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Approach to child with heart disease. Pushpa Raj Sharma Professor of Child Health Institute of Medicine. Diseases of heart. Blood vessels. Endocardium. Myocardium. Pericardium. Congenital Cyanotic: 22% Acyanotic: 68% VSD 25% ASD 6% PDA 6% TOF 5% PS 5% AS 5%. Acquired

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Approach to child with heart disease l.jpg

Approach to child with heart disease

Pushpa Raj Sharma

Professor of Child Health

Institute of Medicine


Diseases of heart l.jpg
Diseases of heart

Blood vessels

Endocardium

Myocardium

Pericardium


Prevalence l.jpg

Congenital

Cyanotic: 22%

Acyanotic: 68%

VSD 25%

ASD 6%

PDA 6%

TOF 5%

PS 5%

AS 5%

Acquired

Kawasaki disease

Rheumatic

Tubercular

Collagen

Prevalence

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

Nelson’s Textbook of pediatrics; 17 ed.


Common acyanotic lesions l.jpg
Common acyanotic lesions

  • Ventricular 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 Cyanotic Lesions

Decreased flow

1. Tetralogy of Fallot

2. Tricuspid Atresia

3. Severe Pulmonic Stenosis

4. Ebstein’s anamoly

Increased Flow

5. Transposition of great vessles

6. VSD with pulmonary atresia


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Common Lesions producing cyanosis

7. Truncus Arteriosus

8. Hypoplastic left heart

9. Single ventricle

10. TAPVR with infradiaphragmatic obstruction


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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

Presenting complaints/signs


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Cyanosis: is it a cardiac cause or lung cause

  • Hyperoxia test

    • Neonates with cyanotic congenital heart disease usually do not have significantly raised arterial Pao2 during administration of 100% oxygen.


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Small VSD

Asymptomatic

A loud, harsh, or blowing holosystolic murmur.

Large VSD

dyspnea, feeding difficulties, poor growth, profuse perspiration, recurrent pulmonary infections, and cardiac failure in early infancy.

Ventricular Defect

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)

Small VSDs, the chest radiograph is usually normal

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.


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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 (up to 80%) than membranous VSDs are (up to 35%).

  • infants with large defects have repeated episodes of respiratory infection and heart failure despite optimal medical management.

  • Surgical repair prior to development of an irreversible increase in pulmonary vasculalr resistance (usually prior to the patient's second birthday).


Atrial septal defects secundum l.jpg

Most common form of ASD (fossa ovalis)

In large defects, a considerable shunt of oxygenated blood flows from the left to the right atrium.

Mostly asymptomatic

The 2nd heart sound is characteristically widely split and fixed.

Atrial Septal Defects: secundum

Secundum


Atrial septal defects primum l.jpg

Situated in the lower portion of the atrial septum and overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.

Combination of a left-to-right shunt across the atrial defect and mitral insufficiency

C/F similar to that of an ostium secundum ASD

Atrial Septal Defects:primum


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Enlargement of the right ventricle overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.

Enlargement of atrium

Large pulmonary artery

increased pulmonary vascularity is.

Atrial Septal Defect


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The overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.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


Atrial septal defects l.jpg
Atrial Septal Defects overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.

  • Secundum ASDs are well tolerated during childhood.

  • Antibiotic prophylaxis for isolated secundum ASDs is not recommended.

  • Surgery or transcatheter device closure is advised for all symptomatic patients and also for asymptomatic patients with a Qp:Qs ratio of at least 2:1.

  • Ostium primum defects are approached surgically


Patent ductus arteriosus l.jpg
Patent Ductus Arteriosus overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.

  • Small defect no symptoms.

  • Large defect:

    • Wide pulse pressure

    • Enlarged heart

    • Thrill in L second IS

    • Continuous murmur

    • X-ray: prominent pulmonary artery with increased vascular markings.


Primary pulmonary hypertension l.jpg

Prominent pulmonary artery. overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.

Prominent right ventricle

Prominent vascularity in the hilar areas

Decreased vascualr marking in the periphery.

No treatment

Primary Pulmonary Hypertension


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Mitral insufficiency: Rheumatic overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.

High volume load

Inflammatory process

Enlarged left ventricles

Dilatation of the left atrium

Pulmonary congestion

Symptoms of left sided failure

Spontaneous improvement

Repeated insult

Chronic mitral insufficiency

Raised Pulmonary AP

Symptoms of right heart failure

Enlarged right ventricle and atrium


Mitral insufficiency rheumatic21 l.jpg

Signs of heart failure overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.

Heaving apical impulse

Apical systolic thrill

Accentuated 2nd sound

Holosystolic murmur radiating to axilla

ECG: bifid P waves and left ventricular hyertrophy

X-ray: prominent left atrium and ventricle (straight left border)

Mitral insufficiency: Rheumatic

Prophylaxis against recurrence of rheumatic fever


Rheumatic valvular disease mitral stenosis l.jpg
Rheumatic valvular disease: overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.Mitral stenosis

  • Takes 10 years to develop

  • Symptoms proportionate to severity

  • Left ventricular failure right ventricular failure

  • Loud first heart sound with opening snap.

  • Diastolic murmur

  • Absent murmur if heart failure.

  • Surgical intervention if symptomatic


Mitral stenosis l.jpg

Loud 1 overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.st sound

Diastolic murmur

left atrial enlargement

prominence of the pulmonary artery

enlarged right-sided heart chambers;

ECG: prominent notched P wave.

Mitral Stenosis


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Presenting complaint overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.

Precordial pain

Cough

Dyspnoea

Abdominal pain

Vomiting

Fever

Other organs involvement

Signs:

Position: leaning forward.

Puffy face

Friction rub

Absent apical impulse

Muffled heart sounds

Pulsus paradoxus

Distended neck veins

Low QRS complex, T inversion

Pericardial Effusion


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A relatively large pericardial effusion must be present to cause an enlarged cardiac shadow with the usual “water bottle” configuration on a chest roentgenogram

Pericardial Effusion


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The test that differentiates cause an enlarged cardiac shadow with the usual “water bottle” configuration on a

The cardiac seize and the vascularity in the chest X-ray


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Cardiac disease with normal/decreased vasculature cause an enlarged cardiac shadow with the usual “water bottle” configuration on a

  • Viral myocarditis

  • Tetralogy of Fallot

  • Pulmonary atresia

  • Tricuspid atresia

  • Endocardial fibroelastosis

  • Aberrant left coronary artery

  • Cystic medial necrosis

  • Diabetic mother


Tetralogy of fallot l.jpg
Tetralogy of Fallot cause an enlarged cardiac shadow with the usual “water bottle” configuration on a

Ventricular septal defect

Pulmonic stenosis

Overriding aorta

Right ventricular hypertrophy

Cyanotic


Cardiac disease with increased vasculature l.jpg
Cardiac disease with increased vasculature cause an enlarged cardiac shadow with the usual “water bottle” configuration on a

  • 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


Congestive cardiac failure l.jpg

Enlarged heart cause an enlarged cardiac shadow with the usual “water bottle” configuration on a

Plethoric lung fields specially at bases

Congestive Cardiac Failure


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