Cardiology in Kids

Question 1

Talk through a cardiac assessment, what investigations would you order? What is the gold standard?

Answer 1

• Hx
• Ex
  
  • Growth
  • Respiratory pattern
  • Liver size
  • Precordial palpation – active, heave, thrill…
  • Heart sounds – Physiologically split S2
  • Femoral pulse
  • Murmurs
• Ix
  
  • ECG
  • Echo (best modality)
    
    • Advantages:
      
      • See them well unlike adults with adipose/skeletal/muscle - children thing
      • Main imaging modality
      • Small size + thin chest wall mean we can see a lot more than in adults
  • High-res CT
  • Cardiac catheterisation
  • Cardiac MRI

Question 2

What is an innocent murmur likely to sound like? What are some aspects on an innocent murmur?

Answer 2

• Hx/Ex otherwise normal
• soft early to mid systolic
• LLSE with minimal radiation (Still’s murmur)
• softer when erect (varies with respiration)
• normal physiological split S2
• no additional sounds

Question 3

What is congenital heart disease? What are the types?

Answer 3

• not common - <1%
• Types:
  
  • VSD (ventricular septal defect) - 1/3
    
    • pansystolic LLSE
    • no symptoms in first few days, will go on to develop in first few weeks
    • Mg: surgical closure + diuretics/ACE I (reduces SVR)
  • Shunt lesions
    
    • ASD (atrial septal defect)
      
      • increased flow against pulmonary valve. Normal S2 id delayed - FIXED splitting (normal respiratory variation gone)
    • PDA (patent ductus arteriosus)
      
      • normal in newborns, depends on size
  • cyanotic
    
    • transposition of great arteries
    • TOF
      
      • decreased pulmonary blood flow
      • 4 findings:
        
        • VSD
        • abnormal RV outflow
        • overriding aorta
        • RVH

Question 4

What murmurs are more likely to be pathological?

Answer 4

• pansystolic
• early to mid systolic click
• instensity >3/6 (subjective) and harsh
• point of maximal intensity at the LUSB
• abnormal S2 (hard to detect)

Question 5

What are some features of VSDs?

Answer 5

• pansystolic murmur at LLSE
• no symptoms in the first few days, will develop in the first couple of weeks. (pulmonary vascular resistance falls)

Question 6

Shunt lesions, what are they and what do they result in?

Answer 6

• disease of increased pulmonary blood flow related to the shunt.
• Increased WOB and RR
• high energy expenditure and FTT
• e.g. VSD, ASD, PDA, obstructive lesions (e.g. coarctation of aorta).

Question 7

What are the signs and symptoms of cyanotic heart lesions?

Answer 7

• plethoric symptoms
  
  • cyanosis
  • skin colour change
  • neurological depression

Question 8

What are the signs and symptoms of acyanotic heart disease?

Answer 8

• feeding difficulties
• failure to thrive
• sweaty
• at 6 weeks AVSD generally presents (gets withing the first two months)
  
  • not at birth because the left to right ventricular pressure is increased which means the shunt is less big.

Question 9

How would you describe a murmur? Describe some murmurs?

Answer 9

1. heart sounds (normal abnormal)
2. grade of the murmur (1-3 no thrill, 4-6 thrill)
3. timing
4. when is it maximal?
5. position

Question 10

Talk through the types of heart disease in children and how to differentiate them?

Answer 10

• Congenital
  
  • cyanotic
    
    • RV outflow obstruction
      
      • TOF (tetralogy of fallot - where there is a VSD, overarching aorta, and RV hypertrophy).
      • pulmonary atresia
    • Mixed:
      
      • transposition of the great arteries
      • truncous arteriosus
      • univentricular heart tetral
  • acyanotic
    
    • Left to right shunt
      
      • VSD
      • PDA
      • ASD
    • LV outflow obstruction
      
      • aortic stenosis
      • coarctation of the aorta
      • pulmonary stenosis
• Acquired
  
  • RHD
  • Endocarditis
  • myocarditis/pericarditis
  • cardiomyopathy
  • Kawasaki

Question 11

A 7 year old boy presents with cough and coryza and is diagnosed with URTI. On exam he has an ESM at the LLSE 3/6. He is not cyanotic.

What is the likely cause of the murmur?

1. flow murmur
2. aortic stenosis
3. mitral regurg
4. ASD
5. VSD

Answer 11

E - VSD - pansystolic murmur

Innocent Murmurs:

• Still’s murmur - most common innocent (vibratory) murmur - early-mid systolic, LLSE, crescendo-decrescendo, 2-6years.
• Pulmonary flow murmur - ESM, LUSE, medium to high pitch, DDx ASD or Pul stenosis - need to Ix
• Branch pulmonary stenosis - <6mths infant, radiates to axilla and back (vs Pul flow murmur), ESM medium-high pitch, LUSE
• Venous hum - low pitch continous - ULSE/URSE - louder when standing, quieter when head turned away, infraclavicular.

VSD:

• Pansystolic murmur LLSE

ASD:

• fixed splitting

Aortic stenosis:

• 4th heart sound in late diastole

Mitral Regurg:

• 5th ICS pansystolic