ACYANOTIC HEART DISEASE
Q&A COUNT: 27*
Relevant findings to this case:
History:
1. Suck rest suck cycle - indicates CCF
2. Forehead sweating - indicates CCF
3. NYHA grading for dyspnea - indicates CCF
4. Orthopnoea, PMD history - indicated LVF
5. Recurrent respiratory tract infection
6. A/N history - any drug intake
7. Any family history?
8. No H/O cyanotic spells, bluish discolouration of body
Examination:
1. Edema present, look for anemia (as it can precipitate CCF), no clubbing, no cyanosis (differential clubbing + cyanosis only in lower limbs seen in reversed shunt PDA)
2. External markers of CCF and Congenital heart disease/down's syndrome should be inspected!
3. CVS - Apical impulse hyperdynamic and location of apex based on age; Murmurs depending on underlying disease (PSM in left 3rd/4th parasternal area - VSD; Continuous murmur - PDA); loud P2 indicates pulmonary hypertension (in our cases, its usually not seen)
NADAS CRITERIA FOR HEART DISEASE in children
Major criteria:
1. Systolic murmur of grade 3 or more
2. Diastolic murmur
3. Cyanosis
4. Congestive cardiac failure
Minor criteria:
1. Systolic murmur of grade 1 or 2
2. Abnormal S2
3. Abnormal Chest X Ray
4. Abnormal ECG
5. Abnormal Blood pressure
*Any 1 major criteria or 2 minor criteria - diagnostic of heart disease in children
HISTORY:
Q&A COUNT: 27*
Relevant findings to this case:
History:
1. Suck rest suck cycle - indicates CCF
2. Forehead sweating - indicates CCF
3. NYHA grading for dyspnea - indicates CCF
4. Orthopnoea, PMD history - indicated LVF
5. Recurrent respiratory tract infection
6. A/N history - any drug intake
7. Any family history?
8. No H/O cyanotic spells, bluish discolouration of body
Examination:
1. Edema present, look for anemia (as it can precipitate CCF), no clubbing, no cyanosis (differential clubbing + cyanosis only in lower limbs seen in reversed shunt PDA)
2. External markers of CCF and Congenital heart disease/down's syndrome should be inspected!
3. CVS - Apical impulse hyperdynamic and location of apex based on age; Murmurs depending on underlying disease (PSM in left 3rd/4th parasternal area - VSD; Continuous murmur - PDA); loud P2 indicates pulmonary hypertension (in our cases, its usually not seen)
NADAS CRITERIA FOR HEART DISEASE in children
Major criteria:
1. Systolic murmur of grade 3 or more
2. Diastolic murmur
3. Cyanosis
4. Congestive cardiac failure
Minor criteria:
1. Systolic murmur of grade 1 or 2
2. Abnormal S2
3. Abnormal Chest X Ray
4. Abnormal ECG
5. Abnormal Blood pressure
*Any 1 major criteria or 2 minor criteria - diagnostic of heart disease in children
HISTORY:
(Q) What is suck rest suck cycle?
When baby is on breast feeding, there is sympathetic overactivity - cauding cardiac compromise. Breathlessness is now aggravated and baby cannot drink breast milk. So it takes rest.
When baby is on breast feeding, there is sympathetic overactivity - cauding cardiac compromise. Breathlessness is now aggravated and baby cannot drink breast milk. So it takes rest.
After some rest, it agains resumes breast feeding
This is called Suck Rest Suck cycle - it is characteristic of CONGESTIVE HEART FAILURE.
This is called Suck Rest Suck cycle - it is characteristic of CONGESTIVE HEART FAILURE.
(Q) Reason for Forehead sweating?
Increased sympathetic response , due to exertion
It occurs in CONGESTIVE HEART FAILURE
It occurs in CONGESTIVE HEART FAILURE
(Q) Why recurrent RS infection occurs in CCF?
Due to Pulmonary Congestion
(Q) What is recurrent Respiratory Tract infection? (or) Tell criteria to say it is recurrent RTI
6-8 episodes of Respiratory Infection in every year
(Q) NYHA classification of Heart failure
(Q) NYHA classification of Heart failure
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| The above picture is taken from OP Ghai Textbook of Paediatrics |
(Q) Drugs causing VSD?
Phenytoin, Lithium, Warfarin, Alcohol (given to mother in antenatal period)
(Q) What is the commonest heart disease with Maternal diabetes?
Most common - Asymmetrical Septal Hypertrophy
2nd Most common - Transposition of Great Arteries (TGA)
2nd Most common - Transposition of Great Arteries (TGA)
(Q) Age of onset of Left to Right shunt - Why?
12 weeks - Because pulmonary pressure reduces at this time
(Q) Name the Only acquired heart disease which can occur below 5 years
(A) KAWASAKI DISEASE
(Q) Importance of birth weight in Term baby with Acyanotic heart disease?
- LBW - as a part of congenital defect, risk of PDA
- LGA - diabetic baby (VSD and other cardiac problems) and TGA
(Q) Which Acyanotic heart disease occurs in Preterm baby?
Increased risk of PDA
(Q) How GDM causes PDA?
- GDM causes placental insufficiency which leads to hypoxia
- Hypoxia results in PDA (normally oxygen closes DA)
EXAMINATION:
(Q) Cause for Differential Cyanosis and Clubbing
Seen in PDA (Patent Ductus Arteriosus) with reversal, where clubbing and cyanosis occurs in the lower limbs only
(Q) Cause for Differential Cyanosis and Clubbing
Seen in PDA (Patent Ductus Arteriosus) with reversal, where clubbing and cyanosis occurs in the lower limbs only
(Q) Name the external markers of Congenital Heart disease
 |
| The above picture is taken from Aruchamy Textbook of Paediatrics |
(Q) Signs of cardiac failure
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| The above picture is taken from OP Ghai Textbook of Paediatrics |
(Q) What is apical impulse?
Lowermost and Outermost point of definite cardiac impulse, which gives maximum thrust to the palpating finger
(Q) How apical impulse position varies with age?
INFANCY - In the left 4th Intercostal space, just "lateral" to the midclavicular line
(then)
UPTO 5 YEARS - In the left 5th Intercostal space, along the midclavicular line
(then)
AFTER 5 YEARS & ADULTS - In the left 5th Intercostal space, just "medial" the midclavicular line
(then)
UPTO 5 YEARS - In the left 5th Intercostal space, along the midclavicular line
(then)
AFTER 5 YEARS & ADULTS - In the left 5th Intercostal space, just "medial" the midclavicular line
(Q) Some Causes of Machinery pulse (or) transmitted continuous murmur
- PDA
- AV fistula (coronary, systemic, periphery)
- Rupture of sinus of Valsalva
- Venous hum
- Persistent truncus arteriosis
- Aortopulmonary window
- TAPVD into right atrium
(Q) Murmurs in different congenital heart diseases?
ASD - ESM in pulmonary area + MDM in tricuspid area
VSD - PSM in left sternal border (at 3rd and 4th IC spaces), ESM in pulmonary area + Delayed Diastolic murmur in Mitral area
PDA - Continuous Murmur (in left 2nd IC space - in Gibson's area) + ESM in aortic area + Delayed Diastolic murmur in Mitral area
TOF - ESM (Left 3rd and 4th IC space)
TOF with cyanotic spell - ESM murmur decreases with intensity or becomes absent*
VSD - PSM in left sternal border (at 3rd and 4th IC spaces), ESM in pulmonary area + Delayed Diastolic murmur in Mitral area
PDA - Continuous Murmur (in left 2nd IC space - in Gibson's area) + ESM in aortic area + Delayed Diastolic murmur in Mitral area
TOF - ESM (Left 3rd and 4th IC space)
TOF with cyanotic spell - ESM murmur decreases with intensity or becomes absent*
MANAGEMENT:
Investigations for Acyanotic Heart Disease
For management of CCF:
1. CBC, Hb% - anemia can precipitate further CCF
2. Serum electrolytes - for Furosemide
3. ECG monitoring - for Digitalis
4. Renal function test - if ACE inhibitors are used
For Diagnosis of underlying disease:
1. Echocardiogram - for definite diagnosis of septal defects, PDA
2. Chest X ray
3. ECG
Management of Congestive Cardiac Failure in paediatrics
1. Diuretics - FUROSEMIDE 1-3 mg/kg/day oral (or) 1 mg/kg per dose IV + SPIRONOLACTONE 1 mg/kg oral every 12 hours
2. Humidified oxygen 40-50%, Maintain temperature 36-37°C
3. Incubator + propped up position (to avoid edema) in neonates
4. Treat fever, give empirical antibiotics for LRI (even the baby is asymptomatic for any LRI)
5. Put child under sedation - Midazolam or Diazepam (reduce cardiac activity)
6. Correct anemia if any (10-20 ml/kg packed cell volume blood with pre-transfusion diuretic been started)
7. Digitalization under PR interval monitoring (0.04-0.08 mg/kg, varies for different ages)
8. Vasodilators (Nitrates or Sodium nitroprusside in case of emergency)
9. Treat underlying cause (surgery for heart defects)
Management of ASD
Size >8 mm: Percutaneous catheter closure of defect (or) surgical closure
Size <8 mm: Observe for spontaneous closure
Management of VSD
Medical - Control CCF, treat LRI
Surgical - Closure using a patch (or) catheter closure for old children or >8-10 kg
Management of PDA
Manage CCF + Indomethacin (or) Catheter closure
Before 2 weeks:
Indomethacin before the age of 2 weeks (0.2 mg/kg/dose orally every 12-24 hours for 3 doses (2nd and 3rd dose are 0.1 mg/kg/dose for <2 days old and 0.25 mg/kg/dose for >7 days old)
After 2 weeks: Catheter based occlusive devices or coils
Contraindication for Cardiac surgery
1. Development of Pulmonary hypertension (inoperable)
2. Too low weight or too young infant (<5-8 kg)
Is IE prophylaxis recommended for VSD,ASD,PDA surgery?
No!