Cardiology Flashcards
What is the epidemiology of congenital heart disease?
- Accounts for 30% of congenital anomalies
- Incidence of 8 in 1,000 live births
- 8 most common lesions account for 80% of the cases of congenital heart disease
What are the 8 commonest congenital anomalies?
- Ventricular septal defect
- Patent ductus arteriosus
- Atrial septal defect
- Pulmonary stenosis
- Aortic stenosis
- Coarctation of the aorta
- Transposition of the great vessels
- Teratology of Fallot
What is the aetiology of congenital heart disease?
- Genetic susceptibility with environmental hazard
- Teratogenic insult 18-60 days post conception
What environmental factors can increase the risk of congenital heart disease?
Drugs
-Alcohol, amphetamines, cocaine, ecstasy, phenytoin, lithium
Infections
-Toxoplasma, rubella, CMV, Herpes, other
Maternal
-Diabetes, SLE
What is the association between CHD and chromosomal abnormalities?
- 6-10% of all CHD have underlying chromosomal problem
- 30% of chromosomal abnormalities have CHD
Give examples of syndromes and their associated CHD.
Trisomy 13
-VSD and ASD
Trisomy 18
-VSD and PDA
Trisomy 21
-AVSD
Turner
-Co-arctation of the aorta
Noonan
-Pulmonary stenosis
Williams
-Supraclavicular AS
22q11 deletion syndrome
-Teratology of Fallot
What history may a child present with?
- Feeding, Weight and Development issues
- Cyanosis
- Tachypnoea, Dyspnoea
- Exercise Tolerance
- Chest Pain
- Syncope
- Palpitation
- Joint Problems
What may be found on examination of child with heart issues?
- Abnormal weight or height
- Dysmorphic features
- Cyanosis
- Clubbing
- Tachypnoea/ dyspnoea
- Pulses/apex (check femoral pulses)
- Hear sounds (clicks, splits, 3rd and 4th)
- Murmurs
What investigations may carried out?
- Blood Pressure
- O2 saturation, arterial BGA
- ECG (12 lead, 24hrs, event monitor)
- CXR
- Echocardiogram
- Catheter
- Angiography
- MRI/A
- Exercise testing (ECG, sO2)
What are the treatment principles for paediatric cardiology?
- If you can fix it then do it
- If you can’t fix it the improve the situation
- If you can do neither then replace it
Give examples of how paediatric cardiology problems can be improved?
Medication
Palliative procedures
-BT shunt, balloon valvoplasty, prostaglandin infusion, pulmonary banding
How can murmurs be characterised?
Timing in Cardiac Cycle
-Systole / Diastole / Continuous
Duration
- Early / Mid / Late
- Ejection / Holo or Pan Systolic
Pitch / Quality
- Harsh or Mixed Frequency (Turbulence)
- Soft or Indeterminate
- Vibratory / Pure Frequency (Laminar Flow
Name 4 sites to check for murmurs.
- Upper right sternal border
- Upper left sternal border
- Lower left sternal border
- Apex
What proportion of childhood murmurs are innocent?
70-80%
What are the 4 innocent murmurs of childhood?
- Still’s murmur (LV outflow murmur)
- Pulmonary outflow murmur
- Carotid/brachiocephalic arterial bruits
- Venous hum
What are the common features of innocent childhood murmurs?
- Systolic murmur (continuous in venous hum)
- No other signs of cardiac disease
- Soft murmur, grade 1/6 or 2/6
- Vibratory, musical
- Localised
- Varies with position, respiration, exercise
Who do Still’s murmurs affect?
2-7 year olds
What do Still’s murmurs sound like?
Soft systolic; vibratory, musical,”twangy”
Where can Still’s murmurs be heard?
Apex and left sternal border
When do Still’s murmurs increase?
In the supine position and with exercise
Who do pulmonary outflow murmurs affect?
- 8-10 year olds
- Often children with a narrow chest
What do pulmonary outflow murmurs sound like?
Soft systolic and vibratory
Where can pulmonary outflow murmurs be heard?
- Upper left sternal border
- They are well localised and do not radiate to the back
When do pulmonary outflow murmurs increase?
In the supine position and with exercise
Who do carotid arterial bruits affect>?
2-10 year olds
What do carotid arterial bruits sound like?
Harsh systolic, 1/6-2/6
Where can carotid arterial bruits be heard?
Supraclavicular, radiates to the neck
When do carotid arterial bruits increase?
With exercise
When do carotid arterial bruits decrease?
On turning head or extending neck
Who does venous hum usually affect?
3-8 year olds
What does venous hum sound like?
- Soft, indistinct
- Continuous murmur, sometimes with diastolic accentuation
Where can venous hum be heard?
Supraclavicular
When is venous hum heard?
When child is in upright position
When does venous hum disappear?
On lying down or turning the head
What are the 3 main types of VSD?
- Subaortic
- Perimembranous
- Muscular
What shunt is associated with VSD?
L to R
What type of murmur is heard in VSD?
- Pansystolic murmur lower left sternal edge, sometimes with thrill
- In very small VSDs, early systolic murmur
- In very large VSDs diastolic rumble due to relative mitral stenosis
What may there be signs of in large VSDs?
Signs of cardiac failure in large VSDs, eventually leading to biventricular hypertrophy and pulmonary hypertension
What is Eisenmenger syndrome?
The process in which a long-standing left-to-right cardiac shunt caused by a congenital heart defect causes pulmonary hypertension and eventual reversal of the shunt into a cyanotic right-to-left shunt.
How can VSDs be closed?
- Amplatzer device
- Patch closure
How are ASD sometimes detected in adulthood?
Patient may present with AF, heart failure or pulmonary hypertension
What murmur is associated with ASDs?
Wide fixed splitting of 2nd heart sound, pulmonary flow murmur
How do ASDs present in childhood?
Very few clinical signs as there is good chance of spontaneous closure
What is atrioventriculo-septal defect associated with?
Trisomy 21
What is AVSD?
Singular AV valve with ostium primum ASD and high VSD
How can pulmonary stenosis present?
- Mild= asymptomatic
- Moderate/severe= severe exertional dyspnoea and fatigue
What murmur is associated with pulmonary stenosis?
Ejection systolic murmur upper left sternal border with radiation to back
How can pulmonary stenosis be managed?
Balloon valvoplasty until the child is well past puberty and a replacement can be performed
How can aortic stenosis present?
- Mostly asymptomatic
- Severe= reduced exercise tolerance, exertional chest pain, syncope
What murmur is associated with aortic stenosis?
Ejection systolic murmur upper right sternal border, radiation into carotids
What changes occur in the foetal circulation at birth?
- Pulmonary vascular resistance falls
- Pulmonary blood flow rises
- Systemic vascular resistance is increased
- Ductus arteriosus closes
- Foramen ovale closes
- Ductus venosus closes
Who is PDA common in?
Very common in pre-term infants
How is PDA treated in pre term babies?
- Fluid restriction/ diuretics
- Prostaglandin inhibitors (indomethacin, ibuprofen)
- Surgical ligation
How is PDA manages in term babies?
Good chance of spontaneous closure, not prostaglandin sensitive
How can coarctation of the aorta be imaged
- ECHO
- MRI
- 3D MRI
- CT angiogram
How is coarctation of the aorta managed?
- Re-open PDA with Prostaglandin E1 or E2
- Resection with end-to-end anastomosis
- Subclavian patch repair
- Balloon Aortoplasty
What is the problem in translocation of the great vessels?
- Aorta comes from RV
- Pulmonary trunk from LV
Essentially means blood circulates without being oxygenated
What procedure is carried out in a transposition of the great vessels to allow blood flow through both sides?
Rashkind’s atrial septostomy
What is the definitive treatment for translocation of the great vessels?
Switch procedure
What are the 4 components of teratology of Fallot?
- Pulmonary stenosis
- VSD
- Right ventricular hypertrophy
- Overriding aorta
