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Year 4 - Paediatrics > Cardiology - Heart Shunts > Flashcards

Cardiology - Heart Shunts Flashcards

1
Q

What are innocent murmurs?

A

AKA flow murmurs

Fast blood flow through heart during systole

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2
Q

What are the typical features of innocent murmurs?

A

Soft
Short
Systolic
Symptomless
Stressed
- Quieter when standing, only appears when child unwell or feverish

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3
Q

What features of murmurs would need further investigation and referral to a paediatric cardiologist?

A
  • Murmur louder than 2/6
  • Diastolic murmurs
  • Louder on standing
  • Failure to thrive
  • Feeding difficulty
  • Cyanosis or SOB
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4
Q

What investigations would you use to establish the cause of a murmur in children?

A

ECG
CXR
Echocardiogram

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5
Q

Which murmurs are pan-systolic and where are they best heard?

A

Mitral regurgitation
Mitral area, 5th ICS, mid-clavicular line

Tricuspid regurgitation
Tricuspid area, 5th ICS, left-sternal border

Ventricular septal defect
Left lower sternal border

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6
Q

Which murmurs are ejection-systolic and where are they best heard?

A

Aortic stenosis
Aortic area, 2nd ICS, right sternal border

Pulmonary stenosis
Pulmonary area, 2nd ICS, left sternal border

Hypertrophic obstructive cardiomyopathy
4th ICS, left sternal border

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7
Q

What causes splitting of the second heart sound?

A

Negative intra-thoracic pressure causes right side of the heart to fill faster as blood taken from venous system

Increased volume in RV causes it to take longer for RV to empty in systole

This causes a delay in the pulmonary valve closing

When pulmonary valve closes later than aortic valve, second heart sound is split

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8
Q

What are the signs of atrial septal defect?

A
  • Mid-systolic, crescendo decrescendo murmur
  • Loudest at upper left sternal border
  • Fixed split second heart sound
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9
Q

What is a fixed split second heart sound?

A

Second heart sound does not change with inspiration and expiration

Blood flows from LA into RA

Increased volume in RV before pulmonary valve can close

Does not vary with respiration

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10
Q

What murmur is heard in patent ductus arteriosus?

A

Small may not cause any sounds

Large PDAs cause normal first heart sound with continuous crescendo-decrescendo machinery murmur

Can continue during second heart sound making the second harder to hear

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11
Q

What murmur is heard in tetralogy of fallot?

A

Ejection systolic, heard best in the pulmonary area 2nd ICS, left sternal border

This is due to the pulmonary stenosis

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12
Q

When does cyanotic heart disease occur?

A

When blood is able to bypass pulmonary circulation and lungs

Right-to-left shunt

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13
Q

What heart defects can cause a right-to-left shunt?

A

Ventricular septal defect
Atrial septal defect
Patent ductus arteriosus
Transposition of the great arteries

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14
Q

When does blood flow from the right to the left in a shunt?

A

If pulmonary pressure increases beyond systemic pressure causes increased RA pressure

LA pressure < RA pressure

Blood now flows from the right to the left - Eisenmenger syndrome

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15
Q

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

A

Right side of the heart directly pumps blood into aorta and systemic circulation

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16
Q

When does the ductus arteriosus stop working and when does it close?

A

1-3 days post birth

Seals completely 2-3 weeks into life

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17
Q

What infection causes PDA?

A

Rubella

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18
Q

What is a big key risk factor for PDA?

A

Prematurity

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19
Q

How can asymptomatic patients suddenly present during adulthood?

A

Heart failure signs

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20
Q

What is the pathophysiology in PDA?

A

Aorta Pa > Pulmonary vessel Pa

Blood flows from aorta to pulmonary artery

Left to right shunt

Increased pressure in pulmonary vessels causing pulmonary hypertension - right sided heart strain as RV struggles to contract against increased resistance

Pulmonary hypertension and right sided heart strain causes right ventricular hypertrophy

Increased blood flowing through pulmonary vessels and returning to left side of heart then causes left ventricular hypertrophy

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21
Q

How does PDA present?

A
  • May have continuous crescendo-decrescendo machinery murmur
  • SOB
  • Difficulty feeding
  • Poor weight gain
  • LRTI
22
Q

What investigations are used for PDA?

A

Echocardiogram
Doppler flow studies to assess size of left to right shunt
Echo also assesses effects on the ventricles

23
Q

How are PDAs managed?

A

Monitored using echocardiograms until 1 year

After 1 year, highly unlikely PDA will close

Trans-catheter or surgical closer can be performed

24
Q

When are patients with PDA treated before 1 year?

A

Evidence of heart failure or symptomatic

25
Q

What is the pathophysiology of atrial-septal defects?

A

Septum grows downwards from top of the heart downwards towards endocardial cushion and fuse to separate atria

Forms Septum primum and Septum secondum

Defects in these septa causes atrial septal defects

Foramen ovale is present in septum secondum, closes after birth

26
Q

What are the different types of atrial septal defects, most to least common?

A

1) Ostium secondum
Septum secondum
2) Patent foramen ovale
Foramen ovale
3) Ostium primum
Septum primum, AV valve defects, atrioventricular septal defect

27
Q

What are the complications of atrial septal defects?

A

Stroke
AF or atrial flutter
Pulmonary hypertension and right sided heart failure
Eisenmenger syndrome

28
Q

How can strokes occur in patients with ASD?

A

If a patient has a large DVT that breaks off

Usually will go to the right-side of the heart and enter the pulmonary circulation causing a PE

If there has been a life-long asymptomatic ASD, this embolus can enter the left side of the heart and travel to the brain causing a large stroke

29
Q

How do ASDs present?

A
  • Mid-systolic, crescendo-decrescendo murmur, heart loudest at upper left sternal border
  • Fixed split second heart sound
  • SOB
  • Difficulty feeding
  • Poor weight gain
  • LRTIs
30
Q

What causes fixed split second heart sound in ASDs?

A

LA Pa > Ra Pa

Blood flows from left to right

Increased volume in RV, takes longer for pulmonary valve to close during systole, causing a splitting sound

31
Q

How are ASDs managed?

A

Referral to paediatric cardiologist

If small and asymptomatic, watchful waiting

Transvenous catheter closure (via femoral vein)
Open heart surgery

32
Q

How are ASDs managed in adults?

A

Anticoagulants e.g. aspirin, warfarin and NOACs

To reduce clot and stroke risk

33
Q

What conditions are VSDs associated with commonly?

A

Down’s syndrome
Turner’s syndrome

34
Q

Why don’t patients with VSD become cyanotic?

A

LV Pa > RV Pa

Blood flows from left to right

35
Q

What does a left to right shunt lead to?

A

Right sided overload
Right heart failure
Pulmonary hypertension

36
Q

What can happen after a long period of time in VSDs?

A

Pulmonary hypertension

Pressure in right side of the heart becomes greater than life

Blood shunted from right to left, leading to cyanosis

37
Q

How do VSDs present?

A

Poor feeding
Dyspnoea
Tachynpoea
Failure to thrive

Can be picked up on antenatal scans or if a murmur is heard during new-born baby check

38
Q

What murmur do patients with VSD typically have?

A

Pan-systolic, heard at left lower sternal border

3rd and 4th ICS

Systolic thrill on palpation

39
Q

How are VSDs treated?

A

Dealt with by paediatric cardiologist

Small VSDs with no symptoms watched over time, they can close spontaneously

Transvenous catheter closure via femoral vein
Open heart surgery

40
Q

What should be given during surgical procedures to patients with VSDs?

A

Antibiotic prophylaxis

Higher risk of infective endocarditis

41
Q

When does Eisenmenger syndrome occur?

A

When blood flows from the right to the left of the heart

42
Q

What lesions can cause Eisenmenger syndrome?

A

Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus

43
Q

How long does it take Eisenmenger syndrome to develop?

A

1-2 years with large shunts

Adulthood with small shunts

Develops more quickly during pregnancy, so women with “hole in the heart” need regular echos and close monitoring

44
Q

What is the pathophysiology of Eisenmenger syndrome?

A

In shunt defects pressure in the left side of the heart is higher than the right

Blood flows from the left to the right

Over time extra blood flowing to the right side and lungs increases the pressure in the pulmonary vessels causing pulmonary hypertension

When pulmonary pressure exceeds systemic pressure blood flows from the right to the left, deoxygenated blood enters systemic circulation causing cyanosis

45
Q

What does cyanosis lead to?

A

Reduced oxygen saturation of the blood

Bone marrow produces more RBCs and Hb to increase oxygen capacity of the blood

This causes polycythaemia, leading to a plethoric complexion

46
Q

What are patients with polycythaemia more susceptible to?

A

Blood clots

Higher concentration of RBCs and Hb makes the blood more viscous

47
Q

What are the examination findings associated with pulmonary hypertension?

A

Right ventricular heave- RV contracts forcefully against increased pressure in lungs
Loud P2- forceful shutting of pulmonary valve
Raised JVP
Peripheral oedema

48
Q

What are the signs of right to left shunting or chronic hypoxia?

A

Cyanosis
Clubbing
Dyspnoea
Plethoric complexion

49
Q

What is the prognosis of Eisenmenger syndrome?

A

Reduced life expectancy by 20 years

Main causes of death :
- Heart failure
- Infection
- Thromboembolism
- Haemorrhage

Mortality up to 50% in pregnancy

50
Q

How is Eisenmenger syndrome managed?

A

Corrected surgically to prevent development

Once pulmonary pressure high enough, not possible to reverse it medically

Definitive treatment is heart-lung transplant, high mortality

  • Oxygen management- symptoms only, does not affect outcome
  • Sildenafil for pulmonary hypertension
  • Treat arrhythmias
  • Venesection for polycythaemia
  • Anticoagulation for thrombosis
  • Prophylactic abx for infective endocarditis

Year 4 - Paediatrics (150 decks)

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