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Cardiac Problems in Children. Dr S Bandi Slides courtesy of Dr M Rajimwale. Cardiac Problems in Children. Congenital heart disease. Arrhythmias. Myocardial/pericardial, endocardial. Congenital heart disease. Incidence - 0.8% live births 10% in still born/ abortus
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Cardiac Problems in Children Dr S Bandi Slides courtesy of Dr M Rajimwale
Cardiac Problems in Children Congenital heart disease Arrhythmias Myocardial/pericardial, endocardial
Congenital heart disease Incidence - 0.8% live births 10% in still born/ abortus < 10% chromosomal abnormality/genetic mutations 25% have extracardiac abnormality
Syndromes Chromosomes Downs (Trisomy 21) AVSD,VSD,TOF Edwards (Tris.18) VSD, various defects Patau (Tris.13) VSD, various defects Turner (XO) Coarct.,AS de-George (22q11deletion) Truncus,IAA,TOF Williams (7q del) Supravalvar AS
More associations Maternal Disease Diabetes Mellitus – TGA,VSD, HOCM SLE - Heart block Associations Oesophageal Atresia - VSD, TOF Anorectal malformation- Any Diag. Hernia - Any Exomphalos - Any Pierre Robin - VSD
Teratogens Teratogenic Exposure Rubella Coarct, VSD, PDA Alcohol VSD Phenytoin ASD Lithium Ebsteins anomaly Warfarin VSD, TOF
FOETAL CIRCULATION Two intracardiac communications Ventricles working in parallel
Right heart Left heart 75% >95% LA RA 3mm 8 75% >95% RV LV 100/8 25/3 75% >95% 25/10 100/60 >95% 75% Aorta PA
VSD 30.5% ASD 9.8% PDA 9.7% PS 6.9% Coarctation of aorta 6.8% AS 6.9% TOF 5.8% TGA 4.2% Truncus 2.2% TA 1.3%
Cardiac failure – (Lt to Rt shunt – first few months LV outflow obstruction – few days/weeks Functional failure-cardiomyopathy) tachypnoea tachycardia poor feeding, sweating failure to thrive hepatomegaly Central Cyanosis - duct dependant - acutely unwell neonate cyanotic spells - TOF Clinical Manifestations • CHD causing cyanosis- • 5 Ts – • TOF • TGA • Tricuspid atresia • TAPVD • Truncus Arteriosus • Pulm atresia
Clinical Manifestations... • Incidental detection of murmur on routine examination MURMUR OFTEN ABSENT IN CYANOTIC CONGENITAL HEART DISEASE
Infective endocarditis - rare < 2 years Sudden death - rare, HOCM, severe AS, long QT Palpitation, dizziness, fainting - arrhythmia, long QT syndrome Chest pain - rare, ischaemia - aortic stenosis, anomalous origin of coronary artery pericarditis Clinical manifestations ...
Examination • General exam • growth, dysmorhism, well/unwell • colour, perfusion, pulse (including femorals) , BP, post-ductal SaO2 • CVS • inspection auscultation (supine and standing) palpation
Auscultation • heart sounds (intensity, splitting of 2nd sound) • systolic murmurs - intensity I - VI, phase of cardiac cycle, area best heard, radiation (listen to neck, axilla, back), change with posture, • diastolic murmurs - I - IV • Other systems - respiratory, abdomen
Commonest cardiac problem a general paediatrician will see? Innocent murmurs
Innocent murmurs • 30% of all children on routine auscultation may have one. • ‘Still’s murmur’- commonest age group 3-7yr – vibratory/musical in quality • ‘pulmonary flow’, ‘venous hum’, ‘peripheral pulmonary stenosis’ • Change in intensity with posture • Always systolic (except venous hum – continuous) • ASYMPTOMATIC
Investigations • Chest X-ray – cardiac size, lung vascularity, • ECG – chamber enlargement • Hyperoxia test - to differentiate between cardiac and pulmonary cause of cyanosis in neonate • Echocardiography - definitive diagnosis • Consider chromosomal analysis ( T21, 22q11)
Normal pulmonary vascularity PS (mild/moderate) AS Coarctation of aorta Pulmonary plethora VSD ASD PDA Severe LV outflow obstruction/ hypoplastic left heart Acyanotic
Pulmonary oligaemia severe PS/atresia TOF TA complex lesion with PS Pulmonary plethora - TGA with VSD - Truncus Arteriosus - Total anomalous pulmonary venous drainage (TAPVD) Cyanotic
Heart block maternal SLE complex congenital defect Tachy-arrhythmias supraventricular tachcardia long QT syndrome - prone to ventricular tachycardia Conduction disorders
Other cardiac problems • Myocardial - cardiomyopathies (genetic, metabolic), myocarditis - viral • Endocardial - infective (bacterial) endocarditis • Pericardial - pericarditis, pericardial effusion
Management strategies MEDICAL • Cardiac failure - rest, may need O2 • afterload reduction - arteriolar dilators (Captopril), diuretics • Inotropes - Digitalis, Dopamine/Dobutamine • arrhythmia - treat • Supportive - nutrition, avoid fluid overload
Antibiotic prophylaxis • all heart defects causing high velocity turbulence, prosthetic material • NOT REQUIRED IN ASD • Dental, surgical/endocsopic, ENT procedures
Cyanosis - • acute presentation in neonate - likely to be a duct dependant lesion • KEEP DUCT OPEN WITH PGE1 INFUSION • may need urgent surgical intervention (atrial septostomy in TGA, balloon dilatation of pulm/aortic valve, TAPVD)
Cyanotic spells in TOF (pulmonary stenosis, large VSD, overriding aorta, RVH) • calm the baby • knee chest position • O2, Morphine
Conduction disorders - permanent pacing for congenital complete heart block • Medication for tachyrrhythmias
Repair of defect • Interventional cardiac catheterisation – • PDA, ASD, VSD – occlusion with device placement • PS, AS – balloon dilatation • Definitive surgical repair • Palliative surgical repair in some complex lesions • Long term cardiology follow-up