Cardiology Flashcards
What cardiac lesions present in the 24 hours of life critically unwell?
Why these ones?
- Ebstein anomaly
- obstructed TAPVD
Severe lesions
Duct is still open- more resp than cardio lesions
What murmurs may present in the first 24 hrs of life?
AS PS or AV REGURG
Which cyanotic lesions can present in the first 24 hrs of life?
TGAs, single ventricle hearts
Mixing lesions
What are the three main reasons duct dependant lesions present?
Depend on the pda for plum flow, systemic flow mixing
When do duct dependant lesions present?
24 hrs to 2 weeks
Using the three subgroups, what are examples of duct dependant lesions
1) need pda for pulm flow
- severe ps
- pulm atresia
- above in single ventricle
2) need pda for systemic flow
- severe co-arc
- critical as
- HLHS
3) need pda to mix
- TGA
How do lesions at 2-6 weeks present?
Congestive cardiac failure
What are examples of lesions presenting at 2-6 weeks
Severe vsd or pda
Truncus
Tof with pulm atresia
dTGA How does it present - murmur -s2 -CXR -ECG
Initial management
Repair and timing
Cyanosis from birth, fails hyperoxia test
- none!
- single
- egg on a string with increased pulm markings
- RVH
Prostaglandin
Septostomy then atrial switch-4 weeks
L-TGA
why is it different?
How does it present?
Ventricles swap over with the great vessels
Asymptomatic unless associated with another defect
D-TGA
What other lesion is commonly found and how frequently
1/3 have coronary artery anomalies
Tricuspid atresia
How do they present
What is seen on ECG
Cyanotic at birth with murmur of VSD
Superior axis and LVH (therefore not AVSD)
Ebstein anomaly
Outline the anatomy
Hugely dilated right atrium
Abnormal valve
Arterialised ventricle
TOF
What are the 4 lesions?
VSD
r ventricle outflow obstruction
Overriding aorta
RVH
In a TOF what determines the degree and magnitide of the shunt?
Degree of pulm stenosis
TOF
What are the two ways they can present
Blue- Murmur at birth. Progressive cyanosis. Tet spells from 2 months
Pink-Acyanotic- signs of heart failure later
Cyanotic TOF- what is the murmur
S2?
What does the murmur correlate to
Long Loud
Ejection systolic with ejection click
Single s2
The pulm stenosis
TOF
ECG findings
Chest X-ray findings
RAD and RVH
Boot shaped heart with reduced pulm markers
Physiologically what does a tet spell indicate? Will there be a murmur?
Acute right to left shunting
No!!
When will a TOF not have a murmur
If there is pulm atresia
How can TOF be conservatively managed (3 things)
When is definitive surgery normally done? What 3 things might make it necessary to do earlier
Beta blockers, balloon dilatation of outflow tract obstructions
Modified BT Shunts
6-12 months
Not growing, low sats, lots of TET spells
What maternal medication is ebstein associated with
What arrhythmia is the baby likely to have?
Maternal lithium
WPW
Ebstein
What is seen on ECG
RAH and likely WPW
Truncus
Outline the anatomy
Single trunk overlying a VSD
Abnormal truncal valve
Truncus- what is the murmur
ECG
To and fro murmur- diastolic of truncal regurgitation, systolic of VSD
Biventricular hypertrophy
Truncus- what syndrome is normally associated
Di George
How is truncus repaired (2 methods)
PA banding
Rastelli repair
How does TAPVD present- 2 ways
Which type is obstructed
Obstructed- cyanosis from day 1 of life and v unwell
Non obstructed- mild cyanosis, mid diastolic rumble and recurrent chest infections
Infra diaphragmatic
Non obstructed TAPVD- CXr?
Snowman in a snowstorm
HLHS
What other lesion is commonly associated?
Severe co-arctation
HLHS- how will it present
Duct dependant- Cyanosis when duct closes Impalpable femoral No murmurs Single s2
Why should sats be kept around 80% in HLHS
Keep pulm vascular resistance high
HLHS outline the steps in the staged Norwood
1- make an asd, BT shunt (svc to r PA) and connect pulm artery to aorta (right subclavian)
2- shunt down, svc to r pa (Glenn)
3- ivc to r pa with gortex or suture atrium to ventricle (fontan)
AS and PS- where are the murmurs and where do they radiate
Aortic upper right- to neck
Pulm upper left- to back
Avsd
- ecg findings
- partial vs complete
- superior axis
- both have mr and primum asd
- complete also has a vsd
What percentage of VSDs close spontaneously
90% if small
65% otherwise
Which type of Vsd Is more common
Membranous
How do large VSDs present
What other murmur might you hear and what does it indicate
When pulm vasc resistance falls (week 2-6)
Heart failure
Pansystolic murmur
Widely split s2
Mid diastolic rumble of relative mitral stenosis
What might be an interim surgical technique for VSDs?
What can an unrepairwd VSD cause
PA banding- protects the lungs
Aortic regurgitation
What ratio of qp to Qs indicates the need for surgery?
2:1
What are the three types of ASD
Where are they found
Which is most common
Secundum- at the foramen ovale- most common
Primum- endocardial cushion
Sinus venison- at the entry of the SVC
What murmur and heart sounds are heard in ASD
Fixed split s2
Ejection systolic murmur
What syndrome is supravalvular aortic stenosis associated with
What syndrome is a bicuspid aortic valve associated with
Williams syndrome (high pitched cry therefore high lesion) Turners
Aortic stenosis
Outline the pathology
What is the classical murmur
Tight aortic valve, hypertrophy of the left ventricle, dilation of the aorta
Ejection systolic, upper, crescendo/decrescendo radiating to the carotid
How does severe AS present
How does critical AS present
Loud murmur with narrow pulse pressure
No murmur but single s2 or narrow split. Poor perfusion. Failure at birth. Can be cyanotic
Severe AS
How will the ECG look
What is seen in CXR
LVH
Prominent aortic notch (right sided). Normal lung fields
PS What type of lesion is seen in Noonan syndrome Alagille syndrome Rubella infection What other 2 syndromes are associated
Noonan- valvular
Alagille- peripheral (branch)
Rubella- supravalvular
NF1 and Williams
Pulmonary stenosis
What is the murmur and s2
Upper left eternal edge radiating to the back
Widely split s2
PS
What is seen on ecg and cxr
RVH
Prominent pulmonary arch (left sided)
Coarctation
What syndrome are they associated with
Turners
Coarctation
How do they present in older children.
Headaches
Hypertension
Murmur at the interscapular area
Coarctation
How do they present if severe in babies
No murmur
Differential cyanosis
Thready peripheral pulses
Loud and single s2
Coarctation
What is seen on cxr
Inverted E (rib notching)
Why will an interrupted arch not present with differential cyanosis
Which syndrome is it most likely associated with
Usually have another mixing lesion like a VSD
Di George
What is the normal function of the ductus arteriosis and when does it physiologically and anatomically close
Blood from the pulmonary artery into the aortic arch
Phys-10-15 hrs of life
Anatomically- 2-4 weeks
PDA
In term babies what does it act like
What therefore dictates the direction and severity
An unrestricted VSD
Pulmonary vascular resistance
PDA
how and when does a large PDA present in term babies
When svr reduces (2-6 weeks) Machinery murmur at the interscapular region Differential cyanosis Bounding pulses Recurrent infections
PDA
What direction is the shunt normally
What can happen with a large shunt
Left to right
Also right to left shunting
PDA
How is it normally closed in term babies
Via catheter
Surgical
PDA
How does it present in preterm babies
Difficult to wean off vent in hyaline membrane disease
Continuous systolic murmur at ULSE
Bounding pulses
What is used to close a pda in premature babies
How does it work (2 mechanisms)
Side effects
Indomethacin
Inhibits COX and PGE2
GI bleeding
Hyponatraemia
Reduced renal or cerebral blood flow
PDA in preterm
When is surgery indicated
If 2x failed attempts at indomethacin
Rheumatic fever
How many positive criteria are needed to make the diagnosis
2 major or 1 major and 2 minor
What are the mnemonics to remember major and minor criteria in rheumatic fever?
Joints O- carditis- sleeping tachy new murmur or conduction defects N- nodules E- erythema marginatum S- Sydenham’s chorea
H- hot- fever
E- elevated esr or crp
L- arthralgia
P- PR interval
Which valve is most likely to be involved in acute rheumatic fever
Mitral
How many positive criteria do you need to diagnose Kawasaki
What are the 5 criteria
Fever more than 5 days plus 4 criteria
Non purulent conjunctivitis Unilateral cervical lymphadenopathy Desquamation Strawberry Polymorphic rash
When do plt elevate in Kawasaki
When is the highest risk phase for coronary artery aneurysms
10d-4w
This stage!!
Treatment of kawasaki
How long is the aspirin continued for
Which MAB might be used in refractory cases
3-4 days or until day 14, whichever comes first
Infliximab
IE
What is the most common cause on normal valves
Damaged valves
Staph epi
Strep viridians
What is the cause of brugada syndrome
What is seen on ecg
What happens
AD Na channel defect
ST elevation with negative p wave in v1& 2
Sudden death in sleep
What are the 2 differences between jervell Lange nelson and Romano ward
JLN-AR and has SN hearing loss
RW- AD no hearing loss
What 3 groups of meds/ chemicals can prolong your QT
1) antipsychotics
2) antibiotics- trimethoprim and erythromycin
3) organophosphates
What triggers the following prolonged QT syndromes 1,2,3,4
Which electrolyte imbalance is most likely
Which condition is LQT 5
1- fun e.g. swimming
2- boo- emotion
3- sleeep
4 unknown
Prolonged K efflux
Romano ward
How is TOF treated medically
Try to increase the SVR Knees up O2 Morphine IV propranolol Iv phenylephrine Emergency shunt or repair
Svt and cardio version
How do you prevent VT from happening
Synch to the r wave
Which asthma drug can cause torsades IN Patients with long QT
Theophylline
What medication is given to treat long QT associated with TCA OD
Sodium bicarbonate
When is VSD repair contraindicated?
Why?
Severe pulm hypertension
Increased mortality with reduced cardiac output
What is the most common cardiac defect seen with na valproate use?
ASD
Fetal cardiac circulation
What do the umbilical arteries and veins carry
Arteries- deoxygenated blood from iliac arteries back to the placenta
Vein- oxygenated blood to the ductus venosus in the liver
What are 2 potential causes of complete vascular rings?
How do they present?
What is seen on bronch?
Double aortic arch with or without ligamentum
Wheeze and stridor from 3m. Later if septum
Bilateral compression- pulsatile
Incomplete rings
What are 2 asymptomatic ones
What causes a vascular sling? What is seen on bronch
What is seen with anterior tracheal compression
Aberrant left coronary, anomalous right subclavian
Anomalous left pulm artery. Deviated trachea
Anomalous innominate
What is the mechanism of the following anti arrhythmics and give examples Class 1 Class 2 Class 3 Class 4
1 sodium blockers- c=flecainide
2- beta blockers- atenolol
3- k blockers- sotalol and amiodarone
4- calcium blockers- verapamil
How does digoxin work
Blocks k-ATPase pump
Causes increased contractility
Which 2 antiarrhythmics do you never use in WPW
Digoxin and verapamil
How are prolonged QT syndromes treated
Beta blockers and ICDs
Prolonged QT
What is the most likely AD cause
What is a cause with associated bilateral SN hearing loss? What is its inheritance
Romano ward
Jervell Lange Nelson-AR
Coarctation what is seen on the ECG of infants vs older children
Infants- RVH
Children- LVH
Long QT
what triggers type 1,2 and 3 and what shape of QT is seen. Which channels do they involve
1-fun- swimming. Long wide QT. K channels
2- boo- emotion- m shaped QT. K channels
3- sleep- Na channel- narrow and late Qt
What are the mean features of right and left isomerism
Left- multiple left lungs and multiple spleens
Right- multiple right lungs and absent spleen
What is the difference between the timing of ASOT and DNAse tests?
ASOT- positive for 1-4 weeks
DNAse- positive 4-6w
What are the 4 main indications for endocarditis prophylaxis
Previous endocarditis
Metalware
<6m from last repair
Cyanotic disease
What does prostaglandin do and how
What are three main side effects
Keeps the ductus arteriosis open- general vasodilator
Reduced plt aggregation, apnoea, tachy or Brady cardia
Which 2 lesions have ejection clicks
Aortic and pulmonary stenosis
What is seen on ECG of L-TGA
LAD and abnormal Q waves in right sided leads
