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Flashcards in Cardiovascular ||| Deck (131):
1

What are the changes from fetal circulation to adult circulation that occur at birth (4)?

1. With the first breaths, resistance to pulmonary blood flow falls and the volume of blood flowing through the lungs increases. This increases the pressure in the LA

2. Volume of blood returning to right atrium falls, umbilical cord vessels constrict to increase systemic pressure

3. This results in closure of the foramen ovale.

4. The ductus arteriosus closes within the first few hours/days

2

How does congenital heart disease present (5)?

1. Antenatal cardiac ultrasound diagnosis at 18-20 weeks
2. detection of a heart murmur
3. Heart failure
4. Shock
5. cyanosis

3

What are the hallmarks of an innoSent ejection murmur?
Main (4)
Others (3)

1. ASymptomatic
2. Soft blowing
3. Systolic murmur only, not diastolic
4. Left Sternal edge

Plus:
1. normal heart sounds with no added sounds
2. No parasternal thrill
3. No radiation

4

What are the symptoms of heart failure (4)?

1. Breathlessness
2. Sweating
3. Poor feeding
4. Recurrent chest infections

5

What are the signs of heart failure (7)?

1. Poor weight gain or faltering growth
2. Tachypnoea
3. Tachycardia
4, Heart murmur, gallop rhythm
5. Enlarged heart
6. Hepatomegaly
7. Cool peripheries

6

What are the more common causes of heart failure in the first week of life/neonates (4)?

Left heart obstruction (duct-dependent):
1. Hypoplastic left heart syndrome
2. Critical aortic valve stenosis
3. Severe coarctation of the aorta
4. Interruption of the aortic arch

7

What are the more common causes of heart failure in infants (3)?

As the pulmonary vascular resistance falls, there is a progressive increase in left-right shunt and increasing high pulmonary blood flow:

1. Ventricular septal defect
2. Atrioventricular septal defect
3. Large persistent ductus arteriosus

8

What are the more common causes of heart failure in older children and adolescents (3)?

1. Eisenmenger syndrome (right heart failure only due to untreated left-right shunt and increasing pulmonary blood flow. This leads to irreversibly raised pulmonary vascular resistance which causes the shunt to go from right to left, and the teenager is blue)
2. Rheumatic heart disease
3. Cardiomyopathy

9

What respiratory rate indicates respiratory distress?

RR > 60 breaths/min

10

What is the upper limit of cyanosis?

Oxygen saturation of 85%

11

What is the cause of cyanosis?

Deoxygenated blood going directly into the systemic circulation

12

What are the 3 main types of left-to-right shunts? (in order of most common)

What is the main symptom of Left-to-right shunts?

1. Ventricular septal defect
2. Persistent arterial duct
3. Atrial septal defect

Breathlessness (left-to-right shunts are types of acyanotic congenital heart disease)

13

What are the 2 main types of right-left shunts?

What is the main symptom of right-to-left shunts?

1. Tetralogy of Fallot
2. Transposition of the great arteries

Cyanosis

14

What is a type of common mixing congenital heart lesion (1) and its symptoms (2)?

Complete Atrioventricular septal defect

Breathless and cyanosis

15

Types of outflow obstruction in a well (2) and sick (1) child, and their symptoms?

Well child:
1. Pulmonary stenosis
2. Aortic stenosis
Asymptomatic with a murmur

Sick neonate
1. Coarctation of the aorta
Collapsed with shock

16

What are the types of congenital heart lesions (4)?

1. Left-to-right shunts
2. Right-to-left shunts
3. Common mixing
4. Outflow obstruction in a well and sick child

17

What investigations are done if congenital heart disease is suspected (3)?

1. Chest radiograph
2. ECG
3. Echocardiography combined with Doppler ultrasound = enables most causes to be diagnosed

18

What are the two main types of Atrial septal defects and how common are they?

1. Secundum ASD (80% of ASD) - defect in the centre of the atrial septum involving the foramen ovale

2. Partial atrioventricular septal defect (AVSD or primum ASD)
Characterised by:
-An interatrial communication between the bottom end of the atrial septum and the atrioventricular valves (primum ASD)
-Abnormal atrioventricular valves which tend to leak (regurgitant valve)

19

What are the symptoms of ASD (3)?

1. Usually asymptomatic
2. Recurrent chest infections/wheeze
3. Arrhythmias from 4th decade onwards

20

What are the physical signs of ASD (3)?

1. Ejection systolic murmur - due to increased flow across the pulmonary valve because of the left-to-right shunt (blood goes from left atria to right atria to right ventricle then up pulmonary artery)
2. A fixed and widely split second heart sound - due to right ventricular stroke volume being equal in both inspiration and expiration
3. With partial AVSD, an apical pansystolic murmur from atrioventricular valve regurgitation

21

In ASD, where would the best place be to hear the murmur?

Upper left sternal edge

22

What investigations would you perform for ASD (3)?

1. Chest radiograph
2. ECG
3. Echocardiography

23

What would you discover on the chest radiograph in a patient with ASD (3)?

1. Cardiomegaly
2. Enlarged pulmonary arteries
3. Increased pulmonary vascular markings

24

What would an ECG of someone with 1. secundum ASD (2) and 2. Partial AVSD (1) show?

1. Secundum ASD:
- partial right bundle branch block
-Right axis deviation due to right ventricular enlargement

2. Partial AVSD:
- a superior QRS complex (due to a defect in the middle of the heart where the AV node is. The displaced node then conducts to the ventricles superiorly, giving the abnormal axis

25

Which groups of patients with ASD need to be treated?

Those with large enough ASDs to cause RV dilatation

26

How are secundum ASDs managed?

By cardiac catheterization with insertion of an occlusion device

27

How are partial AVSDs managed?

Surgical correction

28

At what age are ASDs treated?

3-5 years

29

What % of congenital heart disease is accounted for by ventricular septal defects?

30%

30

What is a ventricular septal defect?

A defect anywhere in the ventricular septum, perimembranous (adjacent to the tricuspid valve) or muscular (completely surrounded by muscle)

31

What different types of VSDs are there (2)?

1. Small VSDs (smaller that the aortic valve in diammeter, maybe up to 3mm

2. Large VSDs - same size or larger than the aortic valve

32

What are the symptoms of a small VSD?

Asymptomatic

33

What are the physical signs of a small VSD (2)?

1. Loud pansystolic murmur (loud murmur implies smaller defect)
2. Quiet pulmonary second sound (P2)

34

In a small VSD, where is the murmur heard best?

Lower left sternal edge

35

What would you find on a chest radiograph for a patient with a small VSD?

Normal

36

What would you find on an ECG for a patient with a small VSD?

Normal

37

What would you find on an echocardiography for a patient with small VSD?

Demonstrates precise anatomy of defect, no pulmonary hypertension

38

Management of a small VSD?

These will close spontaneously

39

What are the symptoms of a large VSD (2)?

1. Heart failure with breathlessness and faltering growth after 1 week old
2. Recurrent chest infection

40

What are the physical signs of a large VSD (7)?

1. Tachypnoea
2. Tachycardia
3. Enlarged liver from heart failure
4. Active precordium (area of chest over the heart moves too much due to pathology of heart)
5. Soft pansystolic murmur or no murmur (implying large defect)
6. Apical mid-diastolic murmur (from increased flow across the mitral valve after the blood has circulated through the lungs)
7. Loud pulmonary second sound (P2) - from raised pulmonary arterial pressure

41

What types of murmurs do you get with a large VSD (2)?

1. Soft pansystolic murmur
2. apical mid-diastolic murmur

42

What do you see on chest radiograph in a patient with a large VSD (4)?

1. Cardiomegaly
2. Enlarged pulmonary arteries
3. Increased pulmonary vascular markings
4. Pulmonary oedema

43

What do you see on an ECG in a patient with a large VSD?

Biventricular hypertrophy by 2 months of age

44

What would you find on an echocardiography for a patient with large VSD (2)?

1. Demonstrates anatomy of defect
2. Pulmonary hypertension due to high flow

45

What is the management of a large VSD (4)?

Manage the heart failure:

1. Diuretics
2. Captopril (ACE inhibitor)
3. Additional calorie input
4. Surgery at 3-6 months

46

What are the consequences of an untreated large VSD?

Eisenmenger syndrome - the pulmonary hypertension leads to irreversible damage of the pulmonary capillary vascular bed

47

What is the general management of heart failure in a child (3)?

1. Diuretics
2. ACE inhibitor
3. Increased calorie input

48

What are the different types of acyanotic congenital heart disease (5)?

1. ASD
2. VSD
3. PDA
4. AS
5. PS

49

What is a persistent ductus arteriosus?

The ductus ateriosus connects the pulmonary artery to the descending aorta in the fetus. In PDA, it fails to close by 1 month after the expected date of delivery. Blood flow is left to right, from the aorta to the pulmonary artery, following the fall in pulmonary vascular resistance after birth

50

What are the clinical signs of PDA (3)?

1. Continuous murmur - continues into diastole because the pressure in the pulmonary artery is lower than in the aorta throughout the cardiac cycle.
2. Collapsing or bounding pulse (a rapidly increasing and subsequently collapsing pulse associated with increased stroke volume of the LV and increased pulse pressure
3. When the duct is large, there is increased pulmonary blood flow with heart failure and pulmonary hypertension

51

Where is the murmur best heard in PDA?

Beneath the left clavicle

52

What do you find on a chest radiograph in PDA (4)?

1. Normal
or maybe
2. Enlarged heart
3. Enlarged pulmonary arteries
4. Increased pulmonary vasculature

53

What do you find on an ECG in PDA (5)?

1. Normal
Or maybe:
2. Maybe LV hypertrophy with
3. Large left-to-right shunt
4. RV hypertrophy
5. Pulmonary hypertension

54

What do you find on an echocardiogram in PDA?

The duct

55

What is the management of PDA?

Closure with coil or occlusion device introduced via a cardiac catheter at 1 year of age

56

Why should PDA be managed?

To avoid the lifelong risk of bacterial endocarditis and pulmonary vascular disease

57

What is a complete atrioventricular septal defect (AVSD)?

Defect in the middle of the heart with a single 5-leaflet (common) valve between the atria and ventricles, which stretches across the entire atrioventricular junction and tends to leak. As there is a large defect there is pulmonary hypertension

58

What are the symptoms of a complete AVSD (2)?

1. Breathlessness
2. Cyanosis at birth or heart failure at 2-3 weeks of life

59

How are complete AVSDs usually diagnosed (2)?

1. Presentation on antenatal ultrasound screening
2. Routine echocardiography screening in a newborn baby with Down's syndrome

60

What murmur is heart with a complete AVSD?

No murmur

61

What is found on an ECG in someone with complete AVSD?

Always a superior QRS axis

62

What is the management of a complete AVSD (2)?

1. Treat heart failure medically (as for a large VSD)
2. Surgical repair at 3-6 months of age

63

In which group of children are complete AVSDs most commonly seen in?

Down syndrome

64

What are the 2 forms of right-to-left shunts, in order of most common?

1. Tetralogy of Fallot
2. Transposition of the great arteries

65

What are the presentations of right-to-left shunts?

Cyanosis (blue, oxygen saturations <94% or collapsed)

66

At what age do children with right-to-left shunts usually present at?

1st week of life

67

What test can be done to help determine the presence of heart disease in a cyanosed neonate?

How does it work?

Hyperoxia (nitrogen washout) test

Infant is placed in 100% O2 (headbox or ventilator) for 10 mins.
If the right radial arterial partial pressure of oxygen from blood gas remains low (<15kPa, 113 mmHg), the a diagnosis of 'cyanotic' congenital heart disease can be made if lung disease and persistent pulmonary hypertension of the newborn have been excluded.
If O2 sats are >20kPa, it is not cyanotic heart disease.
Blood gas analysis must also be performed as O2 sats are not reliable enough

68

What is the management of a cyanosed neonate (2)?

1. Stablise ABC with artificial ventilation in necessary
2. Prostaglandin infusion to maintain ductal patency

69

What are the 4 anatomical features of tetralogy of fallot (4)?

1. Large VSD
2. Overriding aorta with respect to the ventricular septum (means aorta receives blood from both left and right ventricles)
3. Subpulmonary stenosis causing RV outflow tract obstruction
4. RV hypertrophy as a result

70

When is TOF usually diagnosed (2)?

1. Antenatally OR
2. Following the identification of a murmur in the first 2 months of life

71

What are the symptoms of TOF (2)?

1. Severe cyanosis
2. Hypercyanotic spells and squatting on exercise developing in late infancy

72

What are the signs of TOF (2)?

1. Clubbing of fingers and toes in older children
2. Loud harsh ejection systolic murmur from day 1 of life

73

What type of murmur is found in TOF and where is it best heard (2)?

1. Harsh ejection systolic murmur
2. Left sternal edge

74

What is found on a chest radiograph in patients with TOF (5)?

1. Small heart
2. Boot shaped heart due to RV hypertrophy
3. May be a right-sided aortic arch
4. Pulmonary artery 'bay' (concavity on the left heart border where the convex-shaped main pulmonary artery and RV outflow tract would normally be profiled)
5. May be decreased pulmonary vascular markings reflecting reduced pulmonary blood flow

75

What is found on an ECG in a patient with TOF (2)?

1. Normal at birth
2. RV hypertrophy when older

76

What is found on an echocardiogram in a patient with TOF?

Will show the cardinal features

77

What is the management of TOF (3)?

1. Initial management is medical, with definitive surgery at around 6 months. Involves closing the VSD and relieving RV outflow tract obstruction
2. However, infants who are very cyanosed will require a modified Blalock-Taussig shunt to increase pulmonary blood flow, by surgical placement of an artificial tube between the subclavian artery and the pulmonary artery.
3. Hyper-cyanotic spells are usually self-limiting and followed by a period of sleep. If longer than 15 mins, should be treated with:
-sedation and pain relief (morphine)
-IV propanolol
-iv volume administration
-Bicarbonate to correct acidosis
-muscle paralysis and artificial ventilation in order to reduce metabolic O2 demand

78

What is transposition of the great arteries (TGA)?

The aorta is connected to the RV and the pulmonary artery is connected to the LV. The deoxygenated blood is returned to the body and oxygenated blood is returned to lungs.

79

Why is TGA duct dependent?

There must be mixing of blood between the 2 circulations for TGA to be compatible with life.

80

What are the symptoms of TGA (1)? When do they usually present?

Cyanosis -Can be profound and life-threatening

Usually present on day 2 of life when the ductal closure leads to a reduction in the mixing of deoxygenated and oxygenated blood.
Cyanosis is less severe if there is still mixing of blood from other anomalies e.g. an ASD

81

What are the physical signs of a TGA (3)?

1. Cyanosis
2. Second heart sound s often loud and single
3. Usually no murmur, but may be a systolic murmur from increased flow of stenosis within the LV (pulmonary) outflow tract.

82

What would a chest radiograph show in a patient with TGA (2)?

1. Narrow upper mediastinum with an 'egg on side' appearance of cardiac shadow
2. Increased pulmonary vascular markings due to increased pulmonary blood flow

83

What would an ECG show in a patient with TGA?

Usually normal

84

What would an echocardiogram show in a patient with TGA?

Essential to show the abnormal arterial connections and associated abnormalities

85

What is the management for a sick cyanosed neonate with TGA (3)?

Key is to improve mixing
1. Prostaglandin infusion for ductus arteriosus patency is a must
2.A balloon atrial septostomy needs to be done in 20% as a life-saving procedure. A catheter with an inflatable balloon at its tip is passed through the umbilical/femoral vein and through the RA and foramen ovale. The ballooon in the LA is inflated and ripped through the atrial septum, opening the foramen ovale, allowing mixing of the systemic and pulmonary venous blood ithin the atrium.
3. Later, all patients with TGA will have the arterial switch procedure in the first few days of life where the pulmonary artery and aorta are transected above the arterial valves and switched over. The coronary arteries have to also be transferred across to the new aorta.

86

What is Eisenmenger syndrome?

When high pulmonary blood flow due to a large left-to-right shunt or common mixing is not treated, then the pulmonary arteries become thick walled and resistance to flow increases. At 10-15 years of age the shunt reverses and the teenager becomes blue, which is Eisenmenger sydrome. This eventually leads to right heart failure and death, usually in the 4th/5th decade of life

87

Which congenital heart lesions are duct dependent (6)?

1. Transposition of the great arteries
2. Coarctation of the aorta
3. Interruption of the aortic arch
4. Hypoplastic left heart syndrome
5. Critical aortic stenosis
5. Pulmonary atresia
6. Tricuspid atresia

88

What is the management to prevent duct closure?

Prostaglandin infusion

89

What type of outflow obstruction lesions are there (3)?

1. Aortic stenosis
2. Pulmonary stenosis
3. Coarctation of the aorta

90

Which types of outflow obstruction present with a well child (2)?

1. Aortic stenosis
2. Pulmonary stenosis

91

Which types of outflow obstruction present with a sick child?

Coarctation of the aorta

92

What is aortic stenosis?

The aortic valve leaflets are partly fused together, restricting exit from the LV.

93

What are the symptoms of aortic stenosis (4)?

1. Most as an asymptomatic murmur

Those with severe stenosis may present with:
2. reduced exercise tolerance
3. chest pain on exertion
4. syncope

94

What are the physical signs of aortic stenosis (5)?

1. Small volume, slow rising pulse
2. Always carotid thrill
3. Ejection systolic murmur
4. Delayed and soft aortic second sound
5. Apical ejection click

95

What type of murmur is heard with aortic stenosis and where is it heard best?

Ejection systolic murmur

Upper right sternal edge radiating to the neck

96

What is seen on a chest radiograph in a patient with aortic stenosis?

Normal or prominent LV with poststenotic dilation of the ascending aorta

97

What is seen on an ECG in a patient with aortic stenosis?

May be left ventricular hypertrophy

98

What is the management of aortic stenosis?

In children, regular clinical and echocardigraphic assessment is required to assess when to intervene.

Those who have symptoms on exercise or a high resting pressure gradient (>64mmHg) will undergo balloon valvotomy

99

What is pulmonary stenosis?

The pulmonary valave leaflets are partly fused together, restricting exit from the RV

100

What are the symptoms of pulmonary stenosis?

Most are asymptomatic

101

What are the physical signs of pulmonary stenosis (3)?

1. An ejection systolic murmur, thrill may be present
2. An ejection click
3. When severe, there is a prominent RV heave

102

What would you see on a chest radiograph in a patient with pulmonary stenosis?

Normal or poststenotic dilatation of the pulmonary artery

103

What would you see on a ECG in a patient with pulmonary stenosis?

RV hypertrophy (upright T wave in V1)

104

What is the management of pulmonary stenosis?

When the pressure gradient across the pulmonary valve becomes markedly increased (>64mmHg) , transcatheter balloon dilatation is done

105

In pulmonary stenosis, what type of murmur is heard, and where is it best heard?

Where is the ejection click best heard?

Ejection systolic murmur

Both best heard at upper left sternal edge

106

What types of outflow obstruction present with a sick child in order of most common (3)?

1. Coarctation of the aorta
2. Interruption of he aortic arch
3. Hypoplastic left heart syndrome

107

How does an outflow obstruction in a sick child specifically present as?

Heart failure and shock in the neonatal period unless diagnosed on antenatal US

108

What is the immediate management of a sick child with an outflow obstruction (3)?

1. Resuscitate (ABC)
2. Prostaglandin should be started ASAP
3. Referral made to a cardiac centre for early surgical intervention

109

What is coarctation of the aorta?

Due to arterial duct tissue encircling the aorta at the point of insertion of the duct. When it closes, it constricts the aorta causing severe obstruction to the left ventricular outflow.

110

What are the clinical features of coarctation of the aorta and when do they present (5)?

1. Examination on the first day is usually normal
2. The neonates usually present with acute circulatory collapse at 2 days of age when the duct closes
3. a sick baby with severe heart failure
4. absent femoral pulses = always think coarcation of aorta
5. severe metabolic acidosis

111

What is seen on a chest radiograph in a patient with coarctation of the aorta?

Cardiomegaly from heart failure and shock

112

What is seen on an ECG in a patient with coarctation of the aorta?

Normal ECG

113

What is the management of coarcatation of the aorta (3)?

1. Resuscitate (ABC)
2. Prostaglandin should be started ASAP
3. Referral made to a cardiac centre for early surgical intervention where end-to-end anastomosis is done (the narrowed area is removed with anastomosis of the 2 ends to each other)

114

What is interruption of the aortic arch?

No connection between the proximal aorta and distal to the arterial duct so cardiac output is duct dependent (right-to-left i.e. pulmonary to aorta)

115

What is pulmonary atresia?

Pulmonary valve does not form properly, obstructing outflow of blood from the RV to the lungs

116

What is tricuspid atresia?

Tricuspid valves are not formed, so RV is blocked off and small and nonfunctional. Only the LV is effective

117

What is supraventricular tachycardia (SVT)?

The most common childhood arrhythmia. The heart rate is rapid, between 250-300 beats/min. It can cause poor cardiac output and pulmonary oedema

118

What are the symptoms of SVT?

Symptoms of heart failure

119

What does an ECG of SVT show (3)?

1. A narrow complex tachycardia of 250-300 beats/min.
2. It may be possible to discern a P wave after the QRS complex due to retrograde activation of the atrium via the accessory pathway
3. If heart failure is severe, there may be T-ave inversion in the lateral precordial leads indicating myocardial ischaemia.

120

What is the management of SVT?

In a severely ill child, prompt restoration of sinus rhythm is key by:
1. Circulatory and respiratory support - tissue acidosis is corrected, positive pressure ventilation if required
2. Vagal stimulation manoeuvres e.g.carotid sinus massage or cold ice pack to face
3. iv adenosine (treatment of choice). Induces atrioventricular block after rapid bolus injection.

121

What is the aetiology of SVT?

A circuit of conduction is set up, with premature activation of the atrium via an accessory pathway. There is rare a structural heart problem.

122

What is hypoplastic left heart syndrome?

Underdevelopment of the left side of the heart so the mitral valve is small, the left ventricle is diminutive and there is usually aortic valve atresia. The ascending aorta is very small and there is almost always coarctation of the aorta.

123

What is hypoplastic left heart syndrome treated?

Norwood procedure = 3 stage heart surgery to create a new functional systemic curcuit

124

What are some syndromes associated with cardiac disease (3)?

1. Turner's = aortic valve stenosis, CoA
2. Noonan's = Hypertrophic cardiomyopathy, ASD, Pulmonary valve stenosis
3. Down's = ASD, VSD

125

What is myocarditis and what are its causes?
What are its presenting features?

Dilated cardiomyopathy is a large, poorly contracting heart.
It can be inherited, or can result from a direct viral infection of the myocardium
Presents as a child with an enlarged heart and heart failure who has previously been well

126

What are the risk factors for infective endocarditis (3)?

1. An children of any age with congenital heart disease apart from secundum ASD
2. Risk is highest when there is a turbulent jet of blood as with VSD, coarctation of the aorta and PDA
3. Higher risk also with prosthetic material inserted at surgery

127

What are the clinical signs of infective endocarditis (6)?

1. Fever
2. Splinter haemorrhages
3. Clubbing
4. Malaise
5. Unexplained anaemia
6. Haematuria

128

What is the most common causative organism of infective endocarditis?

alpha-haemolytic streptococcus

129

What is the management of infective endocarditis (2)?

1. High dose penicillin with aminoglycoside, giving 6 weeks iv
2. If there is infected prosthetic material, surgical removal may be required.

130

What is pulse pressure?

Difference between systolic and diastolic blood pressure
Reflects greater stroke volume

131

Why is there a widened pulse pressure i.e. a collapsing/bounding pulse in PDA?

The output runoff through the PDA from the left ventricle's output to the pulmonary circulation causes a lower diastolic pressure resulting in a lower than normal pressure in diastole. This gives the feeling of a bounding pulse when the heart beats due to the increased difference between the systolic and diastolic pressure and is interpreted as a bounding pulse in the peripheral vessels.