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Finals > Paediatric Cardiology > Flashcards

Paediatric Cardiology Flashcards

1
Q

Describe the fetal circulation

A

placenta
oxygenated blood enters body via umbilcal vein
bypasses liver via ductus venosus
enters IVC
enters RA
passes into LA via foramen ovale
any blood not in LA continues to RV and pulmonary arteries
ductus arteriosus to aorta to bypass lungs
umbilical arteries from internal iliacs back to placenta

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2
Q

Why do the duuctus venosus, foramen ovale and ductus arteriosus exist?

A

to conserve oxygen and nutrients for the whole of the body

bypassing liver and lungs

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3
Q

What happens to the ductus venosus at birth?

A

umbilical cord cut
leads to umbilical vein shutting off
leads to no ductus venosus!
becomes ligamentum venosum

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4
Q

What happens to the foramen ovale at birth?

A

at birth, air enters the lungs
pulmonary arterioles were vasoconstricted due to hypoxic vasocontriction
at birth, the alveoli become full of oxygen, leading to vasodilation of the arterioles
the previously high pressure pulmonary circulation becomes low pressure
pressure in RV falls to below pressure of LV
this causes the foramen ovale to close in the first few minutes after birth!
becomes fossa ovalis

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5
Q

What happens to the ductus arteriosus at birth?

A

placenta was releasiign prostaglandin into the fetal circulation, keeping it open
at birth, the increase in o2 and the drop in prostaglandins causes the ductus arteriosus to close within a day
becomes the ligamentum arteriosum within 2 weeks

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6
Q

Describe the effects of patent ductus arteriosus (PDA)

A

failure to close leads to overloading of the lungs as blood flows from aorta to pulmonary arteries
can lead to pulmonary HTN

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7
Q

What are the effects of pulmonary HTN in PDA

A

can lead to reversal of blood flow back to aorta as pulmonary P >aorta P. R to L
Eisenmenger’s syndrome!
differential cyanosis - cyanosis in lower extremities
branches to upper extremities and head have left aorta before the PDA

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8
Q

What are the features of PDA

A

most asymptomatic
continuous machinery murmur
thrill at upper left sternal border
bounding peripheral pulse

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9
Q

Why is there a bounding peripheral pulse in PDA

A

run off into pulmonary circulation from aorta
leads to wide pulse pressure
causes bounding peripheral pulse

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10
Q

What is the treatment for PDA

A

surgery to close

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11
Q

How does the atrial septum form?

A

septum primum grows down. ostium primum forms inferiorly, septum fuses with endocardial cushions. ostium secundum forms superiorly. ostium primum regresses.

septum secundum grows on the right hand side of septum primum. foramen ovale forms in it.

blood passes through the foramen ovale and ostium secundum from RA to LA

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12
Q

What causes an ASD

A

secundum ASD = septum secundum growth insufficient
primum ASD = ostium primum remains open
sinus venosus defect
coronary sinus defect

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13
Q

What are the features of ASD in a child

A

asymptomatic!

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14
Q

What are the features of ASD in an adult

A 
SOB
palpitations
fatigue
syncope
peripheral oedema
arrythmia
RHF
Eisenmenger's
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15
Q

Why does Eisenmenger’s occur in ASD

A 
L to R shunt 
overloading of pulmonary circulation
pulmonary HTN
leads to switch to R to L shunt as RA P > LA P
cyanotic
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16
Q

What are the signs on examination in ASD

A

widely split second heart sound

soft systolic ejection murmur at left sternal border

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17
Q

What is a paradoxical embolism?`

A

occurs if shunt switches to R to L in ASD

clot from DVT bypasses lungs and can go straight to head causing stroke

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18
Q

What investigations need to be done is ASD

A

ECG
CXR
echo

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19
Q

What can be seen on an ECG in ASD

A

tall p wave - due to right atrial enlargement
right axis deviation
AF

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20
Q

What can be seen on a CXR in ASD

A

cardiomegaly
enlarged RA and RV
increased pulmonary markings

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21
Q

How is ASD managed

A

diuretics if causign HF

surgical closure - open or transcatheter

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22
Q

What are the complications for women of child bearing age with ASD

A

increased risk of pre-eclampsia, low birth weight and fetal loss
if pulmonary HTN, significant increases risk of mortality in pregnancy - AVOID!!!

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23
Q

Describe the formation of the ventricular septum

A

membranous portion grows down from endocardial cushions

muscular portion grows up from base of heart - accounts for majority of septum

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24
Q

How can VSDs be classified

A

perimembranous defect
muscular defect
subarterial infundibular - adjacent to the arterial valves
Inlet or AV canal - lie beneath the septal leaflet of the tricuspid valve

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25
Q

What conditions are associated with VSD

A 
Down's - trisonomy 21
Patau's - trisonomy 13
Edward's - trisonomy 18
Di george - 22q11 deletion
Turner's - 45X
diabetes in pregnancy
fetal alcohol syndrome
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26
Q

What are the symptoms of VSD

A

asymptomatic at birth

if moderate to large: excercise intolerance - feeding affected - increased RR, slow feeding, increased effort of breathing. leads to poor weight gain

if very large: pulmonary HTN, leads to R to L shunt. causes Eisenmenger’s cyanosis

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27
Q

What are the signs of VSD

A

mild: child well developed and pink, harsh systolic murmur at lower left sternal edge

moderate to large: parasternal heave, grade 2-6 systolic murmur at lower left sternal border

28
Q

State the grading of murmurs

A

1 - The murmur is only audible on listening carefully for some time.
2 - The murmur is faint but immediately audible on placing the stethoscope on the chest.
3 - A loud murmur readily audible but with no thrill.[4]
4 - A loud murmur with a thrill.
5 - A loud murmur with a thrill. The murmur is so loud that it is audible with only the rim of the stethoscope touching the chest.
6 - A loud murmur with a thrill. The murmur is audible with the stethoscope not touching the chest but lifted just off it.

29
Q

What investigations should be done in VSD

A

ECG
CXR
echo

30
Q

What can be seen on ECG of VSD

A

LVH,
RAD
RVH and RAH if pulmonary HTN

31
Q

What can be seen on CXR of VSD

A

cardiomegaly

32
Q

What is the manaagement of VSD

A

30-50% close spontaneously!
moderate to severe: give diuretics, high energy feeds, ACEi to decrease afterload

surgery if HF or poor growth

pulmonary artery banding to protect against pulmonary HTN

33
Q

What are the long term consequences of VSD

A

aortic regurgitation
IE
Eisenmenger’s
RBBB

34
Q

Describe the heart in Tetralogy of fallot

A

RV outflow obstruction
causes RV hypertrophy
VSD - allows R to L shunt
overriding aorta - RV and LV exit via it

CYANOTIC

35
Q

What determines the severity of Tetralogy of fallot

A

the degree of RV outflow obstruction

36
Q

What conditions are associated with Tetralogy of fallot

A

22q11 deletion
down’s
fetal alcohol syndrome
CATCH 22

37
Q

How are most tertalogy of fallot discovered?

A

antenatal USS
newborn baby check - auscultation
low o2 sats at birth

38
Q

How would tetralogy of fallot present in an infant

A 
poor feeding
breathlessness
agitation
low birth weight, growth restricted
dyspnoea on exertion eg. crying
39
Q

How would tetralogy of fallot present in an older child on examination

A

cyanosis
clubbing
RV predominance
systolic thrill over lower left sternal border
systolic ejection murmur - due to pulmonary stenosis
single S2 - no closure of pulmonary valve

40
Q

What investigations should be done in tetralogy of fallot

A

ECG -
CXR
echo

41
Q

What is seen on CXR in tetralogy of fallot

A

boot shaped heart - due to concavity in the area of main pulmonary artery and enlarged aorta

42
Q

What is seen on ECG in tetralogy of fallot

A

RVH, RAD

43
Q

What is the management of tetralogy of fallot in neonates

A

immediate o2
prostaglandin E1 - maintains patency of ductus arteriosus
primary repair or two stage repair

44
Q

What long term complications can occur with tetralogy of fallot

A

Residual pulmonary incompetence.
Aortic root dilation.
Sustained ventricular tachycardia.
Some children may show delayed neurodevelopment.
Sudden death.
After 5-20 years following surgery, patients generally have reduced exercise capacity and cardiac output compared with that of healthy individuals.

45
Q

describe transposition of the great arteries (TGA)

A

the RV empties into the aorta
the LV empties into the pulmonary arteries

therefore there are two circulations in parallel
RV to aorta to IVC and FVC to RV
LV to pulm arteries to pulm veins to LV

CYANOTIC

46
Q

What increases the risk of TGA

A

maternal rubella or viral infection
maternal alchohol
>40y
diabetes in pregnancy

47
Q

What are the types of TGA

A

TGA with intact ventricular septum
TGA with VSD
TGA with VSD and pulmonary stenosis

48
Q

What are the symptoms of TGA

A

with intact septum:
cyanosis, tachypnoea, resp distress, metabolic acidosis within one week

with VSD:
congestive HF leading to tachypnoea, tachycardia, sweating and poor feeding within a few weeks

49
Q

What are the signs of TGA on auscultation

A

with intact septum:
single and loud S2, no murmur

with VSD:
systolic murmur, greater pulmonary resistance leads to decrease in intensity

50
Q

Give some differentials for TGA

A 
infection
IRDS
meconium aspiration
pneumothorax
fallot's
pulmonary atresia
51
Q

What investigations can be done in TGA

A

pulse oximetry
EG
CXR
echo

52
Q

What is seen on CXR in TGA

A

increased pulmonary vascular markings
‘egg on a string’ - due to heart being slightly enlarged and appears like an egg lying on its side, narrow vascular pedicle because aorta and pulmonary artery lie one in front of the other

53
Q

What is the management of TGA

A

immediate: IV prostaglandin E1 infusion to maintain patency ductus arteriosus, oxygen

urgent atrial septostomy - ceates/maintians ASD to increase mixing of pulmonary and systemic circulations

arterial switch operation (ASO) within a few days - most done at day 3 of life

54
Q

What are some of the long term complications of TGA

A 
Neopulmonary stenosis
Neoaortic regurgitation
Neoaortic root dilatation
Coronary artery disease
Obstructed coronary arteries leading to myocardial ischaemia, infarction and death
sudden cardiac death
neurodevelopmental  abnormalities
55
Q

What are the predictors of poor developmental outcome in a child with TGA

A

Low gestational age

high pre-operative lactate

56
Q

What is coarctation of the aorta?

A

narrowing of the aorta, most commonly just distal to the origin of the left subvlavian artery.
close to ligamentum arteriosum/ductus arteriosus
(most commonly before PDA in neonates)

57
Q

Which genetic condition is coarctation of the aorta common in

A

turner’s syndrome

58
Q

How does coarctation of the aorta present in neonates

A

can be seen in neonatal USS

poor feeding
lethargy
tachypnoea
congestive cardiac failure
shock
delayed pulse in lower limbs
differential cyanosis (PDA open, R to L shunt as low pressure in aorta distal to coarctation)
murmur
59
Q

How does coarctation of the aorta present in adults

A

most asymptomatic!
picked up incidentally as high BP or murmur

can cause:
headache, nosebleeds
;eg cramps, lower limb weakness, cold feet, neruological problems

delayed and diminished pulses in lower limbs distal to lesion (radio-femoral delay)
higher BP in arms than legs
systolic or continous murmur best heard under left scapula or in left infracalvicular area

60
Q

What does coarctation increase your risk of?

A

berry aneurysms leading to SAH - increased in pregnancy
aortic dilation
aortic dissecton - high risk in pregnancy.
Infective endocarditis.

61
Q

What are some differentials for coarctation of the aorta

A

hypoplastic left heart
septal defect
AS
cardiomyopathy

62
Q

What investigations need to be done in suspected coarctation of aorta

A

if HTN - U+E, FBC, glucose
if shock - ABG, FBC, U+E, glucose, clotting, cultures

CXR
echo
MRI
ECG
cardiac catheterisation
63
Q

What can be seen on CXR in coarctation of aorta

A

the coarctation itself!
notching of ribs 3-9 (due to dilation of posterior intercostal arteries - increased flow die to high P pushing blood from anterior intercostal arteries)

64
Q

How is coarctation of the aorta managed

A 
neoneates - prostin to keep DA open
diuretics and inotropes in congestive cardiac failire
beta blocker if HTN
surgery!
- balloon angioplasty and stenting
- open heart
65
Q

What are the features of an innocent murmur?

A 
Soft
• Systolic
• S1 and S2 normal
• Symptomless
• Standing/sitting position vary
• Special tests (ECG, CXR) normal

Finals (32 decks)

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