Paeds cardio

Question 1

What are the three shunts in foetal circulation?

Answer 1

1. ductus venosus (bypass live Umbilical -> IVC)
2. Foramen ovale : R-> L shunt
3. Ductus arteriosus -> PA -> aorta (can keep open with prostaglandins)

Question 2

What are innocent/ flow murmurs caused by?

Answer 2

Innocent murmurs are also known as flow murmurs. They are very common in children. They are caused by fast blood flow through various areas of the heart during systole.

Question 3

What are the features of an innocent murmur?

Answer 3

Innocent murmurs have typical features, all beginning with S:

Soft
Short
Systolic
Symptomless
Situation dependent, particularly if the murmur gets quieter with standing or only appears when the child is unwell or feverish

No IX required in this case

Question 4

What are the IX you can do in a child with a concerning murmur?

Answer 4

The key investigations to establish the cause of a murmur and rule out abnormalities in a child are:

ECG
Chest Xray
Echocardiography

Question 5

What are your pansystolic murmurs and where can you hear them the loudest?

Answer 5

The differentials of a pan-systolic murmur and where they are heard loudest are:

Mitral regurgitation heard at the mitral area (fifth intercostal space, mid-clavicular line)
Tricuspid regurgitation heard at the tricuspid area (fifth intercostal space, left sternal border)
Ventricular septal defect heard at the left lower sternal border

Question 6

What are your ejection systolic murmurs and where can you hear them the loudest ?

Answer 6

The differentials of an ejection-systolic murmur and where they are heard loudest are:

Aortic stenosis heard at the aortic area (second intercostal space, right sternal border)
Pulmonary stenosis heard at the pulmonary area (second intercostal space, left sternal border)
Hypertrophic obstructive cardiomyopathy heart at the fourth intercostal space on the left sternal border

Question 7

How can you identify an atrial septal defecrt?

Answer 7

Well R->L shit
Atrial septal defects cause a mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border, with a fixed split second heart sound. Splitting of the second heart sound can be normal with inspiration, however a “fixed split” second heart sound means the split does not change with inspiration and expiration.

Question 8

What murmur does a PDA make?

Answer 8

A small patent ductus arteriosus may not cause any abnormal heart sounds. More significant PDAs cause a normal first heart sound with a continuous crescendo-decrescendo “machinery” murmur that may continue during the second heart sound, making the second heart sound difficult to hear.

Question 9

Murmur in tetralogy of fallot?

Answer 9

The murmur in tetralogy of Fallot arises from pulmonary stenosis, giving an ejection systolic murmur loudest at the pulmonary area (second intercostal space, left sternal border).

Question 10

What is Eisenmengers syndrome?

Answer 10

This is because the pressure in the left side of the heart is much greater than the right side, and blood will flow from the area of high pressure to the area of low pressure. This prevents a right-to-left shunt. If the pulmonary pressure increases beyond the systemic pressure blood will start to flow from right-to-left across the defect, causing cyanosis. This is called Eisenmenger syndrome.

Question 11

Why are ptx with heart defects not cyanotic?

Answer 11

Patients with a VSD, ASD or PDA are usually not cyanotic. This is because the pressure in the left side of the heart is much greater than the right side, and blood will flow from the area of high pressure to the area of low pressure. This prevents a right-to-left shunt.

Exception: Transposition of great arteries -> will always have cyanosis because RHS of heart alwats pumps directly into the Aorta !

Question 12

Why is an unclosed PDA problematic?

Answer 12

The pressure in the aorta is higher than that in the pulmonary vessels, so blood flows from the aorta to the pulmonary artery. This creates a left to right shunt where blood from the left side of the heart crosses to the circulation from the right side. This increases the pressure in the pulmonary vessels causing pulmonary hypertension, leading to right sided heart strain as the right ventricle struggles to contract against the increased resistance. Pulmonary hypertension and right sided heart strain lead to right ventricular hypertrophy. The increased blood flowing through the pulmonary vessels and returning to the left side of the heart leads to left ventricular hypertrophy.

Question 13

What is the presentation of someone with a patent PDA?

Answer 13

Shortness of breath
Difficulty feeding
Poor weight gain
Lower respiratory tract infections
Baso listen out for murmurs - machine like murmur

Question 14

How would you diagnose and treat a PDA?

Answer 14

Echo to dx
After 1 year of age it is highly unlikely that the PDA will close spontaneously and trans-catheter or surgical closure can be performed. Symptomatic patient or those with evidence of heart failure as a result of PDA are treated earlier.

Question 15

What happens in ASDs?

Answer 15

An atrial septal defect leads to a shunt, with blood moving between the two atria. Blood moves from the left atrium to the right atrium because the pressure in the left atrium is higher than the pressure in the right atrium
Shunt then reverses due to Pulmonary HTN -> Ptx becomes cyanotic -> Eisenmenger syndrome
Problems : RVH and LVH and cyanosis

Question 16

What are the complications of an ASD?

Answer 16

1. Stroke in the context of venous thromboembolism (Normally when patients have a DVT and this becomes an embolus, the clot travels to the right side of the heart, enters the lungs and becomes a pulmonary embolism. In patients with an ASD the clot is able to travel from the right atrium to the left atrium across the ASD. This means the clot can travel to the left ventricle, aorta and up to the brain, causing a large stroke)
2. Atrial fibrillation or atrial flutter
   3.Pulmonary hypertension and right sided heart failure
   4.Eisenmenger syndrome

Question 17

What is the px of an ASD?

Answer 17

ASDs cause a mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border with a fixed split second heart sound. Splitting of the second heart sound is where you hear the closure of the aortic and pulmonary valves at slightly different times.
* SOB
* feeding problems
* poor weight gain
* Lower resp tract infections

Question 18

Mx of an ASD?

Answer 18

ASDs can be corrected surgically using a transvenous catheter closure (via the femoral vein) or open heart surgery. Anticoagulants (such as aspirin, warfarin and NOACs) are used to reduce the risk of clots and stroke in adults.

Question 19

What conditions are VSD’’s normally associated with?

Answer 19

Downs and Turners

Will eventually lead to Eisenmengers

Question 20

Presentation of a VSD?

Answer 20

Typical symptoms include:

Poor feeding
Dyspnoea
Tachypnoea
Failure to thrive

pan-systolic murmur more prominently heard at the left lower sternal border in the third and fourth intercostal spaces. There may be a systolic thrill on palpation.

Question 21

tx of vsd?

Answer 21

Treatment should be coordinated by a paediatric cardiologist. Small VSDs with no symptoms or evidence of pulmonary hypertension or heart failure can be watched over time. Often they close spontaneously.

VSDs can be corrected surgically using a transvenous catheter closure via the femoral vein or open heart surgery.

There is an increased risk of infective endocarditis in patients with a VSD. Antibiotic prophylaxis should be considered during surgical procedures to reduce the risk of developing infective endocarditis.

Question 22

What are the three things that cause Eisenmengers ?

Answer 22

Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus

Question 23

Everything about Coarctation of Aorta go

Answer 23

Post PDA constriction of the Aorta.
Often only indication is weak femoral pulses however if you do a 4 limb BP you will find very big differences -BP alot higher upper limbs
Can also present with: Tachypnoea, poor feeding, grey floopy baby

Mx: Keep DA open using prostaglandins till surgery

Question 24

Ebsteins anomaly -> quick summary

Answer 24

Ebstein’s anomaly is a congenital heart condition where the tricuspid valve is set lower in the right side of the heart (towards the apex), causing a bigger right atrium and a smaller right ventricle. R -> L shunt via ASD.

Develops few days after birth -> when PDA closes baby becomes cyanotic and sx
Evidence of heart failure (e.g. oedema)
Gallop rhythm heard on auscultation characterised by the addition of the third and fourth heart sounds
Cyanosis
Shortness of breath and tachypnoea
Poor feeding
Collapse or cardiac arrest

Do an echo and correct surgically

Question 25

What is transposition of the great arteries?

Answer 25

e right ventricle pumps blood into the aorta and the left ventricle pumps blood into the pulmonary vessels. In this scenario are two separate circulations that don’t mix: one travelling through the systemic system and right side of the heart and the other traveling through the pulmonary system and left side of the heart.

Cyanose baby after birth -> emergency
Immediate survival depends on a shunt between the systemic circulation and pulmonary circulation that allows blood flowing through the body an opportunity to get oxygenated in the lungs. This shunt can occur across a patent ductus arteriosus, atrial septal defect or ventricular septal defect.

Question 26

Px and investigation of transposition of great arteries?

Answer 26

diagnosed during pregnancy with antenatal ultrasound scans.

not detected during pregnancy it will present with cyanosis at or within a few days of birth. A patent ductus arteriosus or ventricular septal defect can initially compensate by allowing blood to mix between the systemic circulation and the lungs, however within a few weeks of life they will develop respiratory distress, tachycardia, poor feeding, poor weight gain and sweating.

Question 27

Mx of the transposition of the arteries?

Answer 27

Prostaglanins to keep PDA opne
Balloon septostomy to increase the size of foramen ovale
Resolution: open heart surgery few days after birth

Question 28

Tetralogy of fallot?

Answer 28

Ventricular septal defect (VSD)
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy

Question 29

What happens in tetralogy of fallot?

Answer 29

VSD and overriding aorta -> more deoxygenated blood
Pulmonary stenosis leads to increased RHS pressure and RVH r-> l shunt
this all leads to cyanosis

Question 30

What are the rfs for tetralogy of fallot?

Answer 30

Rubella infection
Increased age of the mother (over 40 years)
Alcohol consumption in pregnancy
Diabetic mother

Question 31

Presentation and IX of tetralogy of fallot

Answer 31

antenatal scans. Additionally, an ejection systolic murmur caused by the pulmonary stenosis may be heard on the newborn baby check.
Always an echo

Cyanosis (blue discolouration of the skin due to low oxygen saturations)
Clubbing
Poor feeding
Poor weight gain
Ejection systolic murmur heard loudest in the pulmonary area (second intercostal space, left sternal border)
“Tet spells”

Question 32

What is a tet spell

Answer 32

“Tet Spells” are intermittent symptomatic periods where the right to left shunt becomes temporarily worsened, precipitating a cyanotic episode. This happens when the pulmonary vascular resistance increases or the systemic resistance decreases. For example, if the child is physically exerting themselves they are generating a lot of carbon dioxide. Carbon dioxide is a vasodilator that causes systemic vasodilation and therefore reduces the systemic vascular resistance. Blood flow will choose the path of least resistance, so blood will be pumped from the right ventricle to the aorta rather than the pulmonary vessels, bypassing the lungs.

Give O2, beta blockers and ABCDE mx

Question 33

Mx of tetralogy of fallot?

Answer 33

In neonates, a prostaglandin infusion can be used to maintain the ductus arteriosus. This allows blood to flow from the aorta back to the pulmonary arteries.

Total surgical repair by open heart surgery is the definitive treatment, however mortality from surgery is around 5%.

Question 34

Presentation and signs of aortic stenosis?

Answer 34

Ejection systolic murmur loudest in the aortic area. Crescendo de crescendo radiates to carotids. May have a slow rising pulse, ejection click and palpable thrill
Worse on exertion and will present with HF few months after birth

Question 35

Mx of aortic stenosis

Answer 35

Percutaneous balloon aortic valvoplasty
Surgical aortic valvotomy
Valve replacement

Question 36

How does pulmonary stenosis present in children? + signs

Answer 36

Ejection systolic murmur heard loudest at the pulmonary area (second intercostal space, left sternal border)
Palpable thrill in the pulmonary area
Right ventricular heave due to right ventricular hypertrophy
Raised JVP with giant a waves

pulmonary valve stenosis can present with symptoms of fatigue on exertion, shortness of breath, dizziness and fainting.

Question 37

What is the mx of pulmonary stenosis?

Answer 37

The gold standard investigation for establishing a diagnosis is an echocardiogram.

In mild pulmonary stenosis without symptoms patients generally do not require any intervention. They are followed up by a cardiologist with a “watching and waiting” approach.

If the patient is symptomatic or the valve is more significantly stenosed, balloon valvuloplasty via a venous catheter is the treatment of choice