Cardiology Flashcards
(178 cards)
1
Q
๐ฎโ๐จ What are the most common causes of chest pain in children, and how is the diagnosis usually made โ๏ธ
A
Non-cardiac chest pain (musculo-skeletal cause).
Diagnosis is usually based on history and physical examination .
Then pulmonary , and cardiac is the least common .
2
Q
๐ง Which is the best treatment for musculo-skeletal chest pain in children โ๏ธ
A
NSAIDs ( Naxyn (naproxen) )
more suitable than Acamol(paracetamol)
3
Q
In which cases chest pain take more importance in pediatrics โ๏ธ
๐ฉRed flags for cardiac chest pain
A
โฆ๏ธ Pain with exertion
โฆ๏ธ Syncope
โฆ๏ธ Fatigue
โฆ๏ธ Shortness of breath with exertion
โฆ๏ธ Pain preceded by tachycardia
โฆ๏ธ Family history of heritable conditions such as hypertrophic cardiomyopathy
4
Q
๐น What is syncope, and what are its key features โ๏ธ
A
๐นDefinition:
Temporary loss of consciousness & muscle tone
โฑ๏ธ Sudden onset, ๐ short duration, followed by spontaneous recovery
๐Usually occurs in standing or sitting position
โ ๏ธ May be preceded by dizziness or blurred vision
coma: persistent loss of consciousness.
5
Q
๐ฉบ๐ก What are the causes of syncope in children โ๏ธ
A
๐น1. Vasovagal ( Most common ):
๐ง Autonomic dysfunction (fainting with standing, stress)
๐น2. Cardiac Structural Defects :
โค๏ธ Hypertrophic cardiomyopathy
๐ Aortic stenosis
๐ซ Coronary anomalies
๐น3. Arrhythmias :
โก Ventricular tachycardia
๐ Complete heart block
๐ Long QT syndrome
๐น4. Non-cardiac :
โ ๏ธ Seizures, ๐ฉธ hypoglycemia, ๐ฐ psychological triggers
6
Q
๐จโค๏ธ Enumerate red Flags ๐ฉ for Cardiac Syncope โ๏ธ
A
๐ Any of the following suggest serious cardiac cause :
๐ Syncope during exertion or while supine
๐ Preceded by palpitations, chest pain, or SOB
๐ Bradycardia
๐ผ Age < 10 yrs , especially < 6
๐ Family history : cardiomyopathy, channelopathies
๐ฉบ Abnormal physical exam findings
๐๏ธ Exercise intolerance , fatigue
๐ซ History of heart disease
7
Q
๐๐งพ How is syncope evaluated initially โ๏ธ
A
๐งช Step 1: ECG
โ๏ธ Rhythm analysis
โ๏ธ Signs of LVH/RVH
๐
Step 2: If suspicion persists
๐ 24-h Holter monitor โ arrhythmias
๐ฅ๏ธ Echocardiogram โ structural disease
8
Q
๐๐ซ What causes the S1 and S2 heart sounds โ๏ธ
A
๐นS1 (โLuBโ) = AV valve closure
๐ฃ Mitral + Tricuspid valves close โ Marks start of systole
๐นS2 (โDuBโ) = Semilunar valve closure
๐ Aortic + Pulmonary valves close โ Marks start of diastole
9
Q
๐๐ซ Which murmurs are heard during systole and diastole โ๏ธ
A
Systolic Murmurs occur between S1 and S2
๐ฉธ Aortic stenosis, Pulmonary stenosis = Ejection murmurs
๐ Mitral regurgitation, Tricuspid regurgitation = Holosystolic
Diastolic Murmurs occur after S2
๐ Aortic regurgitation, Pulmonary regurgitation = Early diastolic
๐ช Mitral stenosis, Tricuspid stenosis = Mid-to-late diastolic (rumble)
10
Q
๐ต๐ซ What are the key features of an Innocent Murmur (Stillโs Murmur) โ๏ธ
A
โ
Functional (innocent) murmur
๐น Early systolic ejection
๐น Short duration , low intensity (Grade 1โ2/6)
๐น Musical / Vibratory quality
๐น Best heard at left lower sternal border
๐น No radiation, no symptoms
##footnote
๐งโโ๏ธ = Normal heart sounds (S1, S2)
๐ซ = Normal ECG & CXR
๐ = Doesnโt change with posture
๐ก๐ง Mnemonic: 7 Sโs of Innocent Murmurs in Pediatrics
1๏ธโฃ Systolic
2๏ธโฃ Short duration
3๏ธโฃ Soft (Grade 1โ2/6)
4๏ธโฃ Symptomless
5๏ธโฃ Sounds normal (S1/S2)
6๏ธโฃ Special tests normal (ECG, X-ray)
7๏ธโฃ Standing/sitting doesnโt change it
11
Q
๐จ๐ What features suggest a pathologic murmur in children โ๏ธ
A
โ ๏ธ Murmur is diastolic or pansystolic
โ ๏ธ Loud (โฅ Grade 3/6)
โ ๏ธ Radiates (e.g., to carotids or axilla)
โ ๏ธ Abnormal heart sounds (clicks, gallops)
โ ๏ธ Associated symptoms : chest pain, syncope, cyanosis
โ ๏ธ Abnormal ECG, CXR, or echo
12
Q
๐ซ๐ What is a normal (physiologic) split S2 โ๏ธ
A
โ
Split during inspiration
๐ Aortic valve (A2) closes before Pulmonary valve (P2)
โก๏ธ A2โP2
๐ซ Inspiration โ โ venous return โ delayed P2
๐ Expiration โ no split (A2 and P2 fuse)
๐ง Heard best at: Left upper sternal border (LUSB)
13
Q
๐งฌ๐ What is wide, fixed splitting of S2 and its cause โ๏ธ
A
๐งท Split S2 in both inspiration & expiration
โ No variation with breathing
๐ โFixedโ split = same during respiratory cycle
๐ฏ Classic cause: Atrial Septal Defect (ASD)
๐ซโ Blood flow across pulmonary valve delays P2 consistently
๐ชข Also seen in: Right bundle branch block (RBBB)
14
Q
๐ข๐ซ What causes a wide split of S2 that varies with inspiration โ๏ธ
A
๐ชง Abnormally wide split
๐ Exaggerated with inspiration
โฑ Delayed P2 > Normal
๐ฉบ Seen in :
โข โ Pulmonary stenosis
โข ๐ Right bundle branch block (RBBB)
โก๏ธ Both delay right ventricular systole
15
Q
๐โฎ What is paradoxical splitting of S2 and its causes โ๏ธ
A
โป๏ธ Split heard on expiration, fuses during inspiration
๐ A2 is delayed โ P2 comes first = reversed order
๐ฉบ Seen in :
โข ๐ **Left bundle branch block (LBBB)
โข ๐ข Aortic stenosis
โข ๐งฌ Hypertrophic cardiomyopathy (HCM)
##footnote
๐ง Mechanism: Delayed A2 , so inspiration (delays P2 ) realigns A2โP2 โ split disappears
16
Q
๐ Enumerate main signs of Heart Failure โ๏ธ
A
๐ป Tachypnea
๐ป Tachycardia
๐ป Tender liver
๐ป Cyanosis or cardiomegally
3T and 2C
17
Q
๐ซWhat is congestive heart failure (CHF) in pediatrics โ๏ธ
A
๐ซ CHF = Heart unable to pump enough blood to meet the bodyโs metabolic needs
โ ๏ธ Results in low cardiac output and/or venous congestion
##footnote
๐ง 2 Main types :
โข Systolic dysfunction : โ contractility
โข Diastolic dysfunction : impaired relaxation
18
Q
๐จ What are the causes of CHF in children โ๏ธ
A
๐ โ Preload (Volume Overload)
โข ๐ฉธ VSD, ASD, PDA
โข ๐ Mitral/Aortic Regurgitation
โข ๐ฅ High-output states: anemia, thyrotoxicosis
๐ Myocardial Dysfunction
โข โค๏ธ Cardiomyopathies
โข โก Myocarditis
โข ๐ง Post-MI (rare in peds)
๐งฑ โ Afterload (Pressure Overload)
โข ๐ฉบ Systemic HTN
โข ๐ช Aortic stenosis
โข ๐ชข Coarctation of aorta
โข ๐ซ Pulmonary stenosis or HTN
19
Q
๐ฌ๏ธ What are symptoms of CHF in infants โ๏ธ
A
โข ๐ผ Failure to thrive
โข ๐ผ Feeding difficulty (dyspnea)
โข ๐ด Fatigue
โข ๐ฎโ๐จ Respiratory distress
Primary symptom is: Difficulty breathing or respiratory distress .
20
Q
๐ฌ๏ธ What are symptoms of CHF in older children โ๏ธ
A
โข ๐ Exercise intolerance
โข ๐คข GI: pain, nausea, vomiting
โข ๐ช Somnolence, anorexia
โข ๐ซ Cough, wheezing, dyspnea
21
Q
๐ ๏ธ What is the treatment of CHF in children โ๏ธ
A
- โ๏ธ Call for help , ensure ABC , PICU if needed
- ๐ช Semi-sitting position
- ๐ฌ๏ธ Oxygen , pulse oximeter
- ๐ Medications :
โข โ Preload: Furosemide
โข โ Afterload: Hydralazine, ACEi (Captopril)
โข โ Contractility: Digoxin, dopamine (shock) - ๐ฝ๏ธ NG feeding , high-calorie diet
- ๐งช Treat underlying cause
22
Q
๐ค What is the purpose of monitoring weight in children with CHF โ๏ธ
A
To track fluid retention and assess treatment effectiveness .
23
Q
๐ง A 10-year-old child presents with shock signs (low BP, tachycardia), shortness of breath, and crepitations. What is the immediate treatment โ๏ธ
A
โ
Dopamine
โก๏ธ Patient has likely developed acute decompensated heart failure โ needs inotropic support
24
Q
๐ฉบ What are the two main types of Congenital Heart Disease (CHD) โ๏ธ
A
โช Acyanotic CHD (LโR Shunt or Obstruction)
โข ๐งฑ VSD (most common CHD overall)
โข ๐งฌ ASD
โข ๐ฌ๏ธ PDA
โข ๐ซ Pulmonary/Aortic stenosis
โข ๐ชข Coarctation of aorta
๐ต Cyanotic CHD (RโL Shunt)
โข ๐งฉ Tetralogy of Fallot (most common cyanotic CHD in children)
โข ๐ Transposition of great arteries (most common in neonates)
โข ๐ซ Tricuspid atresia
โข ๐ Truncus arteriosus
โข โ Total anomalous pulmonary venous return
โข ๐ซ Common ventricle
25
๐ **What are the key fetal shunts in fetal circulation** โ๏ธ
1. **Ductus venosus** ๐ซ
๐ฉธ Bypasses liver โ IVC
โ
Becomes **ligamentum venosum**
2. **Foramen ovale** โ๏ธ
๐ฉธ Right atrium โ Left atrium (bypasses lungs)
โ
Becomes **fossa ovalis**
3. **Ductus arteriosus** ๐
๐ฉธ Pulmonary artery โ Aorta (bypasses lungs)
โ
Becomes **ligamentum arteriosum**
26
๐ **What maintains ductus arteriosus patency in utero** โ๏ธ
๐งช **Prostaglandins (PGE1/PGE2)**
๐ โPG Keep it Patentโ
โฌ๏ธ Oโ tension โ Keeps it open
27
๐ **What causes closure of ductus arteriosus after birth** โ๏ธ
๐ **โ Oโ tension** (first breaths)
โ **โ Prostaglandins**
๐งช Induced pharmacologically by:
๐น **NSAIDs** (e.g. indomethacin)
##footnote
๐ โAnti-PG โ DA Closureโ
28
๐ **What is the fetal circulation pressure pattern** โ๏ธ
๐**Before birth** :
๐ฉธ **Right side pressure > Left side** (due to collapsed lungs + high pulmonary resistance)
๐**After birth** :
๐ฉธ **Left side pressure > Right side**
โก๏ธ **Closure of foramen ovale** (forms **fossa ovalis** )
.
29
๐ฉธ **Which vessels are involved in umbilical circulation** โ๏ธ
โข **Umbilical vein** :
โก๏ธ Brings **oxygenated blood** from **placenta โ fetus**
โข **Umbilical arteries (2)** :
โก๏ธ Return **deoxygenated blood from **fetus โ placenta**
30
๐ง **What are the key components of the clinical approach to a child with suspected CHD** โ๏ธ
1. **History** :
โข ๐ Timing of presentation (neonatal vs. late)
โข ๐ถ Gestational history (e.g., prematurity, infections)
โข ๐งฌ Family history of CHD or genetic syndromes
2. **Physical Exam** :
โข โค๏ธ Cardiac exam (murmurs, S2, thrill, apex)
โข ๐ฌ Respiratory exam (distress, retractions, grunting)
3. **Investigations** :
โข ๐ ECG
โข ๐ฉป Chest X-ray
โข ๐ซ Echocardiography (definitive)
โข ๐งช Labs if shock/metabolic acidosis
31
โ ๏ธ **What are red flags ๐ฉ in a newborn that suggest possible serious CHD** โ๏ธ
๐ด Red Flags:
โข ๐งช **Unexplained metabolic acidosis**
โข ๐ฎโ๐จ **Respiratory distress**
โข ๐จ **Poor peripheral pulses**
โข ๐ฅ **Pulse discrepancy** (brachial vs. femoral)
โข ๐ **Single or loud second heart sound (S2)**
โข ๐ต **Prominent heart murmur**
โข ๐ต **Shock**
โข โ **Persistent cyanosis unresponsive to oxygen**
32
**Do all newborns with murmurs have CHD** โ๏ธ
๐ **No!**
โข Many murmurs in neonates are **innocent/transient**
โข **Not all CHD presents with murmurs**
โข Some serious CHD may **lack murmurs early on**
##footnote
๐ Always consider **consulting pediatric cardiology** if CHD is suspected!
33
๐ก **How can CHD mimic other diseases** โ๏ธ
๐ CHD can mimic:
โข ๐งฌ **Metabolic conditions**
โข ๐ฆ **Sepsis**
โข ๐ฎโ๐จ **Pulmonary disease (e.g., PPHN)**
##footnote
๐ **Clue** : Lack of improvement with oxygen or sepsis treatment โ Think CHD!
34
๐ต **What are the major Acyanotic congenital heart defects** โ๏ธ
๐ซ **Left โ Right Shunts** (โ pulmonary blood flow):
โข **VSD** (most common overall)
โข **ASD**
โข **PDA**
โข **AV Canal (AVSD)**
๐งฑ **Obstructive lesions** (โ systemic flow):
โข **Coarctation of Aorta**
โข **Aortic stenosis**
โข **Pulmonary stenosis**
35
๐ด **What are the major Cyanotic congenital heart defects** โ๏ธ
**โThe 5 Tโsโ** :
1. ๐ **Tetralogy of Fallot (TOF)** โ most common in kids
2. ๐ **Transposition of the Great Arteries (TGA)** โ most common in neonates
3. ๐ซ **Tricuspid atresia**
4. ๐ **Truncus arteriosus**
5. ๐งฌ **Total Anomalous Pulmonary Venous Return (TAPVR)**
โข **Hypoplastic Left Heart Syndrome (HLHS)**
36
๐ซ **What is Eisenmenger Syndrome** โ๏ธ
๐ฃ **Definition** :
A **late complication of uncorrected large left-to-right shunt** (e.g. VSD, PDA, ASD) โ causes **pulmonary hypertension** โ shunt reversal (right-to-left) โ **cyanosis**
๐ฉถ Also called: **โAcquired Cyanotic Heart Diseaseโ**
37
๐ **What causes the shunt reversal in Eisenmenger Syndrome** โ๏ธ
๐ **Chronic high flow** into pulmonary circulation โ
โก๏ธ **Pulmonary arterial hypertension (PAH)**
โก๏ธ **Right ventricular pressure > left**
โก๏ธ **Shunt reverses** from L โ R โก๏ธ R โ L
โก๏ธ **Cyanosis appears** ๐ซ๏ธ
38
๐ฉ **Clinical signs of Eisenmenger Syndrome in children** โ๏ธ
โข ๐ค **Fatigue, malaise**
โข ๐ฎโ๐จ **Dyspnea on exertion**
โข ๐ต **Cyanosis**
โข ๐ Enlarged heart silhouette on CXR
โข ๐ซ Prominent pulmonary artery
##footnote
๐ง Often develops **years after birth** , in **previously known CHD** (esp. large VSDs)
39
๐ **What is the medical treatment for Eisenmenger Syndrome** โ๏ธ
๐น **Symptomatic only** (no curative options):
โข ๐ฉบ **Phosphodiesterase inhibitors** (e.g. sildenafil) โ
โข ๐ **IV prostacyclin therapy**
โข ๐ **Calcium channel blockers** (selected cases of PAH)
##footnote
โ No surgical shunt correction after reversal
๐ **Definitive treatment = heart-lung transplant**
40
**A 12-year-old with history of untreated VSD presents with fatigue, exertional cyanosis, and enlarged pulmonary artery on CXR. Whatโs the most appropriate treatment** โ๏ธ
โ
**Phosphodiesterase inhibitors (e.g. sildenafil)**
41
โ ๏ธ **What is the prognosis of Eisenmenger Syndrome** โ๏ธ
โ **Poor prognosis**
๐ซโ Once reversal occurs, **repair is contraindicated**
๐ฑ Many patients survive into adulthood but with complications
๐ซ Last option: **Heart-lung transplantation**
42
๐งช **When does Eisenmenger syndrome typically develop** โ๏ธ
๐ Typically **after age 4โ6 weeks** in **large LโR shunts**
๐ฉธ Drop in pulmonary resistance โ **โ shunting** โ **โ pulmonary hypertension**
๐ซ If left untreated โ shunt reversal โ Eisenmenger
43
๐ **What is a Ventricular Septal Defect (VSD)** โ๏ธ
๐งฑ A hole in the **interventricular septum** allowing **left-to-right shunting** of blood
๐ Blood flows: **LV** โก๏ธ **RV** โก๏ธ **lungs** โ โ pulmonary blood flow
##footnote
๐ซ Most common congenital heart defect
๐ **Membranous (70%), muscular (20%)**
44
โ๏ธ **What is the hemodynamic consequence of a large VSD** โ๏ธ
โข **โ Left-to-right shunt**
โข **๐ฆ Pulmonary overcirculation**
โข **๐ฃ Biventricular hypertrophy**
โข **๐ฎโ๐จ Pulmonary congestion**
โข **๐ฉธ Eventually may lead to Eisenmenger Syndrome**
45
๐ถ **What are the symptoms of a small vs large VSD** โ๏ธ
๐๏ธ **Small VSD** :
โข **Asymptomatic**
โข May be discovered incidentally
โข Normal growth
๐จ **Large VSD** (usually presents by 2nd week of life):
โข ๐ผ **Difficulty feeding**
โข ๐ฎโ๐จ **Dyspnea**
โข ๐ **Failure to thrive (FTT)**
โข ๐ **Recurrent respiratory infections**
46
๐ซ **What are the physical exam findings in VSD** โ๏ธ
๐ฉบ **Small VSD** :
โข Loud **pan-systolic murmur** (LLSB)
โข ๐ฅ Systolic thrill
โข โ Normal growth
๐ฉบ **Large VSD** :
โข Cardiomegaly
โข ๐จ Hyperdynamic precordium
โข Accentuated **P2** (pulmonary HTN)
โข **Biventricular enlargement**
47
๐งช **What are the diagnostic investigations for VSD** โ๏ธ
โข ๐ธ **Chest X-ray** : Cardiomegaly, โ pulmonary markings
โข ๐ **ECG** : Biventricular hypertrophy
โข ๐ซ **Echocardiogram** : Definitive diagnosis, shows defect + shunt
48
๐ฃ **What are complications of an uncorrected VSD** โ๏ธ
โข โค๏ธโ๐ฉน **Heart failure**
โข ๐ **Recurrent chest infections**
โข ๐ **Failure to thrive**
โข ๐ฆ **Infective endocarditis**
โข ๐ซ๏ธ **Eisenmenger Syndrome** (shunt reversal)
49
๐ **What is the treatment approach for VSD** โ๏ธ
๐งธ **Medical management** (for heart failure):
โข **Diuretics** (furosemide), ACE inhibitors
โข **Nutritional support** (high calorie feeds)
๐ง **Surgical** :
โข ๐ชก **Pulmonary artery banding** (in infants not ready for full repair)
โข ๐ง **Definitive surgical closure** (open heart surgery if large or symptomatic)
โข โ **Heart-lung transplant** : only in Eisenmenger
50
๐ฉบ **What type of murmur is heard in VSD** โ๏ธ
๐ง **Harsh, holosystolic (pan-systolic)** murmur
๐Best heard at **lower left sternal border**
๐ฅ May have **systolic thrill**
๐ฏ Louder in small defects (more turbulence)
51
๐ **What is Patent Ductus Arteriosus (PDA)** โ๏ธ
๐ **Persistent connection** between the **aorta** and **pulmonary artery**
๐ Located **distal to the origin of the left subclavian artery**
##footnote
๐ฉธ Allows **left-to-right shunting** :
**Aorta โก๏ธ Pulmonary artery โก๏ธ Lungs**
๐ซ โ โ Pulmonary blood flow
๐ซ โ LV volume overload
52
โ๏ธ **What is the hemodynamic consequence of a PDA** โ๏ธ
โข โ๏ธ **Pulmonary congestion**
โข ๐ฆ **Left ventricular (LV) enlargement**
โข ๐ฃ **Heart failure (if large PDA)**
53
๐ถ **What is the clinical presentation of PDA** โ๏ธ
๐๏ธ **Small PDA** :
โข **Asymptomatic**
โข May be discovered incidentally
๐จ **Large PDA** :
โข ๐ถ Presents like **VSD** (2ndโ4th week)
โข ๐ผ **Difficulty feeding**
โข ๐ฎโ๐จ **Tachypnea**
โข ๐ **Failure to thrive (FTT)**
โข ๐ **Recurrent respiratory infections**
54
๐ฉบ **What are the physical exam findings in PDA** โ๏ธ
โข ๐ถ **Continuous โmachineryโ murmur** (best at **left infraclavicular area** )
โข ๐ฅ **Systolic thrill**
โข ๐ Accentuated **S2**
โข ๐ **Wide pulse pressure** , bounding peripheral pulses ( **โWater hammer pulseโ** )
โข ๐ LV enlargement signs
55
๐งช **What are the diagnostic investigations for PDA** โ๏ธ
โข ๐ธ **Chest X-ray** : Cardiomegaly, increased pulmonary vascular markings
โข ๐ **ECG** : LV hypertrophy
โข ๐ซ **Echocardiogram** : Confirms PDA size, direction of flow (LโR), and LV overload
56
๐ฃ **What are complications of a large untreated PDA** โ๏ธ
โข โค๏ธโ๐ฉน **Heart failure**
โข ๐ **Recurrent chest infections**
โข ๐ **FTT**
โข ๐ฆ **Infective endocarditis**
โข ๐ซ๏ธ **Eisenmenger syndrome of lower limbs only** (cyanosis in legs, not arms due to PDA position distal to subclavian)
57
๐ **What is the treatment for PDA** โ๏ธ
๐ถ **Medical (closure for preterm neonates)**:
โข โ **Prostaglandin inhibitors** :
โ- **Ibuprofen or Indomethacin** โ promote ductal closure
โโ ๏ธ Not effective in term infants
๐ง **Interventional (for symptomatic or large PDA)** :
โข ๐ ๏ธ **Device closure** via catheterization
โข ๐ช **Surgical ligation** if catheterization fails or unavailable
โ **Prostaglandins (PGE1)** are used to keep the PDA open in ductal-dependent cyanotic heart disease (opposite use)
58
๐ก **What is the most common type of Atrial Septal Defect (ASD)? Where is it located** โ๏ธ
๐ A: **Ostium Secundum ASD** โ located in the **mid interatrial septum** (๐ center of the septum).
59
๐ **What is the blood flow pattern in ASD** โ๏ธ
๐ **Left โ Right Shunt** :
๐ซ **LA โ RA โ RV โ Lungs**
โก๏ธ Causes **pulmonary overcirculation** ๐ซ๏ธ and RV dilation.
60
๐ง **What is the hallmark auscultation finding in ASD** โ๏ธ
๐ก **Key finding** :
๐ **Wide and fixed split S2** (does not vary with respiration)
โข Due to **delayed pulmonary valve closure**
โข ๐ **No murmur** unless pulmonary stenosis coexists
(May hear **soft ejection systolic murmur** from โ flow across pulmonary valve)
61
โฑ๏ธ **Why is S2 splitting โfixedโ in ASD** โ๏ธ
๐ Constant increased **RV volume** โ prolonged **RV systole** โ **pulmonary valve closure is delayed** always, even during expiration.
62
โก **Which ASD type shows Left Axis Deviation (LAD) on ECG** โ๏ธ
๐ **Ostium Primum ASD** ๐ causes **LAD + 1ยฐ AV block often** .
63
๐งช **What investigation confirms ASD diagnosis** โ๏ธ
๐ **Echocardiography** ๐ฉป (with **bubble contrast** if needed) shows **septal defect** and **left-to-right shunt** .
64
๐จ **What complications can develop from untreated ASD** โ๏ธ
๐ ๐ **Pulmonary hypertension,**
๐ซ **Eisenmengerโs syndrome,**
๐ **Atrial arrhythmias,**
๐ง **Paradoxical embolism.**
65
๐ฉน **What is the treatment for a moderate-to-large secundum ASD** โ๏ธ
๐ **Device closure** via **catheterization** ๐ ๏ธ or **surgical patch repair** ๐งต (if unsuitable for device).
66
๐ฅ **Which ASD type usually requires surgical correction** โ๏ธ
๐ **Ostium Primum ASD** + associated defects (e.g. AV canal) โ **Surgical closured** ๐ ๏ธ
67
๐ฉบ **What is coarctation of the aorta (CoA)** โ๏ธ
๐ A **narrowing of the aorta** , usually just **distal to the left subclavian artery** , often near the ductus arteriosus ๐ซ๐
68
โ๏ธ **Describe the hemodynamic consequence of CoA** โ๏ธ
๐ Narrowing โก๏ธ **โ pressure in upper limbs** ๐ง and **โ pressure in lower limbs** ๐ฆต + development of **collateral circulation**
69
๐งธ **How do infants with severe CoA typically present** โ๏ธ
๐ In the **first few days of life** after ductus closes:
โข **Heart failure** ๐ซ
โข **Tachypnea, poor feeding, lethargy**
70
๐ฆ **What symptoms are seen in older children** โ๏ธ
๐
โข **Leg claudication/pain with exercise** ๐โโ๏ธ
โข **Headaches, epistaxis** (โ upper body pressure) ๐ข๐
โข **Cold lower limbs** ๐ฅถ
71
๐ **What is the key blood pressure finding in CoA** โ๏ธ
๐ **BP โ in upper limbs** (e.g. right arm) & **โ in lower limbs** โ BP gradient โฅ 20 mmHg ๐งโโ๏ธ๐ฆต
72
๐ฆ **What pulse findings are characteristic** โ๏ธ
๐
โข **Weak/delayed femoral pulses** โณ
โข **Radiofemoral delay** โ๐ฆถ
73
๐ง **What murmur may be heard in CoA** โ๏ธ
๐ **Systolic murmur** best heard at **interscapular area** ๐ง
74
๐ฉป **What is the classic chest X-ray sign of CoA** โ๏ธ
๐
โข **Figure-of-3 sign** ๐ฅ
โข **Rib notching (from collateral intercostals)** ๐ฆด
75
๐งช **What imaging confirms the diagnosis** โ๏ธ
๐
โข **Echocardiography** ๐ฉบ
โข **CT angiography** or **MRI** ๐ธ
โข **ECG** may show **LVH** ๐
76
๐ **What are complications of uncorrected CoA** โ๏ธ
๐
โข **Heart failure** ๐
โข **Infective endocarditis** ๐ฆ
โข **Aortic rupture or intracranial hemorrhage** (due to โ BP) ๐ง
โข **Accelerated hypertension in adulthood**
77
๐ **How is acute CoA in neonates managed medically** โ๏ธ
๐ Start **Prostaglandin E1 (PGE1)** to keep ductus **open** until surgery ๐งฌ
78
๐ ๏ธ **What are the definitive treatment options for CoA** โ๏ธ
๐
โข **Surgical resection (coarctectomy)**
โข **Balloon angioplasty** (ยฑ stent) via catheter ๐
โข **Lifelong BP monitoring** needed
79
๐ **What is the most common type of congenital aortic stenosis** โ๏ธ
๐ **Valvular AS** (~80โ90%) โ due to **bicuspid aortic valve** ๐ฅโก๏ธ๐ข (instead of 3 cusps)
80
๐ข **What are the less common types of AS** โ๏ธ
๐
โข **Subvalvular** (5โ10%) ๐ฝ
โข **Supravalvular** (1โ2%) ๐ผ
81
โ ๏ธ **What is the main hemodynamic abnormality in AS** โ๏ธ
๐ **Pressure gradient across the aortic valve โก๏ธ LV hypertrophy** (โ afterload) ๐ซ๐
82
๐ถ **How does mild AS present** โ๏ธ
๐ **Often asymptomatic**
83
๐จ **What are symptoms of severe AS** โ๏ธ
๐
โข **Left-sided heart failure** signs ๐
โข **Fatigue, exertional dyspnea, chest pain, syncope** ๐ต
84
๐ฉบ **What is the classic murmur in aortic stenosis** โ๏ธ
๐ **Systolic ejection murmur** with **ejection click** at **right upper sternal border** โ radiates to **neck**
85
๐ก **What are key cardiovascular signs in AS** โ๏ธ
๐
โข **Low systolic BP & weak pulses** ๐
โข **LV heave**
โข **Systolic thrill**
โข **Muffled/soft S2** ๐
86
๐ธ **What are imaging and diagnostic tools for AS** โ๏ธ
๐
โข **CXR** : Post-stenotic aortic dilation ๐ช๏ธ
โข **ECG** : LVH
โข **Echo** : Definitive tool for valve gradient & anatomy ๐ฅ๏ธ
87
๐ **What complications can arise from untreated AS** โ๏ธ
๐
โข **Heart failure** ๐
โข **Sudden cardiac death** ๐ต
โข **Infective endocarditis** ๐ฆ
88
๐ **What is the indication for intervention in AS** โ๏ธ
๐ **Pressure gradient > 50 mmHg** OR symptomatic child
89
๐ ๏ธ **What are treatment options in AS** โ๏ธ
๐
โข **Balloon valvuloplasty** (especially in children) ๐
โข **Valve repair or replacement** (in severe cases) ๐ ๏ธ
90
๐งโโ๏ธ **A 6-year-old child with systolic murmur, weak pulses, and an ejection click. Echo shows bicuspid aortic valve and a 65 mmHg gradient. Whatโs the next best step** โ๏ธ
โ
**Balloon valvuloplasty**
##footnote
๐ (Do NOT wait for progression)
91
๐ **Whatโs the most common site of the stenosis in pulmonary stenosis** โ๏ธ
๐ **Valvular** (~90%) is most common ๐
๐ **Subvalvular** or **supravalvular** are rare (~10%)
92
โ๏ธ **Whatโs the primary hemodynamic consequence of PS** โ๏ธ
๐ **โ Pressure gradient across pulmonary valve** โฌ๏ธโก๏ธ
Leads to **right ventricular hypertrophy (RVH)** ๐ช๐ซ
93
๐ง๐ฉบ **What are typical clinical presentations** โ๏ธ
โข **Mild** PS โ usually **asymptomatic** ๐
โข **Moderate-severe** PS โ
โข **Right-sided HF** ๐ซ๐ซค
โข **ยฑ cyanosis** (if patent foramen ovale โ RโL shunt) ๐ฌ๏ธ๐ต
94
๐ง **What are general & cardiac exam findings** โ๏ธ
๐ **General** :
โข Often normal unless severe
๐ **Cardiac exam** :
โข **RV heave / enlargement**
โข **Systolic thrill** ๐จ
โข **Soft/absent P2** ๐
โข **Harsh systolic ejection murmur at left upper sternal border** โก๏ธ may radiate to back ๐
95
๐งช **What investigations support diagnosis** โ๏ธ
๐ฉป **CXR** :
โข Post-stenotic dilation of pulmonary artery ๐
โข RV enlargement ๐ซ
๐ **ECG** :
โข Right axis deviation
โข RVH
๐ฅ๏ธ **Echo** :
โข Confirms diagnosis
โข Measures gradient ๐
96
โ ๏ธ **What are the main complications of untreated PS** โ๏ธ
๐
โข **Right-sided HF** ๐
โข **Infective endocarditis** ๐ฆ
โข **Cyanosis** if shunt develops ๐ซฅ
97
๐ ๏ธ **What are treatment options for PS** โ๏ธ
๐
โข **Balloon valvuloplasty** = 1st-line in moderate-severe cases ๐
โข **Surgical valvotomy** if anatomy not amenable to balloon ๐ ๏ธ
โข **Surveillance** only in mild cases ๐๏ธ
98
**A 4-year-old child has a harsh systolic murmur at the left upper sternal border and an absent P2. Echo shows valvular PS with a pressure gradient of 60 mmHg. What is the most appropriate next step** โ๏ธ
โ
**Balloon valvuloplasty**
99
**A 2-year-old child is brought in for developmental delay and unusual facial features. Physical exam shows a wide mouth, periorbital puffiness, and a systolic murmur. Labs reveal hypercalcemia. Which congenital heart disease is most commonly associated with this condition** โ๏ธ
**Supravalvular aortic stenosis**
๐ง **Diagnosis: Williams Syndrome**
##footnote
๐ง Mnemonic: WILLIAMS
โข **W** eight โ (low birth weight) โ๏ธ
โข **I** ris: stellate pattern โจ
โข **L** ong philtrum ๐
โข **L** arge mouth ๐ฎ
โข **I** ncreased Caยฒโบ (hypercalcemia) ๐งช
โข **A** ortic stenosis (supravalvular!) ๐
โข **M** ental retardation (intellectual disability) ๐ง
โข **S** welling around eyes (periorbital puffiness) ๐๏ธ
100
๐งฉ **What are the 4 anatomical defects in Tetralogy of Fallot (TOF)** โ๏ธ
1. ๐ณ๏ธ **Ventricular Septal Defect (VSD)**
2. ๐ชค **Pulmonary Stenosis (PS)**
3. โ๏ธ **Overriding Aorta**
4. ๐ช **Right Ventricular Hypertrophy (RVH)**
##footnote
๐ง Mnemonic: **PROVe**
**P** ulmonary stenosis, **R** VH, **O** verriding aorta, **V** SD
101
๐ฉธ **What is the direction of blood flow and hemodynamics in Tetralogy of Fallot** โ๏ธ
๐ซ Right-to-left shunt due to severe **pulmonary stenosis** โก๏ธ โ pulmonary blood flow โก๏ธ systemic hypoxia & cyanosis.
102
๐ถ **What are the classic clinical features of TOF** โ๏ธ
โข ๐ถ **Cyanosis** (may be delayed if PDA open)
โข ๐ **Fatigue & FTT**
โข ๐ **Clubbing** (chronic hypoxia)
โข ๐ต **Hypoxic** (Tet) spells
โข ๐งโโ๏ธ **Squatting** (โ SVR โ โ RโL shunt โ โ cyanosis)
103
๐ซ **What are the auscultation findings in TOF** โ๏ธ
โข ๐ Harsh **ejection systolic murmur** (PS)
โข ๐ข **Systolic thrill**
โข ๐ **Single S2** (due to absent pulmonary component)
104
๐ธ **What are the key investigation findings in TOF** โ๏ธ
โข ๐ท **CXR** : **Boot-shaped heart** ๐ฅพ
โข ๐งช **CBC** : Polycythemia (โHb), โIron
โข ๐ป **ECG** : RVH
โข ๐ **Echo** : All 4 defects
โข ๐งฌ **Cath**: for **surgical** planning
105
โ ๏ธ **What are the main complications of TOF** โ๏ธ
โข ๐ง **Brain abscess**
โข ๐ฉธ **Thrombosis**
โข โค๏ธโ๐ฉน **Infective endocarditis**
โข ๐ฉบ **Iron deficiency anemia**
โข ๐ต **Severe cyanotic spells** โ death
106
๐จ **How is a hypercyanotic (Tet) spell managed acutely** โ๏ธ
1. ๐งโโ๏ธ **Knee-chest position**
2. ๐จ **100% Oโ**
3. ๐ **Morphine**
4. ๐ **IV Propranolol (ฮฒ-blocker)**
5. ๐ง **IV NaHCOโ if acidotic**
6. ๐ง **Volume expansion**
7. ๐ **Sedation/anesthesia โ Surgery**
107
๐ ๏ธ **What are the definitive treatments for TOF** โ๏ธ
โข ๐งฌ **Surgical Repair** (Total correction)
โข ๐ฉบ **Blalock-Taussig shunt** (palliative; โ PBF until surgery)
108
๐ง **What is Blalock taussing princible** โ๏ธ
109
๐งฉ **What is the primary anatomical defect in TGA** โ๏ธ
๐ **Aorta arises from RV**
๐ฌ๏ธ **Pulmonary artery arises from LV**
โก๏ธ Creates **2 separate (parallel) circulations**
110
๐ **Why is TGA immediately life-threatening without additional defects** โ๏ธ
โ Because thereโs **no mixing** between systemic and pulmonary circuits unless thereโs a:
โข ๐ณ๏ธ **ASD**
โข ๐ณ๏ธ **VSD**
โข ๐ฌ๏ธ **PDA**
**Mixing is essential for survival**
111
๐ฉธ **What are the hemodynamics in TGA** โ๏ธ
โข ๐ซ Pulmonary circuit: **LV โ PA โ lungs โ LA โ LV**
โข ๐ซ Systemic circuit: **RV โ Aorta โ body โ RA โ RV**
โก๏ธ Leads to **severe systemic hypoxia** unless thereโs a shunt
112
๐ถ **What are the clinical features of TGA in neonates** โ๏ธ
โข ๐ Early central cyanosis (within 24โ48 hrs)
โข ๐จ **Dyspnea**
โข ๐ค **Recurrent chest infections**
โข ๐ซ **Not improved with 100% Oโ**
โข ๐ **May show signs of FTT or shock if no mixing occurs**
113
๐ซ **What is found on cardiac exam in TGA** โ๏ธ
โข ๐ Single loud **S2** (aortic valve anteriorly placed)
โข โ **No murmur** unless associated VSD/ASD/PDA
โข ๐ช **RV heave** (due to RV hypertrophy)
114
๐งช **What are key investigation findings in TGA** โ๏ธ
โข ๐ท **CXR** : **Egg-on-a-string** (narrow mediastinum, โ pulmonary markings)
โข ๐ป **ECG** : **RVH**
โข ๐ฌ **Echo** : confirms transposed vessels and any mixing defects
โข ๐ **Oโ challenge test** : **no improvement**
115
โ ๏ธ **What are complications of TGA** โ๏ธ
โข ๐ง **Brain abscess**
โข ๐ฆ **Infective endocarditis**
โข ๐ซ **Recurrent infections**
โข ๐ฉธ **Thrombotic events** (especially if polycythemic)
116
๐จ **What is the acute and definitive treatment for TGA** โ๏ธ
๐ฉบ **Medical (Stabilization)** :
โข ๐ **Prostaglandin E1 (PGE1)** โ keep PDA open
โข ๐ช **Balloon atrial septostomy** (Rashkind) โ allow mixing
๐ ๏ธ **Definitive (Surgical)** :
โข ๐ **Arterial switch procedure** (Jatene repair) = gold standard
๐ณ๏ธ May combine with closure of ASD/VSD if present
117
๐ง **What are the 2 major causes of central cyanosis in a newborn** โ๏ธ
1๏ธโฃ **Pulmonary disease**
2๏ธโฃ **Cyanotic congenital heart disease (CHD)**
118
๐งช **What is the purpose of the Hyperoxia Test in a cyanotic newborn** โ๏ธ
๐ก To **differentiate between pulmonary and cardiac causes** of cyanosis.
119
๐ฌ๏ธ **How is the Hyperoxia Test performed** โ๏ธ
โข Give **100% oxygen** for 10 minutes
โข Then measure **arterial PaOโ**
120
๐ **How do you interpret Hyperoxia Test results** โ๏ธ
##footnote
๐ No rise in PaOโ = **right-to-left shunt** , bypassing lungs
121
๐ผ๏ธ **What is the next step if the Hyperoxia Test suggests CHD** โ๏ธ
1๏ธโฃ **Chest X-ray (CXR)** โ check heart size & lung markings
2๏ธโฃ **Echocardiogram with Doppler** โ ๐ฉบ definitive, non-invasive test
122
๐**What is the goal of emergent management in cyanotic congenital heart disease** โ๏ธ
๐ ๏ธ **Bridge to definitive repair** (surgery or intervention) by:
โข **Stabilizing the infant**
โข **Maintaining oxygenation and perfusion**
โข **Keeping the ductus arteriosus open** if needed
123
๐ **What is the drug of choice to maintain ductus arteriosus patency in ductal-dependent CHDs** โ๏ธ
**Prostaglandin E1 (PGE1) = Alprostadil**
##footnote
๐ฆ **Keeps PDA open**
๐จ Used in:
โข ๐ซ Coarctation of the aorta
โข ๐ซ Hypoplastic left heart syndrome
โข ๐ซ Interrupted aortic arch
โข ๐ซ Transposition of great arteries
โข ๐ซ Pulmonary atresia
124
โ ๏ธ **What are the common side effects of PGE1 infusion (Alprostadil)** โ๏ธ
๐ด **Apnea**
๐ก๏ธ **Flushing**
๐ฉธ **Hypotension**
##footnote
โ ๏ธ Always be prepared for **intubation**
125
๐ถ **How does ductal-dependent CHD often present in the first week of life** โ๏ธ
๐ฉป **CHF** or **shock** picture:
โข **โ Perfusion**
โข **โ Pulses**
โข ๐ซ **Tachypnea**
โข ๐ **Acidosis**
โข ๐ **Hepatomegaly**
โข โค๏ธ **Gallop rhythm**
126
๐ **What is the next best step after initiating PGE1 in a neonate with suspected ductal-dependent CHD** โ๏ธ
๐ฒ **Emergency cardiology consultation**
๐ฉบ Arrange for **urgent echocardiogram**
127
๐ค **20 hours old newborn with cyanosis, not responding to 100% oxygen, single and loud heart sound with no murmur with this CXR finding. Interperitate it and give the possible diagnosis** โ๏ธ
๐ป **There is apparent narrowing of superior mediastinum** .
๐ป **The main pulmonary artery posterior to the aorta** .
๐ป **Increase pulmonary vascularity** .
๐ฅ **Egg on string sign**
โ๏ธ **TGA**
128
๐ค **10 years old boy with history of cyanotic spells, presented with this CXR. Interperitate and give diagnosis** โ๏ธ
๐ป Plain chest x-ray
๐ป Demonestrate a **boot shaped heart** and diminshed pulmonary vascular markings.
โ๏ธ **TOF**
129
๐ค **2 months old presents with acute respiratory distress. Interperitate this CXR and give the diagnosis** โ๏ธ
๐ป Plain chest X-ray
๐ป Demonistrate cardiomegally
๐ป Lung plethora ( congested)
๐ป Lt to Rt shunt may comlicated with Rt to Lt with time.
โ๏ธ **Eisenmenrer syndrome**
130
**4 Years old with failure to thrive, dyspnea, recurrent pulmonary infections comes with this CXR. Interperitate and give diagnosis** โ๏ธ
๐ป **Plain x-ray**
๐ป Demonistrate **snowman heart** = dilated SVC+ left vertical vein.
๐ป **Shunt vasculature** due to increased return to right heart
๐ป **Enlargement** of right heart due to volume overload.
โ๏ธ **Supracardiac total anomalous**
131
๐ค **What disease cause this CXR** โ๏ธ
โ๏ธ **Ebsteins anomaly**
## Footnote
๐ป**Tricuspid valve malformation**
๐ป **atrialization of RV**
๐ป **stagnation of blood in the RA**
132
**What is the etiology and peak age of Rheumatic Fever** โ๏ธ
๐ **Autoimmune reaction**
๐ฆ Triggered by **Group A ฮฒ-hemolytic Streptococcus (GABHS)**
๐ถ Peak age: **5โ15 years**
๐ Most common **acquired heart disease in children**
133
**What is the mnemonic for Jones Criteria for diagnosing RF** โ๏ธ
๐๐ง **Mnemonic: โJONES CAFE PALโ**
๐ฅ **JONES** โ Major Criteria
๐ฆ **CAFE PAL** โ Minor Criteria
134
**What are the major criteria in JONES** โ๏ธ
๐ด **JONES** =
โข ๐ฆต **J** : Joint involvement (Migratory Polyarthritis)
โข โค๏ธ **O** : โค๏ธ-shaped letter for **Carditis**
โข ๐ค **N** : Nodules (Subcutaneous)
โข ๐ธ **E** : Erythema marginatum (pink rash)
โข ๐บ **S** : Sydenham chorea (involuntary movements)
135
**What are the minor criteria in CAFE PAL** โ๏ธ
๐ต CAFE PAL =
โข ๐ฅ **C** : โ CRP
โข ๐ค **A** : Arthralgia
โข ๐ก๏ธ **F** : Fever > 38ยฐC
โข ๐ฉธ **E** : โ ESR
โข ๐ **P** : Prolonged PR interval (ECG)
โข ๐ **A** : Anamnesis of previous RF
โข ๐งช **L** : Leukocytosis
136
**How do you make a diagnosis of Rheumatic Fever** โ๏ธ
โ
Confirm **recent GABHS** :
โข ๐งซ Positive throat culture **OR**
โข ๐ **โ ASO titers**
**PLUS** :
โข **2 Major** criteria **OR**
โข **1 Major + 2 Minor**
137
**Describe migratory arthritis in RF** โ๏ธ
๐ฆต Involves **large joints** (knees, ankles)
๐ **Migrates** joint to joint
๐ฅ **Red, swollen, painful**
๐ Dramatic response to **aspirin**
138
**What is the most serious complication of RF** โ๏ธ
โค๏ธ **Carditis** (50%)
โข ๐ซ **Endocarditis** : Mitral > Aortic โ Regurg or stenosis
โข ๐ **Myocarditis** : Tachycardia > fever, muffled heart sounds
โข ๐งท **Pericarditis** : Sharp pain, friction rub, effusion
139
**What is Sydenham chorea** โ๏ธ
๐ง Autoantibodies to **basal ganglia**
๐ **Jerky, irregular movements**
๐ฅ Worse with stress, better at rest
๐ง More common in **girls**
140
๐ก **How do you treat Rheumatic Fever** โ๏ธ
๐ **Antibiotics** : Benzathine Penicillin IM
๐๏ธ **Supportive** : Rest, low salt/fluid diet
๐ **Specific treatments** :
โข Arthritis โ **Aspirin**
โข Carditis โ **Steroids**
โข Chorea โ **Phenobarbital, Valproic acid**
141
โ **How to prevent recurrence of RF** โ๏ธ
๐ก๏ธ **Secondary prophylaxis** :
๐ **Benzathine penicillin** every **3โ4 weeks**
๐ For **10 years** or until **age 21**, whichever is **longer**
142
๐ค **What are long-term complications of RF** โ๏ธ
โข โค๏ธ **Rheumatic Heart Disease (RHD)**
โข ๐ **Heart failure**
โข ๐ฆ **Infective endocarditis**
โข ๐ **Recurrence**
143
**How RF could cause valvular stenosis** โ๏ธ
Acute endocarditis cause **swelling and valvular regurge** and with time (chronic) the valve is **fibrosed and calcified** which cause stenosis
144
๐ซ **What is differentiate tachycardia of myocaditis from other causes of tachycardia** โ๏ธ
**It is disproportionate to degree of fever ๐ค ** .
145
**Discribe SC nodules in RF** โ๏ธ
๐ป **Painless**
๐ป **Hard**
๐ป **Over body prominence**
146
๐ด **Which type of erythema is related to RF disease. And discribe it** โ๏ธ
**Erythema Marginatum**
๐ป **Not pruritic**
๐ป **Progressive margin**
๐ป **central fading**
147
๐น๏ธ **What is the pathophysiology of IE** โ๏ธ
๐ Turbulent blood flow โ๐ฉธ Endothelial injury โ
๐งฌ Subendothelial exposure โ๐งซ Platelet-fibrin thrombus โ๐ฆ Bacterial colonization โ๐ฟ **Vegetations** โ
โข ๐ **Valve destruction**
โข ๐งฌ **Embolization**
โข ๐ค **Immune complex deposition** (rash, GN)
148
๐ **In normally healthy person what is the most common organisms causing Infective Endocarditis** โ๏ธ
**Staph aurus**
## Footnote
Treated by: Methicillin or Vancomycin + Gentamycin
149
๐งช **What are the most common organisms causing Infective Endocarditis** โ๏ธ
๐ฆ **Strep viridans** (post-dental)
๐ฆ **Staph aureus** (esp. normal valves & IV drug users)
๐ฆ **Enterococci** (GI/GU procedures)
๐ฆ **HACEK group** (rare, Gram-negative)
150
๐ **What is the Modified Duke Criteria for diagnosing IE** โ๏ธ
๐ง **Mnemonic: BE TIMER**
๐ด **Major Criteria (BE)** :
โข **Blood cultures** : โฌ๏ธ Positive x2, 12 hrs apart
โข **Echo findings** : ๐ฟ Vegetation, abscess, or new regurg
๐ต **Minor Criteria (TIMER)** :
โข **T** emp > 38ยฐC ๐ก๏ธ
โข **I** mmune signs: Osler nodes ๐ค, Roth spots ๐๏ธ
โข **M** icrobiological evidence not meeting major
โข **E** mbolic signs: Janeway ๐๏ธ, splinter hemorrhages, petechiae
โข **R** isk factors: CHD, prosthetic valve, IV drug ๐
151
๐ฆ **How is a definitive diagnosis of IE made using Duke Criteria** โ๏ธ
โ
**2 Major** , **OR**
โ
**1 Major + 3 Minor** , **OR**
โ
**5 Minor**
##footnote
๐ถ Possible IE:
โ
1 Major + 1 Minor
โ
3 Minor
152
๐ค **Which patients need endocarditis prophylaxis before invasive procedures (AHA guidelines)** โ๏ธ
๐ Recommended if patient has:
1. ๐ง **Prosthetic valves/material**
2. ๐ **Previous IE**
3. ๐ซ **CHD** :
โข Unrepaired cyanotic CHD
โข Repaired with prosthetic material (within 6 months)
โข Repaired CHD with **residual defects**
4. ๐ **Cardiac transplant with valvulopathy**
๐ฆท **Prophylaxis needed** before:
โข **Dental** work involving **gingiva/oral mucosa perforation**
153
๐ **What is the treatment of infective endocarditis** โ๏ธ
๐ **Empiric** :
โข For Staph: ๐ **Vancomycin** + **Gentamicin**
๐ฌ **Based on culture** :
โข **Staph** : Methicillin-sensitive โ **Nafcillin** , resistant โ **Vancomycin**
โข **Strep/Entero/HACEK** โ **Penicillin/Ampicillin/Ceftriaxone + Gentamicin**
โข **Fungal โ Amphotericin B**
โ๏ธ **Surgical** if:
โข Heart failure
โข Fungal IE
โข Persistent bacteremia
โข Recurrent emboli
โข Large vegetations
154
๐ก **What is the prophylactic regimen before dental or GI/GU procedures** โ๏ธ
โข ๐ฆท **Dental** :
๐ **Oral Amoxicillin** 1 hr before
๐ **IV Ampicillin** if unable to take oral
โAllergic: **Azithromycin** or **Clindamycin**
โข ๐งซ **GI/GU procedures** :
๐ **Ampicillin + Gentamycin**
155
โ๏ธ **What is Supraventricular Tachycardia (SVT) and its mechanism in children** โ๏ธ
โก **Most common** symptomatic arrhythmia in childhood
๐ **Re-entry circuit** involving:
โข **AV Node** (AVN) ๐
โข **Accessory pathway** (e.g., in WPW syndrome)
156
๐ค **What is the typical heart rate range for SVT in pediatric patients** โ๏ธ
**250 to 300 beats per minute**
157
๐ค **What are the etiologies of SVT** โ๏ธ
๐งฌ **Idiopathic** โ **Most common**
๐ซ CHD: e.g., **Ebstein anomaly** , single ventricle
๐ **Post-cardiac surgery**, **myocarditis** , **drugs**
๐ง **Electrolyte imbalance**
158
๐ค **What are the clinical presentations of SVT** โ๏ธ
๐ถ **Fetus** : Hydrops fetalis
๐ผ **Neonates/Infants** : Pallor, irritability, vomiting, ๐ซ heart failure (if prolonged)
๐ง **Children** : Palpitations, chest pain, pallor, syncope
159
๐ **What are the key ECG features of SVT** โ๏ธ
๐ **HR** :
โข 220 bpm (infants)
โข 180 bpm (children)
๐งพ **ECG** :
โข **Narrow QRS**
โข ๐ **No visible P waves**
โข Sudden onset/offset
๐งช **ECG normal between attacks**
##footnote
โ ๏ธ If **short PR + delta wave** โ suspect **WPW**
160
๐ค **What is the first-line treatment for stable SVT in pediatric patients** โ๏ธ
1. **Vagal maneuvers**
โข Ice bag ๐ง on face
โข Blowing into syringe ๐ (older kids)
2. **Adenosine**
โข 1st dose: 0.1 mg/kg IV push ๐
โข If no effect โ 2nd dose: 0.2 mg/kg
โข Followed by **saline flush**
##footnote
Role of adenosine in treating SVT:
It convert SVT to normal sinus rhythm.
161
โก๏ธ **What is the acute management of unstable pediatric SVT** โ๏ธ
โ๏ธ โก๏ธโก๏ธ **Synchronized cardioversion**
โฆ๏ธ 0.5โ1 J/kg โ if needed 2 J/kg
โฆ๏ธ Sedation: Midazolam/Propofol if time permits
162
๐ค **What are the options for maintenance/preventive treatment of SVT** โ๏ธ
๐ก๏ธ **Medications** to prevent recurrence:
๐ป **Propranolol**
๐ป **Sotalol**
๐ป **Flecainide**
##footnote
๐ **Usually resolves by age 1**
โก **If WPW present: Accessory bundle ablation** may be needed
163
๐ฆ **What are the main causes of Long QT Syndrome (LQTS)** โ๏ธ
๐งฌ **Congenital (Genetic Channelopathies)** :
โข **Romano-Ward syndrome** (AD) โก๏ธ LQT only
โข **Jervell and Lange-Nielsen syndrome** (AR) โก๏ธ LQT + ๐ฆป deafness
๐ **Acquired causes** :
๐ป **Drugs** :
โข โ ๏ธ Erythromycin
โข โ ๏ธ Ketoconazole
๐ป **Electrolyte disturbances**:
โข โ Potassium (๐ง K)
โข โ Calcium (๐ง Ca)
โข โ Magnesium (๐ง Mg)
164
๐ค **What are the clinical features of Long QT Syndrome** โ๏ธ
โข ๐ **Syncope** (especially during exercise)
โข โค๏ธ **Palpitations**
โข ๐ต **Seizures** (often misdiagnosed as epilepsy!)
โข โฐ๏ธ **Sudden cardiac death** (especially with a **+ve family history** )
165
๐ **What is the key ECG finding in LQTS** โ๏ธ
๐ **QTc > 0.47 seconds** (prolonged QT interval)
โ
Always measure **corrected QT (QTc)** to account for heart rate
๐ซ May show **Torsades de Pointes** in severe cases
166
๐ **What is the treatment for Long QT Syndrome** โ๏ธ
1๏ธโฃ **Propranolol** (mainstay) ๐
2๏ธโฃ If no response or high-risk โก๏ธ **ICD (Implantable Cardioverter Defibrillator)** โก
3๏ธโฃ โ ๏ธ Avoid **QT-prolonging drugs** and correct **electrolytes**
167
๐ตโ๐ซ **A 12-year-old boy collapses during gym class. ECG shows coved ST elevation in V1โV3. What is the most likely cause** โ๏ธ
๐งฌ **Genetic predisposition**
##footnote
๐ Explanation:
โข This is classic for **Brugada Syndrome** , an **autosomal dominant** channelopathy
โข Characteristic **ECG** : Coved **ST elevations in V1โV3**
โข **Common presentation** : **Syncope, palpitations, or sudden cardiac death** , especially during exertion or rest
โข High-risk patients should receive an **ICD (implantable cardioverter-defibrillator)** ๐ฅ
168
**Maternal SLE could cause ____ in her baby heart that treated by ____** โ๏ธ
โ๏ธ
**Congenital complete heart block**
**Perminant pacemaker.**
169
**Maternal diabetes cause __, ______ in her baby heart** โ๏ธ
โ๏ธ
**Hypertrophic cardiomyopathy**
**TGA**
170
**Exposure to lithium during pregnency could cause ____ anomaly in babyโs heart, while alcohol cause ____.** โ๏ธ
โ๏ธ
**Ebstein**
**ASD, VSD**
171
**Retinioc acid during pregnency could be the cause of which congenital cardiac disease** โ๏ธ
โ๏ธ
**TGA**
172
**Marfan syndrome is associated with which cardiac defects** โ๏ธ
โ๏ธ
๐ป**AD**
๐ป**MV prolapse**
173
**Possible diagnosis in case of cyanosis with decreased pulmonary vascularity** โ๏ธ
โ๏ธ
๐ป **TOF**
๐ป **Tricuspid atresia**
๐ป **Pulmonary atresia**
## Footnote
**Rt side stenosis** .
174
**Possible cauese of cyanosis with increased pulmonary vasularity** โ๏ธ
โ๏ธ
๐ป **TGA**
๐ป **Truncus arteriosus**
๐ป **TAPVR**
175
**Possible causes CHF in the first week of life** โ๏ธ
๐ป **COA**
๐ป **Hyperplastic left heart**
๐ป **Interrupted aortic arch**
## Footnote
**Once discovered >> PGE1** .
176
**CHF at 6-8 weeks is often** โ๏ธ
**Lt to Rt shunt**
177
**CHF in older children maily** โ๏ธ
๐ป **Myocarditis**
๐ป **Rheumatic fever**
178
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