Pediatric cardiology

Question 1

What is the foramen ovale?

Answer 1

Connection between right and left atria (fetal)

Question 2

What is the ductus venosus?

Answer 2

Umbilical vein connection with IVC-shunts oxygenated blood

Question 3

What are the 5 T lesions of cyanotic heart disease?

Answer 3

Truncus arteriosis
Total anamalous pulmonary venous drainage
Tricuspid atresia
Tetralogy of Fallot
Transposition of great arteries

Question 4

What is the most common cyanosis heart disease in neonates?

Answer 4

Transposition of the great arteries

Question 5

What is the oxygen saturation cutoff for cyanosis?

Answer 5

75%

Question 6

What is the classic history for tetralogy of fallot?

Answer 6

Hypoxic spells during exertion like crying

Question 7

What signs make a murmur unlikely to be benign?

Answer 7

1. Murmur greater than 4/6 (thrill)
2. Diastolic murmurs
3. Regurgitant systolic murmurs

Question 8

Still’s Murmur

Answer 8

1. Grade 1-2/6
2. Musical systolic ejection murmur
3. Best heard between apex and LLSB, little radiation
4. Increases with exercise, fever, supine
5. Decreases sitting, standing, or Valsalva
6. Age 2-7

Question 9

Pulmonary flow murmur

Answer 9

1. Grade 1/2 SEM
2. Vibratory/soft
3. Best heard @ left base
4. Increases with exercise/supine
5. Ages 8-16
6. S2 is normal*** differentiate from ASD

Question 10

Venous hum

Answer 10

1. Grade 1/2
2. Soft/blowing, continuous into diastole
3. Supra/sub clavicular regions, radiates to neck and base of heart
4. Decreases with supine position or gentle pressure of jugular veins
5. Age 3-8 years.

Question 11

Carotid/brachiocephalic bruits

Answer 11

1. Grade 1/2
2. Harsh systolic ejection murmur
3. Supraclavicular neck region, radiates below clavicles
4. Age 2-10
5. Increase with fever/exercise, decrease with hyperextension of the neck

Question 12

Who should get IE prophylaxis?

Answer 12

1. Prosthetic valve
2. Previous endocarditis
3. Congenital heart defect: unrepaired cyanotic, 6mo or less post repair
4. Heart transplant patients with valvulopathy

Question 13

What are the three fetal shunts?

Answer 13

1. Ductus venosus- bypasses liver with oxygen rich blood (IVC)
2. Foramen ovale- allows blood to go RA-LA and bypass the lungs
3. Ductus arterious- allows blood exiting RV via pulmonary artery to bypass lungs and join aorta

Question 14

What is unique about fetal circulation?

Answer 14

1. Arterial PaO2 is generally low (hb properties)
2. Pulmonary= high resistance to flow until birth
3. RV is dominant (until birth)

Question 15

What changes with fetal circulation at birth?

Answer 15

1. Fluid in airways is cleared, breathing begins= decrease in pulmonary resistance, increase in pulmonary blood flow
2. Systemic circulation becomes high resistance (no more placenta)
3. Increased blood return to LA closes foramen ovale
4. LV becomes dominant over 4-6 weeks

Question 16

Transposition of the Great Arteries

Answer 16

1. Aorta comes from RV, pulm art from LV= two parallel circulations, only mix via ASD or VSD
2. Rapidly progressive severe hypoxemia in neonates, oxygen unresponsive. Loud S2. May get CHF in first weeks
3. CXR= Egg on a string”
4. Tx= Prostaglandin- keeps ductus arteriosus open-MIXING, Balloon atrial septostomy- create ASD for mixing
   Repair when stable

Question 17

Tetralogy of Fallot

Answer 17

1. VSD+RVH+RV outflow tract obstruction+ overriding aorta
2. Progressive cyanosis, hypoxic ‘tet’ spells with crying or feeding
3. CXR=boot shaped heart
4. Surgical repair, manage tet spells in interim

Question 18

Truncus arteriosus

Answer 18

1. Single great vessel gives off aorta, pulmonary artery, coronaries- allows MIXING
2. Tachypnea, cardiomegaly, poor growth
3. Tx= surgical repair in first six weeks

Question 19

Hyperoxic test

Answer 19

Give 100% oxygen and see response

Question 20

Valvular aortic stenosis

Answer 20

1. Severity varies
2. Hx= asymptomatic—> chest pain—> cardiogenic shock
   Starts around time of duct closure (12 h to 1 week ish)
3. Px= SEM @ RUSB, palpable thrill
4. ECG=LVH (sometimes)
   CXR=Cardiomegaly + pulmonary edema (depends)
5. Tx= Emergent or elective valvuloplasty. Prostaglandin

Question 21

Coarctation of the aorta

Answer 21

1. Hx= association with bicuspid aortic valve, turner sydrome. Poor feeding, resp distress,
2. Px= Often CHF from LV failure, weak femoral pulses, S3 gallop, no murmur,
   BP gradient between upper and lower limbs
3. Ix= ECG- RVH +strain (in infancy), LVH later
   CXR= cardiomegaly + pulmonary edema
4. Tx= prostaglandin, tx for CHF, surgical reapair

Question 22

Pulmonary atresia

Answer 22

1. Hx= associated with other congenital heart lesions, syndromes
2. Px= Wide split S2 on expiration, SEM @ LUSB, pulmonary ejection click, hepatomegaly
3. Ix- ECG= RVH
   CXR= dilation of main pulmonary artery
4. Tx= surgical repair

Question 23

What are the Jones criteria?

Answer 23

1. Major: carditis, chorea, polyarthritis, erythema marginatum, subcutaneous nodules
2. Minor: fever, arthralgia, increased acute phase reactants, increased PR interval

Question 24

Atrial septal defect

Answer 24

1. Abnormal persistent opening in the inter atrial septum
2. Blood shunted from left atrium to right atrium,
3. RA enlarges, eventually RV
4. Px= RV heave, fixed split S2, LUSB systolic murmur.
5. Ix= CXR= cardiomegaly, increase in pulmonary vasculature

Question 25

Ventricular septal defect

Answer 25

1. Abnormal opening in interventricular septum. Usually present around 4-6weeks 2. Blood shunted left ventricle to right ventricle, causes increased return to left heart. 3. Left atrial enlargement, leads to LA/LV dilation. Eventually RV hyper trophy due to increased resistance. 3. Hx: failure to thrive, feeding difficulties, 4. Px= displaced apex, RV heave, thrill over VSD! Harsh pan systolic murmur. 5. Sx= signs of CHF= increased work of respiration, crackles, signs of systemic congestion (eyelids, scrotum), disphoresis during feeding, fever, decreased cardiac output. 6. Tx= small will close on their own, large surgical repair

Question 26

Patent ductus arteriosus

Answer 26

1. Persistent connection between the great vessels 2. Blood shunted from aorta to pulmonary artery in systole or diastole. Left atrium enlarges first. Over time RV enlarge. 3. Hx: premature baby, children. See breathlessness 4. Px: continuous machine murmur Bounding pulses, enlarged heart. Thrill LUSB. 5. Tx: surgical ligation. In premature, can use ibuprofen

Question 27

What left to right shunts increase left heart size?

Answer 27

VSD, patent ductus arteriosus

Question 28

Atrioventricular septal defect

Answer 28

1. Common AV valve 2. Left to right shunt on both levels. Enlarges both sides of heart 3. Presents in first month of life 4. Hx= failure to thrive

Question 29

Eisenmenger syndrome

Answer 29

1. Change of shunt from left to right to cyanotic lesion. 2. Erythrocytosis, pulmonary HTN, cyanosis. 3. Leads to early death

Question 30

What is the most worrisome feature of Kawasaki disease?

Answer 30

1. Causes aneurysms of coronary arteries

Question 31

How do we treat Kawasaki disease?

Answer 31

1. IVIG, antiinflammatories

Question 32

General care for cyanotic baby?

Answer 32

1. Administer oxygen 2. Correct underlying things- metabolic acidosis, hypoglycemia etc 3. Prostaglandin if think it would help 4. Echo once stable enough

Question 33

Signs of pediatric CHF?

Answer 33

1. Pulmonary congestion: Increased resp rate, signs of increased work of resp 2. Signs of systemic congestion: hepatomegaly, edema of eyelids, labia/scrotum, hands and feet (NOT JVP NO NECK) 3. Increased sympathetic drive: increased heart rate, resp rate, diaphoresis, fever 4. Decreased cardiac output: pallor, cool extremities