Approach to child with heart disease

Pushpa Raj SharmaProfessor of Child Health

Institute of Medicine

Diseases of heart 

Pericardium

Myocardium

Endocardium

Blood vessels

PrevalencePrevalence CongenitalCongenital Cyanotic: 22% Acyanotic: 68%

VSD 25% ASD 6% PDA 6% TOF 5% PS 5% AS 5%

AcquiredAcquired Kawasaki disease Rheumatic Tubercular Collagen

Ceylon Med J 2001 Sep; 46 (3): 96-8; Indian J Pediatr. 2001 Aug;68 (8):757-7

Nelson’s Textbook of pediatrics; 17 ed.

Common acyanotic lesions

Ventricular septal defects Atrial septal defects Atrio-ventricular septal defects Patent ductus arteriosus Truncus arteriosus Pulmonary stenosis Aortic stenosis Mitral stenosis/incompetence Coarctation of aorta Tricuspid regurgitation

Common Cyanotic LesionsDecreased flow 1. Tetralogy of Fallot 2. Tricuspid Atresia 3. Severe Pulmonic Stenosis 4. Ebstein’s anamoly Increased Flow 5. Transposition of great vessles6. VSD with pulmonary atresia

Common Lesions producing cyanosis

7. Truncus Arteriosus 8. Hypoplastic left heart 9. Single ventricle

10. TAPVR with infradiaphragmatic obstruction

Presenting complaints/signs

Failure to thrive Exercise intolerence Easy fatigability Chest indrawing Sweating during

feeding Bluish spells Fever with rigor Palpitation Convulsion

Fast breathing Oedema Hepatomegaly, spleenomegaly Clubbing Cyanosis Focal neurological

lesion Other organ defects Chromosomal

anomalies

Cyanosis: is it a cardiac cause or lung cause

Hyperoxia test

Neonates with cyanotic congenital heart disease usually do not have significantly raised arterial Pao2 during administration of 100% oxygen.

Ventricular Defect Small VSD

Asymptomatic A loud, harsh, or

blowing holosystolic murmur.

Large VSD dyspnea, feeding

difficulties, poor growth, profuse perspiration, recurrent pulmonary infections, and cardiac failure in early infancy.

80%

Syndromes associated with this condition

VSD: ECG is normal but may show right ventricular hypertrophy, if present indicates defect is large and presence of pulmonary hypertension or pulmonry stenosis

Ventricular Septal Defect (VSD)

Large VSD: The presence of right ventricular hypertrophy, olegeimic lung fields (pulmonary hypertension or an associated pulmonic stenosis), gross cardiomegaly with prominence of both ventricles, the left atrium.

Small VSDs, the chest radiograph is usually normal

Ventricular Septal defects 30–50% of small defects close

spontaneously, most frequently during the 1st 2 yr of life.

Small muscular VSDs are more likely to close (up to 80%) than membranous VSDs are (up to 35%).

infants with large defects have repeated episodes of respiratory infection and heart failure despite optimal medical management.

Surgical repair prior to development of an irreversible increase in pulmonary vasculalr resistance (usually prior to the patient's second birthday).

Atrial Septal Defects: secundum Most common form of

ASD (fossa ovalis) In large defects, a

considerable shunt of oxygenated blood flows from the left to the right atrium.

Mostly asymptomatic The 2nd heart sound

is characteristically widely split and fixed. Secundum

Atrial Septal Defects:primum

Situated in the lower portion of the atrial septum and overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.

Combination of a left-to-right shunt across the atrial defect and mitral insufficiency

C/F similar to that of an ostium secundum ASD

Atrial Septal Defect

Enlargement of the right ventricle

Enlargement of atrium

Large pulmonary artery

increased pulmonary vascularity is.

The electrocardiogram in patients with a complete AV septal defect is distinctive. The principal abnormalities are (1) superior orientation of the mean frontal QRS axis with left axis deviation to the left upper or right upper quadrant, (2) counterclockwise inscription of the superiorly oriented QRS vector loop, (3) signs of biventricular hypertrophy or isolated right ventricular hypertrophy, (4) right ventricular conduction delay (RSR′ pattern in leads V3 R and V1 ), (5) normal or tall P waves, and (6) occasional prolongation of the P-R interval

Atrial Septal Defects Secundum ASDs are well tolerated

during childhood. Antibiotic prophylaxis for isolated

secundum ASDs is not recommended. Surgery or transcatheter device closure

is advised for all symptomatic patients and also for asymptomatic patients with a Qp:Qs ratio of at least 2:1.

Ostium primum defects are approached surgically

Patent Ductus Arteriosus Small defect no

symptoms. Large defect:

Wide pulse pressure Enlarged heart Thrill in L second IS Continuous murmur X-ray: prominent

pulmonary artery with increased vascular markings.

Primary Pulmonary Hypertension

Prominent pulmonary artery.

Prominent right ventricle

Prominent vascularity in the hilar areas

Decreased vascualr marking in the periphery.

No treatment

Mitral insufficiency: Rheumatic

High volume load

Inflammatory processEnlarged left ventricles

Dilatation of the left atrium

Pulmonary congestion

Symptoms of left sided failure

Repeated insult

Spontaneous improvement

Chronic mitral insufficiency Raised Pulmonary AP

Enlarged right ventricle and atriumSymptoms of right heart failure

Mitral insufficiency: Rheumatic Signs of heart failure Heaving apical

impulse Apical systolic thrill Accentuated 2nd

sound Holosystolic murmur

radiating to axilla

ECG: bifid P waves and left ventricular hyertrophy

X-ray: prominent left atrium and ventricle (straight left border)

Prophylaxis against recurrence of rheumatic fever

Rheumatic valvular disease: Mitral stenosis

Takes 10 years to develop Symptoms proportionate to severity Left ventricular failure right

ventricular failure Loud first heart sound with opening

snap. Diastolic murmur Absent murmur if heart failure. Surgical intervention if symptomatic

Mitral Stenosis

Loud 1st sound Diastolic murmur left atrial

enlargement prominence of the

pulmonary artery enlarged right-sided

heart chambers; ECG: prominent

notched P wave.

Pericardial Effusion Presenting complaintPresenting complaint

Precordial pain Cough Dyspnoea Abdominal pain Vomiting Fever Other organs

involvement

Signs:Signs: Position: leaning

forward. Puffy face Friction rub Absent apical impulse Muffled heart sounds Pulsus paradoxus Distended neck veins Low QRS complex, T

inversion

Pericardial Effusion A relatively large

pericardial effusion must be present to cause an enlarged cardiac shadow with the usual “water bottle” configuration on a chest roentgenogram

The test that differentiates

The cardiac seize and the vascularity in the chest X-ray

Cardiac disease with normal/decreased vasculature

Viral myocarditis Tetralogy of Fallot Pulmonary atresia Tricuspid atresia Endocardial fibroelastosis Aberrant left coronary artery Cystic medial necrosis Diabetic mother

Cyanotic

Tetralogy of Fallot

Ventricular septal defect

Pulmonic stenosis Overriding aorta Right ventricular

hypertrophy

Cardiac disease with increased vasculature

Atrioventricular septal defects Congestive cardiac failure Transposition of great arteries with

VSD Total anomalous pulmonary venous

drainage Truncus arteriosus Single ventricle without pulmonary

stenosis Hypoplastic left heart syndrome

Congestive Cardiac Failure

Enlarged heart Plethoric lung

fields specially at bases