Cardiology Flashcards
What are the hallmarks of an innocent ejection murmur? Seven Ss
Asymptomatic (no parasternal thrill)
Sensitive (changes with child’s position or respiration
Soft and single blowing murmur (normla low amplitude heart sounds with no added sounds)
Systolic murmur only, not diastolic
Short duration (not holosystolic)
Left sternal edge (no radiation)
What are causes of heart failure in neonates?
Obstructed (duct dependent systemic circulation)
Hypoplastic left heart syndrome
Critical aortic valve stenosis
Interruption of the aortic arch
What are causes of heart failure in infants?
High pulmonary blood flow
Ventricular septal defect (VSD)
Atrioventricular septal defect (AVSD)
Large persistent ductus arteriosus (PDA)
What are causes of heart failure in older children and adolescents?
Right or left heart failure
Eisenmenger syndrome (right heart failure only)
Rheumatic heart disease
Cardiomyopathy
How do childrenn with heart failure present?
Breathlessness (particularly on feeding or exertion) Poor feeding Poor weight gain/ faltering growth Tachycardia Enlarged heart Cold peripheries Sweating Recurrent chest infections Tachypnoea Heart murmur/ gallop rhythm Hepatomegaly
Why does cyanosis occur in infants?
Peripheral cyanosis (hands & feet) may occur when child is cold or unwell from any cause or with polycythaemia Central cyanosis (on tongue) fall in arterial blood O2 tension. Only clinically recognized if the concentration of reduced haemoglobin exceeds 50 g/L (so less pronounced in anaemic children) Persistent cyanosis in a healthy infant is a sign of structural heart disease
What can cyanosis in a newborn infant with respiratory distress RR > 60 be due to?
Cardiac disorders- cyanotic congenital heart disease
Respiratory disorders- respiratory distress syndrome (surfactant deficiency), meconium aspiration, pulmonary hypoplasia
Persistent pulmonary hypertension of the newborn-failure of the pulmonary
vasculature resistance to fall after birth
Infection-Group B strep septicaemia
Inborn error of metabolism-metabolic acidosis and shock
What occurs with a left to right shunt?
Breathless or asymptomatic
ASD (6%)
VSD (32%
PDA (12%)
What occurs with a right to left shunt?
Blue
Tetralogy of fallot (6%)
Transpostion of great arteries (5%)
What occurs with common mixing congenital heart disease?
Breathless and blue
AVSD (2%)
Complex congenital heart disease
What occurs with well children with obstruction in congenital heart disease?
Asymptomatic Aortic stenosis (AS) Pulmonary stenosis (PS) Adult-type coarction of aorta (CoA)
What occurs with sick neonates with obstruction in congenital heart disease?
Collapsed with shock
Coarction (6%) (acyanotic)
HLHS (cyanotic)
What investigations are carried out if congenital heart disease is suspected?
Chest radiograph and ECG (rarely diagnostic)
Echocardiography and doppler USS
What are the types of atrial septal defect?
Secundum ASD- involves defect in the centre of the atrial septum, involving foramen ovale
Partial atrioventricular septal defect (AVSD) or primum ASD: characterized by an interatrial communication between the bottom end of the atrial septum and the atrioventricular valves, with left valve having 3 leaflets and tending to leak
How do children with a ASD present?
May present with recurrent chest infections, wheeze or arrhythmias
Common with down syndrome
Ejection systolic murmur (upper left sternal edge)
A fixed and widely split second heart sound (due to the right ventricular stroke
volume being equal in both inspiration and expiration
Partial AVSD- an apical pansystolic murmur (from AV valve regurgitation)
What are the investigations for ASD?
Chest radiograph: shows cardiomegaly, enlarged pulmonary arteries and increased pulmonary vascular markings
ECG:
Secundum ASD-partial RBBB (may also occur in normal children) + right axis
deviation (due to ventricular enlargement
Partial AVSD- superior’ QRS axis
Echocardiography
What is the treatment for ASD?
If right ventricle dilation occurs
Secundum ASD- cardiac catheterization with insertion of an occlusion device
Partial AVSD-surgical correction required
Treatment is usually undertaken at about 3-5 years of age in order to prevent RHF and arrhythmias in later life
What are small VSDs?
Smaller than the aortic valve in diameter, up to 3 mm
How do small VSDs present?
Asymptomatic Loud pansystolic murmur at lower left sternal edge (loud murmur = small defect) Quiet pulmonary second sound (P2) NO pulmonary hypertension
How do large VSDs present?
Heart failure with breathlesness and faltering growth after 1 week old and recurrent
chest infections
Tachypnoea, tachycardia and enlarged liver from heart failure
Active precordium
Soft pansystolic murmur or no murmur (implying large defect)
Apical mid-diastolic murmur (due to increased flow across the mitral valve after the
blood has circulated through the lungs)
Loud P2 (from raised pulmonary arterial pressure)
What are the investigations for a large VSD?
X-ray Cardiomegaly Enlarged pulmonary arteries Increased pulmonary vascular markings Pulmonary oedema ECG: biventricular hypertrophy by 2 months of age
What is the treatment for large VSDs?
Treat HF with diuretics. Additional calorie input is required.
Untreated large VSD will lead to irreversible damage of pulmonary capillary vascular bed (Eisenmenger Syndrome) and hence required surgery at 3-6 months of age
What is the treatment for small VSDs?
These lesions will close spontaneously
While the VSD is present, prevent bacterial endocarditis by maintaining good dental hygiene
What are the features of Ebstein’s anomaly?
cyanosis
prominent ‘a’ wave in the distended jugular venous pulse,
hepatomegaly
tricuspid regurgitation
pansystolic murmur, worse on inspiration
right bundle branch block → widely split S1 and S2
Associated with PFO and ASD
