig)
Pulmonary artery banding
Surgery (Glen and later Fondon op)
What are the different types of outflow obstruction in the well child?
Aortic stenosis
Pulmonary stenosis
Adult type coarctation of the aorta
What are the clinical features of AS?
small volume, slow rising pulses carotid thrill (always) ESM at URSE (Asymptomatic) Delayed and soft aortic sternal sound Apical ejection click
What would be seen on ECG or Chest radiograph in AS?
Normal
How is AS managed?
Balloon dilation
What are the clinical features of pulmonary stenosis?
asymptomatic ESM best heard at ULSE
If severe there is a prominent right ventricular heave (RVH)
How is pulmonary stenosis managed?
Balloon dilation
What are the clinical features of adult type coarctation of the aorta?
asymptomatic systemic HTN in the right arm ESM at upper sternal edge
Collateral heard with CONTINUOUS murmur–> Radio-femoral delay
What would be seen on a chest radiograph in coarctation of the aorta? (adult type)
Chest radiograph - Rib notching due to development of large collateral intercostal arteries sign with a visible notch in descending aorta
What would be seen on an ECG in coarctation of the aorta (adult type)
LVH
What is the management for coarctation (adult type) of the aorta?
Stent insertion or surgery
What are the duct dependent lesions?
coarctation of the aorta
interruption of the aorta
hypoplastic left heart syndrome
How does coarctation of the aorta present?
examination on first day of life is normal the neonates usually present with acute circulatory collapse at 2 days of age when the duct closes
What are the physical signs seen in coarctation of the aorta?
a sick baby with severe heart failure
absent femoral pulses
severe metabolic acidosis
What would be seen on a chest X-ray with coarctation of the aorta?
Cardiomegaly
How is coarctation of the aorta managed?
Maintain ABC
Surgical repair is performed soon after diagnosis
What is hypo plastic left heart syndrome?
underdevelopment of the entire left side of the heart (mitral valve is small, aortic valve atresia, ascending aorta is small almost always coarctation of the aorta)
What are the clinical features of hypoplastic left heart syndrome?
- may be detected antenatally on screening
- if detected after birth they are the sickest of all neonates presenting with duct dependent systemic circulation
- there is no flow through the left side of the heart so there is profound acidosis and rapid CV changes
- absence of all peripheral pulses
How is hypoplastic left heart syndrome managed?
Prostaglandin infusion Maintain ABC Norwood procedure (surgery) Further op (Glenn or hemi-Fontan) at 6 months old and again at 3 years (Fontan)
What is superventricular tachycardia (SVT)?
most common childhood arrhythmia
HR rapid - between 250-300
How does SVT present clinically?
Causes poor cardiac output and pulmonary oedema
Presents with symptoms of heart failure in the neonate or young infant
Causes hydrops fetalis and interuterine death
What does SVT look like on an ECG?
narrow complex tachycardia of 250-300 beats/min If heart failure is severe then there may be changes suggestive of MI with T wave inversion in the lateral precordial leads When in sinus rhythm, a short P-R interval may be discernible In Wolf-Parkinson-White syndrome, the early antegrade activation of the ventricle via the pathway results in a short P-R interval and a delta wave
How is SVT managed?
circulatory and respiratory support tissue acidosis is corrected vagal stimulating manoeuvres IV adenosine electrical cardioversion
What are some examples of vagal stimulating manoeuvres?
carotid sinus massage or cold ice pack to face
What is myocarditis?
dilated cardiomyopathy (a large poorly contracting heart) should be suspected in any child with an enlarged heart and heart failure who has previously been well
What causes of myocarditis?
may be inherited
secondary to metabolic disease may result from direct viral infection of myocardium
How is the diagnosis made in myocarditis?
Echocardiography
How is myocarditis treated?
Diuretics ACEI carvediolB-adrenoceptor blocking agents some children ultimately require heart transplantation
What are the risk factors for subacute bacterial endocarditis (SBE)?
all children of any age with congential heart disease - including neonates
highest risk when there is turbulent jet of blood (VSD, coarctation of the aorta, PDA, prosthetic material in surgery)
What are the clinical signs of SBE?
fever anaemia splinter haemorrhages clubbing (late) necrotic skin lesions changing cardiac signs splenomegaly neurological signs from cerebral infarction retinal infarcts arthritis/arthralgia haematuria
What is the common causative organism for SBE?
a-haemolytic streptococcus
How is SBE treated?
high dose penicillin in combination with aminoglycoside, giving 6 weeks of IV therapy and checking serum levels of abx will kill the organism #if infected prosthetic material then less chance of complete eradication and surgical removal may be required
What are the syndromes associated with cardiac disease?
Turners
Downs
Noonans
Marfans
