Presentation of congenital heart disease

Presentation of congenital heart disease

1. ultrasound diagnosis

   • routine fetal scan btw 18-20 weeks gestation
     • includes checking fetal heart anatomy
       • if abnormality detected
         • detailed fetal echo by paed cardiologist
           • also done for fetus at increased risk
             • e.g. suspected Down syn
             • e.g. sibling/mum has congenital heart disease
     • 70% of infants needing surgery in 1st 6 months of life diag antenatally
     • early diagnosis allows for parental counselling
       • parents' choice
         • continue w/ pregnancy
           • child's mx planned antenatally
             • if child has duct dependet lesions mum may be offered Rx at or close to cardiac centre
         • termination of pregancy

2. detection of a heart murmur

   • commonest presentation of congenital heart disease
   • innocent murmur
     • most kids w/ murmurs have normal heart
     • heard in 30% of kids
     • hallmarks (Ss)
       • aSymptomatic pt
       • Soft blowing murmur
       • Systolic murmur only (NEVER DIASTOLIC)
       • left Sternal edge
       • Also
         • HS I+II+0 (normal heart sounds + no added sounds)
         • no parasternal thrill
         • no radiation
     • often heard during febrile illness or anaemia
       • due to increased cardiac output
       • need to re-examine kid when these are corrected
   • if uncertain whether innocent or pathological
     • refer to paed cardiology
       • for ECHO
     • if older than neonate
       • CXR & ECG may help
   • pathological may not be detected till baby weeks old
     • at birth pulmonary vasc res still high
     • only when pul vasc res falls may baby be symptomatic or murmur heard (baby several weeks old)

3. heart failure

   • symptoms
     • breathlessness
       • esp on feeding or exertion
     • sweating
     • poor feeding
     • recurrent chest infections
   • signs
     • poor weight gain or faltering growth
     • tachypnoea
     • heart murmur: gallop rhythm
       • heart failure-> poor quality heart sounds
     • enlarged heart
     • hepatomegaly
       • liver rapidly reflects heart failure
     • cool peripheries
   • right heart failure
     • signs rare in developed countries
       • oedema
         • ankle
         • sacral
       • ascites
     • seen in
       • long standing rheumatic fever
       • pulmonary hypertension
     • tricuspid regurg
     • right atrial dilatation
   • causes
     • neonate- obstructed (duct-dependent) systemic circulation [likely cause 1st week of life]
       • hypoplastic left heart syn
       • critical aortic valve stenosis
       • severe coarctation of aorta
       • interruption of aortic arch
       • closure of duct->
         • severe acidosis
         • collapse
         • death unless patency of duct restored
     • infants (high pulmonary blood flow due to L to R shunt)
       • VSD
       • AVSD
       • large persistent ductus arteriosus
       • as pulmonary res falls
         • pulmonary oedema
         • breathlessness
     • older kids or teens (R or L heart failure)
       • Eisenmenger syn
         • right heart failure only
         • irreversibly raised pul vasc resistance
           • due to chronically raised pulmonary arterial Pa and flow
         • shunt is R to L
         • blue teen
         • heart lung transplant needed
       • rheumatic heart disease
       • cardiomyopathy

4. shock

5. cyanosis

   • peripheral (blueness of hands & feet)
     • cold
     • unwell from any cause
     • polycythaemia
   • central cyanosis
     • slate blue tongue
     • assoc w/ fall in arterial blood O2 tension
     • clinically recognisable only if conc of reduced Hb > 5g/dl
       • hence less pronounced if child anaemic
   • check infant O2 sats
     • normal = 94%+
   • persistent cyanosis in otherwise well infant is usually sign of structural heart disease
   • causes of cyanosis in infant w/ resp distress (RR> 60 b/min)
     • cardiac
       • cyanotic congenital heart disease
     • resp disorders
       • surfactant deficiency
       • meconium aspiration
       • pulmonary hypoplasia
     • persistent pulmonary HTN of newborn
       • failure of pul vasc res to fall after birth
     • infection
       • septicaemia from GBS and other orgs
     • metabolic disease
       • metabolic acidosis
       • shock