Pedi Cardio Flashcards
What can congenital heart disease lead to?
Heart failure, arrhythmias, conduction abnormalities, and death
What are some of the generalized symptoms we look for in a baby that might have a cardiovascular problem?
Difficulty feeding, increased respiratory rate (or labored breathing), sweating, cyanosis, and syncope
In a little person, how do we make the diagnosis of a cardiovascular problem?
Clinical, PE, IMAGING IS EVERYTHING (echo), ECG, chest x-ray, and cardiac cath
There are 6 major complications of cardiovascular disease in a child, what are they?
CHF, Cyanosis, polycythemia, stroke, retardation of growth, pulmonary arterial hypertension, pulmonary vascular obstructive disease (PVOD)
What is PVOD?
destruction of the pulmonary vascular bed in the presence of continuous pressure overload – leading to an increase in pulmonary vascular resistance and elevation of pulmonary artery pressure
What is pulmonary arterial hypertension?
When systemic arterial pressure is very high leading to increased pressures in the right side of the heart; with lower pressures in the pulmonary arterioles it causes constriction to protect the capillaries (that can lead to narrowing and fibrosing)
If we see cyanosis is a baby, what does that commonly indicate?
Common with defects that result in right to left shunting of blood or heart failure
If a child is hypoxic and it is due to heart failure, will they respond to oxygen? What about right to left shunting?
Heart failure = RESPONDS to O2
R to L Shunting does NOT respond to O2
What would we look for on PE with cyanosis?
Clubbing of the finger with long-standing cyanosis
What else would a child have with right to left shunting or chronic hypoxemia?
Polycythemia = Hct >60
What can polycythemia from right to left shunting directly lead to?
Intracranial thrombus (stroke)
What else can cause a stroke in a child?
Paradoxical embolus
A baby presents for a check-up and while listening to their heart, you hear a holosystolic murmur along the left sternal border, what might it be?
VSD
What other murmur in adults has a holosystolic murmur?
Mitral regurg
What part of the ventricle would a child most likely have a ventricular septal defect?
The thin membranous septum (80%)
Muscular septum (20%)
What way does the blood move with a ventricular septal defect?
From left to right
If a child has a large VSD, what can happen?
Pulmonary artery hypertension is common and PVOD develops over time
Large defect results in LV dilation & failure
What would a small “restrictive” VDS cause?
Small L to R shunt that is typically well tolerated
What does a large VSD lead to?
Heart failure early in life
How would you diagnose VSD in a baby?
Echo
How would you manage a small VSD?
Regular follow-up with periodic echo-doppler to confirm closure
Some close by 18 months, 50% by 4 years
How would you treat a moderate to large VSD?
Treat like heart failure in adults
Surgical repair once heart failure is improved
What are the longer term complications of VSD?
If PAH continues over time → irreversible PVOD and then surgery carries high risks
If a 29 year old man presents after a long flight with left arm numbness and weakness with a small visual deficit, what diagnosis?
Atrial septal defect
What is the most common congenital heart defect that is often not detected until adulthood?
Atrial septal defect
How are the two atria formed?
Formed by fusion of 2 overlapping planes of tissue making the atrial septum
What is the problem with an atrial septal defect?
Large enough defect to allow free communication between the atria
Lack of fusion occurs in 25% of adults, leaving a patent foramen ovale
Where do most atrial septal defects occur?
In the mid septum (due to lack of tissue for overlap) AKA Ostium Secundum
What is it known as if the defect is in the lower atrium?
Ostium primum
What is it known as if the defect is high in atrium?
sinus venous defect
What are some of the complications of an atrial septal defect?
Right atrial, ventricle, and pulmonary artery enlargement – due to volume overload
Pulmonary hypertension
Left to right shunting
Why is their left to right shunting is ASD?
Because the right ventricle is more compliant than the left, pulmonary vascular resistance is less than systemic vascular resistance, and the right atrium is lower pressure than the left atrium
How does a child present with ASD?
Asymptomatic
How does a 20-year-old present with ASD?
fatigue, dyspnea, and decreased stamina
How does ASD present in the 3rd & 4th decades of life?
Increasing fatigue, dyspnea, and atrial arrhythmias (Afib)
What is one of the most unfortunate side effects of ASD?
Paradoxical emboli → stroke
How does a paradoxical emboli travel?
DVT → Venous emboli → RA → through the PFO → LA → LV → Right carotid → brain
What do you look for on PE with ASD?
S2 widely split through inspiration/expiration
Grade 2-3 midsystolic crescendo-decrescendo murmr (present during childhood)
How do you confirm diagnosis of ASD?
ECG & Echo-Doppler
Catheter to close ASD
How would you treat an ASD if no symptoms are present?
If the Qp:Qs (pulmonary to systemic blood flow) is >1.5:1 or if PAH present
If a young boy who is otherwise healthy and is presenting with fatigue and SOB with strenuous activity. On PE you note a harsh crescendo/decrescendo murmur at the upper left sternal border, what diagnosis?
Pulmonic stenosis
What is the pathology for pulmonic stenosis?
Domed shaped stenosis of the pulmonary valve along with right ventricular hypertrophy
What does right ventricular hypertrophy occur?
Because it has to push higher pressures to get past the stenotic valve
What is considered severe pulmonic stenosis vs. moderate?
Severe is a pressure gradiant between the RV & the PA >75
Moderate >40mmHg
What would you look for on PE with pulmonic stenosis in a child?
Systolic thrill, early systolic click on the left sternal border, and a LOUD/HARD CRESCENDO-DECRESCENDO at upper LSB that radiates towards the clavicle and is louder with inspiration.
What diagnostics would you do to confirm pulmonic stenosis?
ECG has RVH, Echo shows the obstruction and severity
What can happen to an adult if severe pulmonic stenosis is not identified and treated?
Poor prognosis with RV failure
How do you treat pulmonic stenosis is a child?
Balloon valvuloplasty (has replaced surgery)if gradient is >75
No intervention is gradient is
In utero, how does the heart function?
It develops with a right to left shunt through the patent ductus arteriosus
How long does it take for the PDA to close?
within the first 2-3 days after birth
When does the dutcus most often remain open?
In pre-term deliveries
What happens if there is a moderate ductus opening?
Elevated PAP and significant shunting
What happens if there is a large ductus opening?
Major left to right shunting, pulmonary congestion, LV dysfunction and failure
How does PDA present?
HF develops in the first weeks of life
What do you look for on PE with PDA?
A continuous systolic thrill that is continuous through systole and diastole
“Machienery murmur”
How would you confirm diagnosis of a PDA?
Chest X-ray to see increased LA & LV
ECG – LVH
Echo Doppler – LVH
MRI & CT – identify PDA
How do you treat a premature infant with PAD?
Indomethacin = first line treatment
Surgical or catheter closure
If a young boy presents with hypertension and leg fatigue when running, what diagnosis?
Coractation of the Aorta
What does coarctation of the aorta cause?
Cause obstruction to outflow to the lower half of the body, LVH due to pressure overload, and arterial hypertension
How does coractation present in an infant?
Heart Failure
How does coractation present in older children?
Fatigue, dyspnea, and fatigue of the lower extremities + Hypertension in childhood!!
What would be another cause of hypertension in childhood?
Renal artery stenosis
What would you look for on PE in this child with hypertension and leg fatigue?
Differential blood pressure between arms & legs (difference of >10mmHg is highly suspicious)
Remember! BP is NORMALLY HIGHER in the LE when compared to UE
Well-developed upper body & thin legs
How would you confirm coractation?
Chest x-ray – Figure 3 sign & indentations into the ribs
ECG – LVH
Cardiac MRI//MRA & CT
Cardiac cath
How do you treat coractation?
Surgical direct resection/repair or stent (hypertension may persist if correction is after age 6)
What would cause RVH in a child?
Tetralogy of Fallot
What occurs in a tetralogy of fallot?
Biventricular origin of the aorta
What is one of the most common cause of sudden cardiac death in the young?
Hypertrophic cardiomyopathy (along with Brugada syndrome & Marfan’s)
When a young athlete is in for a sports physical, what must we always ask about?
Family history of sudden death, history of chest pain, dizziness, syncope, and dyspnea
What should our cardiac exam include for our young athletes’ sports physical?
Thorough evaluation for murmurs!! ECG & Echo Doppler should be obtained when structural cardiac pathology is suspected
