Cardiac lecture Flashcards by Cassidy Ruocco

Difficulty feeding
Increased RR
Sweating
Cyanosis
Syncope

Cardiac symptoms in newborns

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Mainstay imaging?

Echocardiography

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Defects that cause right to left shunting can cause…

Cyanosis

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Will hypoxemia from HF respond to oxygen?

Will hypoexmia from R to L shunting respond to oxygen?

HF will respond to O2

R to L shunting will not repsond to O2

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Hematocrit over 60 is common with R to L shunting and associated chronic hypoxemia

Polycythemia

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Polycythemia from R-L shunting can lead to direct intracranial thrombosis.

Paradoxical embolus as noted

this can cause..?

Stroke

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Retardation of growth can be a complication of…

congenital heart disease (CHD)

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Pulmonary arterial hypertensions (PAH)

Pulmonary vascular obstructive disease (PVOD)

Major complications of congenital heart disease

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Destruction of pulmonary vascular (arteriolar) bed in pressure of continous pressure overload (much less common with volume overload alone)

results in marked increase in PuVR and further elevation of PAP

Pulmonary vascular obstructive disease

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An opening in part of the ventricular septum that separates the 2 ventricles

80% involve the thin membranous septum
20% involve the muscular septum

Ventricular septal defect

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Associated with:
Coarctation of the aorta
ASD
PDA
sub-aortic/pulmonic stenosis

Ventricular septal defect

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large resistance to flow through small hole
normal RVP and PAP
small L to R shunt
well tolerated.

*will often close on own. must monitor

Small “restrictive” ventricular septal defect (VSD)

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allow varying transmission of LVP into the RV→PA.
PAH common and PVOD develops over time.

Large defects result in LV dilation and failure.

Moderate to large ventricular septal defects (VSDs)

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When severe, CXR will show cardiomegaly, dialted pulmonary artery and HF

Ventricular septal defects (VSD)

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Which image is diagnostic for ventral septal defect (VSD)

identifies the size and location of the defect and presence of shunting;
RV and pulmonary artery pressures can be estimated .

Echo-doppler

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clinical manifestations:

no symptoms

harsh holosytolic murmur (best heard at LSB) appears within 36 hrs of birth

intensity may change with age.

Small VSD

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HF signs and symptoms early in life; surgical repair indicated.

Large VSD

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Possible systolic thrill at LLSB
nl S2
harsh holosystolic murmur along LSB.

Ventricular septal defect (VSD)

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Are most of the ventricular septal defects small or large?

SMALL!

24% close spontaneously by 18 mos
50% by 4 years
even more by 10 years

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HF occurs in ___% of infants with large VSD

80%

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Risk of PVOD is high in….

moderate to large ventricular septal defects (VSD)

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If the ventricular septal defect remains about, what is the pt at risk for?

Endocarditis

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Do we still give antibiotics for prophylactic endocarditis?

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Timing of surgery is dependent on….

severity of shunt
LV function
Pulmonary artery pressure

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if ______ continues overtime.... progressive, irreversible PVOD develops and surgery carries high mortality with little benefit

Pulmonary artery HTN

In presence of significant \_\_\_\_\_\_\_\_\_\_ PuVR and PAP rise dramatically. This can lead to shunt reversal→R to L shunting→ hypoxemia and Rt sided heart failure (Eisenmenger’s physiology/complex).

Pulmonary vascular obstructive disease (PVOD)

A through and through communication between the atria at the septal level. Pathology: Large enough defect to allow free communication between the atria. Most common form (previously undetected) of CHD in adults; female to male ratio is 2:1.

Atrial septal defect (ASD)

Atrial septum formed by fusion\* of 2 overlapping planes of tissue during fetal development. Most ASD’s occur in _____ septum due to lack of tissue for overlap.

Mid septum!

\*Lack of atrial septal fusion occurs in up to \_\_\_% of adults leaving a “patent foramen ovale”, a potential space/opening between the two atria.

25%

With this defect, it is possible for a clot to form between the flaps, causing a paradoxical embolus

Atrial septal defect (ASD)

defect in mid septum at the fossa ovalis (80%) from incomplete development

Ostium secundum

defect in lower atrial septum; usually associated with additional defects.

Ostium primum

Which of the following is a defect in **mid** atrial septum? which one is a defect in **lower** atrial septum?: Ostrium primum Ostium secundum

Ostium primum= defect in lower septum Ostium secundum= defect in mid septum

RA, RV and PA enlarge - volume overload Pulmonary HTN usually occurs late (3rd or 4th decade) if lesion goes undetected up to that time in life result of chronic volume overload x years.

Atrial septal defects

**L to R shunting at atrial level due to:** Rt atrium more distensible than left RV more compliant than LV PuVR greater than SVR LA pressure greater than RA pressure

Atrial septal defect (ASD)

RV volume overload and increased pulmonary blood flow; well tolerated for many years.

Atrial septal defect

Majority of children are asymptomatic Symptoms when present include fatigue, dyspnea, decreased stamina and usually begin in early 20’s. Most adults become increasingly symptomatic by 3rd or 4th decade: fatigue, dyspnea and atrial arrhythmia’s (Afib). **paradoxical emboli can result in stroke!**

Atrial septal defect

\*Patent foramen ovale: incomplete fusion of atrial septum (tiny defect) allows clot to pass from ______ to \_\_\_\_\_\_\_

**right atrium --\> left atrium**

Hyperdynamic RV (lift): RV volume increase leads to ↑contraction via Starling mechanism. S1 accentuated at LLSB S2 widely split through inspiration/expiration: RV ejection is delayed from volume overload.

Atrial septal defect

Grade II-III midsystolic crescendo-decrescendo mumur, at upper LSB reflects increased blood flow across pulmonic valve. Present during childhood.

Atrial septal defect

ECG shows: rsR’ pattern in Rt precordial leads with mildly widened QRS (incomplete RBBB) arrhythmias common in adults-Afib, Aflutter.

Atrial septal defect

Echo-Doppler shows: RV volume overload enlarged RV, RA 2D echo and doppler identify the defect and semi quantitate the shunt.

Atrial septal defect

Cardiac cath shows: Measurement of RV/PA pressures quantification of shunting identification of anomalous pulmonary veins if present. **Closure of ____ often performed percutaneously using catheters/devices.**

atrial septal defects (ASD)

Is PVOD seen more with ventricular septal defect (VSD) or atrial septal defect (ASD)

VSD (PVOD is uncommon ins ASD)

Harsh, holosytolic murmur at LSB VSD or ASD?

large VSD

Grade II-III mid systolic crescendo-decrescendo murmur at upper LSB VSD or ASD?

ASD (reflects increased blood flow across pulmonic valve)

Undetected ASD can later lead to (right or left) sided HF?

Right

Once symptoms present (including paradoxical emboli), what do you do for ASD?

Surgical/catheter closure

For ASD, if there are NO SYMPTOMS but... **QP:QS ratio is greater than 1.5:1.0** OR **PAH is present** ...what do you do?

Surgical/catheter closure

MC form of pulmonary stenosis= "dome shaped" stenosis of pulmonic valve in pulmonic stenosis, the right ventricle develops _________ hypertrophy, and reflects the degree of obstruction at the valvular level

**concentric!**

Pulmonic valve must be obstructed by \_\_\_% or more to be hemodynamically significant

60%

Peak systolic gradient (pressure between RV and pulmonary artery) is **\>40 mmHg**

**Moderate** pulmonary stenosis

Peak systolic gradient (pressure gradient between RV and pulmonary artery) is **\>75 mmHg**

**Severe** pulmonic stenosis

RV failure occurs with severe obstruction due to pulmonic stenosis this results in a decreased...

cardiac output | (and associated signs/symptoms)

Most infants/children are asymptomatic, unless severe Sx include: DOE, fatigue PE shows: systolic thrill at suprasternal notch **early systolic click** at upper LSB murmur is LOUD! (grade 3-4) **harsh crescendo-decrescendo at upper LSB radiating towards clavicle and LOUDER WITH INSPIRATION**

Pulmonic stenosis

Harsh crescendo-decrescendo murmur at upper LSB, radiating towards clavicle and **louder with inspiration!!!** (usually grade 3-4)

Pulmonic stenosis

Image of choice for pulmonic stenosis Identifies obstruction and estimates severity

Echo/doppler

Tx for pulmonic stenosis

Balloon valvuloplasty opens stenotic valve

Is intervention for pulmonic stenosis required if the gradient is \<25 mmHg

NO! **but intervention is always required if gradient \>75 mmHg**

Persistent patency of the vessel that normally connects the pulmonary arterial system and the aorta in the fetus

Patent Ductus Arteriosus (PDA)

Normally, the patent ductus arteriosus (PDA) closes within _____ days after birth

2-3 days

Risk factors: Maternal exposure to rubella Pre-term deliveries

PDA

High resistance to flow Well tolerated Small L to R shunt ...small, moderate or large PDA?

Small

Aorta and pulmonary artery are in free communication, equal pressures Marked L to R shunting Pulmonary congestion LV dysfunction and failure PVOD ..small, moderate or large PDA?

Large

Elevated pulmonary artery pressure Significant shunting ...small, moderate or large PDA?

Moderate

If there is a large PDA, what type of symptoms can you see within the first weeks of life?

CHF type symptoms

Systolic thrill over pulmonary artery in suprasternal notch and LSB Apical and RV impulse increased Murmur is **continuous (thru systole and disatole) "machinery murmur"** Grade 4 or louder at LSB and beow clavicle Peaks near S2

PDA murmur

First line tx for PDA in premature infants

**Indomethacin** ..if ductus remains open, surgical or catheter closure! | (constriction of ductus)

8-9% of all infants presenting with CHD discrete narrowing of distal segment of the aortic arch, just distal to the origin of the subclavian artery

Coarctation of the aorta

Systolic and diastolic pressures **above** coarctation are....

**elevated!** (systolic and diastolic pressures below coarctation are reduced)

What 2 other cardiac abnormalities are often seen with coarctation of the aorta?

Ventricular Septal Defect Bicuspid Aortic Valve

Prominent collateral circulation to lower body develops via internal mammary and subcostal arteries, causing what to be seen on CXR in coarcation?

Rib notching

Fatigue Dyspnea Fatigue in legs with exertion Frank claudication signs/symptoms of?

Coarctation of aorta

If a child has HTN, what 2 things should you consider?

Coarctation of aorta Renal artery stenosis (HTN secondary cause in kids)

In coarctation of the aorta, what does the BP look like in the legs compared to the arms?

\>10 mmHg drop in leg BP compared to arms (arm BP \>10 mmHg higher than leg BP)

Mechanical obstruction of the coarct PLUS High renin HTN due to decreased perfusion of kidneys ...leads to what in coarctation pts?

Marked HTN in uper body

How does a pt with coarctation of the aorta appear?

Well developed upper body Very thin legs

What will an ECG look like in a pt with coarctation of aorta?

LVH

With coarctation of aorta... progressive HTN develops with age and often persists if surgical correction is performed after age...?

Biventricular origin of the aorta Large VSD Obstruction to pulmonary blood flow RVH

Tetralogy of Fallot

MC cause of SCD in pts under 35 yo

HCM

Cardiac lecture Flashcards

(81 cards)