Why might VSD and patent ductus arteriosus only become clinically apparent (murmur + signs) several weeks later post birth?
decreasing pulmonary vascular resistance
what is important to advise a parent who has a clinically well child with a VSD and normal ECG?
VSD usually closes spontaneously
regular followup and monitoring of murmur is needed
good dental hygiene is paramount due to increased risk of bacterial endocarditis
what happens if we leave a L-R shunt congenital heart defect untreated?
development of right sided heart failure, also known as eisenmenger syndrome
tell me the characteristics of an ASD murmur?
ejection systolic murmur usually heard left sternal edge
fixed widely split 2nd heart sound
sometimes may be pansystolic if partial ASD
what cause of heart failure usually presents in the first week of life?
coarctation of the aorta
(severe obstructive lesion_
what type of murmur is VSD?
pansystolic or no murmur if very large
Aortic stenosis and regurgitation
what is the most common form of ASD? What is the other form of ASD
Secundum ASD most common- hole between atria in the centre of the atrial septum, involving the foramen ovale
other form of ASD is known as partial AVSD where the hole between the atria as at the BOTTOM of the atrial septum, often involving abnormal atrioventricular leaflets
where exactly is the ductus arteriosus in the fetal heart?
between the pulmonary artery and the aorta
bicuspid aortic valve
what are the two types of VSD?
small and large VSD
innocent murmur and S3
why might you get pulmonary valve regurgitation post TOF surgery?
often occurs because the surgery shaves off a bit of the hypertrophied valve, and overtime the PV can become incompetent and leak. requires replacement usually
when does the ductus arteriosus normally close in a newborn?
within hours to 1 day
what are some clinical signs of heart failure to look for on cardiovascular examination in an infant?
central cyanosis and at the end of exam during crying
signs of respiratory distress
feel for right ventricular hypertrophy
listen for any pathological murmurs, loud s2
is the baby clammy?
palpate brachial artery and assess volume
failure to thrive
what are some clinical features of heart failure in a young to older child on CV examination?
SOBOE- so assess exercise tolerance
Assess growth using centiles
look for peripheral oedema/periorbital oedema
look for signs of cyanosis
is the child squatting?- may indicate TOF
what is the most common type of innocent murmur?
still's vibratory murmur
typically heard between 2-6 years age
early to mid systolic
loudest at left lower sternal edge
what are the ddx for pulmonary flow innocent mumur?
what murmur is typically seen ONLY in an infant?
branch pulmonary stenosis
tell me about a venous hum
low pitch continuous murmur
caused by turbulence in the SVC junction
what manouevers could we do to see whether a murmur is innocent?
Innocent murmur dynamics usually involve:
variation with respiration--> increase with inspiration
variation with posture--> audible when lying down and disappears with standing up
so get the child to breathe in and out while listening, and repeat auscultation with the child standing up
when should you be worried about a murmur enough to refer to a cardiologist
subjective intensity greater than 3
Upper sternal border location
child less than 1 yrs + symptomatic/clinical judgement
most common cause of cyanosis AT BIRTH?
transposition of the great arteries
what cardiac structural change is associated with large VSD?
volume loading of the LEFT HEART--> left ventricle dilation
why would ace inhibitors be of any use to a child with VSD?
VSDs become haemodynamically apparent when pulmonary vascular disease occurs
Ace inhibitors reduce the systemic vascular system and this matches the pulmonary vascular system --> so short term management only
what are some medical short term options for large VSD?
diuretics like spironolactone and Lasix
what structural change of the heart is associated with ASD?
volume loading of the right heart (right ventricular dilation)
what is the key clinical implication of weak femoral pulses?
coarctation of the aorta
which gender is more predisposed to transposition of the great arteries?
what are the options for management of PDA (pulmonary ductus arteriosus)
Indomethacin for preterm
Surgery for symptomatic infant
Transcatheter closure for other child
where best on the praecordium can we hear VSD murmurs?
left lower sternal edge
where best on the praecordium can we hear a ASD murmur?
left upper sternal edge
how does inspiration/expiration change the second heart sound?
with inspiration= splitting of S2
with expiration= split narrows and becomes harder to hear
what causes the widely 'fixed' split S2 typical of ASD murmurs?
normally, S2 is split during inspiration as increasd systemic venous return overloads the right ventricle, thus delaying the closure of the pulmonary valve. In ASD, there is a left to right shunt. This means that the right ventricle is always overloaded regardless of respiration and thus the pulmonary valve has a delayed closure every time--> fixed wide S2 split heart sound
Generally pathological murmurs do not change in intensity when the child stands up. Which pathological murmur does NOT follow this rule? Why is this?
hypertrophic cardiomyopathy. Murmur increases as the child stands up.
Venous return decreases as the child stands up, leading to reduced left ventricular end diastolic volume. This narrows the left ventricular outflow tract (due to reduced blood volume) and consequently, systolic outflow obstruction increases --> increased intensity of murmur
where best on the praecordium may we hear the murmur of a PDA?
left upper sternal edge
how might we keep the pulmonary ductus arteriosus open?
with prostaglandins (E2) in the short term
what is this?
tetralogy of fallot
what might delay the presentation of coarctation of aorta?
may be delayed as the ductus remains open