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Cardiovascular Disorders Flashcards

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1
Q

What is the most common form of structural malformations

A

Congenital heart disease

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2
Q

Causes of Chd

A

Genetic chromosomal - 8%
Teratogens
Idiopathic (most common)

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3
Q

Egs of teratogens causing CHD? Cause what?

A 
Congenital rubella (eg PDA, pulmonary stenosis) 
Alcohol (ASD, VSD)
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4
Q

Chromosomal disorders causing CHD ? Eg?

A

Downs - AVSD
Turners - aortic stenosis, coarctation
Williams - supra valvular AS
Chromosome 22 deletions

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5
Q

What are the two types of CHD ? Why?

A

Acyanotic (Lā€“>R shunts)

Cyanosis (R->L shunts)

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6
Q

Egs of L->r shunts

A 
VSD -30%, PDA -12%, ASD -7%.
Outflow obstruction (pulmonary (7%) / aortic (5%) stenosis, coarctation 5%)
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7
Q

Egs of R->L shunts

A

Tetralogy of fallot 5%

Transposition of the great arteries 5%

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8
Q

Outline the fetal circulation.
Placenta ->?
Pressure highest?
What causes change in pressures

A

Placenta delivers oxygenated blood to R atrium
Blood is unable to flow through lungs -> R side pressure Highest.
Blood flows through ductus arteriosus and foramen ovale.
Birth lungs expand -> decreased R sided pressure (smaller than left)

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9
Q

How does CHD present

A 
Antenatal uss diagnosis 
Heart murmur 
Cyanosis
Shock (low cardiac output) 
Cardiac failure
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10
Q

What are the two types of ASD

A

Ostium secundum defect (80%)

Partial AVSD + ostium primum defect

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11
Q

Where does an ostium secundum defect occur ? Who is it more common in?

A

High in atrial septum involving foramen ovale

2x more common in girls

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12
Q

Where is a partial AVSD ? What 2 things characterise it

A

Defect in atrioventricular septum
1- inter atrial communication between bottom end of atrial septum and atrioventricular valves (primium ASD)
2 - abnormal AV valves (typically mitral regurgitation )

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13
Q

Clinical features of ASD

A

Abnormal right ventricular impulse
Widely split and fixed second heart sound (s2)
Tricuspid flow murmur -> rumbling mid diastole murmur at LEFT STERNAL EDGE
Pulmonary flow murmur -> soft ejection systolic murmur in PULMONARY AREA

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14
Q

Symptoms of ASD

A

None - common
Recurrent chest infections / wheeze
Heart failure
Arrythmias - 4th decade onwards

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15
Q

Investigations for ASD ? What is seen?

A

CXR - cardiomegally, enlarged pulmonary arteries and increased pulmonary vascular markings (all NON SPECIFIC)
ECG - right ventricular hyper trophy (R AXIS DEVIATION), partial right bundle beach block (MaRRoW)
Echo - diagnostic without cardiac catheterisation

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16
Q

Management of ASD ? Aim ? What age ?

A

Surgical to prevent heard failure and arrythmias

3-5 best

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17
Q

What is the surgery for secundum ASD

A

Cardiac catheterisation with insertion of occlusive device

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18
Q

Surgical management of partial AVSD

A

Open surgical correction required

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19
Q

What 2 factors alter the prognosis of VSD

A

Size of defect and its position in septum

Development of changes due to L->R shunting

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20
Q

What changes occur in eisenmenger syndrome?

A

Increased blood to lungs -> arteries become stuff and narrow -> pressure becomes so great the shunt reverses. R->L
DANGEROUS

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21
Q

Symptoms of small

A

Asymtomatic

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22
Q

Signs of small VSD

A

Pan systolic murmur (sometimes palpable thrill) at the lower left sternal edge

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23
Q

Investigations for small VSD

A

CXR and ECG - normal

Echo - can demonstrate haemodynamic effects using Doppler echocardiography

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24
Q

Treatment of small VSD

A

Most close spontaneously - followed with ECG and murmur

While VSD present - endocarditis prophylaxis before dental extractions and gold dental hygiene

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25
How big are large VSDs
Same size or bigger than aortic valve
26
Symptoms of large VSDs
Heart failure and failure to thrive after 1 week old | Recurrent chest infections
27
Signs of large VSDs
Acute precordium Harsh pan systolic murmur loudest in 3rd/4th IC space (may be soft or absent if v big) Loud pulmonary s2 (due to increased pulmonary arterial diastolic pressure) Tachycardia, tachypneaand hepatomegally from heart failure
28
Investigations for large VSDs and what's seen
CXR - cardiomegally, enlarged pulmonary markings and arteries, pulmonary oedema ECG - biventricular hyper trophy by 2/12, pulmonary hypertension (tall T waves in V1) Echo - demonstrates anatomy and can elicit haemodynamic effects and pulmonary HTN severity
29
Management of large VSD
Initial - management for heart failure and pulmonary hypertension. Followed by surgery in cardiopulmonary bypass
30
What is done in infants with large VSD ? Why?
Pulmonary artery banding (band around PA to reduce flow / pressure) Allows respite until child has grown enough to withstand definitive correction
31
When is a PDA physiological
Preterm infants
32
Where does the ductus come from ? What does it do!
Demand of 6 aortic arch. | Joins pulmonary artery and aorta (just after origin of left subclavian )
33
When does the PDA usually close
In first week of life
34
Clinical features of PDA
Continuous murmur beneath left clavicle Increased pulse pressure (bounding pulse ) + symtoms if duct is large (heart failure and breathlessness)
35
Investigations for PDA
CXR / ECG - usually normal | Echo - with Doppler
36
Management of PDA
High risk of bacterial endocarditis if left patent -> prostaglandin inhibitors (eg ibuprofen) in premature babies. Surgery - if large at 1-3/12 if small at 1 year (in cardiac catheter lab)
37
Surgical methods in PDA
Division | Ligation or transvenous umbrella occlusion
38
Types of pulmonary stenosis
Valvular (90%), subvalvular (infundibular) or supra valvular
39
Which type of pulmonary stenosis occurs in tetralogy of fallot
Infundibular (with large VSD)
40
Symtoms of pulmonary stenosis
Most are asymtomatic
41
Signs of pulmonary stenosis
Ejection systolic murmur best heard at UPPER LEFT STERNAL EDGE (+thrill) accompanied by 'ejection click' in same area. Widely spit s2 with a soft or absent p2
42
Investigations for pulmonary stenosis
CXR - normal (may have post stenotic dilatation) | ECG - evidence of R ventricular hyper trophy (UPRIGHT T WAVE IN V1)
43
Treatment of pulmonary stenosis
Trans catheter balloon dilatation
44
Types of coarctation ? Which is worse? Who gets more
``` Pre ductal (sick child) - interruption of aortic arch post ductal (asymtomatic ) Males 2x more ```
45
Features of pre ductal coarctation
Sick neonate with absent femoral pulses. | While ductus arteriosus is open the RV maintains cardiac output but after it closes -> HEART FAILURE
46
Treatment of pre ductal coarctation
Prostaglandin infusion to maintain ductal patency then transfer to cardiac surgery
47
Symtoms of post ductal coarctation
Usually asymtomatic - may get leg pains or headaches
48
Signs of post ductal coarctation
Hypertension in the right arm, radio femoral delay / absent femoral pulses Opening click over aortic area (due to associated bicuspid aortic valve) Sometimes ejection systolic murmur audible at L INTERSCAPULAR AREA
49
Investigations for post ductal coarctation
CXR - rib notching (due to development of large collaterals intercostal arteries running under ribs posteriorly (teens and adults)) - 3 sign (visible notch in descending aorta at site of coarctation) ECG - LVH -> inverted T in v6, deep S in v2 and tall R in v6
50
Treatment of post ductal coarctation
Stenting by cardiac catheterisation | Surgical repair in severe cases
51
What needs to be determined in cyanosis
If it is peripheral (any cause eg sick, cold) | Or CENTRAL blueness of tongue and buccal mucosa which is associated with decrease in arterial oxygen tension
52
How do you clinically detect central cyanosis
Only possible if conc is >5g/dl (therefore less pronounced if child is anaemic)
53
Differentials for newborn with respiratory distress
Cardiac disorders - cyanotic CHDs Respiratory disorders - surfactant deficiency, meconium aspiration, pulmonary hypoplasia ...) Persistent pulmonary hypertension of the newborn (PPHN) Infection - septicaemia, group b strep... Polycythaemia
54
Give the two main mechanisms for cyanosis in CHD
1- decreased pulmonary blood flow with shunting of deoxygenated blood from R->L (eg tetralogy of fallot) 2- abnormal mixing of systemic and pulmonary venous return usually associated with an increased pulmonary flow (eg transposition of the great arteries)
55
Diagnosis of CHD without echocardiography
Hyperoxia (nitrogen washout) test (Measure arterial blood gas on air - then on 100% O2 -> if lungs are healthy then will be no effect on ABG (R->L shunt likely) If increased due to lung problem as O2 augments lungs ability)
56
What is the most common cause of cyanotic CHD
Tetralogy of fallot
57
What are the 4 features of tetralogy of fallot
Large VSD Right ventricular outflow obstruction (50%infundibular stenosis,10%pulmonary valve stenosis, 30% both) Aorta overriding ventricular septum Right ventricular hyper trophy
58
Presentation of tetralogy of fallot
Cyanosis in first 1-2/12 | Hyper cyanotic spells (due to infundibular spasm) and squatting on exercise
59
Physical signs of tetralogy of fallot
Cyanosis with /out clubbing Loud and single s2 (A2 without p2) Loud EJECTION SYSTOLIC MURMUR loudest at 3rd L ICS)
60
Tetralogy investigations and results (3 on X-ray)
CXR - usually normal. If child is older small heart (possibly with uptilted apex 'boat sloped) due to RVH. Pulmonary artery 'bay' - con cavity on L heart border where convex shaped main pulm artery and RV outflow are normally profiled. Oligaemic blood flow (decreased pulm vascular markings. ECG - Normal at birth. Then RVH & RIGHT AXIS DEVIATION (upright T wave in v1 and pure R wave (no S wave) )
61
Tetralogy hyper cyanotic spells management and reasons
Morphine - relieves pain and abolishes hyperpnea Sodium bicarbonate IV - correct acidosis Propranolol - cause peripheral vasoconstriction and relieve infundibular spasm
62
When is surgical treatment for tetralogy done ? What is done
BT SHUNT - between subclavian and pulm arteries (increased pulm blood flow Patch closure of VSD and widening of R ventricular outflow tract
63
Who gets more TGA (transposition of great arteries)
Males 3x
64
What happens in a complete 'D' transposition? | What coexists
Aorta arises anteriorly from RV Pulm artery arises posteriorly from LV Defects that allow mixing of 2 circulations (ASD VSD PDA)
65
Features of TGA ? What is it unresponsive to ?
Severe cyanosis - often in first 1-2days of life - usually when ductus closes which decreases mixing of systemic and pulm circulation - arterial hypoxaemia often profound (1-3kPa PaO2) & unresponsive to O2 inhalation
66
Physical signs of TGA
Cyanosis always Clubbing (if child presents after 1year) Second heart sound is single and loud ( may be a murmur of VSD or PDA if septum is not intact)
67
Investigations for TGA and results
CXR - classically narrow upper mediastinum with an 'egg on side' appearance of cardiac show (due to anterior posterior relationship of great vessels and the hypertrophic RV ECG - usually normal
68
What is given to sick cyanosed newborn with TGA
Prostaglandin E1 (PGE1) infusion to reopen ductus arteriosus
69
Management of TGA ? | How is a definitive repair completed
Pge1 infusion Emergency cardiac catheterisation and therapeutic balloon atrial septosomy (rashkind procedure) Repair with an arterial switch procedure in first few weeks of life
70
What is a septosomy
a small hole is created between the atria
71
What's often heard during febrile illness / anaemia and why
Innocent murmurs due to increased cardiac output
72
Hallmarks of innocent murmurs
Asymtomatic No parasternal thrill / radiation No diastolic component Localised to L sternal edge
73
2 egs of innocent murmurs
Soft blowing systolic - firm right pulmonary outflow in the 2nd L ICS ) Short buzzing murmur - from L side of heart due to aortic blood blow I'm 4th L ICS )
74
What is rheumatic fever
Sequela of group A B haemolytic strep infection (usually tonsilopharyngitis) caused by abnormal immune response in 1%
75
Leading cause of valvular disease
Rheumatic fever
76
When after infection does rheumatic fever develop
2-6/52
77
What are the features of rheumatic fever
``` Polyarthriris, fever and malaise Pan carditis (30%) ```
78
What is the arthritis like in rheumatic fever
Fleeting lasting 1-52 in individual joints and commonly affects large eg knees and ankles
79
What are the types of pancarditis in rheumatic fever
Pericarditis (friction rub and pericardial effusion) -> endocarditis which commonly affects L sided valves leading to murmurs eg. Mitral incompetence Myocarditis - can lead to heart failure
80
What is a rare later effect of rheumatic fever
Sydenham's chorea | 6/12 later with emotional liability and chorea
81
How is the diagnosis of rheumatic fever made
Duckett-Jones criteria (2 major or 1M and 2m)
82
Treatment for rheumatic fever? | Acute? Severe? recurrent ?
Acute - bed rest and aspirin to relieve fever and arthritis Steroids for sever carditis Diuretics and ACEi for heart failure Recurrent - prophylactic penicillin
83
When should children get prophylactic Abx
All with CHD (bar secundum ASD ) before any dental procedure / surgical treatment
84
When should you always ?endocarditis
Child with fever and significant heart murmur
85
Features of endocarditis
Bacteraemia (fever, malaise) Valvulitis (HF, murmurs) Immunological changes (gomerulonephritis) Embolic changes (CNS abscess, sprinter haemorrhages )
86
Most common cause of endocarditis
Streptococcus viridans
87
Diagnosis of endocarditis
Blood cultures | Cross sectional Echo
88
Treatment of endocarditis
4-6 weeks high dose IV Abx +/- surgical removal of infected prostheses
89
Acute vs chronic features of myocarditis
Acute - cv collapse | Chronic - gradual onset congestive cardiac failure
90
Myocarditis treatment
Supportive - most recover but some have dilated cardiomyopathy
91
Infections associated with myocarditis
Coxsackie, rubella,
92
Normal arrythmia in children ? Why?
Sinus arrythmia - detectable change in HR with respiration (increase during inspiration and decrease during expiration)
93
What is the most common peadiatric arrythmia ? What is it ?
Supraventricular tachycardia - HR of 250-300
94
Features of supraventricular tachycardia
Most asymtomatic but some develop cardiac failure (and present with decreased feeding, sweating, irritability, sob) Older children may describe palpitations
95
Diagnosis of supraventricular tachycardia
ECG shows narrow complex tachycardia with some p waves discernible after QRS due to retrograde action of atria via accessory pathway When in sinus rhythm - decreased PR interval
96
What's seen in wolf Parkinson white ECG
D wave and decreased PR interval
97
Treatment for supraventricular tachycardia
Vagal stimulation - cold water to face, carotid sinus massage, valsalva manoeuvre IV ADENOSINE (if fails -> DC cardioversion (shock them) )

Peadiatrics (14 decks)

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