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Cardiac Problems in Children

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

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  1. Cardiac Problems in Children Dr S Bandi Slides courtesy of Dr M Rajimwale

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

  3. Congenital heart disease Incidence - 0.8% live births 10% in still born/ abortus < 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. 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

  9. 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%

  10. 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

  11. Clinical Manifestations... • Incidental detection of murmur on routine examination MURMUR OFTEN ABSENT IN CYANOTIC CONGENITAL HEART DISEASE

  12. 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 ...

  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. Commonest cardiac problem a general paediatrician will see? Innocent murmurs

  16. 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

  17. 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)

  18. Normal pulmonary vascularity PS (mild/moderate) AS Coarctation of aorta Pulmonary plethora VSD ASD PDA Severe LV outflow obstruction/ hypoplastic left heart Acyanotic

  19. 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

  20. Heart block maternal SLE complex congenital defect Tachy-arrhythmias supraventricular tachcardia long QT syndrome - prone to ventricular tachycardia Conduction disorders

  21. Other cardiac problems • Myocardial - cardiomyopathies (genetic, metabolic), myocarditis - viral • Endocardial - infective (bacterial) endocarditis • Pericardial - pericarditis, pericardial effusion

  22. 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

  23. Antibiotic prophylaxis • all heart defects causing high velocity turbulence, prosthetic material • NOT REQUIRED IN ASD • Dental, surgical/endocsopic, ENT procedures

  24. 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)

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

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

  27. 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

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