Infant or child with a heart murmur Flashcards
Characteristic of innocent murmurs
Have no clinical significance
systolic
Localised
Soft
vary with position of the child
vary with respiration
Rest of CVS is normal.
- Venous hum - blowing continuous murmur in systole and diastole and heard below the clavicles, disappears on lying down.
- Pulmonary flow murmur- brief high-pitched murmur at second left intercostal space. Best heard with child lying down
- Systolic ejection murmur - short systolic murmur at left sternal edge or apex. Musical sound, Changes with child’s position. Intensified by fever, exercise and emotion
Characteristic of pathological murmur
Pan systolic or diastolic Are harsh or long May radiate and have a thrill Often have associated cardiac symptoms or signs - Aortic stenosis - Atrial septal defect - pulmonary stenosis - ventricular septal defect - Coarctation of the aorta
Congenital heart disease that present with a murmur
Pulmonary valve stenosis Atrial septal defect Ventricular septal defect Coarctation of the aorta Patent ductus arteriosus Aortic valve stenosis Tetralogy of Fallot Transposition of great arteries
Stage of embryology when heart is developed
3-8 wks, Insults in this time result in CHD
Ix for CHD
Echocardiogram
ECG
CXR
Signs of cyanotic heart disease
Blue mucous membranes
Nail beds and skin secondary to an absolute concentration of deoxygenated haemoglobin of at least 3g/dL
Characteristic CXR finding in CHD
Boot shaped heart = tetralogy of ballot, tricuspid atresia
Egg shaped heart = transposition of great arteries
“Snowman” heart: total anomalous pulmonary venous return.
Types of CHD
Acyanotic
- Left to right shunts - most common: Atrial septal defect (ASD) - clinical commonest, Ventricular Septal Defect (VSD) - commonest at birth, Patent Ductus Arteriosus (PDA)
- Obstructions: Coarctation of aorta (CoA) - Turners, Aortic stenosis, Pulmonic stenosis
Cyanotic - 5 T lesion
- Right to Left shunts: Tetralogy of Fallot (FT), Epstein’s anomaly
- Other: Transposition of great arteries, Total anomalous pulmonary venous drainage, Tricuspid atresia, Hypoplastic left heart syndrome,
CHD that presents as Heart failure
VSD
ASD
PDA
CHD that present with shock
Coarctation of aorta
Aortic valve stenosis
CHD that present with cyanosis
Tetralogy of ballot
Transposition of the great arteries.
CHD that typically present in the newborn period
Coarctation of the aorta
Transposition of the great arteries
Tetralogy of Fallot
Patent ductus arteriosus
Types of ASD
Ostium primum - common in down syndrome
Ostium secundrum - most common 50-70%
Sinus venosus - entry at SVC entrance
Symptoms and signs of ASD
Asymptomatic Murmur Grade 2/3 Systolic murmur at 2rd left interspace Widely split S2 and fixed. Breathlessness Tiredness on exertion recurrent chest infection HF Pulmonary HTN Pulmonary vascular abnormalities
Cx of ASD
Eisenmenger’s complex
infective endocarditis
Paradoxical immobilisation
Cardiac arrhythmias
Ix findings in ASD
ECG - Right axis deviation, mild RVH, RBBB
CXR - Increase pulmonary vascular
Tx for ASD
80-100%
Types of VSD
Membranous 90%
Muscular
Clinical presentation of VSD
Asymptomatic Murmur: Harsh pan systolic at lower left sternal edge, May radiate over chest if large enough Parasternal thrill HR 4-6 week if lg Large breathlessness on feeding or crying poor growth recurrent chest infections
Cx of VSD
Increase pulmonary HTN -> Eisenmenger’s syndrome
Ix of VSD
CXR - increase pulmonary marking, cardiomegaly
ECG - RVH, LVH
Echo - confirms diagnosis
Tx of VSD
Many close spontaneously (small)
Prevention of endocarditis
Large membranous defect and cardiac failure need medical tx for CHF and Surgical closure by 1 year
Clinical presentation of PDA
Murmur: Continuous machinery murmur below left clavicle bounding pulse Asymptomatic Apnoea or decreased HR episodes Poor feeding Accessory muscle use Tachycardia Hyperactive precordium Wide pulse pressure
Ix findings in PDA
ECG - LAE, LVH, RVH
CXR - mildly enlarged heart, increase pulmonary vasculature, prominent pulmonary artery
Echo - diagnostic test
Tx for PDA
Premature - spontaneous closure or medical closure with indomethacin or ibuprofen: PGE2 antagonist only effective in premature.
Restrict fluids
blood transfusion if anaemic
Treat HF - furosemide
Surgery - if medical treatment fails, significant HF, ventilator dependence or prolonged failure to close. surgical ligation or by transcatheter occlusion device.
Clinical presentation of coarctation of aorta
Mild
HF
Murmur - absent or systolic with late peak over apex, left axilla, left back
Older children develop HTN
severe
Infant goes into shock when ductus arteriosus closes
Key features - WEAK OR ABSENT FEMORAL PULSES - RADIAL FEMORAL DELAY
Ass with turner’s syndrome (bicuspid aortic valve and aortic dissection.
Ix of coarctation of aorta
ECG - infancy RVH, Childhood LVH
Echo - diagnostic
Tx of coarctation of aorta
Immediately - IV prostaglandin E2 = keeps ductus arteriosus patent
Surgery - Neonate for repair, Older children stunt or balloon to dilate.
Clinical presentation of Aortic stenosis
- Mild - asymptomatic with murmur - ejection systolic on RUSB +/- ejection click, radiates to neck and A2 soft and delayed
- Severe - shock or HF when duct closes
- Older children
Syncope
decreased exercise tolerance
dizziness
exertion chest pain - peripheral pulse sml volume
- Reduced BP
- Palpable thrill at L sternal border and carotid artery
Ix findings for aortic stenosis
CXR - prominent LV and ascending aorta
ECG - LVH
Echo
Cx of aortic stenosis
Sudden death
Tx of aortic stenosis
Severe - ballon valvoloplasty or open heart surgery
Avoid strenuous activity or sport = sudden death.
Clinical presentation of pulmonary stenosis
Murmur short systolic ejection murmur Upper left chest Conducted to back Preceded by ejection click Thrill palpable in severe Wide split S2 on expiration mild - asymptomatic Severe - palpable in pulmonary area, CHF
Ix of pulmonary stenosis
CXR - dilated pulmonary artery, severe - enlarge R atrium and ventricle
Echo to diagnosis
Tx of pulmonary stenosis
Severe - balloon valvuloplasty, usually successful.
Causes of cyanotic heart disease
One big trunk - trunks arteriosus
Two interchanged vessels - transposition of the great vessels
Three leaflets - tricuspid atresia
Four anatomical abnormalities - tetralogy of Fallot
Five words - Total anomalous pulmonary venous return
What is Tetralogy of Fallot
Causes - genetic and seen in fetal alcohol syndrome.
Defective septum development - classic
large VSD - venticular septum defect
RVH (result) -
Pulmonary infundibular stenosis
Overriding aorta - aorta gets blood from both right and left
Clinical features of tetralogy of fallot
intermittent Cyanosis since birth
Clubbing
Murmur - ejection systolic murmur, loud P2
Hyper cyanotic spells on exertion which are relieved by squatting down
presents common at 2-4 months. most common cyanotic CHD beyond infancy
Cx of tetralogy of Fallot
Subacute bacterial endocarditis - right to left shunt predisposes to infection
Ix findings of tetralogy of Fallot
ECG - RVH
CXR - boot shaped heart and oligaemic lung fields, decreased pulmonary vasculature, right aortic arch
Tx for tetralogy of Fallot
Mx of spells - O2, knee chest position, fluid bolus, morphine sufate, propanolol
surgical correction at 2-3 months old or earlier if marked cyanosis.
Protective factors
if patients have PDA and ASD may be there (protective)
Clinical features of transposition of great vessels
severe Cyanosis and acidosis since birth.
Chronic heart failure
Right sided ventricular hypertrophy
Pulmonary hypertension
IF VSD murmur - cyanosis = presents with CHF in first couple of weeks
If no VSD = no murmur but marked cyanosis.
Ix finding for transposition of great vessels
ECG- RAD, RVH or normal
CXR - Egg shaped heart with narrow mediastinum
Tx for transposition of great vessels
Emergency
Prostaglandin infusion
ventilatory
circulatory support
Surgery - Requires atrial septostomy urgently
followed by definitive switch operation within the first couple of weeks- where two great vessels are switched over and coronary arteries are reconnected to the new aorta.
Prognosis
Die in the first month is not treated with surgery.
Neonatal circulation
Placenta -> umbilical vein -> ductus veniosus ->IVC ->RA -> foramen ovale or ductus arteriosus to systemic circulations -> descending aorta -> common iliac -> to umbilical arteries
Diagnostic criteria for Acute rheumatic fever
2 major or 1 major & 2minor +evidence of preceding GAS infection. Major manifestations Carditis- excluding subclinical evidence of rheumatic valve disease of Echo Polyarthritis Sydenham Chorea Erythema marginatum Subcutaneous nodules Minor Fever ESR >/= 30mm/hr or CRP >/= 30mg/L Prolonged P-R interval on ECG Polyarthralgia or aseptic mono-arthritis
Diagnostic criteria for actor rheumatic fever in high risk groups
2 major or 1 major & 2minor +evidence of preceding GAS infection.
Major
Carditis - including subclinical evidence of rheumatic valve disease on echocardiogram
Polyarthritis, aseptic mono-arthritis or polyarthralgia
Sydenham Chorea
Erythema marginatum
Subcutaneous nodules
Minor
Fever
ESR >/= 30mm/hr or CRP >/= 30mg/L
Prolonged P-R interval on ECG
Ix for rheumatic fever
Echo WCC ESR CRP Blood cultures if febrile ECG Throat swab Anti-streptolysin serology (anti-streptolysin O, Anti-DNase B titres)
Mx of rheumatic fever
Regular secondary prevention treatment for people at risk of recurrent ARF
First line = Benzathine penicillin G - 1200 000 U (body wt >/= 20 kg) IM 4 weekly or 3 weekly in selected groups.
second line if IM routine not possible or refused
Phenoxymethylpenicillin (penicillin V) 250mg Oral Twice daily
If penicillin allergy = Erythromycin 250mg oral twice daily
Duration of treatment
all people with ARF or RHD for minimum of 10 years after most recent episode of ARF or until age 21 yrs (which ever is longer)
Status after initial period has elapsed
No RHD or mild RHD = discontinue at that time
Moderate RHD: continue until age 35 yr
Severe RHD: continue until age 40 yrs or longer
Acute management
- Bed rest
- anti-inflammatory drugs e.g. aspirin
- Corticosteroids 2-3 weeks
- diuretics/ACEi if HF
- Antibiotics eg penicillin V for 10 days
