[Fetal Circulation]
Trace the flow of oxygenated blood
- Placenta
- IVC
- RA
- FO
- LA
- LV
- Ascending aorta
[Fetal Circulation]
Trace the flow of deoxygenated blood
- IVC
- RA
- Tricuspid Valve
- RV
- Pulmonary artery
- Ductus arteriosis
- Descending aorta
- Lower part of the body
- 2 umbilical arteries
[Fetal Circulation]
Unique features in fetal circulation
- Ductus venosus
- Foramen Ovale
- Ductus arteriosus
Fetal cardiac output highly depends on ___
HR
SV can be increased
[Fetal Circulation]
What are the effect of interrupting the umbilical cord?
- Increase SVR
2. Closure of ductus venosus
[Fetal Circulation]
Lung expansion results in____
- Reduction of the PVR
- Functional closure of the FO due to increased pressure in the LA
- Closure of PDA as a result of increased arterial O2 saturation
Functional closure of the ductus arteriosus occurs by ____
Constriction of the medial, smooth muscle in the ductus within 10-15 hours after birth
The anatomic closure of ductus arteriosus is completed by ____
2-3 weeks
[Fetal Circulation]
Effect of removing the placenta in SVR
SVR increases
[Fetal Circulation]
the closure of PDA is dependent of
Low O2 and High prostaglandins
What is the strongest stimulus for contraction of the ductal smooth muscles in the ductus arteriosus?
Post natal increase in O2 saturation
[Murmur]
Systolic ejection or blowing murmur are best heard on the ___
base or at the 2nd ICS through stenotic strucutres
[Murmur]
Systolic regurgitant murmur is best heard in ____
apex or at the left lower sternal border
PDA persisting beyond ____ life in a term infant rarely closes spontaneously or with pharmacologic intervention
1st week of life
[Congenital Heart Disease]
What are your Acyanotic Heart Disease
- VSD
- ASD
- PDA
- COA
- ECD
[Congenital Heart Disease]
What are examples of cyanotic heart disease with decreased pulmonary blood flow?
- Pulmonary atresia
- Pulmonary stenosis
- TOF
- Tricuspid atresia
- Ebstein anomaly
[Congenital Heart Disease]
What are examples of cyanotic heart disease with increased pulmonary blood flow?
- TOGA
- TAPVR
- TA
What is the most common type of ASD?
Ostium seccundum
which is present at the site of fossa ovalis
[Congenital Heart Disease]
Acyanotic
Systolic ejection murmur
2nd LICS
Widely split S2
Right sided enlargement
ASD
[Congenital Heart Disease]
Acyanotic
Systolic regurgitant murmur at LLSB
Loud and single S2
Left sided enlargement; biventricular hypertrophy if Eisenmenger Syndrome
VSD
[Congenital Heart Disease]
Acyanotic
Continuous “machinery-like” at 2nd left infraclavicular area
Bounding pulses
Wide pulse pressure
Left-sided enlargement
Enlarged aorta
PDA
Most common cyanotic heart disease
TGA
What are the various mechanisms of hypoxic spell?
- Increase SVR
- RVOT obstruction
- Decrease pulmonary blood flow, pO2, pH, pCO2
- Increase SVR
[Management of Hypoxic Spell]
How will you manage RVOT obstruction?
Propranolol
[Management of Hypoxic Spell]
How will you address systemic venous return?
Knee Chest Position
[Management of Hypoxia Spell]
How will you address Increased systemic vascular resistance?
Vasoconstrictor
[Management of Hypoxic Spell]
How will you address hyperpnea or hyperventilation?
Morphine
[Management of Hypoxic Spell]
How will you address the decreased pBF, pO2, acidic pH
O2, NaHCO3
What is the dose of morphine sulfate to suppress the respiratory center?
0.2mg/kg/dose SC
[Treatment for TOF]
Used to vasoconstrict and increase SVR
- Phenyephrine 0.02 mg/kg IV
Ketamine 1-3mg/kgIV over 60s increases SVR
[Treatment for TOF]
stabilize vascular reactivity of the arteries preventing a sudden decrease in SVR
Propranolol 0.01-0.25 mg/kg
Surgical technique to augment pulmonary blood flow
Blalock-Taussig Shunt
(Not 2DE), method to distinguish CHD from pulmonary disease
Hyperoxia tes
How will you perform hyperoxia test?
100% FiO2 for 10-15 minutes
heart diseases associated with this syndrome
Down
Endocardial Cushion Defect
heart diseases associated with this syndrome
Marfan
MVP, Progressive enlargement of the aorta
heart diseases associated with this syndrome
Hunter Syndrome
thickening of cardiac valves
heart diseases associated with this syndrome
Noonan
Pulmonary stenosis
- Facial anomalies
- Short stature
- Webbed neck
- Chest deformities
- Undescended testes
- Pulmonary stenosis
[Diagnosis]
Cyanosis manifesting within few hours at birth or within few days of life
TGA
[Diagnosis]
Cyanosis manifesting after the first year of life, usually in an infant or a toddler
TOF
What are the heart defects that permit mixing of the 2 circulations for survival
- ASD
- VSD
- PDA
What is the most common cause of cyanotic CH in newbornd
TGA
Unresponsive to oxygen inhalation
What is the pathognomonic CXR finding of TGA
Egg-shaped cardiac sillouette with a narrow superior mediastinum
What are the components of tricuspid atresia?
- Atretic TV
- Hypoplastic RV
- VSD
- ASD
- Pulmonary stenosis
What are the components of truncus arteriosos?
- Pulmonary arteries arise from aorta
- Truncal valve overrides the VSD
- VSD, large
Most commonly associated congenital heart defect in Turner Syndrome/
CoA
How does CoA appear on X-ray?
- Rib notching in children around 7 years old
Treatment of choice for neonates with severe CoA
PGE1 to reopen ductus
[Diagnosis]
Weak or absent femoral pulses
BP arms > legs
Rib notching
CoA
Tx: Primary anastomosis or patch aortoplasty
[Diagnosis]
Systolic ejection murmur at LUSB with radiation to the upper back
Pulmonic stenosis
Brock Procedure (balloon valvuloplasty)
[Diagnosis]
Systolic ejection murmur at RUSB
Aortic stenosis
[Diagnosis: CXR Findings]
boot-shaped heart / Coeur en sabot
TOF
[Diagnosis: CXR Findings]
Egg on string
TGA
[Diagnosis: CXR Findings]
Snowman
TAPVR
[Diagnosis: CXR Findings]
Figure of 8
TAPVR
[Diagnosis: CXR Findings]
Rib notching
CoA
[Diagnosis: CXR Findings]
Inverted E
CoA
[Diagnosis: CXR Findings]
3 sign
CoA
[Diagnosis]
Child, exercise intolerance, easy fatigability
late systolic murmur with an opening click
MVP
[Diagnosis]
Child, exercise intolerance, easy fatigability
Disparity in pulsation and BP in the arms and legs
Weak popliteal, posterior tibial, and dorsalis pedis
CoA
[Diagnosis]
Child, exercise intolerance, easy fatigability
S2 widely split and fixed
ASD
[Diagnosis]
Child, exercise intolerance, easy fatigability
loud, harsh, blowing systolic murmur
VSD
[Diagnosis]
Child, exercise intolerance, easy fatigability
Wide pulse pressure, bounding peripheral arterial pulses, continuous murmur
PDA
[Diagnosis: Indication of Surgical Procedure]
Blalock-Taussig Shunt with GoreTex Conduit
TOF
[Diagnosis: Indication of Surgical Procedure]
Rashkind artrial septostomy
TGA
[Diagnosis: Indication of Surgical Procedure]
Jantene arterial switch
TGA
[Diagnosis: Indication of Surgical Procedure]
Senning ang mustart
TGA
[Diagnosis: Indication of Surgical Procedure]
Fontan Procedure
TA
[Diagnosis: Indication of Surgical Procedure]
Norwood procedure
Hypoplastic Left Heart Syndrome
[Diagnosis: Indication of Surgical Procedure]
Glenn anatomosis
Hypoplastic left Heart syndrome
[Diagnosis]
RV pumping blood to the the lungs and out of the body via patent PDA
Hypoplastic Left Heart Syndrome
[Associated Heart Disease]
Rubella
PDA
[Associated Heart Disease]
DM
TGA
[Associated Heart Disease]
Lupus
Complete heart block
[Associated Heart Disease]
Aspirin
persistent pulmonary hypertension
[Associated Heart Disease]
lcohol
- VSD
2. PS
[Associated Heart Disease]
Lithium
Ebstein anomaly
Tricuspid valve is displaced toward the apex
What are the major components of the Jones Criteria?
- Joints/Polyarthritis
- Carditis
- Nodules, subcutaneous
- Erythema marginatum
- Syndeham chorea
What are the minor components of the Jones Criteria
- Fever
- RHD/RH previously
- Arthralgia
- Prolonged PR interval on ECG
- Elevated acute phase reactants: EST/CRP/Leukocytosis
What is the most consistent feature of ARF?
Valvulitis
In RF, erythema marginatum spares what part of the body?
Face
Nonpruritic serpiginous or annular erythematois evanescent rash prominent on the trunk and inner proximal portions of the extremities
[RF]
___ spontaneous purposeless movements followed by motor weakness
syndeham chorea
What is the set point fever for high risk patients with RF?
> 38 deg C
Low rislk, >38.5 deg C
ASO titers become elevated ___ weeks after strep infection
2 weeks
Peaks at 4-6 weeks
What are the criteria to demonstrate evidence of preceding strep infection?
- Increased or rising ASO or anti-DNAse B
- Positive throat culture for GABHS
- Positive rapid group A strep carbohydrate antige
What is the criteria to diagnose initial ARF?
- > 2 major manifestations
2. 1 Major plus 2 minor manifestations
What is the criteria to diagnose recurrent RF?
Reliable history of ARF or established RHD
- 2 major
- 1 major + 2 minor
- 3 minor
What is the DOC for for acute RF?
- Oral Penicillin or Erythromycin x 10 dyas
2. Single IM injection of benzathin penicillin
What are the drugs used to eradicate Streptococcus?
- Penicillin VK 200-500mg QID x 10 days
- Benzathine PCN 0.6-1.2 MU IM
- Erythromycin 250mg TID x 10 days
What is the secondary prophylaxos for RF?
- Pen VK 250mg BID PO
2. Benzathin PCN 0.6-1.2 MU IM q 21 days
[Duration of prophylaxis for ARF]
RF without carditis
5 year or until 21 years of age
[Duration of prophylaxis for ARF]
RF with carditis but no residual heart disease
10 years or until 21 years old
[Duration of prophylaxis for ARF]
RF with carditis and residual HD
10 years or until 40 years of age
What are the causative agents in Infective Endocarditis?
- Viridans streptococci
2. S. aureus
What is the echocardiographic finding in IE?
- Oscillating mass vegetations
2 Regurgitant flow near a prostheisis - abscess
- partial dehiscence of proshetic valve, new valve regurgitant
How will you collect samples for blood culture if you suspect IE?
- 2 separate sites 12 hours apart
2. 3 or more 1 hour apart
What are the minor criteria in IE?
- Fever
- Predisposing condition
- Vascular
- Immunologic
- Microbiological evidence
- Echocardiographical
[PE in IE]
linear lesions beneath the nails
Splinter hemorrhages
[PE in IE]
painless small erythematous hemorrhagic lesions on the palms and soles
Janeway lesions
[PE in IE]
Tender, pea-sized intradermal nodules in the pads of fingers and toes
Osler nodes
What antibiotics will you give after a dental procedure with manipulation of the gingiva
Patient allergic to amoxicillin
Clindamycin 600mg orally 30-60 minutes before the procedure
[Murmurs]
Characteristics of innocent murmur
- Soft
- Systolic
- Short
- Musical/vibratory
- Symptomless
- Normal diagnostics
[Murmurs: Innocent or pathologic]
Grade I to grade II
sternal border
soft systolic
Innocent
[Murmurs]
Characteristics of pathologic murmur
- Diastolic
- Pancystolic
- Late systolic
- Continuous
- Thrill
[Murmurs: Grades]
Loud but no thrill
Grade III
[Murmurs: Grades]
Loud, with thrill
Grade IV
[Murmurs: Grades]
Thrill and audible with edge of the stethoscope
Grage V
[Murmurs: Grades]
Thrill and audible with stethoscope just off the chest
Grade VI
[Infective endocarditis: organism]
Normal person
No underlying disease
Staphylococcus
[Infective endocarditis: organism]
Underlying heart disease
Dental procedure
viridans Streptococcus
[Infective endocarditis: organism]
Gut or lower bowel manipulation
Group D streptococcus
[Infective endocarditis: organism]
after an open heart procedure
fungal
[Infective endocarditis: organism]
IV drug abusers
- Staphylococcus and
2. Pseudomonas
[Infective endocarditis: organism]
+ CVP
+ Prosthetic valves
Coagulase negative staph
[Diagnosis]
Child with fever, arthralgia, myalgia, acutely ill looking
new heart murmur
Organism?
staphylococcus aureus
[Diagnosis]
Child, known CHD,
fever, fatigue, weight loss, painful skin lesions on the finger
poor oral hygiene
viridans streptococcus
[Diagnosis]
Child, known CHD,
fever, fatigue, weight loss, painful skin lesions on the finger
underwent root canal treatment
viridans streptococcus
[Diagnosis]
Child, known CHD,
fever, fatigue, weight loss, painful skin lesions on the finger
recent repair of VSD
fungal
[Diagnosis]
Child, known CHD,
fever, fatigue, weight loss, painful skin lesions on the finger
IV drug user
pseudomonas
Fishmouth buttonhole deformity
Mitral valve stenosis
What are the consequences of Mitral Stenosis?
LA MV LV
- LA enlargement
- Increased LA pressure
- Pulmonary congestion
- Pulmonary HPN
- AF
How to differentiate VSD and MR since both have systolic regurgitant type of murmur
- VSD - no transcmission to LAAL
2. MR - with transmission to LAAL
[Diagnose]
High pitched diastolic murmur loudest at 3rd to 4th LICS, more audible when sitting and leaning forward
Aortic Regurgitation
- Diastolic thrill at 3rd LICS
- Hyperdynamic precordium
- Bounding water hammer puls
- Wide pulse pressure