Paeds Cardio Flashcards
1
Q
What is ventricular septal defect
A
most common form of heart defect
congenital hole in the septum (wall) between the two ventricles.
causes left to right shunt
2
Q
what can severe untreated VSD lead to
A
severe pulmonary htn and early onset heart failure
3
Q
what can moderate untreated VSD lead to
A
enlarged atria and ventricles can lead to pulmonary HTN and congestive heart failure
4
Q
What direction does blood shunt in VSD
A
Left to right
increased pressure in left ventricle
5
Q
how does ventricular septal defect cause pulmonary htn and heart failure
A
increased pressure in LV compared to RV -> blood flows left to right through hole = right side overload right heart failure and increased flow into pulmonary vessels -> causing pulmonary htn
6
Q
What is Eisenmenger syndrome
A
eventually pulmonary hypertension will cause pulmonary pressure to be greater than the systemic pressure, the shunt reverses and forms a right to left shunt -> blood bypasses the lungs & patient will become cyanotic
7
Q
what are risk factors of ventricular septal defect
A
premature birth
genetic conditions > Downs Turners Edwards Patau
family history of congenital heart defects
8
Q
How does ventricular septal defect present?
A
often can by symptomless
tachypnoea
dyspnoea
failure to thrive
9
Q
How does ventricular septal defect sound on auscultation?
A
pan-systolic murmur more prominently heard at the left lower sternal border in the third and fourth intercostal spaces.
10
Q
How is VSD investigated?
A
Echo *GS
ECG
XRay - show cardiomegaly
11
Q
How is VSD treated?
A
- can close spontaneously
- Diuretics to relieve pulmonary congestion
- ACE inhibitors to reduce systemic pressure
- surgically -> transvenous catheter closure via famoral vein or open heart surgery
12
Q
What are complications of VSD
A
- Eisenmengers
- Endocarditis - antibiotic prophylaxis
- Heart failure
13
Q
What is an atrial septal defect
A
a defect (a hole) in the septum (the wall) between the two atria
14
Q
What direction does blood shunt in ASD
A
Left to Right
higher pressure in left atria
acyanontic
= inc pressure in lungs
15
Q
Causes of ASD
A
- Maternal smoking in 1st trimester
- Family History of CHD
- Maternal diabetes
- Maternal rubella
16
Q
What is the name of the two walls that fuse with endocardial cushion to separate the atria and affected in ASD
A
septum primum and septum secondum
17
Q
What is a small hole in the septum secondum called
A
foramen ovale
18
Q
How is patent foraman ovale distinct from ASD
A
patent foramen ovale due to failed fusion
19
Q
What does prolonged left to right shunt in ASD cause
A
right sided overload and right heart strain.
right sided overload can lead to right heart failure and pulmonary hypertension.
and eventually Eisenmenger syndrome
20
Q
How does ASD present
A
Shortness of breath
Difficulty feeding
Poor weight gain
Lower respiratory tract infections
21
Q
How does ASD present on auscultation
A
ejection systolic murmur with a fixed split second heart sound
loudest at the 2nd IC at the upper left sternal border
22
Q
What is a splitting of the second heart sound
A
closure of the aortic and pulmonary valves at slightly different times
fixed split = does not change on inspiration or expiration
23
Q
Why does ASD have fixed splitting of S2 heart sound
A
increase in RA and RV volume -> increase flow through pulmonic valve = delayed pulmonic valve closure
24
Q
What are two types of ASD
A
Ostium secundum (70% of ASDs)
Ostium primum - present earlier usually occurs with other cardiac conditions
25
How is ASD investiagted
XRay - R heart dilation and pulmonary vasularity
ECG
Echo *GS*
26
What are complications of ASD
- Stroke from DVT **
- Atrial fibrillation
- Pulmonary HTN
- Eisenmenger's syndrome
27
Why is ASD linked to stroke risk
systemic venous emboli use ASD to bypass lungs and become systemic arterial emboli
28
How is ASD managed
can close watch and wait to se eif closes on own
surgically - transvenous catheter closure (via the femoral vein) or open heart surgery
anticoagulants to reduce risk of clots and strokes in adults
29
What is tetralogy of fallot
- Overriding aorta
- VSD
- Pulmonary valve stenosis
- Right ventricular hypertrophy
MC cyanotic congenital heart disease
30
What causes tetralogy of fallot
anterosuperior displacement of the infundibular septum
31
What is the epidemiology of tetralogy of fallot?
more common in males
Rubella
increased maternal age
alcohol consumption in pregnancy
diabetic mother
32
what kind of shunt is present in tetralogy of fallot
Right to Left
blood bypasses lung = cyanosis
decreased RV outflow
33
What determines the degree of cyanosis in tetralogy of fallot
severity of pulmonary stenosis
34
what causes murmurs
turbulent blood
35
How does Tetralogy of fallot present
- Tet spells (squatting child/knees to chest)
- Irritability
- SOB
- Cyanosis
- Clubbing
- Poor feeding
- Poor weight gain
36
What are tet spells
intermittent symptomatic peroids where R to L shunt becomes worsened precipiating a syanotic episode
when exerting increased CO2 (vasodilator) = systemic vasodilation = reduced vascular reisitance = blood pumped RV to aorta rather than pulmonary vessels
37
Why do children squat in tet spells
Squatting increases the systemic vascular resistance. This encourages blood to enter the pulmonary vessels
38
How does tetralogy of fallot present on XRay
boot shaped heart
39
How is tetralogy of fallot investiagted
- MRI/Cardiac catheter
- Echo**
40
What is heard on auscultation with tetralogy of fallot
ejection systolic murmur due to pulmonary stenosis
41
how are tet spells managed
Supplementary oxygen
Beta blockers -> relax the RV and improve flow to the pulmonary vessels.
IV fluids -> increase pre-load
IM Morphine -> decrease respiratory drive and reduce spasm in heart
Sodium bicarbonate -> buffer metabolic acidosis
Phenylephrine infusion -> increase systemic vascular resistance.
42
What causes tet spells
crying
fever
exercise
= exacebation of RV outflow obstruction
43
how is tetralogy of fallot managed
- Prostaglandin infusion PGE1 to maintain ductus arteriosus if found at birth
- Beta blockers
- Morphine to reduce respiratory drive
- Surgical: repair under bypass 3 months - 4 years but needs ICU post op
44
What are the complications of tetralogy of fallot
- Pulmonary regurgitation
- Lifelong follow up
- heart failure
45
Why would you want to maintain ductus arteriosus in tertalogy of fallot
allows blood to flow from the aorta back to the pulmonary arteries.
46
What is transposition of great arteries
Aorta rises from right ventricle and pulmonary artery from left ventricle
not compatible with life unless shunt is present to allow mixing (eg VSD PDA)
47
What is the epidemiology of transposition of great arteries
diabetic mothers
More common in males
Mum>40
alcohol consumption in pregnancy
48
What causes transposition of great arteries
failure of aorticopulmonary septum to spiral
49
why will patients with transposition of great arteries present always have cyanosis
the right side of the heart pumps blood directly into the aorta and systemic circulation.
50
Why is transposition of great arteries not life threatening in utero
gas and nutrient exchange happens in the placenta, therefore it is not necessary for blood to flow to the lungs
51
What direction does blood shunt in transposition of great arteries
Right to Left
52
What are the 5 right to left shunt conditions
truncus arteriosus
transposition of great vessels
tricuspid atresia
tetralogy of fallot
TAPVR
53
How does transposition of great arteries present
Cyanosis at birth if not found on scans
if not detected at birth
respiratory distress, tachycardia, poor feeding, poor weight gain and sweating, death
54
how is transposition of great arteries investigated
often diagnosed during pregnancy with antenatal ultrasound scans.
if not detected during pregnancy it will present with cyanosis at or within a few days of birth
55
How is transposition of great arteries heard on auscultation
- Right ventricular heave
- Loud S2 heart sound
- Systolic murmur if VSD present
56
How is transposition of great arteries investigated
Low SATS
Echo *GS*
CXR
Metabolic acidosis
57
How does transposition of great arteries appear on XRay
egg on a string appearance due to narrowed mediatinum and cardiomegaly
58
How is transposition of great arteries managed
prostaglandin (PGE1) to maintain ductus arteriosus.
Balloon septostomy to create an ASD
Surgical correction -> definitive management “arterial switch” before 4 weeks old
emergency septostomy (maintain PDA)
59
What is patent ductus arteriosus
- Persistent connection between the descending aorta and pulmonary artery
- Normal in utero but usually closes within first 10-15 minutes of life
60
What direction does blood shunt in Patent ductus arteriosus
left to right
61
why does Patent ductus arteriosus usually close in first few breathes of life
increased pulmonary flow which enhances prostaglandins clearance
62
How is ductus arteriosus maintained
PGE synthesis and low O2 tension
63
What are RF for Patent ductus arteriosus
Female
Prematurity
64
How does Patent ductus arteriosus present
- Respiratory distress
- Apnoea
- Tachypnoea
- Tachycardia
- Shortness of breath
- Difficulty feeding
- Poor weight gain
- Lower respiratory tract infections
can remain asymptomatic and present as HF in adulthood
65
how does Patent ductus arteriosus lead to HF
L to R shunt causes pulmonary hypertension leading to R sided heart strain as the right ventricle struggles to contract against increased resistance = right ventricular hypertrophy = left ventricular hypertrophy
66
what is the ausculation finding for Patent ductus arteriosus
Continuous machinery murmur at the left sternal edge
bounding pulse
67
How is Patent ductus arteriosus investigated
- Echo GS
- ECG/CXR
68
How is Patent ductus arteriosus managed
- monitor to close up to 1 year if not closed -> Cardiac catheterisation to close or sooner in more severe cases
- Premature infants: Indomethacin or Ibuprofen inhibits prostaglandin and stimulates closure
69
how is VSD and PDA managed before surgery
increase calories, nasogastric feeds
diuretics -> furosomide/spirolactone
70
What is pulmonary valve stenosis
pulmonary valve has three leaflets when these become thicken or fused of abnormal create narrow opening btwn *R Ventricle and Pulmonary artery*
= congenital pulmonary valve stenosis.
71
What conditions is congenital pulmonary valve stenosis associated with
- Tetralogy of Fallot
- William syndrome
- Noonan syndrome
- Congenital rubella syndrome
72
What are symptoms of pulmonary valve stenosis
often asymptomatic
can present with symptoms of fatigue on exertion, shortness of breath, dizziness and fainting
73
How does pulmonary valve stenosis present on auscultation (4 findings)
- 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
74
What is the gold standard investigation for diagnosing pulmonary stenosis
echocardiogram
75
How is asymptomatic pulmonary stenosis progression managed
if asymptomatic generally do not require any intervention
“watching and waiting” approach.
76
How is symptomatic pulmonary stenosis progression managed
treatment of choice = balloon valvuloplasty via a venous catheter
catheter into femoral vein, through the inferior vena cava and right side of the heart to the pulmonary valve and dilating the valve by inflating a balloon
77
What is coarctation of the aorta
congenital condition where there is narrowing of the aortic arch, usually around the ductus arteriosus
78
What genetic condition is Coarctation of the Aorta often associated with
Turners syndrome
79
What pressure changes does Coarctation of the Aorta result in
- reduces the pressure of blood flowing to the arteries that are distal to the narrowing.
- It increases the pressure in areas proximal to the narrowing, such as the heart and the first three branches of the aorta
80
How does Coarctation of the Aorta present in neonate/infancy
often only presents as weak femoral pulses.
Tachypnoea and increased work of breathing
Poor feeding
Grey and floppy baby
Acidoic
81
How can Coarctation of the Aorta be investigated and what are findings
four limb blood pressure:
- high blood pressure in the limbs supplied from arteries that come before the narrowing
- lower blood pressure in limbs that come after the narrowing.
82
What additional signs may develop over time due to Coarctation of the Aorta
- Left ventricular heave due to left ventricular hypertrophy
- Underdeveloped left arm where there is reduced flow to the left subclavian artery
- Underdevelopment of the legs
83
What murmur is associated with Coarctation of the Aorta
systolic murmur heard below the left clavicle (left infraclavicular area) and below the left scapula.
84
How is Coarctation of the Aorta managed
mild = leave til adulthood
severe = emergency surgery after birth
surgical = balloon valvoplasty or surgical repair
85
What medication is used to keep ductus arteriosus open while waiting for surgery in CoA
Prostaglandin E1 eg alprostadil
allows some blood flow flow through the ductus arteriosus into the systemic circulation
86
What is infective endocarditis
infection of the endothelium (the inner surface) of the heart
MC affects heart valves
87
What are RF for infective endocarditis
- Intravenous drug use
- Structural heart pathology (see below)
- Chronic kidney disease (particularly on dialysis)
- Immunocompromised (e.g., cancer, HIV or immunosuppressive medications)
- History of infective endocarditis
88
What structural pathology can increase risk of infective endocarditis
- Valvular heart disease
- Congenital heart disease
- Hypertrophic cardiomyopathy
- Prosthetic heart valves
- Implantable cardiac devices (e.g., pacemakers)
89
What is the MC infective cause of infective endocarditis
Staphylococcus aureus.
90
What are two other causes of infective endocarditis
- Streptococcus viridans
- Staphylococcus epidermidis
91
how does infective endocarditis present
Fever
Fatigue
Night sweats
Muscle aches
Anorexia (loss of appetite)
92
What are key examination findings for infective endocarditis
- New or “changing” heart murmur
- Splinter haemorrhages (thin red-brown lines along the fingernails)
- Petechiae (small non-blanching red/brown spots) on the trunk, limbs, oral mucosa or conjunctiva
- Janeway lesions (painless red flat macules on the palms of the hands and soles of the feet)
- Osler’s nodes (tender red/purple nodules on the pads of the fingers and toes)
- Roth spots (haemorrhages on the retina seen during fundoscopy)
- Splenomegaly (in longstanding disease)
- Finger clubbing (in longstanding disease)
93
How is infective endocarditis investigated
Blood cultures are essential before starting antibiotic
Three blood culture samples are recommended, usually separated by at least 6 hours and taken from different sites.
94
What is the imagining investigation of choice for infective endocarditis
Echocardiography
Transoesophageal echocardiography (TOE) is more sensitive and specific than transthoracic echocardiograph
Vegetations (an abnormal mass or collection) may be seen on the valves.
95
What is imaging investigation of choice w patients with prosthetic heart valves
- 18F-FDG PET/CT
- SPECT-CT
96
What criteria is used to diagnose infective endocarditis
Modified Duke Criteria
One major plus three minor criteria
Five minor criteria
97
What are major criteria for Modified Duke criteria infective endocarditis
- Persistently positive blood cultures (typical bacteria on multiple cultures)
- Specific imaging findings (e.g., a vegetation seen on the echocardiogram)
98
What are minor criteria for Modified Duke criteria infective endocarditis
- Predisposition (e.g., IV drug use or heart valve pathology)
- Fever above 38°C
- Vascular phenomena (e.g., splenic infarction, intracranial haemorrhage and Janeway lesions)
- Immunological phenomena (e.g., Osler’s nodes, Roth spots and glomerulonephritis)
- Microbiological phenomena (e.g., positive cultures not qualifying as a major criterion)
99
How is infective endocarditis managed
Intravenous broad-spectrum antibiotics (e.g., amoxicillin and optional gentamicin)
4 weeks for with native heart valves
6 weeks for patients with prosthetic heart valves
100
When is surgical management required for infective endocarditis
Heart failure relating to valve pathology
Large vegetations or abscesses
Infections not responding to antibiotics
101
What are key complications of infective endocarditis
- Heart valve damage, causing regurgitation
- Heart failure
- Infective and non-infective emboli (causing abscesses, strokes and splenic infarction)
- Glomerulonephritis, causing renal impairment
102
Is there prophylaxis for infective endocarditis
Antibiotics are not routinely recommended for dental and non-dental procedures as prophylaxis of infective endocarditis.
However, it is still considered on a case-by-case basis in those at particularly high risk.
103
What is Rheumatic Fever
autoimmune condition triggered by streptococcus bacteria. It is caused by antibodies created against the streptococcus bacteria that also target tissues in the body.
T2 hypersensitivity
Multi system disorder
104
What is the infective cause of Rheumatic Fever
group A beta-haemolytic streptococcal, typically streptococcus pyogenes causing tonsillitis.
105
what is the pathophysiology of Rheumatic Fever
the immune system creates antibodies to fight the infection. These antibodies not only target the bacteria, but also match antigens on the cells of the person’s body, for example the muscle cells in the myocardium in the heart.
106
What type of hypersensitivity reaction is Rheumatic Fever
type 2 hypersensitivity reaction
cross-reactive immune response
the immune system begins attacking cells throughout the body
107
When does Rheumatic Fever present
occurs 2 – 4 weeks following a streptococcal infection, such as tonsillitis
Fever
Joint pain
Rash
Shortness of breath
Chorea
Nodules
108
How does Rheumatic Fever affect joints
migratory arthritis affecting the large joints, with hot, swollen, painful joints.
migratory because different joints become inflamed and improve at different times, giving the appearance that the arthritis is moving from one joint to the next.
109
How does Rheumatic Fever affect the heart
Carditis, or inflammation throughout the heart, with pericarditis, myocarditis and endocarditis
110
What are the two key skin findings of Rheumatic Fever
Subcutaneous nodules
Erythema marginatum rash
111
what does Carditis lead to
Tachycardia or bradycardia
Murmurs from valvular heart disease, typically mitral valve disease
Pericardial rub on auscultation
Heart failure
112
how does Rheumatic Fever affect the nervous system
Chorea
113
What is Chorea
irregular, uncontrolled and rapid movements of the limbs.
This is also known as Sydenham chorea
114
What investigations can support a diagnosis of Rheumatic Fever
Throat swab for bacterial culture
Anti-streptococcal antibodies titres peak 3-6 weeks
Echocardiogram, ECG and chest xray can assess the heart involvement
115
What criteria is used to diagnose Rheumatic Fever
Jones criteria
116
What antibodies are present in Rheumatic Fever
Anti-streptococcal antibodies (ASO)
Indicate a recent streptococcus infection
Rise over 2 – 4 weeks
Peak around 3 – 6 weeks
Gradually falls over 3 – 12 months
117
What is the jones criteria for Rheumatic Fever
evidence of recent streptococcal infection, plus:
Two major criteria OR
One major criteria plus two minor criteria
118
What are major Jones criteria
J – Joint arthritis
O – Organ inflammation, such as carditis
N – Nodules
E – Erythema marginatum rash
S – Sydenham chorea
119
What are minor Jones criteria
- Fever
- ECG Changes (prolonged PR interval) without carditis
- Arthralgia without arthritis
- Raised inflammatory markers (CRP and ESR)
FEAR
120
how is Rheumatic Fever managed
Tonsillitis caused by streptococcus should be treated with phenoxymethylpenicillin (penicillin V) for 10 days.
pen allergy = erythromycin or azithromycin
- NSAIDs (e.g. ibuprofen) are helpful for inflammation and fever joint pain
- Aspirin and steroids are used to treat carditis
- diuretics ACE-i, B-B for severity of carditis
- Monitoring and management of complications
121
What are complications of Rheumatic Fever
Recurrence of rheumatic fever
Valvular heart disease, most notably **mitral stenosis**
Chronic heart failure
