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Cardiology Conference

Cardiology Conference. Gatchalian , Gaw , Geraldoy , Geronimo, Geronimo, Geronimo December 22, 2010. C.F. 2 months old / male CC: Fever. C.F. 2 months old / male CC: Fever. C.F. 2 months old / male CC: Fever. Review of Systems. General: (-) noticeable weight loss

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Cardiology Conference

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  1. Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

  2. C.F. 2 months old / maleCC: Fever

  3. C.F. 2 months old / maleCC: Fever

  4. C.F. 2 months old / maleCC: Fever

  5. Review of Systems • General: (-) noticeable weight loss • Cutaneous: (-) rashes, (-) discoloration • HEENT: (-) ear discharge, (-) epistaxis, (-) gum bleeding • Respiratory: refer to HPI • Cardiovascular: refer to HPI • GI: (-) diarrhea, (-) constipation • GUT: yellow urine, (-) edema of the hands and feet • Extremities: (-) swelling, (-) joint swelling • Nervous/Behaviour: (-) tremors, (-) convulsions • Hematopoietic: (-) pallor, (-) easy bruisability

  6. Immunization History • Received the following at a local health center: • BCG 1 • Hepatitis B 1 • DTP 1 • OPV1 • Next dose due on December 27, 2010

  7. Family Profile

  8. Family History • (+) Rheumatic Heart Disease – maternal grandmother • (-) HPN • (-) Diabetes Mellitus • (-) Pulmonary Tuberculosis • (-) Allergies

  9. Socioeconomic and Environmental History • Four bedroom house made of wood and concrete • Well lit and well ventilated • Garbage is collected daily, no segregation • Purified water from a water refilling station. • Baby bottles also sterilized • Stray cats • Second hand smoke

  10. Physical Examination • General Survey: awake, alert, in respiratory distress with alar flaring, ill looking, well-nourished, well-hydrated • Vital Signs: HR 140 bpm, RR 70 cpm Temp 36.0 °C Wt 4.7 kg (z=below 0 normal) Ht: 49 cm (z= below -3 severely stunted) BMI: 19.58 (z= above 2 overweight) • Head circumference 37 cm, chest circumference 36 cm, abdominal circumference 40 cm • Skin: Warm, moist skin, pink in color, good skin turgor, no rashes, no jaundice

  11. Physical Examination • HEENT: normocephalic, anterior fontanel open, symmetric head, (-) scalp lesions, symmetric face; Eyeballs not sunken, pink palpebral conjunctiva, anicteric sclerae, pupils 2-3 mm ERTL; Midline nasal septum, (+) whitish nasal discharge; Moist buccal mucosae, nonhyperemic posterior pharyngeal wall; Supple neck, (-) palpable lymph nodes

  12. Physical Examination • Lungs/Chest: Symmetric chest expansion, (+) subcostal retractions, (+) crackles on both upper lung fields • Cardiovascular: adynamic precordium, no precordial bulge, (-) Harrison’s groove, (+) holosystolic murmur at the lower left parasternal area grade 4/6 • Abdomen: globular abdomen, normoactive bowel sounds, soft, non tender, no masses • Spine: midline, (-) sacral dimpling, (-) tufts of hair • Genitalia: Penis 2cm, testes descended bilaterally, no phimosis, no discharge • Extremities: full peripheral pulses, no cyanosis, no clubbing

  13. Neurologic Examination • Cerebrum: alert • Cranial nerves: Pupils isocoric, 2-3mm ERTL, (+) direct and consensual light reflex, (-) gross facial asymmetry, (+) gag reflex • Cerebellum: (-) no involuntary movements • Motor: (-) rigidity, (-) spasticity, (-) Flaccidity • Meningeal Signs: (-) nuchal rigidity, (-) Brudzinski’s, (-) Kernig’s, (-) tonic neck reflex

  14. Subjective Salient Features

  15. Objective Salient Features

  16. Presenting manifestation • Incessant crying and irritable • Vomiting • Fever • Development at par with age • Alert, awake • respiratory distress with alar flaring • symmetrical chest expansion • RR: 70 cpm (tachypneic); • (+) subcostal retractions • (+) crackles on both lung fields • Ht: 49 cm ( z=-3 severely stunted; BMI: 19.58 ( z= above 2 overweight) • (+) holosystolic murmur at the left parasternal area

  17. small defects: physical findings are primarily cardiac manifestations • moderate-to-large defects: growth may be affected • Infants with small defects • normal vital signs. • Physiologic splitting of S2 is usually retained • harsh, holosystolic murmur is loudest along the lower left sternal border (LSB), and it is well localized. • Small defects can produce a high-pitched or squeaky noise.

  18. Infants with moderate defects • normal length and decreased weight • Poor weight gain is a sensitive indicator of congestive heart failure (CHF). • mild tachypnea, tachycardia, and an enlarged liver • The precordial activity is accentuated. • The murmur associated with thrill • A holosystolic harsh murmur is most prominent over the lower LSB. • The intensity of the pulmonary component is usually normal or slightly increased. • a diastolic rumble may be detected in the mitral area. • This rumble suggests functional mitral stenosis secondary to a large left-to-right shunt and indicates a surgical-level shunt

  19. Infants with large ventricular septal defects • signs of CHF are present • tachycardia, tachypnea, and hepatomegaly • cardiomegaly • The murmur is holosystolic but poorly localized and is usually associated with a diastolic rumble

  20. ASD • first heart sound may be normal or split • best appreciated at the upper left sternal border and may be transmitted to the lung fields. • second heart sound becomes widely split and fixed • fixed splitting of S2 is an important diagnostic finding in atrial-level shunting

  21. PDA • history of premature birth, perinatal distress, or perinatal hypoxia may be present • If the left-to-right shunt is large, precordial activity is increased • The apical impulse is laterally displaced • A thrill may be present in the suprasternal notch or in the left infraclavicular region • The first heart sound is typically normal. The second heart sound (S2) is often obscured by the murmur • Continuous machinery murmur

  22. AS • may present as congestive heart failure in the first week of life that mimic sepsis • Often, neonates with aortic stenosis are asymptomatic but present with a systolic murmur

  23. PS • Most are asymptomatic cardiac murmurs that are detected during routine examination. • moderate or severe pulmonary stenosis : exertionaldyspnea. • severe or critical obstruction: signs of systemic venous congestion • Physical findings depend on the degree of obstruction. • healthy and are well developed. • trivial, mild, or moderate stenosis, and many with severe stenosis, are acyanotic • A thrill may be felt in the suprasternal notch and at the left upper sternal border (pulmonic area) • precordial thrill • first heart sound may be normal; second heart sound is widely split • A fourth heart sound may be heard at the left lower sternal border in patients with severe obstruction • An ejection systolic click is heard along the left sternal border • An ejection systolic murmur of grade II-VI to V-VI is best heard at the left upper sternal border with radiation into infraclavicular regions, axillae, or back. • Hepatosplenomegaly may develop in cases of CHF. • Peripheral pulmonary stenosis (commonly encountered in the neonate) is usually associated with a grade II/VI systolic murmur that radiates into the posterior lung fields and axillae

  24. coA • Early presentation: poor feeding, tachypnea, and lethargy and progress to overt CHF and shock. • Late presentation: Patients often present after the neonatal period with hypertension or a murmur • Other presenting symptoms may include headaches, chest pain, fatigue, or even life-threatening intracranial hemorrhage. • Many patients are asymptomatic except for the incidentally noted hypertension. • As with history, physical examination may conveniently separate patients into 2 groups: those who present early with heart failure and those who present later with hypertension. • Early presentation • Neonates: tachypnea, tachycardia, and increased work of breathing and may even be moribund with shock. • blood pressure discrepancies between the upper and lower extremities and reduced or absent lower extremity pulses to palpation • In patients with low cardiac output and ventricular dysfunction, pulses may be diminished diffusely, and BP gradients may seem minimal • The murmur associated with coarctation of the aorta may be nonspecific yet is usually a systolic murmur in the left infraclavicular area and under the left scapula.

  25. Differential diagnosis

  26. Difficulty breathing (dyspnea) Frequent respiratory infections in children Sensation of feeling the heart beat (palpitations) in adults Shortness of breath with activity Abdominal distention Cyanosis in some patients Chest pain Fainting Fatigue Poor weight gain or failure to thrive in infants with severe blockage Shortness of breath Sudden death Bounding pulse Fast breathing Poor feeding habits Shortness of breath Sweating while feeding Tiring very easily Poor growth Dizziness or fainting Shortness of breath Pounding headache Chest pain Cold feet or legs Failure to thrive Poor growth Breathlessness with activity Chest pain Fainting, weakness, or dizziness with activity Palpitations Shortness of breath Fast breathing Hard breathing Paleness Failure to gain weight Fast heart rate Sweating while feeding Frequent respiratory infections

  27. Clinical Impression Congenital Heart Disease Pneumonia

  28. Ventricular septal defect

  29. Ventricular Septal Defect • most common ACHD (25%) • SYNONYMS * Roger’s disease * Interventricular septal defect * Congenital cardiac anomaly

  30. Ventricular Septal Defect • Physical size of the VSD is a major determinant of the size of the left-to-right shunt • Restrictive VSD (usually <0.5 cm2) - right ventricular pressure is normal • Large nonrestrictive VSDs (usually >1.0 cm2)- right and left ventricular pressure is equalized

  31. Anatomical Classification • Membranous/ perimembranousVSD • Most common CHD (males>females) • • Muscular VSD • “Swiss cheese” VSD • SupracristalVSD • Least common

  32. ANCILLARY PROCEDURES

  33. ECHOCARDIOGRAPHY • Two-dimensional (2D) and Doppler color-flow mapping • May be used to identify the type of defect in the ventricular septum, size of the shunt and the degree of pulmonary hypertension

  34. ECHOCARDIOGRAPHY

  35. ECG OF PATIENT

  36. CHEST RADIOGRAPHY

  37. Interstitial infiltrates are seen in both perihilar areas. The heart is not enlarged. Diaphragms are slightly flattened with intact costophrenic sulci Impression: Consider Pneumonia with mild hyperaeration

  38. TREATMENT Initial medical treatment for infants • Cardiac glycoside (digoxin 10-20mcg/kg per day) • Loop diuretics (furosemide 1–3 mg/kg per day) •  ACE inhibitors (captopril 0.5–2 mg/kg per day)

  39. CARDIAC GLYCOSIDES • possess positive inotropic activity, which is mediated by inhibition of sodium-potassium adenosine triphosphatase (ATPase). • also reduces conductivity in the heart, particularly through the AV node; therefore, they have a negative chronotropic effect • used to slow the heart rate in supraventricular arrhythmias, especially atrial fibrillation.

  40. ACE INHIBITORS • Used to treat CHF • May be of use to treat systemic afterload

  41. SURGICAL CLOSURE • involved placing a restrictive band across the main PA. • proposed since pulmonary vascular disease as a result of unimpeded flow to the lungs was recognized as a dreaded complication of a ventricular septal defect • with low mortality and morbidity

  42. INDICATIONS FOR SURGICAL REPAIR • Uncontrolled CHF • Growth failure • Recurrent respiratory infection • Prolapse of aortic valve cusp

  43. The contribution of pulse oximetry to the early detectionof congenital heart disease in newborns Romaine Arlettaz, Andrea Seraina Bauschatz, Marion Mönkhoff , Bettina Essers, Urs Bauersfeld Eur J Pediatr (2006) 165: 94–98

  44. Objectives • To determine the effectiveness of a pulse-oximetric screening performed on the first day of life for the detection of congenital heart disease in otherwise healthy newborns • To determine if a pulse-oximetric screening combined with clinical examination is superior in the diagnosis of congenital heart disease to clinical examination alone

  45. Methods • Study design: prospective multi-centre study • Zurich, Switzerland; May 2003 to May 2004 • Population: infants above 35 weeks of gestation (n=3,262)

  46. Methods

  47. Results

  48. Results

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