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Cardiac Problems in Children
Dr S BandiSlides courtesy of Dr M Rajimwale
Arrhythmias
Cardiac Problems in Children
Congenital heart disease
Myocardial/pericardial,endocardial
Congenital heart disease
Incidence - 0.8% live births10% in still born/ abortus
< 10% chromosomal abnormality/genetic mutations
25% have extracardiac abnormality
Syndromes
Chromosomes
Downs (Trisomy 21) AVSD,VSD,TOFEdwards (Tris.18) VSD, various defectsPatau (Tris.13) VSD, various defectsTurner (XO) Coarct.,ASde-George (22q11deletion) Truncus,IAA,TOFWilliams (7q del)Supravalvar AS
More associations
Maternal DiseaseDiabetes Mellitus – TGA,VSD, HOCMSLE - Heart block
AssociationsOesophageal Atresia - VSD, TOFAnorectal malformation- AnyDiag. Hernia - AnyExomphalos - AnyPierre Robin - VSD
Teratogens
Teratogenic Exposure
Rubella Coarct, VSD, PDAAlcohol VSDPhenytoin ASDLithium Ebsteins anomalyWarfarin VSD, TOF
FOETAL CIRCULATION
Two intracardiac communications
Ventricles working in
parallel
>95%
>95%
>95%
>95%
75%
75%
75%
75%
3mm
25/3
8
100/8
25/10 100/60
Left heart
Right heart
LA
LV
RA
RV
AortaPA
VSD 30.5%
ASD 9.8%
PDA 9.7%
PS 6.9%
Coarctation of aorta 6.8%
AS 6.9%
TOF 5.8%
TGA 4.2%
Truncus 2.2%
TA 1.3%
Clinical Manifestations
• Cardiac failure – (Lt to Rt shunt – first few monthsLV outflow obstruction – few
days/weeksFunctional failure-cardiomyopathy)
– tachypnoea– tachycardia– poor feeding, sweating– failure to thrive– hepatomegaly
• Central Cyanosis -– duct dependant -
acutely unwell neonate– cyanotic spells - TOF
CHD causing cyanosis-5 Ts –TOFTGATricuspid atresiaTAPVDTruncus ArteriosusPulm atresia
Clinical Manifestations...
• Incidental detection of murmur on routine examination
MURMUR OFTEN ABSENT IN CYANOTIC CONGENITAL HEART DISEASE
Clinical manifestations ...
• Infective endocarditis - rare < 2 years
• Sudden death - rare, HOCM, severe AS, long QT
• Palpitation, dizziness, fainting - arrhythmia, long QT syndrome
• Chest pain - rare, ischaemia - aortic stenosis, anomalous origin of coronary artery pericarditis
Examination
• General exam – growth, dysmorhism, well/unwell– colour, perfusion, pulse (including femorals) , BP,
post-ductal SaO2
• CVS
inspection auscultation (supine and standing)
palpation
• Auscultation – heart sounds (intensity, splitting of 2nd sound)– systolic murmurs - intensity I - VI, phase of
cardiac cycle, area best heard, radiation (listen to neck, axilla, back), change with posture,
– diastolic murmurs - I - IV
• Other systems - respiratory, abdomen
Murmur Best heard Other features
VSD Harsh pansystolic
Lt lower sternal edge
Thrill +-
ASD Soft, ejection systolic
Lt upper sternal edge
Wide, fixed splitting of 2nd sound
PS Ejection systolic
Lt upper sternal edge
Ejection click
AS Ejection systolic
Rt upper sternal edge Ejection click at apex
Thrill in suprasternal notch, radiation to neck
Commonest cardiac problem a general paediatrician will see?
Innocent murmurs
Innocent murmurs• 30% of all children on routine auscultation may have
one. • ‘Still’s murmur’- commonest age group 3-7yr –
vibratory/musical in quality • ‘pulmonary flow’, ‘venous hum’, ‘peripheral pulmonary
stenosis’• Change in intensity with posture • Always systolic (except venous hum – continuous)• ASYMPTOMATIC
Investigations
• Chest X-ray – cardiac size, lung vascularity,
• ECG – chamber enlargement
• Hyperoxia test - to differentiate between cardiac and pulmonary cause of cyanosis in neonate
• Echocardiography - definitive diagnosis • Consider chromosomal analysis ( T21, 22q11)
Acyanotic
• Normal pulmonary vascularity
– PS (mild/moderate)– AS– Coarctation of aorta
• Pulmonary plethora
– VSD– ASD– PDA– Severe LV outflow
obstruction/ hypoplastic left heart
Cyanotic
Pulmonary oligaemia
– severe PS/atresia– TOF– TA– complex lesion with
PS
Pulmonary plethora
- TGA with VSD- Truncus Arteriosus- Total anomalous
pulmonary venous drainage (TAPVD)
Conduction disorders
• Heart block – maternal SLE– complex congenital
defect
• Tachy-arrhythmias– supraventricular
tachcardia
– long QT syndrome - prone to ventricular tachycardia
Other cardiac problems
• Myocardial - cardiomyopathies (genetic, metabolic), myocarditis - viral
• Endocardial - infective (bacterial) endocarditis
• Pericardial - pericarditis, pericardial effusion
Management strategies
MEDICAL
• Cardiac failure - rest, may need O2– afterload reduction - arteriolar dilators (Captopril), diuretics– Inotropes - Digitalis, Dopamine/Dobutamine– arrhythmia - treat– Supportive - nutrition, avoid fluid overload
• Antibiotic prophylaxis – all heart defects causing high velocity
turbulence, prosthetic material– NOT REQUIRED IN ASD
• Dental, surgical/endocsopic, ENT procedures
• Cyanosis - – acute presentation in neonate - likely to
be a duct dependant lesion
– KEEP DUCT OPEN WITH PGE1 INFUSION
– may need urgent surgical intervention (atrial septostomy in TGA, balloon dilatation of pulm/aortic valve, TAPVD)
• Cyanotic spells in TOF (pulmonary stenosis, large VSD, overriding aorta, RVH)– calm the baby– knee chest position– O2, Morphine
• Conduction disorders - permanent pacing for congenital complete heart block
• Medication for tachyrrhythmias
Repair of defect
• Interventional cardiac catheterisation –– PDA, ASD, VSD – occlusion with device placement – PS, AS – balloon dilatation
• Definitive surgical repair• Palliative surgical repair in some complex lesions
• Long term cardiology follow-up