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Cardiology Conference
Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo
December 22, 2010
C.F. 2 months old / male
CC: Fever
Gestational
History
Birth History
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16 y/o primigravid G1P1 (1001)
Prenatal check-up (?) - ferrous sulfate (unrecalled dose and duration of intake)
No viral exposure
1 month of pregnancy – (+) alcohol and smoking
4 month of pregnancy – (+) UTI – completed cephalexin 500mg/cap q6 and
amoxicillin 500mg/cap q8 x 7 days
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Full term
3.2 kg (N 3-3.5 kg) via NSD, singleton, cephalic presentation at a local hospital
No complications
APGAR not known
C.F. 2 months old / male
CC: Fever
Feeding
History
• Mixed breastfeeding and milk formula
• No feeding difficulty
• (-) cyanosis
• No regular check-up
Developmental • At par with development
History
C.F. 2 months old / male
CC: Fever
• Incessantly crying and irritable
• 2 episodes of vomiting of previously ingested food, ~1/2 cup/episode
2 days PTA • (-) cyanosis, good appetite
• Crying and irritability persisted
• Fever 38°C, colds with whitish nasal discharge and difficulty in breathing
1 day PTA • Health center – 0.65% NaCl drops 1-2 drops/nostril q8 and paracetamol 100mg/mL 0.5mL prn for fever
Few hours
PTA
• Symptoms persisted
• ADMISSION
Review of Systems
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General: (-) noticeable weight loss
Cutaneous: (-) rashes, (-) discoloration
HEENT: (-) ear discharge, (-) epistaxis, (-) gum bleeding
Respiratory: refer to HPI
Cardiovascular: refer to HPI
GI: (-) diarrhea, (-) constipation
GUT: yellow urine, (-) edema of the hands and feet
Extremities: (-) swelling, (-) joint swelling
Nervous/Behaviour: (-) tremors, (-) convulsions
Hematopoietic: (-) pallor, (-) easy bruisability
Immunization History
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Received the following at a local health center:
BCG 1
Hepatitis B 1
DTP 1
OPV1
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Next dose due on December 27, 2010
Family Profile
Age/
Gender
Relation to the
patient
Educational
Attainment
Occupation
Health
P. F
17 y/o
Male
Father
3rd year high
school
Student
Healthy
C. R
16 y/o
Female
Mother
High School
graduate
Housewife
Healthy
A.C
63 y/o
Male
Grandfather
2nd year
college
Government
employee
Healthy
Y.C
54 y/o
Female
Grandmother
2nd year
college
Housewife
(+) RHD
Family History
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(+) Rheumatic Heart Disease – maternal grandmother
(-) HPN
(-) Diabetes Mellitus
(-) Pulmonary Tuberculosis
(-) Allergies
Socioeconomic and
Environmental History
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Four bedroom house made of wood and concrete
Well lit and well ventilated
Garbage is collected daily, no segregation
Purified water from a water refilling station.
Baby bottles also sterilized
Stray cats
Second hand smoke
Physical Examination
• General Survey: awake, alert, in respiratory distress with alar
flaring, ill looking, well-nourished, well-hydrated
• Vital Signs: HR 140 bpm, RR 70 cpm Temp 36.0 °C Wt 4.7 kg
(z=below 0 normal) Ht: 49 cm (z= below -3 severely stunted)
BMI: 19.58 (z= above 2 overweight)
• Head circumference 37 cm, chest circumference 36 cm,
abdominal circumference 40 cm
• Skin: Warm, moist skin, pink in color, good skin turgor, no
rashes, no jaundice
Physical Examination
• HEENT: normocephalic, anterior fontanel open, symmetric
head, (-) scalp lesions, symmetric face; Eyeballs not sunken,
pink palpebral conjunctiva, anicteric sclerae, pupils 2-3 mm
ERTL; Midline nasal septum, (+) whitish nasal discharge;
Moist buccal mucosae, nonhyperemic posterior pharyngeal
wall; Supple neck, (-) palpable lymph nodes
Physical Examination
• Lungs/Chest: Symmetric chest expansion, (+) subcostal
retractions, (+) crackles on both upper lung fields
• Cardiovascular: adynamic precordium, no precordial bulge, (-)
Harrison’s groove, (+) holosystolic murmur at the lower left
parasternal area grade 4/6
• Abdomen: globular abdomen, normoactive bowel sounds,
soft, non tender, no masses
• Spine: midline, (-) sacral dimpling, (-) tufts of hair
• Genitalia: Penis 2cm, testes descended bilaterally, no
phimosis, no discharge
• Extremities: full peripheral pulses, no cyanosis, no clubbing
Neurologic Examination
• Cerebrum: alert
• Cranial nerves: Pupils isocoric, 2-3mm ERTL, (+) direct and
consensual light reflex, (-) gross facial asymmetry, (+) gag reflex
• Cerebellum: (-) no involuntary movements
• Motor: (-) rigidity, (-) spasticity, (-) Flaccidity
• Meningeal Signs: (-) nuchal rigidity, (-) Brudzinski’s, (-) Kernig’s, (-)
tonic neck reflex
Subjective Salient Features
Pertinent Positives
Pertinent Negatives
• 2 months old/ Male
• Born to a 16 year old primigravid
• Prenatal check-up (?)
• (+) Smoking and alcohol – 1st month
of pregnancy
• (+) UTI, treated – 4th month of
pregnancy
• Full term, NSD
• No viral exposure
• No complications at birth
• Normal birth weight 3.2 kg
• No feeding difficulties
• At par with development
• (+) URTI
• Acyanotic
• (+) RHD – maternal grandmother
Objective Salient Features
Pertinent Positives
• Awake, alert, in respiratory distress
with alar flaring, ill looking, wellnourished
• PR 140 bpm, RR 70 cpm Temp 36.0
°C
• (+) whitish nasal discharge
• Symmetric chest expansion, (+)
subcostal retractions, (+) crackles on
both upper lung fields
• Adynamic precordium, no precordial
bulge, (-) Harrison’s groove, (+)
holosystolic murmur at the lower left
parasternal area grade 4/6
Pertinent Negatives
• Warm, moist skin, pink in color
• Full peripheral pulses, no cyanosis,
no clubbing
Presenting manifestation
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Incessant crying and irritable
Vomiting
Fever
Development at par with age
Alert, awake
respiratory distress with alar flaring
– symmetrical chest expansion
– RR: 70 cpm (tachypneic);
– (+) subcostal retractions
– (+) crackles on both lung fields
• Ht: 49 cm ( z=-3 severely stunted; BMI: 19.58 ( z= above 2
overweight)
• (+) holosystolic murmur at the left parasternal area
• small defects: physical findings are primarily
cardiac manifestations
• moderate-to-large defects: growth may be affected
• Infants with small defects
– normal vital signs.
– Physiologic splitting of S2 is usually retained
– harsh, holosystolic murmur is loudest along the lower
left sternal border (LSB), and it is well localized.
• Small defects can produce a high-pitched or squeaky noise.
• Infants with moderate defects
– normal length and decreased weight
• Poor weight gain is a sensitive indicator of congestive heart
failure (CHF).
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mild tachypnea, tachycardia, and an enlarged liver
The precordial activity is accentuated.
The murmur associated with thrill
A holosystolic harsh murmur is most prominent over the
lower LSB.
– The intensity of the pulmonary component is usually
normal or slightly increased.
– a diastolic rumble may be detected in the mitral area.
• This rumble suggests functional mitral stenosis secondary to a
large left-to-right shunt and indicates a surgical-level shunt
• Infants with large ventricular septal defects
– signs of CHF are present
• tachycardia, tachypnea, and hepatomegaly
• cardiomegaly
– The murmur is holosystolic but poorly
localized and is usually associated with a
diastolic rumble
ASD
• first heart sound may be normal or split
– best appreciated at the upper left sternal
border and may be transmitted to the lung
fields.
– second heart sound becomes widely split and
fixed
• fixed splitting of S2 is an important diagnostic
finding in atrial-level shunting
PDA
• history of premature birth, perinatal distress, or
perinatal hypoxia may be present
• If the left-to-right shunt is large, precordial activity
is increased
• The apical impulse is laterally displaced
• A thrill may be present in the suprasternal notch or
in the left infraclavicular region
• The first heart sound is typically normal. The
second heart sound (S2) is often obscured by the
murmur
• Continuous machinery murmur
AS
• may present as congestive heart failure in
the first week of life that mimic sepsis
• Often, neonates with aortic stenosis are
asymptomatic but present with a systolic
murmur
PS
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Most are asymptomatic cardiac murmurs that are detected during routine examination.
moderate or severe pulmonary stenosis : exertional dyspnea.
severe or critical obstruction: signs of systemic venous congestion
Physical findings depend on the degree of obstruction.
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healthy and are well developed.
trivial, mild, or moderate stenosis, and many with severe stenosis, are acyanotic
A thrill may be felt in the suprasternal notch and at the left upper sternal border (pulmonic area)
precordial thrill
first heart sound may be normal; second heart sound is widely split
A fourth heart sound may be heard at the left lower sternal border in patients with severe
obstruction
An ejection systolic click is heard along the left sternal border
An ejection systolic murmur of grade II-VI to V-VI is best heard at the left upper sternal border with
radiation into infraclavicular regions, axillae, or back.
Hepatosplenomegaly may develop in cases of CHF.
Peripheral pulmonary stenosis (commonly encountered in the neonate) is usually associated with a
grade II/VI systolic murmur that radiates into the posterior lung fields and axillae
coA
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Early presentation: poor feeding, tachypnea, and lethargy and progress to overt CHF and
shock.
Late presentation: Patients often present after the neonatal period with hypertension or a
murmur
Other presenting symptoms may include headaches, chest pain, fatigue, or even lifethreatening intracranial hemorrhage.
Many patients are asymptomatic except for the incidentally noted hypertension.
As with history, physical examination may conveniently separate patients into 2 groups:
those who present early with heart failure and those who present later with hypertension.
Early presentation
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Neonates: tachypnea, tachycardia, and increased work of breathing and may even be moribund
with shock.
blood pressure discrepancies between the upper and lower extremities and reduced or absent
lower extremity pulses to palpation
In patients with low cardiac output and ventricular dysfunction, pulses may be diminished diffusely,
and BP gradients may seem minimal
The murmur associated with coarctation of the aorta may be nonspecific yet is usually a systolic
murmur in the left infraclavicular area and under the left scapula.
Differential diagnosis
CHD
Cyanotic
Noncyanotic
Noncyanotic
Difficulty
breathing
(dyspnea)
Frequent
respiratory
infections in
children
Sensation of
feeling the heart
beat
Shortness of breath (palpitations) in
Fast breathing
adults
Hard breathing
Shortness of
Paleness
breath with
Failure to gain
activity
weight
Fast heart rate
Sweating while
feeding
Frequent
respiratory
infections
VSD
ASD
Bounding
pulse
Fast
breathing
Poor feeding
habits
Shortness of
breath
Sweating
while
feeding
Tiring very
easily
Poor growth
PDA
Abdominal distention
Cyanosis in some
patients
Chest pain
Fainting
Fatigue
Poor weight gain or
failure to thrive
in infants
Dizziness
or fainting
Breathlessness with with severe blockage
Shortness of breath
activity
Shortness of
breath headache
Pounding
Chest pain
Sudden death
Chest pain
Fainting, weakness,
Cold feet or legs
or dizziness with
Failure to thrive
activity
Poor growth
Palpitations
AS
PS
CoA
Clinical Impression
Congenital Heart Disease
Pneumonia
VENTRICULAR SEPTAL
DEFECT
Ventricular Septal Defect
• most common ACHD (25%)
• SYNONYMS
* Roger’s disease
* Interventricular septal defect
* Congenital cardiac anomaly
Ventricular Septal Defect
• Physical size of the VSD is a major determinant of the size of
the left-to-right shunt
• Restrictive VSD (usually <0.5 cm2) - right ventricular pressure
is normal
• Large nonrestrictive VSDs (usually >1.0 cm2)- right and left
ventricular pressure is equalized
Anatomical Classification
• Membranous/
perimembranousVSD
– Most common CHD
(males>females)
• • Muscular VSD
– “Swiss cheese” VSD
• Supracristal VSD
– Least common
ANCILLARY PROCEDURES
ECHOCARDIOGRAPHY
• Two-dimensional (2D) and Doppler colorflow mapping
• May be used to identify the type of defect
in the ventricular septum, size of the shunt
and the degree of pulmonary hypertension
ECHOCARDIOGRAPHY
Size of Defect
Results
Small restrictive VSDs
Normal tracing
Medium-sized VSDs
Broad, notched P wave characteristic of
left atrial overload
• Signs of LV volume overload —
deep Q and tall R waves with tall T
waves in leads V5 and V6
• Signs of atrial fibrillation are often
present
Large VSDs
Right ventricular hypertrophy with rightaxis deviation.
With further progression, the ECG shows
biventricular hypertrophy; P waves may be
notched or peaked.
ECG OF PATIENT
CHEST RADIOGRAPHY
Size of Defect
Radiographic Findings
Small VSDs
Normal
Medium-sized VSDs
Minimal cardiomegaly
Borderline increase in pulmonary
vasculature may be observed
Large-sized VSDs
Gross cardiomegaly with prominence
of both ventricles, the left atrium, and
the pulmonary artery
Interstitial infiltrates are seen in both
perihilar areas.
The heart is not enlarged.
Diaphragms are slightly flattened with intact
costophrenic sulci
Impression: Consider Pneumonia with mild
hyperaeration
TREATMENT
Initial medical treatment for infants
• Cardiac glycoside (digoxin 10-20mcg/kg per
day)
• Loop diuretics (furosemide 1–3 mg/kg per day)
• ACE inhibitors (captopril 0.5–2 mg/kg per day)
CARDIAC GLYCOSIDES
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possess positive inotropic activity, which is mediated by
inhibition of sodium-potassium adenosine triphosphatase
(ATPase).
• also reduces conductivity in the heart, particularly
through the AV node; therefore, they have a negative
chronotropic effect
• used to slow the heart rate in supraventricular
arrhythmias, especially atrial fibrillation.
ACE INHIBITORS
• Used to treat CHF
• May be of use to treat systemic afterload
SURGICAL CLOSURE
• involved placing a restrictive band across the
main PA.
• proposed since pulmonary vascular disease as
a result of unimpeded flow to the lungs was
recognized as a dreaded complication of a
ventricular septal defect
• with low mortality and morbidity
INDICATIONS FOR SURGICAL
REPAIR
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Uncontrolled CHF
Growth failure
Recurrent respiratory infection
Prolapse of aortic valve cusp
The contribution of pulse
oximetry to the early detection
of congenital heart disease in
newborns
Romaine Arlettaz, Andrea Seraina Bauschatz, Marion Mönkhoff , Bettina Essers, Urs
Bauersfeld
Eur J Pediatr (2006) 165: 94–98
Objectives
• To determine the effectiveness of a pulseoximetric screening performed on the first day of
life for the detection of congenital heart disease
in otherwise healthy newborns
• To determine if a pulse-oximetric screening
combined with clinical examination is superior in
the diagnosis of congenital heart disease to
clinical examination alone
Methods
• Study design: prospective multi-centre
study
• Zurich, Switzerland; May 2003 to May
2004
• Population: infants above 35 weeks of
gestation (n=3,262)
Methods
Results
Results
Conclusion
• Postductal pulse-oximetric screening in
the first few days of life is an effective
means for detecting cyanotic congenital
heart disease in otherwise healthy
newborns