Paediatrics: Cardio

Question 1

What are the features of a large VSD?

Answer 1

Heart failure presents with increased dyspnoea and FTT past 1 yo
Increased RR/HR
Hepato-splenomegaly

Soft pansystolic murmur at Lower L sternal edge (4th ICS)
Mid diastolic murmur heard at apex
Loud P2

Question 2

What investigative findings would you have for a large VSD?

How would you treat it?

Answer 2

1. CXR showing HF
   - Alveolar oedema
   - Kerley B lines
   - Cardiomegaly
   - Dilated upper lobe vessels
   - Pleural effusion if severe
2. Echo
   - biventricular (R and L) hypertrophy
   - VSD

Treatment
1. Diuretics and Captopril (ACEi)

Question 3

What are the features of a small VSD and what is the treatment?

Answer 3

Symptomless
Loud pan systolic murmur at Lower L sternal edge (4th ICS)
Quiet P2

Tx:
Often self-limiting - will close by next follow up
Maintain dental health to avoid infective endocarditis

Question 4

What are the features of an ASD?

Answer 4

Symptom free
May have recurrent chest infections and wheeze
May develop arrhythmia in 4th decade

Ejection systolic murmur heard at upper L sternal edge (2nd ICS)
Fixed or Widely split S2

NB: fixed is a widened S2 (A2 and P2 heard separately); widely split is a widened S2 which becomes wider during inspiration

Question 5

What are the causes of an widely split and fixed split S2?

Answer 5

Wide - conduction delay e.g. RBB, pulmonary stenosis

Fixed - ASD, RHF, Pul HTN

Question 6

What is the treatment for ASD?

Answer 6

Secundum (ASD is in middle of atria at foramen ovale i.e. osteum secondum)
- Cardiac catheter and occlusive device

Partial
- Surgical correction

Question 7

What are the features of a patient with a patent ductus arteriosus?

Answer 7

A/W premature babies due to failure of closure of ductus arteriosus 1 month after birth - blood from descending aorta mixes into pul.A (due to lower pressure in pul circulation)

Machine hum murmur heard over L clavicle
Collapsing or bound pulse
Often asymptomatic but if severe can have HF + pul HTN

Question 8

What is the treatment of PDA?

Answer 8

Should close within 1 year
if not - surgery with coil or occlusion
Paracetamol and Ibuprofen can oppose effect of prostin

Question 9

What is a the common complication of all untreated Left to Right shunts?

Answer 9

Eisenmeger’s syndrome

• ASD, VSD and PDA all cause a left to right shunt due to lower pulmonary pressure
• eventually the pulmonary pressure increases causing a right to left shunt
• This causes cyanosis (teens) and death from RHF (4/5th decade)

Question 10

What are the features and treatment of a patient with transposition of the great arteries?

Answer 10

Presents soon after birth - Pulmonary artery linked to Left ventricle and aorta linked to Right ventricle

Congenital cyanosis and hypoxia

• patient survives with patency of DA
• cyanosis worsens when duct closes, which is 2d after birth

Treatment

• Prostin - maintains patency of DA
• Arteries transected and switched

Question 11

What is the tetraology of Fallot?

Answer 11

RV hypertrophy
Subpulmonary artery stenosis
Ventricular septal defect (VSD)
Over-riding/arching aorta

Question 12

How does tetralogy of Fallot present?

Answer 12

Cyanosis - can become progressively worse in neonate
Cyanotic attacks - sudden, without warning periods of dyspnoea, pallor, irritability and loss of consciousness

Loud, harsh ejection systolic murmur at upper left sternal edge
Right ventricular heave
Clubbing

Question 13

What CXR findings may you find with transposition of great arteries?

Answer 13

Egg shaped heart

Question 14

What are the CXR findings of tetralogy of Fallot?

Answer 14

Small, “boot’ shaped heart

Question 15

What is the treatment of tetralogy of Fallot?

Answer 15

if not relieved by 6 months

• close VSD
• relieve RV outflow obstruction

Acute if cyanotic attack lasts > 15 mins

• BBs (IV propanolol)
• Morphine and oxygen
• IV fluid
• Bicarbonate to correct acidosis

Question 16

What are the features of AVSD?

Answer 16

1. Birth - 1/2 weeks
   No murmur
   Cyanotic at birth
   HF over 1-2 wks - dyspnoea, pallor etc.
2. Congestive cardiac failure - 1-2months
   Dyspnoea and increased WoB (nasal flaring)
   Cyanosis
   Sweating
   Tiring easily
   FTT and slow growth with weight loss

Question 17

How is AVSD managed?

Answer 17

1. Treat HF
   - Diuretics and ACEi (captopril)
2. Surgery at 3-6 months
   - closed septal defect

Question 18

What are the features of aortic coarctation?

Answer 18

This is a duct dependent lesion. When ductus arteriosus closes at 2d the aorta constricts causing:

• Severe HF - dyspnoea, increased WoB, resp distress
• Absent or weak femoral pulses
• Metabolic alkalosis and renal failure
• May also hear systolic mumur

Question 19

What does the CXR show of aortic coarctation?

Answer 19

Cardiomegaly

Question 20

what is the treatment for aortic coarctation?

Answer 20

Prostin to maintain DA until surgery

Surgery immediately after diagnosis

Question 21

Name the 3 common innocent murmurs.

Answer 21

Venous hum murmur
Pulmonary flow murmur
Vibratory murmur (most common)

Question 22

What are the features of a venous hum murmur?

Answer 22

Symptomless
Continuous blowing noise heard over L clavicle
- relieved when lying down
- changes with respiration

Question 23

What are the features of a pulmonary flow murmur?

Answer 23

Symptomless
Soft ejection systolic murmur heard at 2nd ICS L
- increases with fever, anaemia or exercise

Question 24

What are the features of a vibratory murmur?

Answer 24

Most common innocent murmur  
Buzzing at apex with loud parasternal ejection murmur 
- heard best at L mid-sternal border
- varies with posture 
- loudest when supine