Neonate in Cardiac Distress Clinical Recognition

1. Neonate in Cardiac Distress Clinical Recognition SavitriShrivastava Director - Pediatric & Congenital Heart Diseases Fortis Escorts Heart Institute New Delhi, India

2. Why Important ? - 1% Live Births - 2 % in Premature infant 30% need Urgent Attention Infant Mortality - 25 % due to Heart Defects Early recognition and prompt management can save most of them New Born in Cardiac Distress • Congenital Heart Disease

3. Neonatal Heart Disease High index of suspicion Prompt recognition Early stabilization Timely referral New Born in Cardiac Distress “ Crucial for an optimal outcome”

4. New Born in Cardiac Distress Fetal Diagnosis

5. Is the Neonatal Distress due to Heart Disease? Bed side evaluation has limitations! • Some important clinical clues are useful • - History/Physical Examination • - X Ray Chest • - EKG • - Pulseoximeter/Hyperoxia test • Echocardiogram

6. New Born in Cardiac Distress Neonate in Cardiac Distress Presentation Symptoms:- • Lethargy , Irritability • Difficulty in feeding • Fast respiration • Increased precordial activity • Bluish discoloration Sudden deterioration in symptoms (Duct dependant Lesions) Contd..

7. New Born in Cardiac Distress Neonate in Cardiac Distress Physical Examination • Pallor , Mottled Skin, Cyanosis • Respiratory distress, Grunting • Weak /unequal pulses • Low/ unequal B.P.

8. Cyanosis - Hyperoxia Test New Born in Cardiac Distress 100% O2~10 min.. < 70 < 150 150 to 200 >200 CHD very likely CHD likely  CHD unlikely PO2 (mmHg)

9. New Born in Cardiac Distress Duct Dependent Mixing Severe Cyanosis with Cardiomegaly • Tachypnoea, Tachycardia • Hypatomegaly, Gallop • Insignificant murmur • X Ray Chest – CE / narrow pedicle / pulmonary plethora Most likely dTGA Intact septum, without PS

10. New Born in Cardiac Distress Duct Dependent Pulm. Circulation Severe Cyanosis PBF • No CHF, No Cardiomegaly • Single Second Sound • Ejection murmur + • Continuous murmur + • No S3, No mdr • Pulm. Atresia / Severe RVOTO with TOF physiology • Pulmonary atresia Intact septum

11. New Born in Cardiac Distress CHF, Shock Duct Dependent Syst. Circulation • Weak femoral pulses • B.P. - Right Upper Limb - Lower Limb • Saturation - Right Upper Limb - Normal - Lower Limb - Low • Severe Coarctation • Arch Interruption • HLHS - Unequal

12. New Born in Cardiac Distress Respiratory Distress , Cyanosis, PAH • CHF • Cardiomegaly + • No murmur or TR murmur • P2 loud, S3 • Chest X ray TAPVC with Obstruction Contd….

13. Respiratory Distress , Cyanosis, PAH Marked  in PO2 • PA Chest New Born in Cardiac Distress Hyperoxia Test No Significant  in PO2 Pulm. Lesion PPHN

14. New Born in Cardiac Distress CHF, Severe Cyanosis, No PAH • CE, PBF, CHF • Multiple Heart Sounds • TR murmur Ebstein’s Anomaly Contd..

15. New Born in Cardiac Distress CHF, Severe Cyanosis, No PAH • Ejection Syst. Murmur • TR Murmur • S3, S4 Critical PS + TR

16. New Born in Cardiac Distress CHF, Mild Cyanosis • Cardiomegaly • Flow murmurs • Admixture Lesions • TGA Physiology without PS • TAPVC without Obstruction • AR murmur • - Patent Trunkus Arteriosus

17. New Born in Cardiac Distress Respiratory Distress, Mild Cyanosis • Ejection systolic murmur • PR murmur • X Ray Chest Absent Pulmonary Valve Syndrome

18. New Born in Cardiac Distress Acyanotic, CHF, Shock • Lethary/Irritability • CHF • MR murmur ALCAPA Contd..

19. Acyanotic, CHF,Shock Weak Pulses Cardiomegaly Ejection Syst. Murmur , S3, S4 X Ray Chest – Cardiomegaly EKG New Born in Cardiac Distress Critical AS

20. New Born in Cardiac Distress Acyanotic with CHF • Cardiomegaly • Flow murmurs - Multiple sites of shunts - Associated * LVOT Obstruction * Regurgitant lesion

21. New Born in Cardiac Distress Acyanotic CHF • Primary myocardial disease • Secondary myocardial dysfunction • Hypocalcaemia/Hypoglycemia/Diabetes • Perinatal asphyxia, Sepsis • Adrenal insufficiency • Metabolic and Genetic Disorders • Glycogen Storage Disease( Pompe’s disease) Contd..

22. New Born in Cardiac Distress Arrhythmia resulting in Myocardial Dysf. & CHF • Tachyrrhythmia - SVT • Bradyarrhythmia - CHB

23. New Born in Cardiac Distress Acyanotic CHF with High Output State Bounding Pulses • Term Baby • - No significant cardiac murmur • - Continuous murmur over head • A-V Fistula – Cerebral • Premature Baby - Good volume pulses - Pulsation 2LIC space, arch - Continuous murmur + - Ejection murmur below left clavicle • PDA in premature babies • Severe Anemia

24. New Born in Cardiac Distress Neonate in Cardiac Distress Cyanotic Mild Cyanosis Severe Cyanosis PA Chest * PBF – PS *  PBF – TGA * Severe PVH Obst. TAPVC Shock, Weak Fenorals * Coarct. * AA Interruption * HLHS Resp. Distress PA Chest - Hilar Pas ++ * APV CHF PA Chest PBF * Admixture Lesions

25. New Born in Cardiac Distress Neonate in Cardiac Distress Acyanotic, CE, CHF PA Chest – CE, NPBF • High Output State • Cerebral AVM • PDA Premature NB • Severe Anemia • ALCAPA • Critical AS • Critical Coarct. • Arrhythmia • Myocardial diseases • Primary • Secondary

26. New Born in Cardiac Distress Take Home Message • High Index of Suspicion • Systematic approach without panic • Careful evaluation of Bedside Clues, Chest X ray and EKG gives enough information to plan emergency management and prompt referral, to tertiary care centre resulting in excellent results.

27. Thanks

28. New Born in Cardiac Distress Neonate with Cyanosis ↓ PBF

29. Regurgitant lesions with CHF(AV/Semilunar valves) MR / TR murmur » AVSD Isolated TR murmur »Ebstein’s / Dysplastic TV Isolated MR murmur » DCM, ALCAPA, Cleft MV AR murmur » PTA New Born in Cardiac Distress Medical Stabilization ALCAPA - Urgent Surgery

30. New Born in Cardiac Distress Neonate in Distress without Cyanosis Gross CHF  Myocardial diseases  ALCAPA  LVOT Obstruction  Arrthymia

31. New Born in Cardiac Distress CHF Acyanotic with High Output State Bounding Pulses • Term Baby • - No significant cardiac murmur • - Continuous murmur over head • A-V Fistula – cerebral • Premature Baby - Good volume pulses - Pulsation 2LIC space, arch - Continuous murmur + - Ejection murmur below left clavicle • PDA in premature babies • Severe Anemia

32. CHF, Cyanosis • PBF • Multiple heart sounds • TR murmur • PA Chest • EKG

33. Indicators of Heart Disease Dysmorphic features Poor Feeding, Weight  Lethargy / Irritability Tachypnoea, Tachycardia, CHF Respiratory Distress, Cyanosis Abnormal pulses / Shock New Born in Cardiac Distress

34. New Born in Cardiac Distress Severe Pulmonary Stenosis

35. New Born in Cardiac Distress Figure-12 b& c Critical AS

36. TOF Physiology Tricuspid atresia,PS • LAD (-30 to –60 ) • Rt atrial overload • LVH

37. TOF Physiology Single ventricle,PS • Discordant axis and ventricular hypertrophy • Monomorphic QRS complexes

38. TOF Physiology TOF • RAD upto +150 • RVH • Abrupt change to rS pattern in V2 • Extreme rt axis > 150 / Abnormal quadrant • DORV / D-TGA ,VSD,PS

39. ALCAPA • Deep Q wave in left sided leads • Evidence of ischemia/infarction

40. Pompe’s Disease • Short PR interval • Tall QRS complexes

41. Neonate with Shock HLHS/ Arch interruption/ critical Coarctation Immediate resuscitation and urgent transportation

42. Neonate in Distress Cyanosis Duct Dependant * Pulmonary Circulation * Mixing * Systemic Circulation Cyanosis with Severe PAH Severe Respiratory distress * Cardiac * Pulmonary New Born in Cardiac Distress