Paediatrics: Cardiology Flashcards
(150 cards)
1
Q
Fetal Circulation: Where does gas exchange occur?
A
placenta
2
Q
Fetal circulation: what gets exchanged at the placenta?
A
- Collect oxygen + nutrients
- Dispose of waste products (CO2 + lactate)
3
Q
How many shunts are there in the Fetal circulation ? name them?
A
3
- Ductus venosus
- Foramen ovale
- Ductus arteriosus
4
Q
Why does blood not go to fetal lungs?
A
Fetal lungs not developed or functional so shunts allow blood to bypass lungs
5
Q
From where to where does ductus venous shunt? what does it bypass?
A
Umbilical vein => Ductus venosus => Inferior vena cava
- Bypass the liver
6
Q
If there was no ductus venosus, then where would blood flow?
A
Umbilical vein => portal vein => liver => hepatic vein => inferior vena cava
7
Q
From where to where does foramen ovale shunt? what does it bypass?
A
Right atrium => foramen ovale => left atrium
- Bypass RV + pulmonary circulation
8
Q
From where to where does ductus arteriosus shunt? what does it bypass?
A
Pulmonary artery => ductus arteriosus => aorta
- Bypass pulmonary circulation
9
Q
Fetal circulation: what different ways can blood get from RA to aorta?
A
- RA => foramen ovale => LA => LV => aorta
- RA => RV => pulmonary artery => ductus arteriosus => aorta
10
Q
At birth describe what happens to foramen ovale? explain
what does it become?
A
fist breath expands alveoli in lungs => decrease vascular resistance => decrease pressure in RA => LA pressure > RA pressure => closure of foramen ovale (eventually => fossa ovalis)
11
Q
What is required to keep ductus arteriosus open? be specific
A
prostaglandins (E1)
12
Q
At birth describe what happens to ductus arteriosus? explain
What does it become?
A
At birth: increased blood oxygenation => decreased prostaglandin conc => closure of ductus arteriosus (=> ligament arteriosum)
13
Q
What are congenital heart defects?
A
Group of structural abnormalities of the heart the are present at birth
14
Q
What physiology would cause a cyanotic CHD? briefly
A
L => R shunt
15
Q
Give examples of Cyanotic CHD (3)
A
- Tetralogy of fallot
- Transposition of the great arteries
- Tricuspid atresia
16
Q
give the 2 categories of cyanotic CHD?
A
- Shunt lesions
- obstructive lesion
17
Q
Give examples of shunt lesions? are these cyanotic or not? (3)
A
VSD, ASD, Patent ductus arteriosus
asyanotc but can beomce cyanotic (Eisenmenger syndrome)
18
Q
how to obstructive CHD affect the heart?
A
narrowing/blockage in heart => increase pressure load => hypertrophy
19
Q
what are innocent murmurs also known as, are they common?
A
innocent/flow murmurs are common in children
20
Q
what physiology causes an innocent murmur
A
caused by fast blood flow through hear in systole
21
Q
What are the typical features of an innocent murmur?
A
SSSSSSSSS
- Soft
- Short
- Systolic
- Symptomless
- Situation dependant
22
Q
When would you want to investigate a murmur in a child? what signs?
A
- Loud murmur
- diastolic
- louder on standing
- Other symptoms (failure to thrive, feeding difficulty, cyanosis, sob)
23
Q
Describe a pan systolic murmur?
A
continue throughout the whole systolic contraction of the heart
24
Q
What can cause a pnasystolic murmur? (3)
A
- Mitral regurgitation
- Tricuspid regurgitation
- VSD
25
What can cause an ejection systolic murmur? (4)
- Aortic stenosis
- Pulmonary stenosis
- ASD
(- tetralogy of Fallot (due to pulmonary stenosis))
26
What causes splitting of the second heart sound? During which bit of respiration is it normally heard?
Splitting of the second heart sound: normal sound heard on inspiration caused by the negative intrathoracic pressure (generated when chest wall + diaphragm pull lungs open)
- normal on inspiration
27
What pathology could cause a fixed split second heart sound? describe the murmur associated with this
ASD: ejection systolic, crescendo-descrendo murmur, loudest at the upper left sternal border, with fixed split second heart sound (on inspiration + expiration)
28
what heart murmur would teroatlofy of fallot present with? what is this due to?
murmur due to pulmonary stenosis => ejection systolic murmur
29
What is tetralogy of Fallot?
Congenital cardiac condition with 4 co-existing pathologies
30
what are the 4 pathologies in ToF?
- VSD
- overriding aorta
- Pulmonary stenosis
- Right ventricular hypertrophy
Think of the cowboy riding the aorta, squeezing the pulmonary artery in the boot shaped heart.
31
Describe the pathophysiology of ToF? of each pathology
VSD allos blod to flow through ventricles
- Overriding aorta means ta entrance to aorta (aortic valve) is placed further ro the right than normal => when RV contracts => more (more deoxy blood sent through aorta)
- Stenosis of pulmonary valve => greater resistance against flow of blood form RV => more blood through VSD into aorta => R to L shunt => cyanosis
- Increased strain on RV + pulmonary stenosis => RV hypertrophy
32
ToF RF? (4)
- Rubella infection
- Increased maternal age
- Maternal alcohol use
- trisomy 21
33
ToF presentation?
- Mostly picked up antenately, or ejection systolic murmur at NIPE
- cyanosis, clubbing, poor feeding, poor weight gain
- tet spells
34
What are Tet spells?
intermittent spells wehre R => L shunt temporarily worsens => cyanotic episode
35
What causes tet spells ? (physiology)
Due to increase in pulmonary vas resistance or decrease in systemic resistance
36
Features of tet spells? (3)
- Rapid, deep respiration
- Irritability
- Increasing cyanosis
37
Management of ToF? medical and surgical?
medical: squatting, prostaglandin infusion, BB, morphine
- Surgical (definitive): total surgical repair by open heart surgery
38
what is the common CXR finding of ToF
boot shaped heart
39
What is PDA?
Patent Ductus Arteriosus
- Failure of closure of the ductus arteriosus
40
when does normal functional and structural closure of ductus arteriosus occur?
Functional: 1-3 days
Structural: 2-3 weeks
41
PDA RF? (2)
- Prematurity
- Maternal rubella
42
what kind of shunt in PDA? describe the pressures briefly ?
L => R shunt
- Pressure in aorta > pressure in pulmonary vessels
43
what does the shunt in PDA cause? describe the steps
L to R shunt => increased blood flow through pulmonary circulation => pulmonary hypertension + R sided heart strain => R sided hypertrophy => pulmonary pressure greater than systemic => eisenmengers syndrome => cyanosis
44
PDA presentation in infants?
- SOB
- difficulty feeding
- Poor weight gain
- Recurrent LRTI
- murmur
45
What heard on auscultation of patient with PDA?
continuous crevscendo-descrencend machinery murmur during 2nd heart sound
46
when might PDA first be picked up?
murmur on newborn exam
47
what is the gold standard investigation of PDA?
transthoracic echo + doppler (to assess size and character of L=>R shunt)
48
describe the management of PDA?
- monitor up until 1 yr (unless severe)
- After 1 yr it is unlikely to close spontaneously so surgery: transcatheter, open heart surgery
49
What is an atrial septal defect?
When the septum between the R + L atria is not formed properly?
50
what is the most common CHD?
VSD
(ASD is second)
51
describe what forms and makes up the atrial septum? ahem the layers?
2 walls grow downward to fuse with endocardial tissue to separate atria
- septum primum + septum secondum
52
what makes up the foramen ovale?
small space formed between septum primum + secondum
53
what kind of shunt does ASD cause ? cyanotic ?
LA => RA shunt (a-cyanotic)
54
describe what the shunt in ASD can cause?
shunt LA to RA => R sided overload + R heart strain => pulmonary hypertension + RHF => Eisenmenger Syndrome (where pulmonary pressure is greater than systemic pressure) => shunt reverse (R=>L) => cyanosis
55
what are the 3 types of ASD?
- Ostium primum
- Ostium Secondum
- PFO (technically not ASD)
56
what is the most common type of ASD?
Ostium Secundum (I think)
57
Patient presents with DVT that develops a large stroke. What condition should be on your mind? why?
ASD
- DVT enters systemic circulation through shunt and goes to brain
58
What are some complications of ASD?
- Stroke
- AF
- Atrial flutter
- Pulmonary hypertension
- R sided HF
- Eisenmenger Syndrome
59
ASD RF?
- Maternal smoking (1st trimester)
- Maternal diabetes
- Maternal rubella
60
ASD presentation? childhood?
vast majority of ASD are asymptomatic
- SOB
- Difficulty feeding
- Poor weight gain
- Recurrent LRTI
61
ASD presentation? Adulthood?
- Stroke
- HF
- Dyspnoea
62
ASD gold standard investigation ?
transthoracic echo (gold standard)
63
management for small ASD?
Just keep watching it
64
what medical management might you have for ASD? why?
anticoags (aspirin, warfarin, NOACs) to reduce stroke risk
65
ASD definitive management?
surgical
- transvenous Catheter (via femoral vein) or open heart surgery
66
What is VSD?
congenital hold in the septum between the 2 ventricles
67
what is VSD often associated with?
underlying genetic condition (downs, turners)
68
what type of shunt in VSD?
L to R shunt (acyanotic)
69
what does the shunt in VSD lead to?
L to R shunt => R sided overload + RHF + increased flow to pulmonary vessels => pulmonary hypertension => R to L shunt (eisenmengers) => cyanosis
70
VSD RF?
- genetic: Downs, Turners
- GDM
- FAS
- VSD FHx
71
What does septal defect presentation depend on
the size of the defect
72
VSD most common presentation
asymptomatic
73
VSD presentation in babies?
- Poor feeding
- SOB
- failure to thrive
- Tachypnoea
74
What heart on auscultation of ASD?
Ejection systolic murmur
Heard loudest at the upper left-sternal edge
Widely fixed splitting of the second heart sound
75
what heard on auscultation of VSD?
pansystollic murmur hear at L lower sternal border
76
What can a pan-systolic murmur indicate? (3)
- VSD
- MItral regurg
- Tricuspid regurgitaiton
77
Gold standard investigation for VSD?
transthoracic Echo
78
what complications associated with VSD?
- Increased risk of IE
- Recurrent LRTI
- Arrhymias
- Growth failure
- Congestive HF
79
what medications might you consider in VSD?
- Prophylactic Abx (for IE risk)
- Dieretic to relieve pulmonary congestion
80
When does Eisenmenger Syndrome occure
When blood can flow from R side of heart to L across structural heart lesion
- R=>L shunt means blood bypasses lungs what
81
3 underlying lesion can cause Eisenmenger Syndrome ?
- ASD
- VSD
- PDA
82
when does Eisenmenger Syndrome develop ?
can develop after 1-2 years with large shunts + adulthood with small
83
what condition makes Eisenmenger develop more quickly?
pregnancy so need echo check ups
84
what is cyanosis and what is this due to?
blue discolouration of the skin due to low level oxy sats
85
Eisenmenger Syndrome: what is the body's response to chronic low oxy sats? what does this cause?
Increased RBC + haemoglobin production => polycythaemia => high blood viscosity => more prone to blood clots
86
what are some signs of pulmonary hypertension on examination?
- R ventricular heave
- Raised JVP
- Peripheral oedema
87
What are some of the signs you might see related to chronic hypoxia on examination?
- Cyanosis
- Clubbing
- Dyspnoea
- Plethoric completion (red complexion related to polycythaemia)
88
Pansystolic murmur: what CHD?
VSD
89
Mid systolic crescendo-descrecendo fixed split heart sound: what CHD?
ASD
90
Contiunous crescendo-descrendo machiar murmurou during 2nd heart sound: what CHD?
PDA
91
How does eisenmengers affect life expectancy ?
reduces life expectancy by 20 yrs
92
Eisengmengers management ?
heart lung transplant
Prostaglandins?
Oxygen?
93
What is coarctation of the aorta? usually located where?
It is a congenital condition where there is narrowing of the aortic arch (usually located around the ductus arteriosus)
94
what genetic condition is coarctation of the aorta often associated with?
Turners syndrome
95
Pathophysioloyf of coarctation of the aorta?
narrowing of aorta => decreased pressure of blood flowing to arteries distal to narrowing + increased pressure to those proximal (heart _ usually fist 3 branches of aorta
96
Presentation of coarctation of the aorta?
- Weak femoral pulses
- tachypnoea
- Increased work of breathing
- Poor feeding
- Grey floppy baby
97
what might you find on examination of baby with coarctation of the aorta ?
4 limb blood pressure (increased BP in limbs proximal to narrowing + decreased BP distally)
98
management of coarctation of aorta?
May live symptom free till adulthood
- If severe emergency surgery
- Prostaglandin
99
why use prostaglandin in critical management of coarctation of aorta?
Prostaglandin E keeps ductus arteriosus open while waits for surgery (allows bleed flow through DA into systemic circulation distal to coarctation)
100
What is Congenital Aortic calve stenosis? why bad?
Patients born with a narrow aortic valve => restrict blood flow from LV to aorta
101
how many leaflets usually in the aortic valve?
3
102
what are the leaflets of the aortic valve also known as?
aortic sinuses of valsalva
103
how many leaflets might the aortic valves of patients with congenital aortic valve stenosis have?
1,2,3 or 4 (compared to the normal 3)
104
how does congenital aortic valve stenosis usually present?
asymptomatic (discovered as incidental murmur on routine checkup)if
105
symptomatic, how would congenital aortic stenosis present?
- fatigue
- SOB
- dizziness
- Fainting
(all worse on exertion)
106
describe the murmur associated with congenital aortic stenosis ? hear loudest where?
ejection systolic murmur heard loudest at aortic area
- crescendo-descrenscdo character that radiates to the carotids
107
where is the aortic area (anatomical) ?
2nd ICS R sternal border
108
109
Congenital aortic stenosis complications:
- LV outflow tract obstruction
- HF
- Ventricular arrhythmias
- Sudden death on exertion
110
how may leaflets are there usually in the pulmonary valve?
3
111
what causes pulmonary valve stenosis?
when the 3 leaflets of the pulmonary calve develop abnormally => thicken or fuse
112
pulmonary valve stenosis causes a narrowing from where to where
between RV + pulmonary arteries
113
what condition is pulmonary valve stenosis associated with?
TOF
114
describe the murmur associated with pulmonary valve stenosis ?
ejection systolic murmur heard loudest in pulmonary areaw
115
here is the pulmonary area (anatomical)
2nd ICS L sternal border
116
What is ebsteins anomaly ?
congenital heart condition where the tricuspid valve is set lower in R heart (towards apex)
117
how does Ebstein's affect RA + RV ?
bigger RA
smaller RV
( because lower tricuspid valve)
118
what septal defect is Ebstein's anomaly associated with?
ASD
119
What is transposition of the Great Arteries ?
It is where the attachments of the aorta + pulmonary trunk swap (transpose)
120
in Transposition of the great arteries where to RV and LV pump blood to?
- RV pump blood to aorta
- LV pump blood to pulmonary vessels
121
why is transposition of the great arteries life threatening?
there is no connection between systems circulation + pulmonary circulation => baby will be cyanosed
122
what does immediate survival in transposition of the great arteries depend on?
depends on a shunt (PDA, ASD, VSD)
- allows mixing of oxy + deoxy blood
123
egg on string appearance seen on CXR. what condition is this?
transposition of the great arteries
124
what is the most common septal defect found in those with Down syndrome ?
AVSD
125
what CHD is most commonly associated with turners syndrome?
- Coarctation of the aorta
- Bicuspid aortic valve
126
where is an asd best heard?
This murmur is heard in the second intercostal space at the upper left sternal border (pulmonary area)
(same as AVSD)
127
In transposition of the great arteries, what is the acid-base status commonly found in these patients that requires correction? explain
Metabolic acidosis
- Distal organs have a low oxygen supply and thus respire anaerobically producing lactate
128
What is Infective endocarditis ?
it is infection of the endothelium (inner surface) of the heart
- Mostly effects the heart valves
129
what are the 3 things in the IE triad ? (things required for IE to happen)
- Endothelial damage
- Platelet adhesion
- Microbial adhesion
130
which bit of IE triad do CHDs increase the risk of?
structural abnormalities of heart or great vessels => endo damage by sheer stress forces
131
IE RF?
Mostly seen in patients with hx of congenital or acquired cardiac disease
- IVDU (quite low is this population group but higher in adults)
132
2 most common causative organisms for IE?
- Staphylococcus aureus
- Streptococcus viridans
133
IE presentation ?
(non-specific)
- Low-grade fever
- malaise
- Fatigue
134
what would be seen on examination for patient with IE?
- New or changing heart murmur
- Splinter haemorrhages, janeway lesions, oslers nodes, roth spots, finger clubbing, petechiae
135
what investigations for IE?
- Blood cultures (before Abx)
- Echo (TOE (transoesophageal))
136
what would be seen on echo of IE
echo (TOE)
- identify vegetations
137
what score can confirm IE diagnosis?
Modified duke criteria: Has major and minor criteria
138
IE management ?
- IV broad spectrum Abx (amoxicillin or ceftrioxone)
- Surgery: if HF, or large vegetations, or not responding to Abx
139
What is Acute rheumatic fever? associated with what other illness?
It is an autoimmune illness that occurs after pharyngitis in some people due to cross reactivity to streptococcus bacteria
140
which system does rheumatic fever affect?
Multi system disorder
- affects joints, heart, skin, nervous system
141
which bacteria involved in rheumatic fever? what type of bacteria is this?
group A beta-haemolytic strep (e.g. strep pyogenes)
142
rheumatic fever pathophysiology ? describe it
type to hypersensitivity reaction
- caused by antibodies created against strep bacteria that also target tissues in body
143
how long after initial infection will symptoms of rheumatic fever present?
2-4 weeks following strep infection (e.g. tonsillitis)
144
describe the symptoms rheumatic fever can present with 9think systems)
- Fever
- Joint: arthritis
- heart: pericarditis/myocarditis/endocarditis
- Skin: sub cutaneous nodules, erythema marginatum
- HS: chorea
145
describe the arthritis associated with rheumatic fever?
migratory arthritis affecting the large joints
146
what is used to determine a rheumatic fever diagnosis?
Jones criteria (has major - minor criteria)
147
what investigations would you do for rheumatic fever?
- throat swab for bacterial culture
- ASO antibody titres
- Echo, ECG, CXR (for heart involvement)
148
rheumatic fever management ?
- the tonsillitis caused by streptococcus should be treated with phenoxymethyl penicillin
- Clinical features of RF: NSAIDs (joint pain), aspirin and steroids (carditis), prophylactic Abx
149
rheumatic fever complications (3)
- Recurrence of RF
- Valvular heart disease (mitral stenosis)
- Chronic HF
150
