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Multidisciplinary
Congenital heart disease
understood
Quality Education for a Healthier Scotland
Multidisciplinary
Objectives
Understand physiology and relate to
clinical findings
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Facts and Figures
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• Congenital Heart Disease (CHD) – incidence 8:1000
live births
• 4:1000 are symptomatic
• Up to 60% of neonates have a murmur at some stage
• Up to 1.6% have murmur at routine exam.
• 54% of babies with murmurs have CHD
• Routine neonatal examination fails to detect more
than half of babies with CHD
• Normal examination does not exclude CHD
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Purpose of Screening
for CHD
Early identification before failure or hypoxia develop
Prevention of irreversible damage
Remember heart rate and rhythm
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Multidisciplinary
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Normal cardiac circulation
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Postnatal Anatomy and Function
(picture from British Heart Foundation – www.bhf.org.uk)
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Congenital Heart
Problems
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Cyanotic Congenital Heart Disease
= blue
Acyanotic Congenital Heart Disease
= pink
Cardiac Arrhythmias – fast or slow
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Why Cyanosis / blue?
Low or no pulmonary blood flow - less oxygen picked
up
Transposition streaming
Complete intra-cardiac mixing
i.e mixed blue and pink
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Low pulmonary flow
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Separate streaming of blue and pink blood –
transposition great arteries
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Tetralogy of fallots
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Cyanotic Congenital
Heart Defects
•Tricuspid Atresia
•Pulmonary Atresia
•Transposition of the Great Arteries (7%)
•Tetralogy of Fallot (10%)
•Total Anomalous Pulmonary Venous Drainage
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Multidisciplinary
Cyanotic summary
Not pick up enough oxygen
Mix blue and pink blood
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Acyanotic Congenital
Heart Defects ie. pink
Ventricular Septal Defect (25%)
Atrial Septal Defect (7%)
Atrio-ventricular Septal Defect
Patent Ductus Arteriosus (12%)
Coarctation of Aorta
Aortic Stenosis (5%)
Pulmonary Stenosis (5%)
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Ventricular septal defect
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Aortic stenosis
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Congenital
Arrhythmias
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Irregular Rhythm – atrial or ventricular extrasystoles
Bradycardia – sinus bradycardia, congenital heart block
Tachycardia – supraventricular tachycardia
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Prior to Examination
Multidisciplinary
Note family history
Note maternal drug/alcohol/illness history
Note antenatal pointers to cardiac abnormality eg. Scan
reports, high risk of Down’s Syndrome, irregular fetal
heart
Parents view of baby’s well being
Ensure baby’s comfort
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Examination of
Cardiovascular System
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Colour
( Dysmorphic features )
Respiratory rate and effort
Palpation of apex beat
Palpation for thrills and heave
Heart rate and rhythm
Heart sounds and murmurs
Peripheral pulses
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Murmurs
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• Timing – pan systolic, ejection systolic, continuous,
diastolic
• Intensity – graded 1-6
• Location – maximal intensity and radiation
• (May be innocent – quiet and short at left sternal
edge with no accompanying symptoms or signs)
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Site of Murmurs
Multidisciplinary
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Abnormal Symptoms
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Feeding difficulties
Poor Colour
Dyspnoea
Restlessness
Lethargy
Sweating
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Abnormal Signs
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Poor colour or cyanosis
Tachypnoea
Displaced apex beat
Hyperdynamic praecordium
Thrill or heave present
Abnormal cardiac rate or rhythm
Added heart sounds or murmurs
Poorly palpable or absent peripheral pulses
Hepatomegaly
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Referral pathway
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Refer registrar or ANNP
Assessment of well-being and saturations
echo telelink?
Seek feedback
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CONTROVERSIES
Should saturation monitoring be part of
routine assessment?
Prevent Mortality and Morbidity
Estimate MISS 50%
Only Detect Hypoxia- Blue
Duct Dependant Lesions more critical
Routine antenatal screening picks up most and
introduced to practise
Multicentre UK study to assess benefits
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Multidisciplinary
“pulseOx test accuracy study”
Multidisciplinary
Multi-centre study to recruit 20,055
Saturations before discharge or 24 hours
If less than 95% - examine and repeat
Access to reliable echo and follow up
53 major CHD with 24 critical. 34 known from antenatal
screen
Sensitivity= 75% for critical and 49% for major
Miss low output e.g aortic stenosis
Lancet august 2011, issue 9793,p 785-794
WWW.HTA.AC.UK/1624
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Summary
Multidisciplinary
• Newborn examination is an opportunity to identify
CHD early
• Normal examination does not exclude CHD
• Cardiac assessment includes consideration of family
and antenatal factors as well as clinical examination
• Symptomatic babies may require urgent referral for
further assessment
• If in doubt …
ASK FOR HELP
Do not be afraid to refer
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