Zero to finals- Cardio Flashcards
What are the 3 foetal shunts?
Ductus venosus
Foramen ovale
Ductus arteriosus
What is the ductus venosus
Shunt connects umbiliacal vein to IVC and allows bypass of liver
What is the foramen ovale?
Shunt connects RA to LA and allows blood to bypass the RV and pulmonary circulation
What is the ductus arteriosus
Connects pulmonary artery with aorta and allows blood to bypass the pulmonary circulation
How does the foramen ovale close?
First breath baby takes expans alveoli. Decreases pulmonary vascular resistance
This decrease causes a fall in pressure in RA
At this point LA pressure is greater than RA which squashes atrial septum to cause functional closure of foramen ovale
What does the foramen ovale become?
Fossa ovalis
What keeps the ductus arteriosus open?
Prostaglandins
What causes the closure of the ductus arteriosus?
Increased blood oxygenation causes a drop in circulating prostaglands. This causes closure of the ductus arteriosus which becomes the ligamentum arteriosum
What does the ductus venosus become?
Ligamentum venosum
What are innocent murmurs also called? What are they caused by?
Flow murmurs
Fast blow flow through various areas of the heart during systole
What are the features of innocent murmurs?
Soft Short Systolic Symptomless Situation dependent
What investigations can rule out abnormalities in murmurs in children?
ECG
CXR
Echocardiography
What causes negative intra thoracic pressure?
During inspiration the chest wall and the diaphragm pull the lungs open. Also pulls the heart open
What does an atrial septal defect sound like?
Mid systolic, crescendo-decresendo murmur. Loudest at the upper left sternal border, with a fixed split second heart sound
What does fixed split mean?
Heart sound does not change with inspiration and expiration
What sound may be heard in PDA?
Small PDA may not cause any abnormal heart sounds
More significant PDAs cause a normal first heart sound with a continuous crescendo decresendo machine murmur that may continue during the second heart sound, making the second heart sound more difficult to hear
What does the murmur in teratology of the fallout sound like?
It arises from pulmonary stenosis giving an ejection systolic murmur loudest at the pulmonary area
What is cyanosis?
When deoxygenated blood enters the systemic circulation
When does cyantoic heart disease occur?
When blood is able to bypass the pulmonary circulation and the lungs
Allows a right to left shunt
Heart defects that can cause a right to left shunt:
Ventricular septal defect
Atrial septal defect
Patent ductus arteriosus
Transposition of the great vessels
What is Eisenmenger syndrome?
If the pulmonary pressure increases beyond the systemic pressure, blood will start to flow from right to left across the defect causing cyanosis
What can having an asymptomatic PDA throguh childhood present with as in adulthood?
HF
PDA presenting symptoms
Murmur may be pciked up SOB Difficulty feeding Poor weight gain LRTI
How can a diagnosis of PDA be confirmed
Echocardiogram
Doppler flow during ECHO can assess size and characteristics of left to right shunt
What is the management of PDA?
Monitored until 1 year of age using echocardiograms
After 1 it is highly likely close spontaneously and transcatheter or surgical closure can be performed
What is an atrial septal defect?
A hole in the septum between the two atria
In ASD what way does the blood move?
From LA to RA as pressure higher in LA
What can ASD lead to?
Blood flows to lungs to patient not cyantoiv but increased flow and pressure in right side of heart leads to right sided overload and heart strain
RHF and pulmonary hypertension
What is Eisenmenger syndrome?
Pulmonary pressure is greater than systemic. Shunt reverses and becomes right to left shunt. Blood bypasses lungs and becomes cyanotic
Examples of Atrial septal defects?
Ostium secundum
Patent foramen ovale
Ostium primum
Complications of ASD?
Stroke
AF
Pulmonary hypertension and RHF
Eisenmenger syndrome
What is important to think about in relation to atrial septal defects and DVT?
Clot goes to RA then LA due to ASD instead of being a PE!
What are symptoms of ASD?
SOB
Difficulty feeding
Poor weight gain
LRTI
What is the management of PDA?
Refered to paediatric cardiologist
When it is small and asymptomatic watch and wait
Corrected surgically using a transvenous catheter colusure. Anticoagulants such as aspirin, warfarin and NOACs reduce risk of clots and stroke in adults
what is VSD
Congeital hole in the septum between ventricles
Can occur by themselves but commonly associated with Down’s syndrome and Turner’s syndrome
What are symptoms of VSD>
Poor feeding
Dysponea
Tachynponea
Failure to thirve
What is found in examination of a VSD
Pan systolic murmur more prominent over left lower sternal border in the third and fourth intercostal spaces
Systolic thrill on palpation
What is the treatment of a VSD?
Watched if small
Corrected surgically using a transvenous catheter closure via femoral vein or open heart surgery
Risk of IE in patients with VSD. Abx prophylaxis should be considered during surgery to reduce risk of IE
What is Eisenmenger syndrome?
Blood flows from right tp left side of heart cross a structural lesion bypassing the lungs
ASF, VSD, PDA
Can develop 1-2 years with large shunts or in adulthood with small shunts
What is cyanosis?
Blue discolouration of skin relating to a low level of oxygen in blood
How does bone marrow respond to low oxygen saturation?
Produces more red cells and hameoglobin to increased oxygen carrying capacity in the blood
Leads to polycythaemia which is a high concentration of haemoglobin in blood
Gives patients a plethoric complexion
High concentration of RBCs and haemoglobin make the blood more viscous making patients more prone to thrombus formation
Examinatin findings in pulmonary hypertension
Right ventricular heave
Loud P2
Raised JVP
Peripheral oedema
What are the findings related to right to left shunt and chronic hypoxia?
Cyanosis
Clubbing
Dysponea
Plethroic complexion
What is the management of eisenmengers syndrome?
Once the pulmomnary pressure is high enough to cause the syndrome it cant be medically reversed. Only definitive treatment is a heart lung transplant
Closely followed by a specialist
Medical manegemtn involves: Oxygen can help manage symptoms
Pulmonary hypertension: sildendail
Arrhythmia treatment
Treatment of polycythemia with venesection
Prevention and treatment of thrombosis with anticoagulation
Prevention of IE using prophylactic abx
What is coarctation of the aorta?
Congenitral condition where there is a narrowing of the aortic arch
What is the presentation of coarctation of the aorta?
Often the only indication is a weak femoral pulse
Four limb bp- high bp in ones before narrowing and low bp in ones after
May be a systolic murmur below the left clavicle and below the left scapula
Tachyponea and increased work of breathing
Poor feeding
Grey and floppy baby
Left ventricular heave
Underdeveloped left arm where there is reduced flow to the subclavian artery
Underdevelopment of the legs
What is the management of coarctation of the aorta
Mild- Ca live symtpom free until adulthood without requiring surgical input
Severe-Patients will require emergency surgery shortly after birth
Critical- Risk of HF and death. Prostanglandin E is used to keep ductus arteriosus opem while awaiting surgery. Then surgery asap
What is the presentation of aortic stenosis?
Mild- Asymptomatic. Incidental discovery
More severe- Fatigue, SOB, dizziness and fainting
Symptoms worse on exertion
Severe- Present with HF within months of birth
Signs of aortic stenosis
Ejection systolic mumur in aortic area Crescendo-decrescendo Radiates to carotids Ejection click just before the murmure Palpable thrill during systole Slow rising pulse and narrow pulse pressure
Management of aortic stenosis?
Percutaneous baloon aortic valvoplasty
Surgical aortic valvotomy
Valve replacement
What are the complications of aortic stenosis?
Left ventricular outflow tract obstruction HF Ventricalr arrhythmias Bacterial endocarditis Sudden death
Congenital pulmonary valve stenosis is associated with what?
Teratology of fallot
William syndrome
Noonan syndrome
Congenital rubella syndrome
What is the presentation of pulmonary valve stenosis
Asymptomatic
More significant- Pulmonary valve stenosis
Can present with symptoms of fatigue on exertion, SOB, dizziness and fainting
What is the management of pulmonary valve stenosis?
ECHO to investigate
Mild- Symptoms patients generally do not require any interventions
Symptomatic or significantly stenosed, balloon valvulopasty via a venous catheter
Open heart surgery
What are the 4 coexisting patholgies of the teratology of fallout?
VSD
Overriding aorta
Pulmonary valve stenosis
RVH
What are the risks factors of teratology of fallout?
Rubella infection
Increased age of the mother
Alcohol consumption in pregnancy
Diabetic mother
Investigation of teratology of fallot?
ECHO
Doppler flow study
CXR- Boot shaped heart due to RV thickening
What is the presentation of teratology of the fallout?
Most cases are picked up before the child is born during the antenatal scans
Ejection systolic murmur caused by the pulmonary stenosis may be heard on newborn check
Severe cases will present with HF before one year of age
In milder cases they can present as older children once they start to develop signs and symptoms of HF
What are signs and symptoms of HF?
Cyanosis Clubbing Poor feeding and poor weight gain Tet spells Ejection systolic murmur loudest in pulmonary area
What are Tet spells?
Intermittent symptomatic periods where the right to left shunt becomes temporarily worsened precipitating a cyanotic episode
Pulmonary vascular resistant increases or systemic resistance decreases for example If child exerting get more CO2
CO2 is a vasodilatorand therefore reduces systemic vascular resistance
Blood goes from RV to aorta rather than pulmonary vessels
Episodes percipitated by waking, physical exertion or crying
Child will become irritable, cyanotic and SOB
Severe spells can lead to reduced consciousness, seizures and potentially death
Tet spell treatment options
Older children may squat
Younger children can be positioned with their knees to chest
These increase systemic vascular resistance
Any medical management should involve an experience paediatrician as they can be potentially life threatening: Supplementary oxygen, beta blockers, IV fluid, morphine, sodium bicarbonate and phenylephrine infusion
What is the management of teratology of fallout?
In neonates, a prostaglandin infusion can be used to maintain the ductus arteriosus. 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%
Prognosis depends on the severity, however it is poor without treatment. With corrective surgery 90% of patients will live into adulthood
What is ebstein’s anomaly?
Congenital heart condition where the tricuspid valve is set lower in the right side of the heart causing a bigger RA and a smaller RV
Leads to poor flow from RA to RV
Poor flow to pulmonary vessels
Often associated with a right to left shunt via an atrial septal defect
Also associated with WPW
What is the presentation of Ebsteins anomaly
Evidence of hearth failure Gallop rhythm heard on auscultation Cyanosis SOB and tachyponea Poor feeding Collapse or cardiac arrest
What are the investigations for ebstein’s anomaly?
ECG: Arrhythmias, right atrial enlargement, right bundle branch block, left axis deviation
CXR: Cardiomegaly and right atrial enlargement
Echocardiogram: Investigation of choice for confirming the diagnosis and assessing the severity
What is the management of ebstein’s anomaly?
Treat arrhytmias and HF
Prophylatic ABX may be used to prevent IE
Defintive management is by surgical correction of the underlying defect
What is the transposition of great vessels?
Where the attachments of the aorta and the pulmonary trunk to the heart are swapped
RV pumps blood into the aorta and LV pumps blood into the pulmonary vessels
2 separate circulations do not mix: one travelling through the systemic systems and right side of the heart and other travelling through the pulmonary system and left side of the heart
What is transposition of the great vessels associated with?
VSD
Coarctation of the aorta
Pulmonary stenosis
What is the presentation of transposition of the great vessels?
Often diagnosed during pregnancy with antenatal US scans
If not detected in pregnancy it will present with cyanosis at or within a few days of birth
ASD or VSD can initially compensated by allowing blood to mix between circulation but within a few weeks of the life they will develop respiratory distress, tachycardia, poor feeding, poor weight gain and sweating
What is the management of transposition of the great vessels?
When there is a VSD this will allow some mixing of blood
Prostanglandin infusion can be used to maintain the ductus arteriosus. This allow blood from the aorta to flow to the pulmonary arteries for oxygenation
Balloon septostomy involves inserting a catheter into the foramen ovale via the umbilicus and inflating a balloon to create a large ASD. Allows blood returning from the lungs to flow to the right side of the heart and out through to the aorta to the body
Open heart surgery-Definitive management. Cardiopulmonary bypass machine is used to perform an arterial switch procedure within a few days of birth
