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Cardiology Flashcards

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1
Q

What is the ductus arteriosus?

A

Connects the pulmonary artery to the aorta so that blood doesn’t flow to the lungs, closes within first few hours or days

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2
Q

What % of congenital heart defects are picked up antenatally? And when?

A

70% at 18-20 week anomaly scan

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3
Q

What is the most common presentation of congenital heart disease - complication of presentation?

A

A heart murmur - however 30% of children will have an innocent murmur at some point which is present in a normal heart

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4
Q

What are the hallmarks of an innocent ejection murmur?

A 
4 s's
aSymptomatic patient 
Soft blowing murmur 
Systolic murmur only - not diastolic
left Sternal edge - no radiation 
Also - normal heart sounds with no added sounds and no parasternal thrill
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5
Q

What can be causes of innocent murmur

A

Anaemia or febrile illness due to increased cardiac output

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6
Q

Main cause of heart failure in first week of life

A

Coarctation of the aorta

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7
Q

What can be important in maintaining arterial perfusion in coarctation of the aorta

A

Right to left flow of blood via the arterial duct = duct dependant systemic circulation
If the duct closes then severe acidosis, collapse and death

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8
Q

Main cause of heart failure after first week of life - mechanism and symptoms (when?)

A

Left to right shunt. As weeks go on, pulmonary vascular resistance falls, progressive increase in left to right shunt and increase pulmonary blood flow
Causes pulmonary oedema and breathlessness - about 3 months of life

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9
Q

What will happen if left to right shunt goes untreated

A

Children will develop Eisenmenger syndrome - irreversibly raised pulmonary vascular resistance as resistance rises in response to the left right shunt
Shunt is now from right to left due to raised pulmonary pressure and TEENAGER is blue

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10
Q

Treatment of Eisenmenger syndrome

A

Only really heart lung transplant - medication is available to palliate symptoms

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11
Q

Causes of neonatal heart failure other than coarctation of the aorta x3

A

Hypoplastic left heart syndrome
Critical aortic valve stenosis
Interruption of the aortic arch

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12
Q

Causes of heart failure in infants

A

Due to high pulmonary flow therefore ventricular septal defect, atrioventricular septal defect and large persistent ductus arteriosus

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13
Q

Causes of heart failure in older children

A

Rheumatic heart disease and cardiomyopathy

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14
Q

When can peripheral cyanosis occur? X3

A

If child is cold, unwell from any cause or due to polycytheamia

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15
Q

When does central cyanosis occur? What level of reduction needs to be present for its identification

A

Due to fall in arterial blood oxygen tension
Can only be recognised if concentration of reduced haemoglobin in blood exceeds 5g/dl
Therefore less pronounced if child is anaemic

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16
Q

What is persistent cyanosis in an otherwise well child a sign of?

A

Structural heart disease

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17
Q

Presentation of right to left shunt symptom wise

A

Blue child

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18
Q

Presentation of left to right shunt symptom wise

A

Breathlessness or asymptomatic

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19
Q

3 causes of left to right shunt

A

ASD, VSD, or persistent ductus arteriosus

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20
Q

Two types of ASD and incidence

A 
Secundum ASD (80%) 
Partial atrioventricular septal defect
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21
Q

What is Secundum ASD

A

Defect in centre of atria where foramen ovale is

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22
Q

What is partial AVSD?

A

Defect of AV septum involving atrial septum and av valves

Also 3 leaflet defect in left av valve with regurgitant leak

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23
Q

Symptoms of ASD

A

Asymptomatic or recurrent lung infections/wheeze

Arrhythmias from 4th decade onward

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24
Q

Physical signs of ASD on auscultation

A

Ejection systolic murmur best heard at left Sternal edge because increase blood flow over pulmonary valve

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25
Physical sign of partial AVSD on auscultation
Apical pan systolic murmur due to regurgitation through AV valve
26
Signs of ASD and AVSD on chest X-ray x3
Cardiomegaly, increased pulmonary vascular markings, enlarged pulmonary arteries
27
ECG signs with Secundum ASD
Partial right bundle branch block is common | Right axis deviation due to right ventricle enlargement
28
ECG in partial AVSD
Superior QRS complex - mainly negative in avF - because defect is near av node therefore displaced node conducts to the ventricles superiorly
29
Management of Secundum ASD
Cardiac catheterisation with insertion of occlusion device usually done 3-5 years of age
30
Management of partial AVSD
Surgical correction. - usually done 3 years of age
31
What % of congenital heart disease is due to VSD
30%
32
Symptoms and signs of small VSD (what size?)
No symptoms and loud pan systolic murmur at lower left sternal edge (louder the murmur, smaller the defect) Smaller than 3mm
33
Investigations in small VSD
Normal ecg normal X-ray - echo will show defect
34
Management of small VSD
They will close spontaneously
35
Symptoms of large VSD x4
Heart failure Breathlessness and failure to thrive in 1 week old Recurrent chest infections
36
Signs of large VSD x 5
Tachycardia, tachypnoea and enlarged liver from heart failure Active precordium Soft pansystolic murmur or no murmur Apical mid-diastolic murmur (increased flow across mitral valve with return of blood through lungs) Loud pulmonary second sound from raised pulmonary arterial pressure
37
Chest X-ray with large VSD
Cardiomegaly Enlarged pulmonary arteries Increased pulmonary vascular markings Pulmonary oedema
38
What is the foramen ovale?
Hole between the right and left atrium. As the lungs are not in use, pressure in them is high and blood flow is low, therefore pressure is low in the left atria...also pressure in the right atria is high as it receives all the blood flow from the placenta. Therefore hole stays open. When lungs start breathing, blood flow to lungs increases and pressure in right atria drops as no more placenta therefore pressure higher in left atria and foramen closes
39
ECG in large VSD
Biventricular hypertrophy by 2 months of age
40
Management of large VSD
Treat heart failure with diuretics and captopril Additional calorie intake Surgery at 3-6months to prevent Eisenmenger syndrome
41
Two causes of patent ductus arteriosus
Congenital heart defect or prematurity (if in preterm infant)
42
Clinical features of patent ductus arteriosus with additional features if it's a large duct
Continuous murmur upper left sternal edge (always a murmur because pressure is lower in the pulmonary artery than in the aorta throughout the cardiac cycle) Pulse pressure increased causing a bounding or collapsing pulse Large duct - heart failure and pulmonary hyper tension
43
Investigations in patent ductus arteriosus
X-ray and ECG usually normal | However if large the signs are the same as with large VSD
44
Management of patent ductus arteriosus
Closure with coil or occlusion device via cardiac catheterisation at 1 year of age Occasionally surgical ligation
45
What sort of heart disease does right to left shunts cause
Cyanotic heart disease - present with cyanosis and O2 sats
46
Diagnostic test of cyanotic heart disease
Hyperoxia (nitrogen washout) test Place infant in 100% oxygen for 10min - if right radial artery pao2 from blood gas remains low diagnosis can be made (if lung disease and persistent pulmonary hypertension of newborn have been excluded)
47
Management of neonatal cyanotic heart disease
Start prostaglandin infusion - maintain duct patency as they are duct dependant
48
What is most common cause of cyanotic heart disease and features x4
Tetralogy of fallot - large VSD - overriding aorta with respect to ventricular septum - sub pulmonary stenosis causing right ventricular outflow tract obstruction - right ventricular hypertrophy as a result
49
When are most tetralogy of fallot diagnosed?
Most are diagnosed antenatally or following identification of murmur in the first 2 months of life Cyanosis may not be obvious at this stage - although a few present with severe cyanosis in first few days of life
50
Classical description of symptoms of tetralogy of fallot
Severe cyanosis Hypercyanotic spells (irrability, crying, breathlessness and pallor) and squatting on exercise Developing late in infancy - now rarely seen in developed countries
51
Murmur in tetralogy of fallot
Loud harsh ejection systolic murmur at left Sternal edge from day 1 of life With increasing outflow obstruction (due to muscular hypertrophy) murmur will shorten and cyanosis with increase
52
Chest X-ray in tetralogy of fallot
May have pulmonary artery 'bay' - concavity on left heart border where artery and outflow tract would normally be Decreased pulmonary vascular markings
53
Management of tetralogy of fallot
Surgery to remove obstruction and close VSD at around 6 months of age Very cyanosed infants may require shunt in the meantime eg. from subclavian artery to pulmonary artery
54
What does transposition of the great arteries cause
Right to left shunt
55
What is transposition of the arteries anatomically
Pulmonary artery is connected to the left ventricle and aorta to the right ventricle therefore oxygenated blood returns to the lungs and deoxygenated blood returns to the body Unless there is a defect such as VSD, ASD or pda this is not compatible with life
56
Symptoms/presentation of transposition of the great arteries
Cyanosis - usually at 2 days of life when closure of pda leads to decreased mixing
57
Auscultation in transposition of great arteries
Usually no murmur but may be systolic murmur due to stenosis of left pulmonary outflow tract
58
Management of transposition of great arteries
Maintain ductus arteriosus - prostaglandin infusion Balloon atrial septostomy may be life saving Most need surgery - arterial switch procedure within first few days of life - transected above the valves and switched over Transfer coronary arteries over to new aorta
59
Which syndrome cause common mixing cardiac problems
Complete atrioventricular septal defect and complex congenital heart disease (such as mitral atresia, tricuspid atresia) Breathless and blue
60
When is complete AVSD commonly seen?
Down's syndrome
61
What are the defects present in complete AVSD
5 leaflet av valve - defect stretches all across the av junction and tends to leak
62
Which lesions cause outflow obstruction in a well child x3
Aortic stenosis, pulmonary stenosis, adult-type coarctation of the aorta
63
Features and symptoms of aortic stenosis
Can occur in association with mitral stenosis and coarctation of the aorta Most have asymptomatic murmur but may present with chest pain on exertion, reduced exercise tolerance or syncope
64
Signs of aortic stenosis
Ejection systolic murmur - maximal at left Sternal edge and radiating to neck Small volume, slow rising pulses Apical ejection click
65
Features of pulmonary stenosis
Most are asymptomatic Ejection systolic murmur best heard upper left Sternal edge If severe might be right ventricular hypertrophy and heave
66
Features of adult-type coarctation of the aorta
Not duct dependant - gradually becomes more severe over many years
67
Features of coarctation of the aorta
Asymptomatic Systemic hypertension in the right arm Ejection systolic murmur at upper sternal edge Collaterals heard with continuous murmur at the back Radio femoral delay
68
Adult type coarctation of the aorta on X-ray
Rib notching - due to development of large intercostal arteries running under ribs to bypass obstruction '3' sign with visible notch in the descending aorta at site of coarctation
69
Adult type coarctation of the aorta on ecg
Left ventricular hypertrophy
70
Causes of outflow obstruction in a sick child
Coarctation of the aorta Interruption of the aortic arch Hypoplastic left heart syndrome
71
How do sick children with outflow obstruction present?
Sick with heart failure and shock in neonatal period | Prostaglandin should be commenced straight away
72
When do children with coarctation of the aorta present?
Usually at 2 days of age with acute circulatory collapse when the da closes
73
Physical signs in children with coarctation of the aorta
Severe heart failure Absent femoral pulses Severe metabolic acidosis
74
Management of coarctation of the aorta
Surgical repair
75
What is interruption of aortic arch
Aorta does not continue to lower body - instead the connection to the pulmonary artery becomes the vessel and continues this way, there is also a VSD therefore cardiac output is maintained via left-to right flow across duct
76
What is Hypoplastic left heart syndrome?
Underdevelopment of the left side of the heart - surgical treatment with complicated operation
77
What is the most common childhood arrhythmia
Supra ventricular tachycardia
78
Treatment of supraventricular tachycardia in neonate
Very fast heartbeat (250-300bpm) therefore need circulatory and respiratory support Vagal stimulating manoeuvres (carotid sinus massage or cold ice pack to face) successful in 80% IV adenosine or cardio version if that fails Maintenance with flecainide or sotalol Resting ECG will remain normal but 90% will have no further attacks after infancy therefore treatment can be stopped at age 1
79
What mostly causes syncope in teenagers
Neurocardiogenic, situational, orthostatic or ischaemic causes
80
Features of a cardiac cause of syncope
Symptoms on exercise Family Hx of sudden unexplained death Palpitations
81
What age usually affected by rheumatic fever
5-15 years | Following group a b-haemolytic strep -2-6 weeks later
82
Most common cardiac sequela of rheumatic fever
Mitral stenosis, can also get carditis, also less frequently aortic, tricuspid and rarely pulmonary disease
83
Acute management of rheumatic fever heart disease
Aspirin for inflammation and bed rest If aspirin doesn't work then corticosteroids Antibiotics if evidence of persisting infection
84
Management following resolution of acute rheumatic fever episode
Prophylaxis with monthly penicillin injections Up until the age of 18-21 Severity of episodes influences length of treatment
85
What are all children with congenital heart disease (except for Secundum ASD) at high risk of
Infective endocarditis - highest risk with turbulent jet of blood - eg. VSD, coarctation of the aorta and persistent DA
86
Most common organism for infective endocarditis
A-haemolytic strep | Treat with high dose penicillin + amino glycoside given IV for 6 weeks

Paediatrics (16 decks)

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