Download Approach to an infant with cyanotic heart disease

Approach to child with heart
disease
Pushpa Raj Sharma
Professor of Child Health
Institute of Medicine
Diseases of heart
Blood vessels
Endocardium
Myocardium
Pericardium
Prevalence
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Congenital
Cyanotic: 22%
Acyanotic: 68%
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VSD
ASD
PDA
TOF
PS
AS
25%
6%
6%
5%
5%
5%
Acquired
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Kawasaki disease
Rheumatic
Tubercular
Collagen
Ceylon Med J 2001 Sep; 46 (3): 96-8; Indian J Pediatr. 2001 Aug;68 (8):757-7
Nelson’s Textbook of pediatrics; 17 ed.
Common acyanotic lesions
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Ventricular septal defects
Atrial septal defects
Atrio-ventricular septal defects
Patent ductus arteriosus
Truncus arteriosus
Pulmonary stenosis
Aortic stenosis
Mitral stenosis/incompetence
Coarctation of aorta
Tricuspid regurgitation
Common Cyanotic Lesions
Decreased flow
1. Tetralogy of Fallot
2. Tricuspid Atresia
3. Severe Pulmonic Stenosis
4. Ebstein’s anamoly
Increased Flow
5. Transposition of great vessles
6. VSD with pulmonary atresia
Common Lesions producing
cyanosis
7. Truncus Arteriosus
8. Hypoplastic left heart
9. Single ventricle
10. TAPVR with infradiaphragmatic
obstruction
Presenting complaints/signs
Fast breathing
Failure to thrive
 Oedema
Exercise intolerence  Hepatomegaly,
Easy fatigability
 spleenomegaly
Chest indrawing
 Clubbing
Sweating during feeding Cyanosis
Bluish spells
 Focal neurological lesion
Fever with rigor
 Other organ defects
Palpitation
 Chromosomal anomalies
Convulsion
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Cyanosis: is it a cardiac cause or
lung cause
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Hyperoxia test
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Neonates with cyanotic congenital heart
disease usually do not have significantly
raised arterial Pao2 during administration
of 100% oxygen.
Ventricular Defect
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Small VSD
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Asymptomatic
A loud, harsh, or
blowing holosystolic
murmur.
Large VSD
dyspnea, feeding
difficulties, poor
growth, profuse
perspiration, recurrent
pulmonary infections,
and cardiac failure in
early infancy.
Syndromes associated with this condition
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80%
VSD: ECG is normal but may show right ventricular
hypertrophy, if present indicates defect is large and presence
of pulmonary hypertension or pulmonry stenosis
Ventricular Septal Defect
(VSD)
Small VSDs, the chest radiograph is usually normal
Large VSD: The presence of right ventricular hypertrophy, olegeimic lung fields
(pulmonary hypertension or an associated pulmonic stenosis), gross
cardiomegaly with prominence of both ventricles, the left atrium.
Ventricular Septal defects
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30–50% of small defects close spontaneously,
most frequently during the 1st 2 yr of life.
Small muscular VSDs are more likely to close (up
to 80%) than membranous VSDs are (up to
35%).
infants with large defects have repeated
episodes of respiratory infection and heart
failure despite optimal medical management.
Surgical repair prior to development of an
irreversible increase in pulmonary vasculalr
resistance (usually prior to the patient's second
birthday).
Atrial Septal Defects:
secundum
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Most common form of
ASD (fossa ovalis)
In large defects, a
considerable shunt of
oxygenated blood flows
from the left to the right
atrium.
Mostly asymptomatic
The 2nd heart sound is
characteristically widely
split and fixed.
Secundum
Atrial Septal Defects:primum
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Situated in the lower
portion of the atrial septum
and overlies the mitral and
tricuspid valves. In most
instances, a cleft in the
anterior leaflet of the mitral
valve is also noted.
Combination of a left-toright shunt across the atrial
defect and mitral
insufficiency
C/F similar to that of an
ostium secundum ASD
Atrial Septal Defect
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Enlargement of the
right ventricle
Enlargement of
atrium
Large pulmonary
artery
increased pulmonary
vascularity is.
The electrocardiogram in patients with a complete AV septal defect is distinctive. The
principal abnormalities are (1) superior orientation of the mean frontal QRS axis with left
axis deviation to the left upper or right upper quadrant, (2) counterclockwise inscription
of the superiorly oriented QRS vector loop, (3) signs of biventricular hypertrophy or
isolated right ventricular hypertrophy, (4) right ventricular conduction delay (RSR′ pattern
in leads V3 R and V1 ), (5) normal or tall P waves, and (6) occasional prolongation of the
P-R interval
Atrial Septal Defects
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Secundum ASDs are well tolerated during
childhood.
Antibiotic prophylaxis for isolated
secundum ASDs is not recommended.
Surgery or transcatheter device closure is
advised for all symptomatic patients and
also for asymptomatic patients with a
Qp:Qs ratio of at least 2:1.
Ostium primum defects are approached
surgically
Patent Ductus Arteriosus
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Small defect no
symptoms.
Large defect:
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Wide pulse pressure
Enlarged heart
Thrill in L second IS
Continuous murmur
X-ray: prominent
pulmonary artery
with increased
vascular markings.
Primary Pulmonary
Hypertension
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Prominent
pulmonary artery.
Prominent right
ventricle
Prominent
vascularity in the
hilar areas
Decreased vascualr
marking in the
periphery.
No treatment
Mitral insufficiency: Rheumatic
High volume load
Enlarged left ventricles
Inflammatory process
Dilatation of the left atrium
Pulmonary congestion
Spontaneous improvement
Repeated insult
Symptoms of left sided failure
Chronic mitral insufficiency
Symptoms of right heart failure
Raised Pulmonary AP
Enlarged right ventricle and atrium
Mitral insufficiency: Rheumatic
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Signs of heart failure
Heaving apical
impulse
Apical systolic thrill
Accentuated 2nd
sound
Holosystolic murmur
radiating to axilla
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ECG: bifid P waves
and left ventricular
hyertrophy
X-ray: prominent left
atrium and ventricle
(straight left border)
Prophylaxis against recurrence of rheumatic fever
Rheumatic valvular disease:
Mitral stenosis
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Takes 10 years to develop
Symptoms proportionate to severity
Left ventricular failure
right ventricular
failure
Loud first heart sound with opening snap.
Diastolic murmur
Absent murmur if heart failure.
Surgical intervention if symptomatic
Mitral Stenosis
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Loud 1st sound
Diastolic murmur
left atrial enlargement
prominence of the
pulmonary artery
enlarged right-sided
heart chambers;
ECG: prominent
notched P wave.
Pericardial Effusion
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Presenting complaint
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Precordial pain
Cough
Dyspnoea
Abdominal pain
Vomiting
Fever
Other organs
involvement
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Signs:
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Position: leaning forward.
Puffy face
Friction rub
Absent apical impulse
Muffled heart sounds
Pulsus paradoxus
Distended neck veins
Low QRS complex, T
inversion
Pericardial Effusion
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A relatively large
pericardial effusion
must be present to
cause an enlarged
cardiac shadow with
the usual “water
bottle” configuration
on a chest
roentgenogram
The test that differentiates
The cardiac seize and the vascularity in
the chest X-ray
Cardiac disease with normal/decreased
vasculature
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Viral myocarditis
Tetralogy of Fallot
Pulmonary atresia
Tricuspid atresia
Endocardial fibroelastosis
Aberrant left coronary artery
Cystic medial necrosis
Diabetic mother
Tetralogy of Fallot
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Ventricular septal
defect
Pulmonic stenosis
Overriding aorta
Right ventricular
hypertrophy
Cyanotic
Cardiac disease with increased
vasculature
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Atrioventricular septal defects
Congestive cardiac failure
Transposition of great arteries with VSD
Total anomalous pulmonary venous
drainage
Truncus arteriosus
Single ventricle without pulmonary
stenosis
Hypoplastic left heart syndrome
Congestive Cardiac Failure
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Enlarged heart
Plethoric lung fields
specially at bases