Final Exam Flashcards
Caused by the closure of the mitral and tricuspid valves.
Loudest at the apex
S1
Caused by the closure of the aortic and pulmonic valves.
Loudest at the base.
S2
Diagnostic test: checks the rhythm, can tell you size of chambers
EKG
Diagnostic test: can see anatomy, ventricular function, valve function using high frequency sound waves
ECHO
Diagnostic test: assess vitals and EKG while you exercise
stress test
Diagnostic test: 24-48 hour EKG
holter
Diagnostic test: record arrhythmias when infrequent
Event Monitor
Diagnostic test: evaluation of anatomy and RV disease, flow measurements
CMR
Diagnostic test: adapted for coronary/vessel imaging, shorter time than MRI
CT
Diagnostic test: get heart pressures, images with contrast dye
cath
Diagnostic test: determine where arrhythmia is coming from
EP
3 acyanotic defects. Most children symptomatic or asymptomatic?
ASD, VSD, PDA
asymptomatic
Diagnosis?
Grade I-III systolic ejection murmur
Fixed Split S2, EKG: RBBB
ASD
What type of ASD is most common and how do you treat?
Ostium Secundum: transcatheter device closure
Is ASD more common in males or females?
females
Diagnosis?
Harsh, holosystolic murmur heard best at LLSB
EKG would show RVH and LVH if defect is large
VSD
If no lifts, heaves, thrills and there’s a Grade 3-4
high pitched, harsh murmur, VSD most likely ___
small
If there’s additionally a thrill and heave with a
mitral diastolic murmur indicates higher
pulmonary venous return, VSD likely ____
moderate
If there’s additionally precordium and sternum
prominence, VSD likely ___.
large
If VSD very large or the pressures on both ventricles are near equal, a murmur ___ be heard
cannot
Small VSD < 3 mm treatment?
will most likely close on it’s own
85%
Moderate 3-5 mm and asymptomatic VSD tx?
follow serially
Large 6-10 mm VSD need surgical repair before age ___
2
Diagnosis?
At left 2nd intercostal – crescendo-decrescendo
peaking at S2 continuous murmur through systole and diastole, bounding pulse
• EKG: may be normal or show LVH. If PH caused by increase flow there will be RVH and LVH
PDA
CXR for PDA would show left __ and left ___ enlarged
Left atria and left ventricle
PDAs close at birth when
1) placenta clamped and prostaglandin levels go ___
2) Oxygen tension increases causing pulmonary
vascular resistance to decrease
down
Premature babies have increased frequency of PDA
as they have increased _____ and
pulmonary prematurity leading to hypoxia
prostaglandin sensitivity
___ and ____, can be used to tx PDA in premies
Indomethacin, prostaglandin inhibitor
Spontaneous closure of PDA is rare after ___ months
5
If large PDA, needs repair < ___ yr of age to
prevent development of pulmonary vascular
disease
1
How to tx large PDA?
If large PDA, will get ligated in hospital
Cyanotic heart defects (5)
TOF Pulmonary valve stenosis Aortic stenosis Coarctation of the aorta HLHS TGA
Diagnosis?
– mild to moderate are asymptomatic. Ejection click at 3rd L intercostal space. Moderate can have split S2
– Severe obstruction can develop cyanosis, have a
heave/thrill. Harsh SEM at LUSB
• EKG: RVH and Right axis deviation
Pulmonary valve stenosis
Mild Pulmonary stenosis tx?
no treatment necessary. Serial follow up
PS causing 2/3 systemic RVp tx?
will need cardiac catheterization and balloon valvuloplasty
Diagnosis?
– Ejection click heard at apex. Harsh murmur at 1st
and 2nd intercostals and radiates to suprasternal
notch.
– If stenosis > 80 mmHg, then pulses diminished.
— Can have thrill if moderate-severe.
• EKG: Can show LVH, but usually normal
Aortic stenosis
Can aortic stenosis cause a fib?
yes
If AS gradient 60-80 mmHg, tx?
If AS turns into developing aortic insufficiency, tx?
Cardiac Catheterization –> balloon valvuloplasty
AI: Ross procedure or repair/replace valve
Diagnosis?
—Diminished femoral pulses in infants.
—Older children and older have a radiofemoral
delay.
—Upper extremity SBp >20 mmHg than
lower extremity SBp.
—Systolic murmur heard in left infraclavicular area radiates to back. Ejection click at LLSB
• EKG: RVH in neonates, older children may show LVH
Coarctation of the aorta
Coarctation of aortic usually occurs where?
at proximal thoracic aorta after left subclavian artery, but before the PDA
Coarctation of the aorta treatment?
- in infancy, reopen PDA with PGE
• Surgical repair
• If recurs can undergo transcatheter stent
placement
Diagnosis?
- cyanotic, III/VI systolic ejection murmur at LUSB
- Tet Spells: cyanosis, dyspnea, altered
consciousness, irritable
• EKG: QRS axis is rightward with RVH
CXR: boot shaped heart
Cath: RVOT obstruction
Tetralogy of Fallot (VSD, pulmonary stenosis, hypertrophy of right ventricle, overriding aorta)
TOF treatment?
• Surgical repair ~3-4 months of age.
• Will usually need additional surgery for PV
replacement or with percutaneous pulmonary
valve placement
Note: Coarctation of the aorta is diagnosed by pulse and blood pressure discrepancy of ___ between arms and legs
> 20 mm hg
Diagnosis?
Children are usually stable at birth, but they deteriorate rapidly as the PDA closes in the first week of life –> cyanosis, shock after ductal closure
- CXR: pulmonary venous congestion
- EKG: right axis deviation, RAE, RVH
HLHS
Diagnosis of HLHS is usually made when?
prenatally by fetal echo
4 steps of initial tx for HLHS after birth
1) Start PGE
2) If inter-atrial restriction: transeptal puncture with
septoplasty or stent placement
3) Respiratory management: PaO2- 30-45 mmHg and SaO2 70-85% to balance Qp:Qs
4) Start Vasodilators
3 types of surgical repair for HLHS
Norwood, Glenn, Fontan
What type of surgical repair for HLHS is this? enlarge aorta, enlarge atrial connection, BT shunt or through RV-PA conduit
Norwood
What type of surgical repair for HLHS is this? SVC connects to PA and previous shunt takedown
Glenn
What type of surgical repair for HLHS is this? IVC connects to PA via conduit
Fontan
Diagnosis?
Many neonates are large (up to 4kg) and profoundly Cyanotic but without respiratory distress or murmur, normal CXR
• EKG: normal
Transposition of the Great Arteries
TGA treatment: Cardiac Cath interventionist open up the atrial septum to increase interatrial mixing
Rashkind balloon atrial septostomy (this is frequently performed)
TGA treatment at 4-7 days old?
Arterial Switch Operation:
Ascending aorta and pulmonary artery
transected above the valves and switched.
Coronary arteries are excised and reimplanted
with new aorta
Which Cardiomyopathy?
- HF symptoms: exercise intolerance, FTT, diaphoresis,
tachypnea
• CXR: cardiomegaly
• EKG: ST segment changes. Check for
supraventricular tachycardia
• ECHO: LV and LA enlargement with decreased
ejection fraction, mitral insufficiency, end
diastolic volume increased
• Cath: check coronaries and endomyocardial
biopsy
Dilated Cardiomyopathy
Dilated cardiomyopathy treatment - which 4 meds? what other types of surgery/tx
DCM: Treatment • Medical therapy – ACE inhibitor to decrease after load – Lasix or aldactone to diurese – Digoxin to increase contractility and to prevent arrhythmias – Lasix or warfarin for anticoagulants
• If myocarditis, patient may recover. Some pts may remain stable for years • If severely depressed function= ICD • VAD • Heart Transplantation
Which Cardiomyopathy?
• Symptoms: angina, syncope, palpitations,
exercise intolerance, sudden cardiac death
• EKG: LV Hypertrophy, can see ST segment
changes
• ECHO: Asymmetrical septal hypertrophy,
LVOTO, mitral insufficiency, hypercontractile -
> poor contractility and LV dilation, diastolic
dysfunction
• Cardiopulmonary testing: check for ischemia,
arrhythmia
• Cath: Elevated LA pressures
Hypertrophic Cardiomyopathy
HCM treatment - what meds? when surgery or AICD?
– Beta blockers or calcium channel blockers if
moderate to severe obstruction
– Amiodarone for anti-arrhythmias
• Surgery: myotomy or MV replacement
• AICD: pts who have any arrhythmia. 50% are
sudden deaths
• Heart Transplantation
Which Cardiomyopathy?
• Symptoms: exercise intolerance, fatigue,
orthopnea
• EKG: will show right and lee atrial
enlargement. Diastolic dysfunction
• ECHO: Will show bilateral atrial enlargement
with normal ventricular size and normal
systolic function
• Catheterization: regular caths to monitor
atrial pressures and PVR
restrictive
TX for restrictive cardiomyopathy
– Lasix for diuresis and to decrease congestion
– Coumadin for anti-coagulation
• AICD: pts who have any arrhythmia. 28% are
sudden deaths
• VAD
• Heart Transplantation
Rate: normal for age Rhythm: regular P-waves: normal, sinus QRS complexes: narrow, <100 ms P-R relationship: 1:1 with PR interval 70-180 msec
normal sinus rhythms
Rate: normal for age Rhythm: irregular, varies with respirations P-waves: normal, sinus QRS complexes: narrow P-R relationship: normal, 1:1
sinus arrhythmia
Rate: fast for age, <220 bpm Rhythm: regular P-waves: normal, sinus QRS complexes: narrow P-R relationship: normal, 1:1
sinus tachycardia
Rate: slow for age, <80 bpm in infants, <60 bpm in child Rhythm: regular P-waves: normal, sinus QRS complexes: narrow P-R relationship: normal, 1:1
sinus bradycardia
Rate: normal
Rhythm: irregular – ectopic early beat, followed by pause
P-waves: morphology differs from normal sinus P-wave
QRS complexes: narrow
P-R relationship: normal, 1:1 (except for blocked)
Premature Atrial Contractions (PACs)
Rate: very fast, typically >220 bpm Rhythm: very regular P-waves: abnormal, difficult to see QRS complexes: narrow (wide in 10% due to aberrancy) P-R relationship: 1:1, difficult to see
Supraventricular Tachycardia (SVT)
Rate: normal to fast
Rhythm: regular or irregular
P-waves: none, F-waves (“saw-tooth” baseline)
QRS complexes: narrow
P-R relationship: fixed or variable ratio of F-waves to R-waves
atrial flutter
Rate: normal
Rhythm: irregular – ectopic early beat, followed by pause
P-waves: normal, sinus
QRS complexes: wide, bizarre ___
P-R relationship: P-waves march through ___
Premature Ventricular Contractions (PVCs)
Rate: fast Rhythm: irregular P-waves: difficult to see QRS complexes: wide, bizarre, but all similar P-R relationship: none
Ventricular Tachycardia
Rate: very fast Rhythm: irregular P-waves: none QRS complexes: fibrillatory waves P-R relationship: none
ventricular fibrillation
Rate: fast Rhythm: irregular P-waves: difficult to see QRS complexes: wide, bizarre, different (“twisting of the \_\_\_”) P-R relationship: none
VT: Torsades de Pointes
Normal PR interval:
0.12 - 0.20 sec
Normal QRS duration:
< 0.10 sec
Normal QTc:
< 0.44-0.46 sec
Sustained VT can lead to ____ and ____
V fib and sudden collapse
How do you treat PACs?
no tx necessary
How do you treat PVCs
tx directed at underlying disorder
How do you treat SVT (3)
- synchronized cardio version (0.5-1J/kg)
- adenosine (may cause transient AV block); give 0.1-0.2 mg/kg as a rapid bolus. DO NOT GIVE FOR WPW - leads to VF
- Vagal maneuvers (ice to face, valsalva)
How do you treat Atrial flutter
cardioversion
NO adenosine
How do you treat VT with pulse
cardio version 0.5-2J/kg
may also attempt cardio version with amiodarone (5mg/kg) or procinamide 15mg/kg
How do you treat VF with pulse
cardio version 0.5-2J/kg
may also attempt cardio version with amiodarone (5mg/kg) or procinamide 15mg/kg
How do you treat long QT syndrome (3)
Exercise restriction
Treatment with Beta blockage
Possible placement of internal cardioverter/defibrillator
Adenosine does not work to treat ____
Atrial flutter
How do you treat pulseless VT
Defibrillation 2J/kg then 4j/kg
CPR
How do you treat VF without pulse
Defibrillation 2J/kg then 4j/kg
CPR
How do you treat Torsades
- Immediate defibrillation (2j/kg, 4J/kg)
- IV magnesium, lidocaine, esmolol
- Repeated ICD shocks
NO epi, no amiodarone
Avoid QT prolonging meds
No epi and no amiodarone for ____
torsades
Electrical depolarization of the atria corresponds to the ___ on EKG
p wave
Flat interval where the impulse is held onto the AV node before passing to the ventricles corresponds to the ___ on EKG
PR interval
Ventricular depolarization corresponds to the ___ on EKG
QRS complex
Ventricular repolarization corresponds to the ___ on EKG
T wave
Sinus brady is less than ___ bpm for infants, less than ___ bpm for children
80 infants
60 child
treat sinus bradycardia with ___ ___ or ____ if unstable
epi, atropine or cardiac pacing
SVT onset: gradual or abrupt?
abrupt
VT onset: gradual or abrupt
gradual
Describe heart rate in SVT vs VT
SVT: >220
VT: <200
Describe R-R intervals in SVT vs VT
SVT: regular
VT: variable
