Paeds cardio Flashcards
(37 cards)
What are the three shunts in foetal circulation?
- ductus venosus (bypass live Umbilical -> IVC)
- Foramen ovale : R-> L shunt
- Ductus arteriosus -> PA -> aorta (can keep open with prostaglandins)
What are innocent/ flow murmurs caused by?
Innocent murmurs are also known as flow murmurs. They are very common in children. They are caused by fast blood flow through various areas of the heart during systole.
What are the features of an innocent murmur?
Innocent murmurs have typical features, all beginning with S:
Soft
Short
Systolic
Symptomless
Situation dependent, particularly if the murmur gets quieter with standing or only appears when the child is unwell or feverish
No IX required in this case
What are the IX you can do in a child with a concerning murmur?
The key investigations to establish the cause of a murmur and rule out abnormalities in a child are:
ECG
Chest Xray
Echocardiography
What are your pansystolic murmurs and where can you hear them the loudest?
The differentials of a pan-systolic murmur and where they are heard loudest are:
Mitral regurgitation heard at the mitral area (fifth intercostal space, mid-clavicular line)
Tricuspid regurgitation heard at the tricuspid area (fifth intercostal space, left sternal border)
Ventricular septal defect heard at the left lower sternal border
What are your ejection systolic murmurs and where can you hear them the loudest ?
The differentials of an ejection-systolic murmur and where they are heard loudest are:
Aortic stenosis heard at the aortic area (second intercostal space, right sternal border)
Pulmonary stenosis heard at the pulmonary area (second intercostal space, left sternal border)
Hypertrophic obstructive cardiomyopathy heart at the fourth intercostal space on the left sternal border
How can you identify an atrial septal defecrt?
Well R->L shit
Atrial septal defects cause a mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border, with a fixed split second heart sound. Splitting of the second heart sound can be normal with inspiration, however a “fixed split” second heart sound means the split does not change with inspiration and expiration.
What murmur does a PDA make?
A small patent ductus arteriosus may not cause any abnormal heart sounds. More significant PDAs cause a normal first heart sound with a continuous crescendo-decrescendo “machinery” murmur that may continue during the second heart sound, making the second heart sound difficult to hear.
Murmur in tetralogy of fallot?
The murmur in tetralogy of Fallot arises from pulmonary stenosis, giving an ejection systolic murmur loudest at the pulmonary area (second intercostal space, left sternal border).
What is Eisenmengers syndrome?
This is because the pressure in the left side of the heart is much greater than the right side, and blood will flow from the area of high pressure to the area of low pressure. This prevents a right-to-left shunt. If the pulmonary pressure increases beyond the systemic pressure blood will start to flow from right-to-left across the defect, causing cyanosis. This is called Eisenmenger syndrome.
Why are ptx with heart defects not cyanotic?
Patients with a VSD, ASD or PDA are usually not cyanotic. This is because the pressure in the left side of the heart is much greater than the right side, and blood will flow from the area of high pressure to the area of low pressure. This prevents a right-to-left shunt.
Exception: Transposition of great arteries -> will always have cyanosis because RHS of heart alwats pumps directly into the Aorta !
Why is an unclosed PDA problematic?
The pressure in the aorta is higher than that in the pulmonary vessels, so blood flows from the aorta to the pulmonary artery. This creates a left to right shunt where blood from the left side of the heart crosses to the circulation from the right side. This increases the pressure in the pulmonary vessels causing pulmonary hypertension, leading to right sided heart strain as the right ventricle struggles to contract against the increased resistance. Pulmonary hypertension and right sided heart strain lead to right ventricular hypertrophy. The increased blood flowing through the pulmonary vessels and returning to the left side of the heart leads to left ventricular hypertrophy.
What is the presentation of someone with a patent PDA?
Shortness of breath
Difficulty feeding
Poor weight gain
Lower respiratory tract infections
Baso listen out for murmurs - machine like murmur
How would you diagnose and treat a PDA?
Echo to dx
After 1 year of age it is highly unlikely that the PDA will close spontaneously and trans-catheter or surgical closure can be performed. Symptomatic patient or those with evidence of heart failure as a result of PDA are treated earlier.
What happens in ASDs?
An atrial septal defect leads to a shunt, with blood moving between the two atria. Blood moves from the left atrium to the right atrium because the pressure in the left atrium is higher than the pressure in the right atrium
Shunt then reverses due to Pulmonary HTN -> Ptx becomes cyanotic -> Eisenmenger syndrome
Problems : RVH and LVH and cyanosis
What are the complications of an ASD?
- Stroke in the context of venous thromboembolism (Normally when patients have a DVT and this becomes an embolus, the clot travels to the right side of the heart, enters the lungs and becomes a pulmonary embolism. In patients with an ASD the clot is able to travel from the right atrium to the left atrium across the ASD. This means the clot can travel to the left ventricle, aorta and up to the brain, causing a large stroke)
- Atrial fibrillation or atrial flutter
3.Pulmonary hypertension and right sided heart failure
4.Eisenmenger syndrome
What is the px of an ASD?
ASDs cause a mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border with a fixed split second heart sound. Splitting of the second heart sound is where you hear the closure of the aortic and pulmonary valves at slightly different times.
* SOB
* feeding problems
* poor weight gain
* Lower resp tract infections
Mx of an ASD?
ASDs can be corrected surgically using a transvenous catheter closure (via the femoral vein) or open heart surgery. Anticoagulants (such as aspirin, warfarin and NOACs) are used to reduce the risk of clots and stroke in adults.
What conditions are VSD’’s normally associated with?
Downs and Turners
Will eventually lead to Eisenmengers
Presentation of a VSD?
Typical symptoms include:
Poor feeding
Dyspnoea
Tachypnoea
Failure to thrive
pan-systolic murmur more prominently heard at the left lower sternal border in the third and fourth intercostal spaces. There may be a systolic thrill on palpation.
tx of vsd?
Treatment should be coordinated by a paediatric cardiologist. Small VSDs with no symptoms or evidence of pulmonary hypertension or heart failure can be watched over time. Often they close spontaneously.
VSDs can be corrected surgically using a transvenous catheter closure via the femoral vein or open heart surgery.
There is an increased risk of infective endocarditis in patients with a VSD. Antibiotic prophylaxis should be considered during surgical procedures to reduce the risk of developing infective endocarditis.
What are the three things that cause Eisenmengers ?
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Everything about Coarctation of Aorta go
Post PDA constriction of the Aorta.
Often only indication is weak femoral pulses however if you do a 4 limb BP you will find very big differences -BP alot higher upper limbs
Can also present with: Tachypnoea, poor feeding, grey floopy baby
Mx: Keep DA open using prostaglandins till surgery
Ebsteins anomaly -> quick summary
Ebstein’s anomaly is a congenital heart condition where the tricuspid valve is set lower in the right side of the heart (towards the apex), causing a bigger right atrium and a smaller right ventricle. R -> L shunt via ASD.
Develops few days after birth -> when PDA closes baby becomes cyanotic and sx
Evidence of heart failure (e.g. oedema)
Gallop rhythm heard on auscultation characterised by the addition of the third and fourth heart sounds
Cyanosis
Shortness of breath and tachypnoea
Poor feeding
Collapse or cardiac arrest
Do an echo and correct surgically
