Pediatric Cardiology - Primary Care Flashcards
Heart Sounds
S1 - Heard in the beginning of systole; indicate closure of AV valves; “lubb”; often a single sound
S2 - Composed of aortic and pulmonic components; marks end of systole; “dubb”; may be split on inspiration in children
S3 - Associated with rapid ventricular filling; may be heard in quiet infant or with rapid heart rate; when heard with S1 and S2 sounds like “Kentucky” has a gallop rhythm
S4 - always pathologic; increased force of atrial contraction and ventricular distention; seems like “Tennessee”
Murmurs
80% of children have innocent or functional murmurs
All murmurs intensified by factors increasing cardiac output (anemia, fever, exercise)
Grades or Intensity of Murmur
Grade I: barely audible; heard faintly after a period of attentive listening
Grade II: Soft but easily audible
Grade III: Moderately loud; no thrill
Grade IV: Loud, present over widespread area; palpable thrill
Grade V: Loud, audible with stethoscope barely on chest; precordial thrill present
Grade VI: Heard without stethoscope (rare)
Innocent Murmurs
Table 38.5 - page 715
Stills (innocent, vibratory, functional, physiologic, “head start” murmur)
Pulmonary Flow Murmur of Childhood (Flow murmur)
Pulmonary Flow Murmur of Infancy (Peripheral pulmonary stenosis)
Venous Hum
Congenital Heart Disease
Occurs during 2nd to 8th week of gestation
2-4% caused by teratogens (Lithium, retinoic acid, anti-epileptics, ibuprofen/naproxen, ACE inhibitors, TCAs)
Congestive Heart Failure
Peds CHF may be caused by congenital malformations leading to ventricular dysfunction, volume overload, or pressure overload
Largest group: excessive left to right shunting
Traditional therapies: diuretics, inotropes, afterload reducers
Conditions associated with CHF in children
- Premature infant: PDA
- Birth to 1 week old: Hypoplastic left heart syndrome, coarctation of the aorta, critical aortic stenosis, interrupted aortic arch, arteriovenous malformations, tachycardia, cardiomyopathy
- 1 week to 3 months: VSD, truncus arteriosus, AV canal (endocardial cushion defect), total anomalous pulmonary venous return, coarctation, tachycardia, PDA, aortic stenosis, tricuspid atresia
- Older than 1 year: bacterial endocarditis, rheumatic fever, myocarditis
Signs and symptoms of congestive heart failure
Infants: Tachypnea, tachycardia, rales or wheezing, cardiomegaly and hepatomegaly, orbital edema, poor feeding/tires easily when feeding, poor weight gain, diaphoresis
Children and teens: tachypnea, tachycardia, rales or wheezing, cardiomegaly and hepatomegaly, orthopnea, shortness of breath or dyspnea with exertion, peripheral edema, poor growth and development
Left to Right Shunting (acyanotic) - Atrial septal defect (ASD)
- Ostium secundum - most common; mid septum in area of foramen ovale
- Primum ASD - lower portion of septum
- Defects of sinus venosus - high in atrial septum; associated with anomalous pulmonary venous return
Clinical findings: often asymptomatic; may fatigue easily; frequent URI/pneumonia
- Murmur not typical until 2 to 3 years
- Possible mild left anterior chest bulge
- S1 normal or splint; S2 often widely split, fixed
- Grade I to III, widely radiating, medium-pitched, not harsh systolic murmur at pulmonic area
Management:
- Small defects may close spontaneously
- Large defects require intervention after 1 year/before school
- SBE prophylaxis for 6 months after cardiac surgery or device closure
- Right ventricular enlargement if unrepaired (Severe irreversible pulmonary hypertension)
- Exercise restriction unnecessary
Left to Right Shunting (acyanotic) - Ventricular septal defect (VSD)
20% to 30% of all CHDs
Perimembraneous is most common
30-50% are small and close by age 4
Clinical findings:
- Murmur often not heard until 2 to 8 weeks
- Classic loud murmur associated with signs of CHF
- Small VSD - harsh, high-pitched grade II to IV/VI, holosystolic at LLSB
- Large VSD - low-pitched, grade II to V, holosystolic; signs of CHF
Management: monitor defects every 6 months during first year, then biannually to assess for closure; no SBE prophylaxis
- Larger defects with CHF: Lanoxin, diuretics, ACE inhibitors, beta-blockers; surgery for closure if no improvement (SBE prophylaxis 6 months after surgery)
Left to Right Shunting (acyanotic) - Atrioventricular septal defect (AVSD)
Atrioventricular canal defect/endocardial cushion defect (septal portion of AV valves, lower portion of atrial septum, and upper portion of ventricular septum)
Common in children with down syndrome
Clinical findings:
- If only primum ASD (partial AV canal), may not have symptoms
- Infants with complete AV Canal may have CHS
- Partial AV Canal - same as secundum ASD with soft, blowing murmur
- Complete AV - low-pitched grade II-V murmur at LLSB; diastolic rumble at apex; thrill at LLSB; signs of progressing CHF; gallop rhythm
ECG: right ventricular hypertrophy
Management: monitor every 3 to 6 months in first year and then biannually until defect closed surgically in toddler or preschooler
- May gain weight slowly; usually do not have CHF
- Infants with complete AV Canal need surgery before six months - Prior to surgery will take digoxin, diuretics, ACE inhibitors, beta-blockers
Left to Right Shunting (acyanotic) - Patent Ductus Arteriosus (PDA)
Normal closure in first 12 to 72 hours
Frequency increases with decreasing gestational age
Clinical findings: asymptomatic if small; CHF signs in 1st weeks of life
- Soft, systolic murmur immediately after birth
- Grade II-V, harsh, rumbling, machinery like murmur after first few weeks
- Large shunts - CHF
ECG: left ventricular hypertrophy with large shunt
Management:
- indomethacin or ibuprofen to affect closure in preterm infants
- If asymptomatic or small – follow for spontaneous closure
- Interventional cardiology to close shunt
- SBE prophylaxis for 6 months after closure
Right to Left Shunting (cyanotic) - Transposition of the Great Arteries
Aorta arises from right ventricle; pulmonary artery from left ventricle
Clinical findings: cyanosis immediate; CHF symptoms may be present; often LGA infant; may or may not have murmur at birth
Dx:
- EKG maybe normal early on
- Echocardiography shows defect: pulmonary artery rising from left ventricle in the aorta arising from the right
Management:
- Immediate referral to pediatric cardiologist
- Correction of electrolytes, acid-base imbalance
- IV prostaglandin E1 to delay closure of ductus
- Balloon atrial septosomy to promote mixing of oxygenated and deoxygenated blood
- Arterial switch surgery in first days of life
- Monitored closely throughout life; annual echo
- SBE prophylaxis for life
Prognosis: 50% mortality in first month; 90% by first-year without treatment
- Referred patients with history of palpitations, syncope, dyspnea
Right to Left Shunting (cyanotic) - Tetralogy of Fallot
Four defects:
- Pulmonary valve stenosis
- Right ventricular hypertrophy
- Ventricular septal defect
- Overriding aorta
Right to left shunting across VSD; cyanosis increase over first few months
Clinical findings:
- Cyanosis usually present at six months
- Dyspnea and cyanosis (TET spells) increase by 2-4 months
- Poor weight gain
- Cyanosis of mucous membranes; dyspnea
- Grade III-V harsh, systolic ejection murmur at the left to upper sternal border
- Palpable thrill/holosystolic murmur at LLSB
- Sternal lift from right ventricular hypertrophy
Dx: Boot shaped heart; ECG with right ventricular hypertrophy; pulse ox values decrease overtime
Management:
- Ductus maintained with prostaglandin E1 in newborns with severe pulmonary obstruction
- Hypercyanotic episodes - knee-chest position, oxygen, morphine sulfate
- Complete repair with open heart surgery in infancy
- Lifelong cardiology follow-up
- SBE prophylaxis before surgery and until six months after surgery
Right to Left Shunting (cyanotic) - Tricuspid atresia, hypoplastic left heart syndrome, other single ventricle defects
Oxygenated/deoxygenated blood mix in ventricles - cyanosis
Most require palliative procedures to survive
Clinical findings:
- Cyanosis after birth, increased respiratory rate, fatigue with crying/feeding
- Progression to cardiorespiratory shock as ductus closes
- Grade I-III early systolic murmur
- Cyanosis as soon as ductus closes
- Hepatomegaly
Dx:
- Chest radiography - Heart size is initially normal; cardiomegaly, decreased pulmonary blood flow over time
- ECG – always abnormal for age
- Two-dimensional echocardiography is diagnostic
Management:
- IV prostaglandins E1 in newborns
- Aortopulmonary shunts initially, then continued palliation with surgery
- May require transplant
- SBE while child cyanotic
Complications: development of collateral arterial/venous vessels; Protein-losing enteropathy; arrhythmias, thromboembolic events
Obstructive Cardiac Lesions – Aortic Stenosis and Insufficiency
Narrowing at aortic vavular subvalvular, or supravalvular level (usually bicuspid)
Left ventricular hypertrophy from increased pressure load
Ischemia, fatal arrhythmias may occur
Clinical findings:
- Growth/development maybe normal
- Activity intolerance, fatigue, chest pain, syncope
- CHF, low cardiac output, shock if severe in newborns
- Sudden death from arrhythmias
