Download Cardiac Problems in Children

Cardiac Problems in Children
M Rajimwale
Cardiac Problems in Children
Congenital heart disease
Myocardial/pericardial,
endocardial
Arrhythmias
Congenital heart disease
Incidence - 0.8% live births
10% in still born/ abortus
< 10% chromosomal abnormality/genetic
mutations
25% have extracardiac abnormality
Syndromes
Chromosomes
Downs (Trisomy 21)
Edwards (Tris.18)
Patau (Tris.13)
Turner (XO)
de-George (22q11deletion)
Williams (7q del)
AVSD,VSD,TOF
VSD, various defects
VSD, various defects
Coarct.,AS
Truncus,IAA,TOF
Supravalvar AS
More associations
Maternal Disease
Diabetes Mellitus – TGA,VSD, HOCM
SLE - Heart block
Associations
Oesophageal Atresia Anorectal malformationDiag. Hernia
Exomphalos
Pierre Robin
-
VSD, TOF
Any
Any
Any
VSD
Teratogens
Teratogenic Exposure
Rubella
Alcohol
Phenytoin
Lithium
Warfarin
Coarct, VSD, PDA
VSD
ASD
Ebsteins anomaly
VSD, TOF
FOETAL
CIRCULATION
Two intracardiac
communications
Ventricles
working in
parallel
Right
heart
Left
heart
75%
LA
RA
75%
3mm
RV
25/3
25/10
>95%
>95%
8
LV
75%
75%
PA
>95%
>95%
Aorta
100/8
100/60
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 months
LV outflow obstruction – few
days/weeks
Functional failure-cardiomyopathy)
–
–
–
–
–
tachypnoea
tachycardia
poor feeding, sweating
failure to thrive
hepatomegaly
• Central Cyanosis – duct dependant acutely unwell neonate
– cyanotic spells - TOF
CHD causing cyanosis5 Ts –
TOF
TGA
Tricuspid atresia
TAPVD
Truncus Arteriosus
Pulm atresia
Clinical Manifestations...
• Incidental detection of murmur on routine
examination
MURMUR OFTEN ABSENT IN CYANOTIC
CONGENITAL HEART DISEASE
Clinical manifestations ...
• Palpitation, dizziness,
fainting - arrhythmia,
long QT syndrome
• Infective endocarditis
- rare < 2 years
• Chest pain - rare,
ischaemia - aortic
stenosis, anomalous
origin of coronary
artery
pericarditis
• Sudden death - rare,
HOCM, severe AS,
long QT
Examination
• General exam
– growth, dysmorhism, well/unwell
– colour, perfusion, pulse (including femorals) , BP,
post-ductal SaO2
• CVS
inspection
palpation
auscultation (supine
and standing)
• 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
Thrill +sternal edge
ASD Soft,
ejection
systolic
PS
Ejection
systolic
Lt upper
Wide, fixed
sternal edge splitting of 2nd
sound
Lt upper
Ejection click
sternal edge
AS
Rt upper
Thrill in
sternal edge suprasternal notch,
Ejection
radiation to neck
click at apex
Ejection
systolic
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)
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