Cardiac Problems in Children

1
Cardiac Problems in Children

• Dr S Bandi
• Slides courtesy of Dr M Rajimwale

2
Cardiac Problems in Children
Arrhythmias
Congenital heart disease
Myocardial/pericardial, endocardial
3
Congenital heart disease

• Incidence - 0.8 live births
• 10 in still born/ abortus
• lt 10 chromosomal abnormality/genetic mutations
• 25 have extracardiac abnormality

4
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
•  

5
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

6
Teratogens

• Teratogenic Exposure
• Rubella Coarct, VSD, PDA
• Alcohol VSD
• Phenytoin ASD
• Lithium Ebsteins anomaly
• Warfarin VSD, TOF

7
FOETAL CIRCULATION Two intracardiac
communications Ventricles working in parallel
8
Left heart
Right heart
gt95
75
LA
RA
3mm
8
75
gt95
RV
LV
100/8
25/3
gt95
75
25/10
100/60
gt95
75
Aorta
PA
9
VSD 30.5 ASD 9.8 PDA 9.7 PS 6.9 C
oarctation of aorta 6.8 AS 6.9 TOF 5.8 TG
A 4.2 Truncus 2.2 TA 1.3
10
Clinical Manifestations

• Central Cyanosis -
• duct dependant - acutely unwell neonate
• cyanotic spells - TOF

• 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

CHD causing cyanosis- 5 Ts TOF TGA Tricuspid
atresia TAPVD Truncus Arteriosus Pulm atresia
11
Clinical Manifestations...

• Incidental detection of murmur on routine
  examination

MURMUR OFTEN ABSENT IN CYANOTIC CONGENITAL HEART
DISEASE
12
Clinical manifestations ...

• Infective endocarditis - rare lt 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

13
Examination

• General exam
• growth, dysmorhism, well/unwell
• colour, perfusion, pulse (including femorals) ,
  BP,
• post-ductal SaO2

• CVS
• inspection auscultation (supine and
  standing) palpation

14

• 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

15
(No Transcript)
16
Commonest cardiac problem a general paediatrician
will see?

• Innocent murmurs

17
Innocent murmurs

• 30 of all children on routine auscultation may
  have one.
• Stills 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

18
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)

19
Acyanotic

• Normal pulmonary vascularity
• PS (mild/moderate)
• AS
• Coarctation of aorta

• Pulmonary plethora
• VSD
• ASD
• PDA
• Severe LV outflow obstruction/ hypoplastic left
  heart

20
Cyanotic

• Pulmonary oligaemia
• severe PS/atresia
• TOF
• TA
• complex lesion with PS

• Pulmonary plethora
• - TGA with VSD
• - Truncus Arteriosus
• - Total anomalous pulmonary venous drainage
  (TAPVD)

21
Conduction disorders

• Heart block
• maternal SLE
• complex congenital defect

• Tachy-arrhythmias
• supraventricular tachcardia
• long QT syndrome - prone to ventricular
  tachycardia

22
Other cardiac problems

• Myocardial - cardiomyopathies (genetic,
  metabolic), myocarditis - viral
• Endocardial - infective (bacterial) endocarditis
• Pericardial - pericarditis, pericardial effusion

23
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

24

• Antibiotic prophylaxis
• all heart defects causing high velocity
  turbulence, prosthetic material
• NOT REQUIRED IN ASD

• Dental, surgical/endocsopic, ENT procedures

25

• 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)

26

• Cyanotic spells in TOF (pulmonary stenosis, large
  VSD, overriding aorta, RVH)
• calm the baby
• knee chest position
• O2, Morphine

27

• Conduction disorders - permanent pacing for
  congenital complete heart block
• Medication for tachyrrhythmias

28
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