Cardiology Flashcards
Cardiac Anomalies seen in Marfan syndrome
Mitral valve prolapse
Aortic regurgitation
Dilated aorta
Aortic aneurysm
Murmur heard with ASD
Low pitched systolic ejection murmur at base with fixed split S2
Murmur heard with Aortic Stenosis
Systolic ejection murmur radiating to neck
Murmur of pulmonary stenosis, PDA, coarctation
Systolic ejection murmur radiating to back
Murmur of VSD and mitral regurgitation
High pitched short systolic regurgitant murmur at the apex or LLSB
What are the symptoms of Neurocardiogenic Syncope (benign)?
Prodrome – grey-out, nausea
Short lived (usually 1-2min) never > 5 min
Often associated with position change
Not during exercise (though may follow exercise)
May be situational (see blood)
Not associated with palpitations or chest pain
Usually occurs in otherwise healthy children
Often a family history of neurocardiogenic fainters
Normal examination
What are the symptoms of cardiac syncope?
Little or no prodrome Prolonged LOC (>5 min) Exercise-induced Fright/startle induced Associated chest pain or palpitations History of cardiac disease – AS, Pulmonary hypertension Positive family history for: – Long QT, arrhythmia syndromes, devices – Cardiomyopathy – Sudden death May have abnormal exam
What symptoms on history would make you think about long QT?
History
– Details of any “events” – palpitations, syncope, SOB
– Sudden onset palpitations or syncope with exercise or startle/fright
– “unusual” Seizures, or seizures not responsive to usual medications
– Palpitations while swimming
– Deafness
– Family history of sudden death, unexplained MVA, drownings, deafness
What exam findings are in keeping with long QT syndrome?
Normal Examination
Equation for Qtc
QTc= QT/√RR
What are normal ranges for prolonged QT
Boys older than 10 years <0.45
Girls <0.47
Causes of prolonged QT
Long QT interval not the same as long QT syndrome
– Low Ca, Low Mg, Low K, Drugs (eg. tricyclic
antidepressants)
Work up of prolonged QT
• Suspected long QT syndrome or borderline QT interval:
– Careful history and physical. If still unclear or risk factors:
• Schwartz Score – available online
• Serial ECG’s on child
• Parental ECG’s may diagnose a patient with borderline long QT if parent has long QT on their ECG
• Echo
• Holter
• Exercise test – NB recovery period
Treatment for prolonged QT
• Beta blockers are first line therapy
Bad complications prolonged QT
Polymorphic VT: torsades de pointes
Causes of torsades de pointes
• Occurs in long QT syndrome and hypomagnesemia
What is WPW?
Accessory atrioventricular pathway allows “early” depolarization of ventricles (pre-excitation)
What conditions are associated with WPW?
Associated with Ebsteins and CCTGA
What are the EKG findings found with WPW?
Seen only in sinus rhythm
– Short PR interval
– delta wave
What are the side effects/arrhythmias seen with WPW?
• Can cause both SVT (retrograde conduction through accessory pathway) and sudden death (rapid antegrade conduction of atrial arrhythmia)
Treatment for WPW
• Optimal treatment controversial
– No symptoms – No treatment
– SVT – beta blockers or ablation (no digoxin)
– Fainting with palpitations - ablation
Most common diagnosis/CHD with trisomy 21
AVSD (RAD)
VSD (LAD)
EKG with VSD
NSR, normal axis, biventricular hypertrophy, RV strain
EKG with LAD: what is the differential?
– Left axis deviation
• AVSD
• Small RV (eg tricuspid atresia)
• Noonan Syndrome
LV hypertrophy EKG findings?
– LV Hypertrophy
• Tall R waves for age V6
• Deep S waves for age V1
RV hypertrophy EKG findings?
– RV Hypertrophy • Tall R waves for age V1 • Deep S waves for age V6 • Q waves in V1 • Upright T waves in V1 after day 5 and before “latency age” 9-10 years
Who gets the RSV vaccine?
– CPS Recommends immunization for children under 1
year old with cyanotic CHD or hemodynamically
significant acyanotic CHD (requiring meds) if you need meds to control, that’ hemodynamically significant
– Given in 5 doses beginning with start of season
– Give anytime after OR
• Flu shot also recommended for those over 6mo
• Regular immunizations given on schedule
What is the Norwood procedure and what is it for?
- Used for patients with Hypoplastic Left Heart Syndrome
- Connect PA to aorta, augment the aortic arch, create atrial septal defect and place a shunt from right subclavian to RPA or Sano shunt from RV to PA
- Usual saturations 75-85%
When is the Norwood performed?
1-2 weeks
What is the modified Blalock-Thomas-Taussig shunt
- Done in patients with inadequate pulmonary blood flow who cannot undergo complete correction as an initial procedure
- Usual saturations 75- 85%
What is the operation performed on TGA?
• Arterial switch operation (TGA)
– Usual saturations 100%
Complications of Fontan’s surgery?
Long-term Complications
• Arrhythmias
– Sinus node dysfunction
– Atrial flutter/SVT
• Cyanosis
– Collaterals
– Pulmonary AVM’s
- Protein Losing Enteropathy
- Plastic Bronchitis
- Thromboembolism
Surgeries for single ventricle?
- Glenn or Bidirectional cavopulmonary connection
(4-6mo)
– SVC to RPA
– Expected sats75-85%
• Fontan or Total cavopulmonary connection (2-4 years)
– IVC to RPA
– Expected sats >90% (usually)
Who needs ASA in Kawasaki disease?
Under the new guidelines, unless there was never a problem or if it completely resolves, ASA needs to be considered long-term
What are the two conditions that need to be met for needing SBE prophylaxis?
High Risk Lesion
+ High Risk Procedure
What are high risk lesions that need SBE prophylaxis?
Patients that have …
– A prosthetic heart valve or who have had a heart valve
repaired with prosthetic material.
– A history of endocarditis.
– A heart transplant with abnormal heart valve function
– Certain congenital heart defects including:
• Cyanotic congenital heart disease
• A congenital heart defect that’s been completely repaired with prosthetic material or a device for the first six months after the repair procedure.
• Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at or adjacent to a prosthetic patch or prosthetic device.
What are high risk procedures that need SBE prophylaxis?
- A dental procedure where the gums or lining of the mouth are likely to be injured (eg extraction or surgery)
• Usually not routine cleaning - ? scaling
• Gut or genitourinary surgery through an area
that is infected
What are the cyanotic congenital heart defects?
6T’s: – Transposition of the great arteries – Tetralogy of Fallot – Tricuspid atresia – Total anomalous pulmonary venous connections – Truncus arteriosus (common arterial trunk) – ‘Tingle’ Ventricle (Single ventricle) • 2A’s – Pulmonary atresia – Ebsteins anomaly
Management of cyanotic newborn?
Warm, sweet and pink (B Sinclair)
• ABC + iv access
• Transillumination and CXR
• Labs: CBC/diff, Ca, Mg, glucose, gas, cultures
• Maintain normothermia
• Correct hypoglycemia and acidosis
• Start antibiotics if sepsis a concern (usual)
• If no response to O2 and no other cause obvious, start prostaglandin (0.05mcg/kg/min)
– Monitor continuously for apnea
– Intubate if necessary
• Urgent consult - cardiology (CALL
What findings on history would make you suspicious of pericarditis?
History – More common in older children – Sharp, stabby or squeezing chest pain – Better sitting, worse lying down – Often pleuritic
What exam findings make you suspicious of pericarditis?
Exam
– Pericardial friction rub
– Narrow pulse pressure
– Pulsus paradoxus >15mmHg
What investigations would make you think about pericarditis?
Investigations
ECG: 4 stages. ST elevation/PR depression, T wave flattening, T wave inversion, resolution
CXR-worry if big heart
Echocardiogram
Management of pericarditis?
Management – ABC’s
– If stable: NSAIDS (naproxen or ibuprofen) with regular echo f/u
– Steroids if persistent
– Pericardial tap if evidence of tamponade or persistent on meds
– Antibiotics if suppurative pericarditis suspected (uncommon and very sick)
What is congestive heart failure?
– Inability of the heart to pump enough blood to meet the body’s needs
– Results in loss of equilibrium between hydrostatic and osmotic pressures in the tissues, thus causing “congestion”
What are the main causes of CHF during the first week of life?
First Week of life: Obstructions primarily – Hypoplastic Left Heart Syndrome (d 3-5) – Severe aortic stenosis – Coarctation(d7-10) • Asphyxia • Severe mitral or tricuspid regurgitation • Uncontrolled tachycardias (eg SVT>24h)
What are the main causes of CHF weeks 2-6
Week 2-6: Left to right shunts primarily • Ventricular Septal Defects (VSD) • Atrioventricular Septal Defects (AVSD) • PDA • NOT ASD
What are the main causes of CHF in older children?
Older Children - “Pump failure”
• Dilated Cardiomyopathy
• Myocarditis
• Tachycardias
Three main symptoms of CHF in children?
- Tachycardia
- Tachypnea
- Hepatomegaly
Treatment of CHF?
• Supportive:
– head-up position (decrease respiratory distress)
– tube feeds (decrease work for heart)
– high calorie formula (increase growth, limit free water)
– salt restriction (in older children- avoids excess preload)
– fluid limitation (if severe)
• Medication:
– Improve contractility
• Dopamine, dobutamine, milrinone, epi, norepi
– Decrease preload or filling of the heart
• Diuretics(serialtubular block)
– Decrease afterload
• ACE inhibitors, angiotensin receptor blockers
– Minimize ongoing damage
• Beta blockers
• Surgery
What arrhythmia is associated with deafness?
Long QT
Are Osler nodes tender or non tender?
tender!
O=Ow
Are Janeway lesions tender or non tender
non tender!
What are some term findings of infective endocarditis?
Janeway lesions
Osler nodes
Splinter hemorrhages
thromboembolism
Symptoms of infective endocarditis?
Fever
Malaise and endurance fatigue
A new or changing heart murmur
weight loss
coughing
Vascular phenomena: septic embolism, Janeway lesions, bleeding in the brain, conjunctival hemorrhage, splinter hemorrhages, kidney infarcts, and splenic infarcts.
Infective endocarditis can also lead to the formation of mycotic aneurysms.
Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots on the retina, positive serum rheumatoid factor
Other signs may include night sweats, rigors, anemia, spleen enlargement
What are Aschoff bodies associated with?
Rheumatic fever
How do you make the diagnosis of rheumatic fever?
Need 2 major or 1 major and 2 minor criteria for new Dx
Major diagnostic criteria – Carditis – MR, AI (clinical OR echo-based) – Polyarthritis – Chorea – Subcutaneous nodules – Erythema marginatum
Minordiagnostic criteria
– Fever (>38.5 for low risk)
– Polyarthralgia (low risk)
– Prolonged PR interval on ECG (if carditis not Major)
– Elevated acute-phase reactants (ESR>60, CRP>3mg/dL)
