Cardiology

Question 1

What are the most common congenital heart lesions and how do they present?

Answer 1

Left to right shunts (breathless)
-Ventricular septal defect
-Persistent ductus arteriosus
-Atrial septal defect
Right to left shunts (blue)
-Tetralogy of Fallot
-Transposition of the great arteries
Common mixing (breathless and blue)
-AV septal defect

Question 2

What are the 3 shunts that exist in the fetal circulation?

Answer 2

The ductus arteriosus allows blood from the pulmonary artery to flow into the aorta
The foramen ovale allows blood from the right atrium to skip the lungs and flow into the left atrium
The ductus venosus allows oxygenated blood from the placenta to skip the liver and flow into the inferior vena cava

Question 3

What changes occur to the fetal circulation at birth and why?

Answer 3

There is a decrease in vascular resistance in the lungs as the first breath opens them up
This causes a fall in pressure in the right atrium causing the formaen ovale to shut due to pressure being higher in the left atrium
Oxygenated blood causes a fall in prostaglandin levels which causes the ductus arteriosus to close
The ductus venosus closes when the umbilical cord is clamped

Question 4

What are the characteristics of innocent flow murmurs?

Answer 4

Soft
Short
Systolic
Symptomless
Situation dependent

Question 5

What are the key investigations when a murmur is heard?

Answer 5

ECG
Echo
CXR

Question 6

What are the differentials for pan systolic murmurs in children?

Answer 6

Mitral region - mitral regurge
Tricuspid region - tricuspid regurge
Ventricular septal defect is heard loudest at the left lower sternal border

Question 7

What are the differentials for ejection systolic murmurs in children?

Answer 7

Aortic region - Aortic stenosis
Pulmonary region - pulmonary stenosis
Hypertrophic obstructive cardiomyopathy - heard loudest in the 4th intercostal space left sternal border

Question 8

What murmur is heard with an atrial septal defect?

Answer 8

It causes a midsystolic crecendo decrecendo murmur
There is also fixed splitting of the second heart sound due to increased filling of the right atrium and ventricle causing delayed closure of the pulmonary valve

Question 9

What murmur is heard in patent ductus arteriosus?

Answer 9

It causes a continous machinery murmur

Question 10

What murmur is heard in tetralogy of fallot?

Answer 10

The pulmonary stenosis causes an ejection systolic murmur that is heard loudest over the left upper sternal border

Question 11

Why will patients with transposition of the great arteries always be cyanotic?

Answer 11

Because the right heart pumps deoxygenated blood directly into the aorta and into circulation

Question 12

Why do right to left shunts cause cyanosis?

Answer 12

Because the blood bypasses the lungs so it is not oxygenated

Question 13

At what age does the ductus arteriosus close?

Answer 13

1-3 days after birth it stops functioning

At 2-3 weeks it fully closes

Question 14

What are the consequences of a patent ductus arteriosus?

Answer 14

Blood flows from the aorta into the pulmonary artery
This increased pressure causes pulmonary hypertension and right heart strain leading to right ventricular hypertrophy
Increased blood flowing through the pulmonary vessels leads to left ventricular hypertrophy

Question 15

What presenting feautres does a patent ductus arteriosus cause?

Answer 15

Leads to breathlessness
Difficulty feeding
Poor weight gain

Question 16

How is patent ductus arteriosus diagnosed?

Answer 16

Echo with doppler flow can be used to identify

Question 17

What is the management of patent ductus arteriosus?

Answer 17

It is usually monitored by ultrasound for 1 year, after this point is is unlikely to close by itself so it is done surgically

Question 18

What is the pathophysiology in atrioseptal defects?

Answer 18

As the pressure is higher in the left atrium the blood shunts to the right atrium therefore there is no cyanosis
This leads to right heart sided overload and failure with pulmonary hypertension

Question 19

What is eisenmenger syndrome?

Answer 19

This is when a left to right shunt causes right sided failure and pulmonary hypertension which eventually causes the right sided pressure to be higher
The blood then starts tot shunt from right to left causing cyanosis because the lungs are missed out

Question 20

What abnormality are patients likely to have if a DVT causes a stroke rather than a PE?

Answer 20

An atrial septal defect

Question 21

What genetic conditions are ventricular septal defects commonly associated with?

Answer 21

Down’s syndrome and Turner’s syndrome

Question 22

Why are patients with eisenmonger syndrome more likely to develop clots?

Answer 22

They are cyanotic due to the deoxygenated blood shunting right to left, this leads to increased RBC production and polycythaemia

Question 23

What is the management of eisenmonger syndrome?

Answer 23

The only definitive management is heart and lungs transplant
Other management includes:
Treatment of pulmonary hypertension, for example using sildenafil
Treatment of arrhythmias
Treatment of polycythaemia with venesection
Prevention and treatment of thrombosis with anticoagulation
Prevention of infective endocarditis using prophylactic antibiotics

Question 24

What is the presentation of coarctation of the aorta?

Answer 24

There will be weak femoral pulses
A systolic murmur under the left clavicle
Breathlessness
Poor feeding

Question 25

What is the presentation of aortic stensosis?

Answer 25

It presents with symptoms of outflow obstruction
Dizziness and fainting
Fatigue
Shortness of breath
Worse on exertion

Question 26

What are the examination findings of aortic stenosis?

Answer 26

Ejection systolic murmur heard loudest at the right sternal border radiating to the carotids
Slow rising pulse and narrow pulse pressure
Palpable systolic thrill

Question 27

What is the treatment of aortic stenosis?

Answer 27

Percutaneous baloon valvoplasty
Surgical aortic valvotomy
Valve replacement

Question 28

What are the 4 features of tetralogy of fallot?

Answer 28

ventricular septal defect
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy

Question 29

What kind of shunt occurs in tetralogy of fallot? what symptoms does this cause?

Answer 29

Because of the right ventricular hypertrophy there is a right to left shunt resulting in cyanosis as blood is bypassing the lungs

Question 30

What are the signs and symptoms of tetralogy of fallot?

Answer 30

Cyanosis
clubbing
difficulty feeding
poor weight gain
ejection systolic murmur over left sternal border
tet spells - temporary episode where pulmonary valve closes off and shunting becomes worse

Question 31

What is the management of tet spells?

Answer 31

Trying to calm the child down
Older children can squat to increase systemic vascular resistance
IV fluids and beta blockers can be given

Question 32

What is ebstains anomoly?

Answer 32

There is a larger right atrium and a smaller right ventricle

There is often a right to left shunt through an atrial septal defect

Question 33

What is transposition of the great arteries?

Answer 33

This is where the aorta and pulmonary arteries are swapped leading to two independent circulations that do not mix

Question 34

What is the presentation of transposition of the great arteries? How is it treated?

Answer 34

It causes cyanosis
It is treated surgically by opening the foramen ovale to allow mixing of the blood
More definitively open heart surgery is conducted to swap the arteries back