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Yr 4 - Paediatrics > Cardiology: Congenital Heart Disease > Flashcards

Cardiology: Congenital Heart Disease Flashcards

1
Q

What are the 3 acyanotic lesions?

A

1) Ventricular septal defects (VSD)

2) Atrial septal defects (ASD)

3) Patent ductus arteriosis (PDA)

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2
Q

What is seen in acyantoic cardiac lesions?

A

There is left to right shunting, mixing of oxygenated blood with deoxygenated blood.

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3
Q

How is pulmonary blood flow affected in acyanotic lesions?

What is there a risk of?

A

Increased pulmonary blood flow –> risk of pulmonary HTN and untreated acyanotic heart disease can lead to Eisenmenger syndrome.

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4
Q

What can untreated acyanotic heart disease lead to?

A

Eisenmenger syndrome.

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5
Q

What type of murmur do acyanotic lesions ABOVE the level of the nipple give rise to?

A

usually give rise to ejection systolic murmurs

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6
Q

What type of murmur do acyanotic lesions BELOW the level of the nipple give rise to?

A

typically cause pan systolic murmurs

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7
Q

Typical symptoms seen in the different sizes of VSD:

1) small
2) moderate
3) large

A

1) may be asymptomatic, normal growth

2) poor feeding, failure to thrive (FTT), short of breath (SOB)

3) poor feeding, FTT (falls below centiles), SOB, sweaty and pale with feeds

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8
Q

What is the most common congenital heart lesion?

A

VSD

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9
Q

What genetic condition is VSD associated with?

A

Down’s syndrome

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10
Q

When is VSD typically diagnosed antenatally?

A

Scan at 16-18 weeks

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11
Q

When does VSD typically present after birth?

A

1) Presentation at 6-8 weeks

2) Congestive heart failure typically presents after 4-6 weeks

3) Persistent pulmonary hypertension of the newborn (PPHN) may become established by 6-12 months

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12
Q

Clinical findings in VSD?

A

Palpate:
- Check for the presence of a thrill
- Might be useful to palpate the liver (enlarged in heart failure)

Auscultate:
- Pan-systolic murmur heard loudest at the lower left sternal border (LLSB)
- Typically grade 3-4
- Loud P2 suggests the presence of pulmonary hypertension

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13
Q

What murmur is typically heard in VSD?

A

Pan-systolic murmur heard loudest at the lower left sternal border (LLSB).

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14
Q

Investigations in VSD?

A

1) O2 sats

2) Echo: visualise defect directly

3) CXR

4) ECG

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15
Q

What may an ECG show in VSD?

A

If severe –> cardiomegaly and pulmonary oedema (increased pulmonary vascular markings) due to presence of heart failure.

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16
Q

What may an ECG show in VSD?

A

Moderate or large VSD –> may demonstrate LV hypertrophy (LVH)

Elevated RV pressure –> may demonstrate RV hypertrophy (RVH)

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17
Q

How does left ventricular hypertrophy manifest on an ECG?

A

Increased voltage in V5 and V6 or leads II, III, and aVF.

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18
Q

How does right ventricular hypertrophy manifest on an ECG?

A

Often manifests as tall R waves in leads V4R and V1, or upright T waves in these leads.

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19
Q

Management of small VSD lesions (<5mm)?

A

< 5mm usually close spontaneously, no repair required (30-40%)

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20
Q

Management of moderate VSD lesions?

A

1) Diuretic therapy (furosemide and spironolactone)

2) Feeding with high caloric feeds (Infantrini)

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21
Q

Management of large VSD lesions?

A

1) Manage as per moderate lesion

2) Optimise weight gain for surgery

3) Schedule for surgery before 12 months to prevent persistent pulmonary hypertension of the newborn (PPHN)

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22
Q

What is the 2nd most common acyanotic heart lesion?

A

Atrial septal defect (ASD)

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23
Q

Typical symptoms seen in ASD?

A

1) Typically asymptomatic

2) Some children will have recurrent chest infections

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24
Q

What is the mean age of ASD diagnosis?

A

The mean age of diagnosis is 4.5 years from an incidental finding of murmur.

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25
Q

When does symptomatic presentation of ASD typically occur?

A

Symptomatic presentation is usually before the age of 40 years with arrhythmias, dyspnoea.

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26
Q

Potential auscultation findings in ASD?

A

May also have no auscultatory finding in infants (asymptomatic).

1) Ejection systolic murmur heard loudest at the upper-left sternal border

2) Widely fixed splitting of the second heart sound (L→ R shunting increases RV filling, thus RV ejection time is increased and pulmonary valve closure is delayed for a significant amount of time after aortic valve closure)

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27
Q

What murmur is heard in ASD?

A

Ejection systolic murmur heard loudest at the upper-left sternal border.

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27
Q

What causes a fixed splitting of the 2nd heart sound in ASD?

A

L→ R shunting increases RV filling, thus RV ejection time is increased and pulmonary valve closure is delayed for a significant amount of time after aortic valve closure.

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28
Q

Investigations & their findings in ASD?

A

1) Pulse oximetry

2) ECHO – visualise defect directly, shows dilated RV and increased RV filling and ejection time

3) CXR – usually no findings

4) ECG – incomplete RBBB

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29
Q

What will an ECHO show in ASD?

A

Shows dilated RV and increased RV filling and ejection time

30
Q

What may an ECG show in ASD?

A

Incomplete RBBB

31
Q

Management of ASD?

A
  • Most children are asymptomatic and rarely require congestive heart failure (CHF) therapy
  • Spontaneous closure in lesions smaller than 7-8mm
  • Large defects require repair – percutaneous (catheter closure) or surgery using median sternotomy incision
32
Q

What size ASD typically spontaneously close?

A

<7-8 mm

33
Q

Symptoms of a patent ductus arteriosus?

1) small
2) moderate
3) large

A

1) asymptomatic

2) congestive heart failure with failure to thrive (poor feeding)

3) poor feeding, severe failure to thrive, recurrent lower respiratory tract infections (preterm infants may experience failure to wean from ventilation)

34
Q

What is the major risk factor for PDA?

A

Preterm birth

35
Q

When do symptoms of PDA typically present?

A

Symptoms usually present 3-5 days after birth when the duct begins to close

36
Q

Cardiac exam features in PDA?

A

Palpate:
- Might be useful to palpate the liver (enlarged in heart failure)
- Bounding pulses and wide pulse pressure

Auscultate:
- Continuous machinery murmur typically heard at the upper-left sternal border (best heard below left the clavicle)
- Check for the presence of a thrill at the upper left sternal border

37
Q

What murmur is typically heard in PDA?

A

Continuous machinery murmur typically heard at the upper-left sternal border (best heard below left the clavicle).

38
Q

Management options in PDA?

A

If preterm – good probability of spontaneous closure

If term – less likely to close spontaneously

Medical –> indomethacin/ibuprofen (not effective in term infants)

Surgical – catheter closure or PDA ligation (left lateral thoracotomy incision) when weight is at least 5kg

39
Q

What happens in coarctation of the aorta?

A

There is obstruction to the left ventricles outflow tract that leads to an increase in left ventricular afterload –> causes left ventricular hypertrophy.

40
Q

What genetic condition is coarctation of the aorta often assoicated with?

A

Turner’s syndrome (5-15% of girls with coarctation)

41
Q

When do symptoms of coarctation of the aorta typically present?

A

Symptoms present 3-5 days after birth when the duct begins to close as the PDA and foramen ovale allows blood to bypass the outflow obstruction.

42
Q

Exam findings in coarctation of the aorta?

A

1) Systolic blood pressure is high when measured with BP cuff

2) Absent femoral pulses (do 4-limb BP measurement)

3) Cold extremities (especially feet)

4) Hepatomegaly in heart failure due to severe coarctation

5) Murmur heard at the back between the scapulae

43
Q

Location of murmur in coarctation of aorta?

A

Murmur heard at the back between the scapulae

44
Q

Medical management of coarctation of the aorta?

A

1) Continuous IV infusion of prostaglandin E1 to keep the ductus arteriosus open

2) Dopamine or Dobutamine to improve contractility in those with heart failure

3) Supportive care to correct metabolic acidosis, hypoglycemia, respiratory failure, and anaemia that may contribute to or be a consequence of heart failure

45
Q

Surgical repair options in coarctation of aorta?

A
  • Balloon angioplasty
  • Resection with end-to-end angioplasty
  • Bypass graft
  • Subclavian flap
46
Q

What do cyanotic lesions occur as a result of?

A

Occur due to the mixing of deoxygenated blood with oxygenated blood (right → left shunt).

47
Q

The differentials of cyanotic lesions can remembered by the ‘6 Ts’.

What are they?

A

Tetralogy of Fallot

Transposition of great arteries

Truncus arteriosus

Total anomalous pulmonary venous connection

Tricuspid valve abnormalities

Ton of others – hypoplastic left heart, double outlet right ventricle, pulmonary atresia

48
Q

What 4 abnormalities are seen in Tetralogy of Fallot (ToF)?

A

1) Ventricular septal defect
2) Overriding aorta
3) Pulmonary stenosis
4) Right ventricular hypertrophy

49
Q

Symptoms of ToF?

A

1) Cyanosis
2) Poor feeding
3) Sweating during feeds

50
Q

When does ToF typically present?

A

During the neonatal period when the patent ductus arteriosus begins to close (day 3-5)

51
Q

Clinical findings in ToF?

A

1) Cyanotic “tet” spells

2) Murmur may be present due to right ventricular outflow tract obstruction (RVOTO) caused by pulmonary stenosis and not VSD.

52
Q

What murmur is heard in ToF?

A

Crescendo-decrescendo with a harsh ejection systolic quality, heard loudest over the upper-left sternal angle with posterior radiation.

53
Q

What is the murmur caused by in ToF?

A

Caused by right ventricular outflow tract obstruction (RVOTO) caused by pulmonary stenosis and not VSD

54
Q

What causes a tet spell?

A

Cyanotic “tet” spells due to increased RV to LV shunt due to pulmonary stenosis causing RV outflow tract obstruction

55
Q

Investigations in ToF?

A

1) ECG

2) CXR

56
Q

ECG findings in ToF?

A

Shows right atrial enlargement and right ventricular hypertrophy (right axis deviation, prominent R waves anteriorly and S waves posteriorly).

57
Q

CXR findings in ToF?

A

Classic “boot-shaped heart”, with a right aortic arch seen in 25% of patients

58
Q

Management of ToF in neonates with severe cyanosis?

A

Prostaglandin infusion to maintain patency of ductus and pulmonary flow until the time of surgical repair.

59
Q

Medical management of tet spells?

A
  • Knee to chest position to increase systemic vascular resistance and promote blood flow into the pulmonary circulation
  • Oxygen
  • Morphine
  • B-blockers
60
Q

What happens in transposition of the great arteries (TGA)?

A

The aorta arises from the RV and pulmonary artery from the LV, resulting in deoxygenated blood from the RV being circulated around the body.

61
Q

Symptoms of TGA?

A

1) Cyanosis
2) Poor feeding, sweating during feeds

62
Q

When does TGA typically present?

A

During neonatal period when the patent ductus arteriosus begins to close (day 3-5)

63
Q

Clinical findings of TGA?

A

1) Cyanosis
2) Tachypnea
3) Murmur

64
Q

What is the classic CXR finding in TGA?

A

classic “egg on a string” appearance

65
Q

Management of TGA?

A

1) Balloon atrial septostomy to increase mixing of the two circulatory systems

2) Arterial switch procedure

66
Q

What are the 3 types of innocent murmurs?

A

1) Still’s murmur

2) Venous hum

3) Turbulent flow in the pulmonary artery bifurcation

67
Q

What % of full-term neonates have a murmur?

A

25%

68
Q

Features of an innocent murmur? (10 S’s)

A

Soft
Systolic
Short
S1 and S2 normal
Symptomless
Special test (X-ray and ECG) normal
Standing/sitting vary with position
Sternal depression

69
Q

What is a Still’s murmur?

A

A soft vibratory murmur heard over the lower-left sternal border most frequently in childhood when there is normal blood flow and no cardiac lesion.

70
Q

What is a venous hum?

A

Continuous murmur heard loudest over the clavicles due to venous return from the head and neck, and this varies with position.

71
Q

What is a turbulent flow in pulmonary artery bifurcation?

A

A soft ejection systolic murmur caused by turbulent flow in the pulmonary artery (PA) bifurcation as the PA bifurcation and branches are small.

72
Q
A

Yr 4 - Paediatrics (78 decks)

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