Presentation of congenital heart disease

ultrasound diagnosis
1. routine fetal scan btw 18-20 weeks gestation
  1. includes checking fetal heart anatomy
    1. if abnormality detected
      1. 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
  2. 70% of infants needing surgery in 1st 6 months of life diag antenatally
  3. early diagnosis allows for parental counselling
    1. parents' choice
      1. 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
      2. termination of pregancy
detection of a heart murmur
1. commonest presentation of congenital heart disease
2. innocent murmur
  1. most kids w/ murmurs have normal heart
  2. heard in 30% of kids
  3. hallmarks (Ss)
    1. aSymptomatic pt
    2. Soft blowing murmur
    3. Systolic murmur only (NEVER DIASTOLIC)
    4. left Sternal edge
    5. Also
      1. HS I+II+0 (normal heart sounds + no added sounds)
      2. no parasternal thrill
      3. no radiation
  4. often heard during febrile illness or anaemia
    1. due to increased cardiac output
    2. need to re-examine kid when these are corrected
3. if uncertain whether innocent or pathological
  1. refer to paed cardiology
    1. for ECHO
  2. if older than neonate
    1. CXR & ECG may help
4. pathological may not be detected till baby weeks old
  1. at birth pulmonary vasc res still high
  2. only when pul vasc res falls may baby be symptomatic or murmur heard (baby several weeks old)
heart failure
1. symptoms
  1. breathlessness
    1. esp on feeding or exertion
  2. sweating
  3. poor feeding
  4. recurrent chest infections
2. signs
  1. poor weight gain or faltering growth
  2. tachypnoea
  3. heart murmur: gallop rhythm
    1. heart failure-> poor quality heart sounds
  4. enlarged heart
  5. hepatomegaly
    1. liver rapidly reflects heart failure
  6. cool peripheries
3. right heart failure
  1. signs rare in developed countries
    1. oedema
      1. ankle
      2. sacral
    2. ascites
  2. seen in
    1. long standing rheumatic fever
    2. pulmonary hypertension
  3. tricuspid regurg
  4. right atrial dilatation
4. causes
  1. neonate- obstructed (duct-dependent) systemic circulation [likely cause 1st week of life]
    1. hypoplastic left heart syn
    2. critical aortic valve stenosis
    3. severe coarctation of aorta
    4. interruption of aortic arch
    5. closure of duct->
      1. severe acidosis
      2. collapse
      3. death unless patency of duct restored
  2. infants (high pulmonary blood flow due to L to R shunt)
    1. VSD
    2. AVSD
    3. large persistent ductus arteriosus
    4. as pulmonary res falls
      1. pulmonary oedema
      2. breathlessness
  3. older kids or teens (R or L heart failure)
    1. Eisenmenger syn
      1. right heart failure only
      2. irreversibly raised pul vasc resistance
        due to chronically raised pulmonary arterial Pa and flow
      3. shunt is R to L
      4. blue teen
      5. heart lung transplant needed
    2. rheumatic heart disease
    3. cardiomyopathy
shock
cyanosis
1. peripheral (blueness of hands & feet)
  1. cold
  2. unwell from any cause
  3. polycythaemia
2. central cyanosis
  1. slate blue tongue
  2. assoc w/ fall in arterial blood O2 tension
  3. clinically recognisable only if conc of reduced Hb > 5g/dl
    1. hence less pronounced if child anaemic
3. check infant O2 sats
  1. normal = 94%+
4. persistent cyanosis in otherwise well infant is usually sign of structural heart disease
5. causes of cyanosis in infant w/ resp distress (RR> 60 b/min)
  1. cardiac
    1. cyanotic congenital heart disease
  2. resp disorders
    1. surfactant deficiency
    2. meconium aspiration
    3. pulmonary hypoplasia
  3. persistent pulmonary HTN of newborn
    1. failure of pul vasc res to fall after birth
  4. infection
    1. septicaemia from GBS and other orgs
  5. metabolic disease
    1. metabolic acidosis
    2. shock

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Presentation of congenital heart disease

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	Created by v.djabatey about 10 years ago