cardiology conference

Cardiology Conference

Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo

December 22, 2010

C.F. 2 months old / maleCC: Fever

Review of Systems

• 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

• Received the following at a local health center:

• BCG 1

• Hepatitis B 1

• DTP 1

• OPV1

– Next dose due on December 27, 2010

Family Profile

Family History

• (+) Rheumatic Heart Disease – maternal grandmother

• (-) HPN

• (-) Diabetes Mellitus

• (-) Pulmonary Tuberculosis

• (-) Allergies

Socioeconomic and Environmental History

• 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


• 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


• 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

Objective Salient Features

Presenting manifestation

• 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).

– 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• 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.

– 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• 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 life-

threatening 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

– 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

Shortness of breathFast breathingHard breathingPalenessFailure to gain weightFast heart rateSweating while feedingFrequent respiratory infections

Difficulty breathing (dyspnea)Frequent respiratory infections in childrenSensation of feeling the heart beat (palpitations) in adultsShortness of breath with activity

Bounding pulseFast breathingPoor feeding habitsShortness of breathSweating while feedingTiring very easilyPoor growth

Breathlessness with activityChest painFainting, weakness, or dizziness with activityPalpitations

Abdominal distentionCyanosis in some patientsChest painFaintingFatiguePoor weight gain or failure to thrive in infants with severe blockageShortness of breathSudden death

Dizziness or faintingShortness of breathPounding headacheChest painCold feet or legsFailure to thrivePoor growth

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 color-flow mapping

• May be used to identify the type of defect in the ventricular septum, size of the shunt and the degree of pulmonary hypertension

ECHOCARDIOGRAPHYSize 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 right-axis deviation.With further progression, the ECG shows biventricular hypertrophy; P waves may be notched or peaked.

ECG OF PATIENT

CHEST RADIOGRAPHYSize of Defect Radiographic Findings

Small VSDs Normal

Medium-sized VSDs Minimal cardiomegalyBorderline 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

• 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

• Uncontrolled CHF

• Growth failure

• Recurrent respiratory infection

• Prolapse of aortic valve cusp

The contribution of pulse oximetry to the early detectionof 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 pulse-oximetric 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

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

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