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What are acyanotic lesions of the heart?
- aortic & pulmonary stenosis
- coarctation of the Aorta
What are cyanotic lesions of the heart?
- tetrology of Fallot
- transposition of the great vessels
- tricuspid atresia
- truncus arteriosus
- total anomalous venous return
- hypoplastic left heart syndrome
- ebstein's anomaly
What can cause acquired cardiac disease?
- rheumatic fever
- myocarditis & pericarditis
INFANTS with congenital heart defects often have no murmurs, so what symptoms do they present with?
- sweating with feeding
- failure to thrive
How do you rule out cardiac disease in older children that come in with "chest pain"?
- fam hx of structrual disease, CAD
- onset, timing, duration of sxs
- cardiac exam
- asthma (common cause of peds CP)
What is the normal systolic and diastolic blood pressure for peds?
- systolic: 80 + (2 x age)
- diastolic: 2/3 systolic
What is the normal pulse pressure for peds?
systolic bp MINUS diastolic bp
What is considered a "widened" pulse pressure? What conditions can cause this?
- if pulse pressure is > 1/2 SBP
- caused by PDA and Aortic regurgitation
What causes a fixed split S2?
atrial septal defect
What causes an S3 heart sound? Can this be normal in pediatrics? What causes an S4 heart sound?
- poor systolic function (can be normal in peds)
- poor diastolic function (hypertrophic cardiomyopathy)
What are you listening for when identifying heart murmurs?
- location (valve area)
- duration (systolic, diastolic, continuous)
- intensity (>IV often pathological)
- quality (soft, harsh, musical)
- variation with posture/valsalva
What sound does a holosystolic (pansystolic) murmur obscure?
What are the indirect cardiac tests you can perform?
How would you obtain CXR to test for cardiac disease? What can the CXR show? What does it help rule out?
- Standard PA/LAT (always 2 views)
- May show LVH/RVH, abn aortic arch, etc (but usually nonspecific)
- Help r/o pulmonary disease
How is the 100% oxygen test performed? What is it used for?
- get baseline O2 sat or Pa O2, place child under 100% O2 x 30 mins, recheck O2 sat or PaO2
- differentiates lung vs cardiac etiology in cyanotic infant (no change in O2 suggests cardiac rather than pulmonary condition)
What are the cardiocentric tests you can perform?
- echocardiography (usually test of choice-non invasive)
- cardiac catheterization (definitive but invasive)
What are ECGs most helpful with?
Why is sinus arrhythmia common in peds?
immature cholinergic input
What is the most common symptomatic arrhythmia? What does it respond well to?
- vagal maneuvers/adenosine
What is an echocardiography good for?
structural & functional info
What cardiocentric test is diagnostic AND therapeutic?
What does the acronym PASS PAID stand for as it refers to cardiac murmurs?
- Pulmonary and Aortic Stenosis are Systolic
- Pulmonary and Aortic Insufficiency are Diastolic
What are the functional (benign/innocent) peds murmurs?
- peripheral arterial pulmonary stenosis
- venous hum
- Still's murmur (LV outflow)
- pulmonary flow murmur (RV outflow)
What are the pathologic peds murmurs?
- aortic & pulmonic stenosis/regurge
- mitral & tricuspid stenosis/regurge
- ASD, VSD, PDA, MVP (mitral valve prolapse)
What causes a functional murmur of peripheral arterial pulmonary stenosis? What does it sound like? Are there positional changes? When is it typically heard?
- blood flow through slightly constricted pulmonary arteries
- soft, systolic, I-II, LSB, RSB and BACK
- no positional change
- from 1-12 weeks old
What causes a venous hum? What does it sound like? Are there positional changes? When is it typically heard?
- jugular venous flow
- musical, continuous, I-II, right AND left USB
- increases w/ sitting or standing, may disappear supine; commonly heard inf to clavicles
- from 2-5 years old
What causes a Still's murmur? What does it sound liked? Are there positional changes? When is it typically heard?
- LV outflow tract vibration
- musical, systolic, I-III, apex & LLSB
- increases in supine position/fever (incr blood flow rate)
- from 1-10 years old
What causes a pulmonary flow murmur? What does it sound like? Are there positional changes? When is it typically heard?
- flow in RV outflow tract
- med pitch, systolic, I-II LUSB
- increases when supine and w/ forced expiration, decreases when sitting
- from 7-10 years
Where is a pathologic systolic (ejection) murmur best heard? What causes these murmurs?
- heard best at the BASE
- aortic & pulmonic stenosis, ASD
Where is a pathologic systolic (holosystolic) murmur best heard? What causes these murmurs?
- heard best at the APEX
- mitral & tricuspid regurge, VSD
What causes a pathologic systolic (late w/ mid systolic click) murmur?
MVP (mitral valve prolapse)
What causes a pathologic diastolic (early) murmur?
aortic & pulmonary regurge
What causes a pathologic diastolic (middle) murmur?
mitral & tricuspid stenosis
What causes a pathologic diastolic (continuous) murmur?
Opening between right & left atrium allowing for right to left shunt. (fetal circ)
Opening between the pulmonary artery & aorta allowing for a right to left shunt. (fetal circ)
Opening between the umbilical vein and inferior vena cava allowing oxygenated blood from the placenta to bypass the liver and head to the heart. (fetal circ)
Lesions that are CYANOTIC usually need what to keep DA open for compensatory left to right shunting?
prostaglandin E 1 (PGE)
How are lesions that produce CHF or pulmonary hypertension medically stabilized?
lasix & digoxin (give till surgery or cath can be performed)
When are nonurgent acyanotic lesions typically corrected? What about nonurgent cyanotic lesions?
- after development matures, approx 2 years old
- generally corrected in staged procedures
If acyanotic and cyanotic cardiac lesions are left untreated, most of them can cause what conditions?
- pulmonary HTN
- subacute bacterial endocarditis (SBE) risk
Which lesions implicate either no shunt or a left to right shunt?
Name the different acyanotic lesion and identify which is most common.
- VSD (most common)
- aortic & pulmonary stenosis
- coarctation of the aorta
Most common congenital heart defect, size determines lesion symptoms (< 3mm asx, 3-5mm mod sx, >5mm CHF & FTT).
ventricular septal defect (VSD)
What does the exam reveal in a child with VSD?
"harsh", II-V pansystolic murmur at LLSB
What will a CXR, and ECG show in a pt with VSD? How is it treated? What is the prognosis?
- CXR: biventricular enlargement/CHF
- ECG: LVH
- <5mm often resolve spontaneously (80%)
- normal life post-surgery (small ones don't need closure, instead SBE prophylaxis)
Exam: I-III early systolic murmur at LUSB, fixed split S2, may have rumbling diastolic murmur due to increased flow across tricuspid valve.
atrial septal defect
What are the CXR and EKG findings of atrial septal defect?
- CXR: may show CHF
- EKG: may show RAD
How is atrial septal defect treated?
- catheter (small defects)
- other open surgical correction (high success)
Second most common cardiac defect, often associated with other conditions.
patent ductus arteriosus (PDA)
What are the exam findings of patent ductus arteriosus?
- "bounding" pulses with widened pulse pressure
- continuous "machinery" murmur at LUSB
What are the CXR and EKG findings of patent ductus arteriosus?
- CXR: may show CHF
- EKG: may show RVH
What is the treatment for patent ductus arteriosus?
- indomethacin (most effect in premies, may cause transient renal insufficiency)
- cath closure (via hemostatic coil/PDA closure device by age 2 if asx)