approach to heart

8/3/2019 Approach to Heart

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Diseases of heart

Pericardium

Myocardium

Endocardium

Blood vessels


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PrevalencePrevalence CongenitalCongenital

Cyanotic: 22%

Acyanotic: 68%

VSD 25%

ASD 6%

PDA 6% TOF 5%

PS 5%

AS 5%

AcquiredAcquired

Kawasaki disease

Rheumatic

Tubercular

Collagen

Ceylon Med J 2001 Sep; 46 (3): 96-8; Indian J Pediatr. 2001 Aug;68 (8):757-7

Nelsons Textbook of pediatrics; 17 ed.


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Common acyanotic lesionsVentricular 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


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Common Lesions producing

cyanosis

7. Truncus Arteriosus

8. Hypoplastic left heart9. Single ventricle

10. TAPVR with infradiaphragmatic

obstruction


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Presenting complaints/signs Failure to thrive

Exercise intolerence

Easy fatigability Chest indrawing

Sweating during feeding

Bluish spells

Fever with rigor

Palpitation

Convulsion

Fast breathing

Oedema

Hepatomegaly,

spleenomegaly Clubbing

Cyanosis

Focal neurological lesion

Other organ defects

Chromosomal anomalies


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Cyanosis: is it a cardiac cause or

lung cause

Hyperoxia test

Neonates with cyanotic congenital heartdisease usually do not have significantlyraised arterial Pao2 during administration

of100% oxygen.


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Ventricular Defect Small VSD

Asymptomatic

A loud, harsh, or

blowing holosystolicmurmur.

Large VSD dyspnea, feeding

difficulties, poor

growth, profuseperspiration, recurrentpulmonary infections,and cardiac failure inearly infancy.

80%

Syndromes associated with this condition


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VSD: ECG is normal but may show right ventricular

hypertrophy, if present indicates defect is large and presence

of pulmonary hypertension or pulmonry stenosis


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Ventricular Septal Defect

(VSD)

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.

Small VSDs, the chest radiograph is usually normal


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Ventricular Septal defects

30

50% of small defects close spontaneously,most frequently during the 1st 2 yr of life.

Small muscular VSDs are more likely to close (upto 80%) than membranous VSDs are (up to

35%). infants with large defects have repeated

episodes of respiratory infection and heartfailure despite optimal medical management.

Surgical repair prior to development of anirreversible increase in pulmonary vasculalrresistance (usually prior to the patient's secondbirthday).


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Atrial Septal Defects:

secundum Most common form of

ASD (fossa ovalis)

In large defects, aconsiderable shunt ofoxygenated blood flowsfrom the left to the rightatrium.

Mostly asymptomatic

The 2nd heart sound ischaracteristically widelysplit and fixed.

Secundum


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Atrial Septal Defects:primum Situated in the lowerportion of the atrial septumand overlies the mitral and

tricuspid valves. In mostinstances, a cleft in theanterior leaflet of the mitralvalve is also noted.

Combination of a left-to-right shunt across the atrialdefect and mitralinsufficiency

C/F similar to that of an

ostium secundum ASD


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Atrial Septal Defect

Enlargement of theright ventricle

Enlargement ofatrium

Large pulmonaryartery

increased pulmonaryvascularity is.


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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


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Atrial Septal Defects Secundum ASDs are well tolerated during

childhood.

Antibiotic prophylaxis for isolatedsecundum ASDs is not recommended.

Surgery or transcatheter device closure isadvised for all symptomatic patients andalso for asymptomatic patients with aQp:Qs ratio of at least 2:1.

Ostium primum defects are approached

surgically


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Patent Ductus Arteriosus Small defect no

symptoms.

Large defect: Wide pulse pressure

Enlarged heart

Thrill in L second IS

Continuous murmur X-ray: prominent

pulmonary arterywith increasedvascular markings.


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Primary Pulmonary

Hypertension Prominent

pulmonary artery.

Prominent rightventricle

Prominentvascularity in thehilar areas

Decreased vascualrmarking in theperiphery.

No treatment


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Mitral insufficiency: RheumaticHigh volume load

Inflammatory processEnlarged left ventricles

Dilatation of the left atrium

Pulmonary congestion

Symptoms of left sided failure

Repeated insult

Spontaneous improvement

Chronic mitral insufficiency Raised Pulmonary AP

Enlarged right ventricle and atriumSymptoms of right heart failure


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Mitral insufficiency: Rheumatic Signs of heart failure

Heaving apical

impulse

Apical systolic thrill

Accentuated 2nd

sound Holosystolic murmur

radiating to axilla

ECG: bifid P wavesand left ventricular

hyertrophy X-ray: prominent left

atrium and ventricle(straight left border)

Prophylaxis against recurrence of rheumatic fever


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Rheumatic valvular disease:

Mitral stenosis Takes 10 years to develop

Symptoms proportionate to severity

Left ventricular failure right ventricularfailure

Loud first heart sound with opening snap.

Diastolic murmur

Absent murmur if heart failure.

Surgical intervention if symptomatic


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Mitral Stenosis Loud 1stsound

Diastolic murmur

left atrial enlargement

prominence of thepulmonary artery

enlarged right-sidedheart chambers;

ECG: prominentnotched P wave.


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Pericardial Effusion Presenting complaintPresenting complaint

Precordial pain

Cough Dyspnoea

Abdominal pain

Vomiting

Fever

Other organsinvolvement

Signs:Signs:

Position: leaning forward.

Puffy face Friction rub

Absent apical impulse

Muffled heart sounds

Pulsus paradoxus

Distended neck veins Low QRS complex, T

inversion


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Pericardial Effusion A relatively large

pericardial effusion

must be present tocause an enlargedcardiac shadow withthe usual water

bottle configurationon a chestroentgenogram


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The test that differentiates

The cardiac seize and the vascularity inthe chest X-ray


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Cardiac disease with normal/decreasedvasculature

Viral myocarditis

Tetralogy of Fallot

Pulmonary atresia

Tricuspid atresia

Endocardial fibroelastosis

Aberrant left coronary artery Cystic medial necrosis

Diabetic mother


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Cyanotic

Tetralogy of Fallot

Ventricular septaldefect

Pulmonic stenosis

Overriding aorta

Right ventricular

hypertrophy


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Cardiac disease with increasedvasculature

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


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Congestive Cardiac Failure

Enlarged heart

Plethoric lung fieldsspecially at bases

approach to heart

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