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Approach to child with heart disease
Pushpa Raj SharmaProfessor of Child Health
Institute of Medicine
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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
Nelson’s Textbook of pediatrics; 17 ed.
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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 LesionsDecreased flow 1. Tetralogy of Fallot 2. Tricuspid Atresia 3. Severe Pulmonic Stenosis 4. Ebstein’s anamoly Increased Flow 5. Transposition of great vessles6. 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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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 heart disease usually do not have significantly raised arterial Pao2 during administration of 100% oxygen.
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Ventricular Defect 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.
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 (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).
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Atrial Septal Defects: secundum 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. Secundum
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Atrial Septal Defects:primum
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
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Atrial Septal Defect
Enlargement of the right ventricle
Enlargement of atrium
Large pulmonary artery
increased pulmonary vascularity 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 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
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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 artery with increased vascular markings.
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Primary Pulmonary Hypertension
Prominent pulmonary artery.
Prominent right ventricle
Prominent vascularity in the hilar areas
Decreased vascualr marking in the periphery.
No treatment
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Mitral insufficiency: Rheumatic
High 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 waves and 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
ventricular failure 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 1st sound Diastolic murmur left atrial
enlargement prominence of the
pulmonary artery enlarged right-sided
heart chambers; ECG: prominent
notched P wave.
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Pericardial Effusion Presenting complaintPresenting complaint
Precordial pain Cough Dyspnoea Abdominal pain Vomiting Fever Other organs
involvement
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 to cause an enlarged cardiac shadow with the usual “water bottle” configuration on a chest roentgenogram
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The test that differentiates
The cardiac seize and the vascularity in the chest X-ray
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Cardiac disease with normal/decreased vasculature
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 septal defect
Pulmonic stenosis Overriding aorta Right ventricular
hypertrophy
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Cardiac disease with increased vasculature
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
fields specially at bases