Cardiology

Question 1

What are the hallmarks of an innocent ejection murmur? Seven Ss

Answer 1

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)

Question 2

What are causes of heart failure in neonates?

Answer 2

Obstructed (duct dependent systemic circulation)
Hypoplastic left heart syndrome
Critical aortic valve stenosis
Interruption of the aortic arch

Question 3

What are causes of heart failure in infants?

Answer 3

High pulmonary blood flow
Ventricular septal defect (VSD)
Atrioventricular septal defect (AVSD)
Large persistent ductus arteriosus (PDA)

Question 4

What are causes of heart failure in older children and adolescents?

Answer 4

Right or left heart failure
Eisenmenger syndrome (right heart failure only)
Rheumatic heart disease
Cardiomyopathy

Question 5

How do childrenn with heart failure present?

Answer 5

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

Question 6

Why does cyanosis occur in infants?

Answer 6

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

Question 7

What can cyanosis in a newborn infant with respiratory distress RR > 60 be due to?

Answer 7

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

Question 8

What occurs with a left to right shunt?

Answer 8

Breathless or asymptomatic
ASD (6%)
VSD (32%
PDA (12%)

Question 9

What occurs with a right to left shunt?

Answer 9

Blue
Tetralogy of fallot (6%)
Transpostion of great arteries (5%)

Question 10

What occurs with common mixing congenital heart disease?

Answer 10

Breathless and blue
AVSD (2%)
Complex congenital heart disease

Question 11

What occurs with well children with obstruction in congenital heart disease?

Answer 11

Asymptomatic 
Aortic stenosis (AS)
Pulmonary stenosis (PS)
Adult-type coarction of aorta (CoA)

Question 12

What occurs with sick neonates with obstruction in congenital heart disease?

Answer 12

Collapsed with shock
Coarction (6%) (acyanotic)
HLHS (cyanotic)

Question 13

What investigations are carried out if congenital heart disease is suspected?

Answer 13

Chest radiograph and ECG (rarely diagnostic)

Echocardiography and doppler USS

Question 14

What are the types of atrial septal defect?

Answer 14

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

Question 15

How do children with a ASD present?

Answer 15

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)

Question 16

What are the investigations for ASD?

Answer 16

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

Question 17

What is the treatment for ASD?

Answer 17

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

Question 18

What are small VSDs?

Answer 18

Smaller than the aortic valve in diameter, up to 3 mm

Question 19

How do small VSDs present?

Answer 19

Asymptomatic 
Loud pansystolic murmur at lower left
sternal edge (loud murmur = small defect)
Quiet pulmonary second sound (P2)
NO pulmonary hypertension

Question 20

How do large VSDs present?

Answer 20

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)

Question 21

What are the investigations for a large VSD?

Answer 21

X-ray
Cardiomegaly
Enlarged pulmonary arteries
Increased pulmonary vascular markings
Pulmonary oedema
ECG: biventricular hypertrophy by 2 months of age

Question 22

What is the treatment for large VSDs?

Answer 22

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

Question 23

What is the treatment for small VSDs?

Answer 23

These lesions will close spontaneously

While the VSD is present, prevent bacterial endocarditis by maintaining good dental hygiene

Question 24

What are the features of Ebstein’s anomaly?

Answer 24

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