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Paediatric Cardiology

Valmiki K. Seecheran.Year V MBBS

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Fetal circulation.

• Fetus.– Placenta is the oxygenator; lungs do little work.

• Shunts necessary for survival.– Ductus venosus – by pass liver.– Foramen ovale – R-L atrial shunt.– Ductus arteriosus – R-L arterial shunt.

• RV & LV contribute equally to systemic circulation.

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Transitional circulation.

• Birth.– 1st few breaths, lungs expand and serves as

oxygenator.– Foramen ovale functionally closes.– Ductus arteriosus usually closes within 1-2 days.

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Neonatal Circulation.

• RV pumps to pulmonary circulation and LV pumps to systemic circulation.

• By 6 weeks pulmonary resistance drops and LV becomes dominant.

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Pediatric Circulation.

• RV is a more compliant chamber than LV.• LV pressure is 4-5x RV pressure.– RV pumps against lower resistance than LV.

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Congenital Heart Disease.

• 0.5 – 1% of live births.• Classification– L-R shunts.– Cyanotic CHD (R-L) shunts.– Obstructive lesions.

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‘Acyanotic CHD’ – L-R shunts.

• VSD– Infancy.– Heart Failure, murmurs & FTT.

• PDA– Infancy.– Heart Failure, murmurs & FTT.

• ASD– Childhood/ Exercsise intolerance.– Right heart enlargement.– Transmits flow only.

• AVSD

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Eisenmenger’s Syndrome.

• L-R shunt.– Irresversible pulmonary vascular disease.– Unrepaired VSD’s & PDA’s due to high pressure.– PVR high, the shunt reverses, becomes R-L and

patient becomes cyanotic.

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R-L Shunts.

• Classified based on pulmonary blood flow:

1. Increased PBF (pulmonary blood flow).– Transposition of great arteries.– Truncus arteriosus.– Total anamalous pulm return.

2. Decreased PBF (pulmonary blood flow).– Tetraology of Fallot.– Tricuspid atresia.

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R-L Shunts.

• Increased PBF.– Presents often with heart failure.– Pulmonary congestion worsens as neonatal PVR

decreases.– P02 can be 93-94%.

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R-L Shunts.

• Decreased PBF.– Cyanosis.– Closure of PDA may worsen cyanosis.

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Innocent murmurs.

• Peripheral pulmonic stenosis.– Newborns – disappears by 1 year of age.– ULSB – best heard in axilla/back.– Differentiate between PS – associated with a

valvular click and heard best of precordium.

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Innocent murmurs.

• Still’s murmur.– Classic.– 3-5 years commonly.– Vibratory – heard along LSB and apex.– Increased in intensity when patient is supine/

patient in high output states (fever, dehydration).– Differentiate from VSD.

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Syndrome Associations.

• Down’s Syndrome – AV canal & VSD.• Turner’s Syndrome – CoA & AS.• Trisomies 13 & 18 – VSD & PDA.• Fetal Alcohol Syndrome – L-R shunt, ToF.

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Kawasaki Disease.

• #1 cause of acquired heart disease.• Autoimmune & < 5 years of age.• System vasculilitis (necrotizing); veins & arteries. –

idiopathic.• Work up.

– CBC, U&E, CRP, ESR, EKG, ECHO.• Treatment.

– IVIG, Salicylate therapy, Aspirin, Corticosteroids.• Prognosis.

– Coronary artery dilation 25% w/o IVIG and 5% w/IVIG.– Frequent ECHOs.

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Kawasaki Disease

• Clinical Criteria – Fever for atleast 5 days and 4 of the following 5 parameters:– Eyes – conjuctivial injection.– Lips & mouth – erythema, cracked lips, strawberry

tongue.– Hands & feet – edema/ erythema.– Skin – rash.– Unilateral, cervical lyphadenopathy.

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Rheumatic Fever

• Post infectious connective tissue disease• Antibody cross-reactivity – Group A Strep.• Work up– Throat Cx, CRP, ESR, EKG, ECHO.– Jones criteria.

• Major – Polyarthritis, Carditis, Nodules, Erythema marginatum.• Minor – Fever, Arthralgia, Raised ESR, Leukocytosis,

prolonged PR interval.

• Treatment– Aspirin, corticosteroids, Penicillin.

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Thank you.