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Year 4- Paediatrics > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What is the ductus venosus?

A

Shunt in the heart which connects umbilical vein to the inferior vena cava and allows blood to bypass the liver.

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2
Q

What is the Foramen OVALE?

A

Shunt connecting the right atrium with the left atrium and allows blood to bypass the right ventricle and pulmonary circulation.

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3
Q

What is the ductus arteriosus?

A

A shunt in the heart which connects the pulmonary artery with the aorta, allowing blood to bypass the pulmonary circulation.

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4
Q

At birth the Foramen ovale closes, what is it called once it closes?

A

Fossa ovalis

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5
Q

What is required to keep the ductus arteriosus open and what is it called when it closes?

A

Prostaglandins
Increased blood oxygenation causes a drop in circulating prostaglandins
When the ductus arteriosus closes it becomes the ligamentum arteriosum.

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6
Q

What does the ductus venosus become when it closes?

A

Ligamentum venosum

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7
Q

What are innocent murmurs?

A

They are also called flow murmurs, they are fast blood flow through areas of the heart during systole.

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8
Q

What are the typical features of innocent murmurs?

A 
Soft 
Short 
Systolic 
Symptomless 
Situation dependent (murmur gets quieter with standing or only appears when child is unwell)
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9
Q

What features of a murmur would be concerning?

A

Murmur louder than 2/6
Diastolic murmurs
Murmurs louder on standing
Other symptoms- failure to thrive, feeding difficulty, cyanosis, SOB

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10
Q

What are the key investigations to establish the cause of the murmur?

A

ECG
CXR
ECHO

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11
Q

What are the differentials for pan systolic murmur?

A

Mitral regurgitation heard at mitral area (fifth intercostal space, mid clavicular line)
Tricuspid regurgitation heard at the tricuspid area (fifth intercostal space, left sternal boarder)
Ventricular septal defect heard best at the left lower sternal border

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12
Q

What are the differentials for ejection systolic murmurs?

A

Aortic stenosis heard at the aortic area (2nd intercostal space, right sternal border)
Pulmonary stenosis heard at the pulmonary area (2nd intercostal space, left sternal border)
Hypertrophic obstructive cardiomyopathy (heard loudest at the fourth intercostal space on the left sternal border).

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13
Q

When May splitting of the second heart sound occur normally?

A

Normally occurs in inspiration when the pulmonary valve closes slightly later than the aortic valve.n

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14
Q

What murmur does an atrial septal defect cause?

A

Mid systolic crescendo decrescendo heard loudest at the upper left sternal border with a fixed split second heart sound.n

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15
Q

What would you hear with a patent ductus arteriosus?

A

A small patent ductus arteriosus May not cause any abnormal heart sounds, more significant PDAs will cause a continuous crescendo decrescendo machinery murmur which may count in us during the second heart sound, making it more difficult to hear.

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16
Q

What are the 4 defects found in tetralogy of fallot?

A

Pulmonary stenosis
Over-riding sorta
Abnormal enlargement of right ventricle
Ventricular septal defect

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17
Q

What is the murmur in teratology of fallot?

A

Arises from the pulmonary stenosis
Gives an ejection systolic murmur which is loudest Atheroma pulmonary area (second intercostal space, left sternal border).

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18
Q

What are the heart defects which cause cyanosis heart disease?

A

Transposition of the great arteries, teratology of fallot

AVSD, truncus arteriosus, hypoplastic left heart, interrupted aortic arch

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19
Q

What is Eisenmenger syndrome?

A

So patients with PDA, VSD, ASD are usually not cyanotic. If the pulmonary pressure increases beyond the systemic pressure, blood flow from right to left across the defect, causing cyanosis this is called Eisenmenger syndrome.

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20
Q

Why will patients with transposition of the great arteries always have cyanosis?

A

The right side of the heart pumps blood directly into the aorta and systemic circulation.

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21
Q

How does a patent ductus arteriosus present?

A 
May not have any abnormal heart sounds 
May be discovered at birth due to murmur 
Shortness of breath 
Difficulty breathing 
Poor weight gain 
Lower respiratory tract infections
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22
Q

What murmur do baby’s with patent ductus arteriosus have?

A

Continuous crescendo decrescendo machinery murmur, which is continuous during the second heart sound, making the second heart sound more difficult to hear.

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23
Q

How do you diagnose patent ductus arteriosus?

A

Echocardiogram and using Doppler flow studies to assess the size and characteristics of the left to right shunt. Echo is also useful for assessing the effects of PDA on the heart.

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24
Q

What is the management of a PDA?

A

For the first year patients are monitored by echocardiograms.
After 1 year it is unlikely that the PDA will close spontaneously and trans catheter or surgical closure can be performed.

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25
Q

What is the pathophysiology behind an atrial septal defect?

A

Usually two walls which grow down from the top of the heart (septum primum and septum secondum) they grow down and fuse with the ENDOCARDIAL cushion in the middle of the heart to separate the atria, defects in these two walls leads to atrial septal defects. There is a small hole in the septum secondum called the foramen ovale, this normally closes at birth.

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26
Q

What are the types of atrial septal defect?

A 
Ostium secondum (septum secondum fails to close) 
Patent FORAMEN ovale 
Ostium primum (septum primum fails to close- leads to atrioventricular valve defect)
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27
Q

What are the complications of atrial septal defects?

A

Stroke in the context of VTE (bypasses lungs- so you don’t get a PE)
Atrial fib or atrial flutter
Pulmonary hypertension and right sided heart failure
Eisenmenger syndrome

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28
Q

What is the presentation of atrial septal defect?

A

ASDs cause a mid systolic crescendo decrescendo murmur heard at the left sternal border with a fixed second heart sound

Can be found on antenatal scans/newborn examinations

May be asymptomatic in childhood and present in adulthood with dyspnoea, heart failure, stroke.

SOB, difficulty feeding, poor weight gain, lower resp tract infections

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29
Q

What is the management of patients with ASD?

A

Patients should be referred to a paediatric cardiologist for ongoing management
In cases where the ASD is small and asymptomatic watch and waiting May be appropriate
ASDS can be corrected surgically using a trans venous catheter closure (via. Femoral vein) OR open heart surgery.
Anticoagulants such as: aspirin, warfarin and NOACS are used to reduce the risk of clots and strokes in adults.

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30
Q

What is the presentation of a ventricular septal defect?

A

Often symptomless And patients can present as late as adulthood
May be picked up on antenatal scans or when a murmur is heard during the newborn baby check

Typical symptoms include: poor feeding, dyspnoea, tachypnoea, failure to thrive.

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31
Q

VSDs can occur in isolation, however there is often underlying genetic conditions, what are VSDs most commonly associated with?

A

Down’s syndrome and turners syndrome

32
Q

What is the murmur heard when a patient has a ventricular septal defect?

A

Pan systolic murmur more prominently heard at the left lower sternal boarder in the third and fourth intercostal spaced.
There may be a systolic thrill on palpation.

33
Q

What are the causes of a pan systolic murmur?

A

Ventricular septal defect
Mitral regurgitation
Tricuspid regurgitation

34
Q

What is the treatment of VSD?

A

Similarly to ASD, small VSDs (<3mm) with no symptoms or evidence of pulmonary hypertension or heart failure can be watched over time. Often they close spontaneously or can be treated surgically at 3-6 months using a trans venous catheter closure via. The femoral artery or open heart surgery.
Heart failure can be treated with diuretics
There is an increased risk of infective endocarditis with VSD therefore ABx prophylaxis should be used in patients with VSD.

35
Q

What is Eisenmenger syndrome?

A

This is where there is a septal defect (which normally results in a flow of blood from left to the right) however the pulmonary pressure increases above the systemic pressure and blood begins to flow from the right side of the heart to the left across the septal defect.

36
Q

What happens as a result of cyanosis?

A

Low level of oxygen in the blood therefore the bone marrow responds to this low oxygen saturation by producing more red blood cells and haemoglobin to increase the oxygen carrying capacity in the blood. The high concentration of red blood cells and haemoglobin make the blood more viscous, making people more prone to thrombus formation.

37
Q

What are the examination findings for Eisenmenger syndrome?

A 
Pulmonary hypertension...
. Right ventricular heave 
. Loud second heart sound due to forceful shutting of the pulmonary valve 
. Raised JVP 
. Peripheral oedema

Murmurs relating to the underlying septal defect

Findings related to right to left shunt and chronic hypoxia
. Cyanosis
. Clubbing
. Dyspnoea
. Plethoric complexion (due to polycythaemia)

38
Q

What are the main causes of death with eisenmenger syndrome?

A

Infection
Heart failure
Dyspnoea
Plethoric complexion (a red complexion leads to polycythaemia)

39
Q

What is the management of eisenmenger syndrome?

A

Ideally the defect should be managed optimally or corrected surgically
Once the pulmonary pressure is high enough then it is not possible to medically reverse the condition and the only definitive option is a heart- lung transplant.

40
Q

What is coarctation of aorta?

A

This is the narrowing of the aortic arch, usually around the ductus arteriosus, the severity of the narrowing ranges from mild to severe and is often associated with an underlying genetic condition (like turners).

41
Q

What is the pathophysiology behind the problems caused by th3 coarctation of the aorta?

A

Narrowing of the aorta reduces the Pressure of blood flowing distal to the arteries that are distal to the narrowing. It increases the pressure in the areas proximal to the narrowing (heart and 3 branches of the aorta).

42
Q

What is the presentation of coarctation of aorta?

A

Severity dependent
Interrupted or severely narrowed arches present with neonatal collapse in the first few days of life

Less severe May only be picked up from hypertension is noticed or if the child has symptomatic hypertension (headaches, visual changes, Renal impairement).

43
Q

What is the management of coarctation of the aorta?

A

Depends on severity
Mild cases patients can live symptom free until adulthood without requiring surgical input

In a symptomatic neonate prostaglandin E1 (prostin) can be used to maintain patent ductus arteriosus, treat hypertension and urgent surgical repair.

In an asymptomatic child surgery is indicated in hypertension, CHF or collateral blood vessel formation. Medically manage hypertension and closely monitor for secondary organ damage.

44
Q

How many leaflets is the aortic valve normally made up of?

A

Three, called the aortic sinuses of valsalva, these allow blood to go from the left ventricle to the aorta but prevent blood flowing back to the left ventricle.

45
Q

How does aortic stenosis present?

A

Mild can be asymptomatic or found as an incidental murmur during a routine examination.
More significant can present with symptoms of fatigue, shortness of breath, dizziness and fainting. Symptoms are often worse exertion. Severe aortic stenosis will present with heart failure within months of birth.

46
Q

What is the sign of aortic valve stenosis?

A

Ejection systolic murmur heard loudest at the aortic area, second intercostal space right sternal border. The murmur has a crescendo decrescendo character and radiates to the carotids.

Ejection click just before murmur , palpable thrill during systole, slow rising pulse and narrow pulse pressure.

47
Q

What is the gold standard investigation for establishing a diagnosis of aortic stenosis?

A

Echocardiogram

48
Q

What is the management of aortic stenosis?

A

Congenital aortic stenosis tends to be a progressive conditions which worsens over time, patients will need regular follow up under a paediatric cardiologist with echocardiograms, ECGS and exercise testing to monitor the progression of the condition.

Options for treating the stenosis: percutaneous balloon aortic valvoplasty, surgical aortic valvotomy, valve replacement.

49
Q

What are the complications of aortic stenosis?

A 
Left ventricular outflow tract obstruction 
Heart failure 
Ventricular arrhythmia 
Bacterial endocarditis 
Sudden death, often on exertion.
50
Q

What is pulmonary valve stenosis?

A

When the three leaflets which make up the pulmonary valve develop abnormally and becomes,e thickened or fused, resulting in a narrow opening between the right ventricle and pulmonary artery.

51
Q

What are the symptoms of heart failure in the child?

A

Breathlessness (particularly on feeding or exertion)
Sweating
Poor feeding
Recurrent chest infections

52
Q

What are the signs of heart failure in a baby?

A 
Poor weight gain/faltering growth 
Tachypnoea 
Tachycardia 
Heart murmur (gallop rythm) 
Enlarged heart 
Hepatomegaly 
Cool peripheries
53
Q

What are the causes of heart failure in neonates?

A 
In the first week of life this usually results from a left heart obstruction 
Hypoplastic left heart syndrome 
Critical aortic valve stenosis 
Severe coarctation of the aorta 
Interruption of the aortic arch
54
Q

What are the causes of heart failure in infants?

A

VSD
ASD
Large persistent ductus arteriosus

55
Q

What is the cause of heart failure in older children?

A

Eisenmenger syndrome
Rheumatic heart disease
Cardiomyopathy

56
Q

Both pulmonary stenosis and aortic stenosis have ejection systolic murmurs, how would you distinguish between them?

A

Pulmonary stenosis defects are loudest over the pulmonary area while aortic stenosis is loudest over the aortic area.

57
Q

What are the heart sounds for ASD?

A

Fixed, split loud S2 sound

With potentially an ejection systolic murmur

58
Q

What is the examination finding in coarctation of aorta?

A

Weak or absent femoral pulses

59
Q

Why does Ventricular septal defect normally occur at around 3 months?

A

The amount of blood that moves across the defect depends on the pulmonary vascular resistance and the size of the defect.
In the first few months of life the pulmonary vascular resistance decreases and therefore more blood can move across.

60
Q

What are the risk factors for atrial septal defect?

A 
Female sex (2:1 F:M) 
Maternal alcohol intake in pregnancy 
Family history
61
Q

What would you see on an ECG of someone with ventricular septal defect?

A

Right axis deviation
Right BBB
Right ventricular hypertrophy

62
Q

What are the risk factors for coarctation of aorta?

A

Male sex

Turners

63
Q

What is pulmonary stenosis?

A

Any lesion which restricts outflow through the pulmonary area. It can be valvular (90% usually due to partial fusion or thickening of the valve leaflets), subvalvular (tetralogy of fallot) or supravalvular.

64
Q

What are the risk factors for pulmonary stenosis?

A

Family Hx
Noonan syndrome
Tetralogy of fallot

65
Q

How does pulmonary stenosis present?

A

Usually asymptomatic
If stenosis is critical, it will present in the neonatal period as cyanosis and circulatory collapse.
Older children with moderate will develop exertional dyspnoea and fatigue
Severe stenosis will result in heart failure

66
Q

What is the management of pulmonary stenosis?

A

Critical pulmonary stenosis is an indication for prostaglandin infusion and urgent transfer to a cardiac centre.
Balloon valvulopasty performed in severe or symptomatic stenosis
Surgery is indicated in subvalvular stenosis or those with valvular stenosis which is resistant to ballon dilatation.

67
Q

What are the causes of cyanotic heart disease?

A

Right to left shunts: transposition of the great arteries and tetralogy of fallot
Baby will not be breathless with reduced pulmonary blood flow

Mixed shunts: AVSD, truncus arteriosus

Outflow obstruction: hypoplastic left heart, interrupted aortic arch. When the ductus arteriosus closes the child will present in circulatory collapse leading to shock acidosis and sometimes death. Outflow obstructions are duct dependent, all the blood to the pulmonary and systemic circulation is via. The ductus arteriosus.

68
Q

What is the clinical sequelae of cyanotic heart disease?

A

Cyanosis
Clubbing
Hypoxic tet spells
Polycythaemia

69
Q

What are the causes of digital clubbing in children?

A

. Cystic fibrosis
. GI diseases-crohns, UC, coeliac
. Cyanotic heart disease
. TB

70
Q

What are the risk factors for teratology of fallot?

A 
Rubella in pregnancy 
Maternal age>40 
FH 
Maternal diabetes 
Maternal poor nutrition or alcohol intake during pregnancy
71
Q

What would be seen on an ECG of tetralogy of fallot?

A

Right axis deviation and right ventricular hypertrophy

72
Q

What would you see on the CXR of someone with tetralogy of fallot?

A

Boot shaped heart

73
Q

What is the management of teratology of fallot?

A

Surgical repair is typically performed around 6 months of age
Manage CHF and iron deficiency if present

Child May experience tet spells these are when the child has an acute drop in pulmonary blood flow and usually occur after an episode of rapid breathing and curing
Hold the child knee to chest to increase the venous return, give small morphine dose to settle rapid breathing and relax ventricular outflow tract, occasionally propranolol is needed.

74
Q

What is the pathophysiology of transposition of the great arteries?

A

The aorta arises from the right ventricle and the pulmonary artery from the left ventricle meaning there is entirely two separate circulations. Consequently there is an associated ASD/VSD or PDA to allow some mixing of the two systems.

Without this the child will present quickly with circulatory collapse, acidosis and death.

75
Q

What are the risk factors for TGA?

A

Male sex

Maternal diabetes

76
Q

How would a neonate with transposition of the great arteries present?

A

They would present unwell, tachypnoea, tachycardic, cyanotic and often hypoglycaemic. There will be no murmur, unless there is a VSD. S2 is loud and single.
There may be signs of heart failure (oedema, hepatomegaly)

77
Q

What is the management of transposition of the great arteries?

A

Prostaglandin infusion (maintains PDA)
Urgent transfer to cardiac centre
Those without a VSD require urgent balloon septostomy
Surgery is usually performed at 3 weeks of age (arterial switch procedure)

Year 4- Paediatrics (21 decks)

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