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Congenital heart disease

Congenital heart disease. understood. Understand physiology and relate to clinical findings. Objectives. Congenital Heart Disease (CHD) – incidence 8:1000 live births 4:1000 are symptomatic Up to 60% of neonates have a murmur at some stage Up to 1.6% have murmur at routine exam.

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Congenital heart disease

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  1. Congenital heart disease understood

  2. Understand physiology and relate to clinical findings Objectives

  3. Congenital Heart Disease (CHD) – incidence 8:1000 live births 4:1000 are symptomatic Up to 60% of neonates have a murmur at some stage Up to 1.6% have murmur at routine exam. 54% of babies with murmurs have CHD Routine neonatal examination fails to detect more than half of babies with CHD Normal examination does not exclude CHD Facts and Figures

  4. Purpose of Screening for CHD • Early identification before failure or hypoxia develop • Prevention of irreversible damage • Remember heart rate and rhythm

  5. Normal cardiac circulation

  6. Postnatal Anatomy and Function(picture from British Heart Foundation – www.bhf.org.uk)

  7. Congenital HeartProblems • Cyanotic Congenital Heart Disease = blue • Acyanotic Congenital Heart Disease = pink • Cardiac Arrhythmias – fast or slow

  8. Low or no pulmonary blood flow - less oxygen picked up Transposition streaming Complete intra-cardiac mixing i.e mixed blue and pink Why Cyanosis / blue?

  9. Low pulmonary flow

  10. Separate streaming of blue and pink blood – transposition great arteries

  11. Tetralogy of fallots

  12. Tricuspid Atresia Pulmonary Atresia Transposition of the Great Arteries (7%) Tetralogy of Fallot (10%) Total Anomalous Pulmonary Venous Drainage Cyanotic CongenitalHeart Defects

  13. Cyanotic summary • Not pick up enough oxygen • Mix blue and pink blood

  14. Ventricular Septal Defect (25%) Atrial Septal Defect (7%) Atrio-ventricular Septal Defect Patent Ductus Arteriosus (12%) Coarctation of Aorta Aortic Stenosis (5%) Pulmonary Stenosis (5%) Acyanotic Congenital Heart Defects ie. pink

  15. Ventricular septal defect

  16. Aortic stenosis

  17. Congenital Arrhythmias • Irregular Rhythm – atrial or ventricular extrasystoles • Bradycardia – sinus bradycardia, congenital heart block • Tachycardia – supraventricular tachycardia

  18. Prior to Examination • Note family history • Note maternal drug/alcohol/illness history • Note antenatal pointers to cardiac abnormality eg. Scan reports, high risk of Down’s Syndrome, irregular fetal heart • Parents view of baby’s well being • Ensure baby’s comfort

  19. Examination of Cardiovascular System • Colour • ( Dysmorphic features ) • Respiratory rate and effort • Palpation of apex beat • Palpation for thrills and heave • Heart rate and rhythm • Heart sounds and murmurs • Peripheral pulses

  20. Murmurs • Timing – pan systolic, ejection systolic, continuous, diastolic • Intensity – graded 1-6 • Location – maximal intensity and radiation • (May be innocent – quiet and short at left sternal edge with no accompanying symptoms or signs)

  21. Site of Murmurs

  22. Abnormal Symptoms • Feeding difficulties • Poor Colour • Dyspnoea • Restlessness • Lethargy • Sweating

  23. Abnormal Signs • Poor colour or cyanosis • Tachypnoea • Displaced apex beat • Hyperdynamic praecordium • Thrill or heave present • Abnormal cardiac rate or rhythm • Added heart sounds or murmurs • Poorly palpable or absent peripheral pulses • Hepatomegaly

  24. Referral pathway • Refer registrar or ANNP • Assessment of well-being and saturations • echo telelink? • Seek feedback

  25. CONTROVERSIESShould saturation monitoring be part of routine assessment? • Prevent Mortality and Morbidity • Estimate MISS 50% • Only Detect Hypoxia- Blue • Duct Dependant Lesions more critical • Routine antenatal screening picks up most and introduced to practise • Multicentre UK study to assess benefits

  26. “pulseOx test accuracy study” • Multi-centre study to recruit 20,055 • Saturations before discharge or 24 hours • If less than 95% - examine and repeat • Access to reliable echo and follow up • 53 major CHD with 24 critical. 34 known from antenatal screen • Sensitivity= 75% for critical and 49% for major • Miss low output e.g aortic stenosis Lancet august 2011, issue 9793,p 785-794 WWW.HTA.AC.UK/1624

  27. Summary • Newborn examination is an opportunity to identify CHD early • Normal examination does not exclude CHD • Cardiac assessment includes consideration of family and antenatal factors as well as clinical examination • Symptomatic babies may require urgent referral for further assessment • If in doubt … • ASK FOR HELP • Do not be afraid to refer

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