Cardiology Flashcards
What is the most common cardiological problem / presenting feature in children?
A MURMUR
Are most murmurs concerning?
Most murmurs are completely innocent (30% of children will have an innocent murmer at some point)
What percentage of children will have an innocent murmur at some point during their childhood?
30% of children will have an innocent murmer at some point in their life
What are some features that will make a murmur REASSURING?
THE S FACTORS
- Systolic (commonly ejection systolic) - no diastolic murmur present
- Soft, blowing murmur
- aSymptomatic patient
- Left Sternal edge
***these are all factors that would reassure you to a murmur being innocent
Extra re-assuring factors:
- Normal heart sounds with no added sounds
- No parasternal thrill
- No radiation
What are some causes of innocent murmurs?
Mostly the murmurs are idiopathic and we don’t identify a cause. Organic causes include:
- FEBRILE ILLNESS
- ANAEMIA
***Any disease process that might mean that the cardiac output is increased could theoretically lead to the development of a murmur
What should you do if you hear a murmur?
Describe: Site Character (e.g. harsh, soft, blowing) Radiation Intensity Pitch Timing
-refer to PAEDIATRIC CARDIOLOGY if parents are concerned or worrying features
How do we investigate murmurs to rule out pathology?
Echocardiogram - gold standard
ECG
CXR
What are the four cardinal features of TOF?
PROV:
- Pulmonary stenosis (ejection systolic murmur)
- RVH (right side has to work harder because of stenosis)
- Overridng aorta (the aorta sits in front of the VSD-picking up blue blood from right side of heart)
- VSD (mix of red and blue blood)
How is TOF identified?
- Nowadays usually antenatally or following identification of a murmur in the first 2 months
- If not there might be severe CYANOSIS in the first few days of life
What symptomatic features of TOF can you see?
Severe CYANOSIS and breathlessness and pallor
worsened by: exercise/crying
relieved by: squatting
-Important to be able to identify the cyanotic spells as they may lead to an MI if not treated properly
What signs might you find o/e in TOF?
- Might find soft murmur during tet spell
- May have clubbing
- LOUD, HARSH EJECTION SYSTOLIC MURMUR at Left sternal edge
What investigations should you do if suspecting TOF?
CXR -uptilted apex (boot shaped-pulmonary artery bay)
ECG-might show RVH in older child
Echo -cardinaly features
How should a tet spell be managed?
Usually limited and followed by sleep. If 15mins+:
- oxygen
- sedation and pain relief (morphine)
- IV propanolol - perisperhal vasoconstrictor
- IV fluids
- Bicarbonate to correct respiratory acidosis
When will definitive surgery for TOF be offered and what will it involve?
-At 6 MONTHS
○ Close the VSD
○Pulmonary valve replacement
A surgery can be offered in the neonatal period as well in severe cyanotic cases - SHUNT between the subclavian and pulmonary arteries to improve blood flow to the lungs
What is transposition of the great arteries (TGA)?
- When the pulmonary artery connects to the LV and the aorta to the RV
- 2 closed circulations (red>red, blue>blue)
- INCOMPATIBLE WITH LIFE UNLESS there is a defect that stays open (VSD)
How and when does TGA present?
- Profound cyanosis
- Usually presents around day 2 of life when ductus arteriosus starts to close
What clinical signs might we be able to hear on TGA?
- Second heart sound often loud and single
- Usually no murmur but might be one associated with increased pressure through pulmonary artery (smaller than aorta)
What three investigations should be done for TGA?
CXR, Echo (anatomy) and ECG (usually normal)
What will the CXR show in TGA?
- Egg on its side
- There might also be some signs of pulmonary oedema due to the increased pressures through the pulmonary system
What is the initial management for TGA and what is the definitive management?
- Initial management is to preserve blood mixing and so PROSTAGLANDINS are given to keep the ducts arteriosis patent
- Sometimes a BALLOON ATRIAL SEPTOSOTOMY may be needed - rupture the foramen oval to improve blood mixing
- The definitive treatment - an operation to switch the arteries then ideally occurs in the second week of life
What are the two types of atrial septal defect?
Secundum (80%)
Primum / AVSD (Downs syndrome-involves AV valves)
What condition is assosiated with ASD?
Fetal alcohol syndrome
Downs syndrome
How are atrial septal defects detected clinically?
- Often ASx (sometimes chest infections, or arrhythmias in later life)
- Detected when a murmur is heard on routine examination (think about mum)
What will the murmur with a ASD sound like?
- Ejection systolic and at the upper left sternal edge (due to increased blood flow across the pulmonary valve due to L-R shunt-all the red blood taking another trip to lungs)
- Fixed and widely split second heart sound (increased volume in right side
What condition are AVSDs commonly associated with?
Down Syndrome
How do we managed ASDs?
- Secundum ASDs can be treated with cardiac catheterisation
- For primum AVSDs surgical intervention is often needed Usually treated around 3-5yo
What is the most common congenital cardiac defect?
VSDs - 30% of all cases of cardiac abnormalities
How do we describe VSDs?
According to their size (Small or large)
Small <3mm, large >3mm
What are some of the clinical features and clinical signs of VSDs?
- Loud panysystolic murmur at LLSE (keep pans in bottom cupboard)
- Small will be asymptomatic, large will have symptoms
Do small or large VSDs produce louder murmurs?
Small - more resistance
How do we investigate VSDs?
CXR, Echo and ECG
CXR and ECG both normal
How do we managed small VSDs?
Watch and wait - usually they will close spontaneously but arrange regular follow up
How will large VSDs present clinically?
- Acute breathlessness due to pulmonary oedema (increase blood flow to right hand side -backflow to lungs
- Failure to thrive after 1 week old
- Recurrent chest infections
What are some clinical signs in large VSDs?
Tachypnoea, tachycardia, enlarged liver due to heart failure
What murmur will be heard in large VSDs?
A very soft one or no murmur at all
What will a chest radiograph/ECG/echo show in large VSDs?
CXR shows heart failure
○ Cardiomegaly
○ Enlarged pulmonary arteries
○ Increased pulmonary vascular markings
○ Pulmonary oedema
-ECG will show biventricular hypertrophy by 2 months, -ECHO will show anatomy
How should large VSDs be managed?
Drug therapy for heart failure - DIURETICS AND CAPTOPRIL (ACE-i used in HF)
What is a potential complication of large VSDs?
Persistent L-R shunt could lead to EISENMENGER SYNDROME which is a R-L shunt (cyanosis)
When is corrective surgery offered in large VSDs?
3-6 months to prevent eisenmenger and risk of endocarditis
What structures does the ductus arteriosus connect in the foetus?
The pulmonary artery to the aorta to bypass pulmonary circulations (pulmonary circulations very high pressure in the unborn baby)
What changes happen at birth that lead to the closure of the DA?
The baby takes its first breath and pulmonary vascular resistance plummets and the direction of the shunt changes enabling it to close
How long does the DA have to remain patent for before we class it as pathological?
1 month (corrected gestational age - so prems have longer)
How are children with PDAs usually identified?
With PERSISTANT murmurs under the L clavicle (heard in both systole and diastole)
-MACHINE-HUM MURMUR
What happens to the pulse in children with PDA?
Becomes collapsing or bounding due to increase in pulse pressure
How is PDA managed? What complications could there be if it is not treated?
Coil or occlusion device via cardiac catheterisation at around 1 year of age
Lifelong risk of infective endocarditis if it is not corrected. Also risk of pulmonary hypertension and cyanosis (increased pressure in RHS)
What is stills murmur?
-Still’s murmur is a low-pitched sound heard at the lower left sternal edge (benign)
What do you think might cause a murmur that can be heard just below clavicles?
- Venous hums can be heard just below clavicles
- Due to the turbulent blood flow in the great veins returning to the heart (benign)
What paediatric cardio conditions present with cyanosis (right to left shunt)?
Cyanosis occurs in:
- Tetrology of Fallot (most common cause of cyanosis)
- Transposition of great arteries
TofF vs. transposition of arteries?
- TGA occurs early after birth as it is duct dependent
- Whereas TOF occurs around 1-2 months as the VSD is left to right until the RV hypertrophy increases sufficiently to overcome left ventricular pressures (causing a right to left shunt)
In paediatric coarctation of the aorta, where is the narrowing?
-paediatric coarctation/narrowing of the aorta occurs after aortic arch but PRE ductus arteriosis.
Who is more likely to get coarctation of aorta?
How will neonates with CoA present?
- Turners syndrome increased risk of coarctation of the aorta
- Neonates will have lower extremity discoloration-really important to detect (otehrwise might die in neonatal period)
- radio femoral delay
