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Similar to St Johns case discussion.ppt Mudhal Nee Mudivum Nee, Moondru Kalam Nee, You are the beginning. You are the end. You are all three manifestations of time. Kadal Nee Karaiyum Nee, Katru Kooda Nee, You are the ocean. You are also the shore. Manadhoaram O
St Johns case discussion.ppt Mudhal Nee Mudivum Nee, Moondru Kalam Nee, You are the beginning. You are the end. You are all three manifestations of time. Kadal Nee Karaiyum Nee, Katru Kooda Nee, You are the ocean. You are also the shore. Manadhoaram O
- 1. Clinical Cardiovascular Clinical Cardiovascular Examination Examination DrUsha MK Dr Usha MK Associate Professor of pediatric cardiology Associate Professor of pediatric cardiology Sri Jayadeva institute of Cardiovascular sciences Sri Jayadeva institute of Cardiovascular sciences Bangalore Bangalore
- 2. Clinical pearls toCHD Clinical pearls to CHD Child with failure to thrive Child with failure to thrive Persistent tachypnea and retractions Persistent tachypnea and retractions Fever of prolonged duration – 1 week Fever of prolonged duration – 1 week Genetic malformations Genetic malformations Newborn who has failed screening Newborn who has failed screening First degree relative with CHD First degree relative with CHD Hypertension Hypertension Syncope, palpitations, breathlessness Syncope, palpitations, breathlessness
- 3. Five basic questions Fivebasic questions Is the patient acyanotic or cyanotic? Is the patient acyanotic or cyanotic? Is the pulmonary arterial flow increased? Is the pulmonary arterial flow increased? Does the malformation originate in the left or Does the malformation originate in the left or right side of the heart? right side of the heart? Which is the dominant ventricle? VOLUME Which is the dominant ventricle? VOLUME OR PRESSURE? OR PRESSURE? Is pulmonary hypertension present or not? Is pulmonary hypertension present or not?
- 4. INCREASED PBF –can be INCREASED PBF – can be both cyanotic or acyanotic both cyanotic or acyanotic Failure to thrive – emaciated Failure to thrive – emaciated child child Recurrent LRTI Recurrent LRTI Feeding difficulty, sweating Feeding difficulty, sweating Fast breathing and retractions Fast breathing and retractions Mild cyanosis even in cyanotic Mild cyanosis even in cyanotic CHD CHD Palpitations or increased Palpitations or increased precordial activity precordial activity REDUCED OR NORMAL PBF REDUCED OR NORMAL PBF Good growth - usually Good growth - usually Cyanotic spells Cyanotic spells Squatting episodes Squatting episodes Deep cyanosis Deep cyanosis Syncope Syncope Exercise intolerance Exercise intolerance GENERAL RULES
- 5. Volume overload Volumeoverload Palpitations Palpitations Fatigue Fatigue Brisk Pulse Brisk Pulse Palpable impulse Palpable impulse Hyperdynamic Hyperdynamic precordium precordium AR,MR,VSD,PDA AR,MR,VSD,PDA Pressure Overload Pressure Overload Decresed exercise Decresed exercise tolerance or fatigue tolerance or fatigue Slow rising , low volume Slow rising , low volume pulse pulse Sustained or heaving Sustained or heaving apex/parasternal heave apex/parasternal heave Reduced systolic pressure Reduced systolic pressure AS,PS,COA AS,PS,COA
- 6. Right heartfailure Right heart failure Pedal edema Pedal edema Ascites Ascites Tender abdomen – Tender abdomen – congestive hepatomegaly congestive hepatomegaly Elevated JVP Elevated JVP Left heart failure Left heart failure Dyspnea on exertion Dyspnea on exertion Orthopnea Orthopnea PND PND Sweating while feeding Sweating while feeding and tachypnea and tachypnea
- 7. Heart Failure -Class Heart Failure - Class
- 8. Does the childhave heart Does the child have heart disease? disease? Dr Alexander Nadas 1 major or 2 minor
- 9. Newborn presentation Newborn presentation Shock – most common D/d – Septic shock – Shock – most common D/d – Septic shock – think of duct dependant systemic circulation – think of duct dependant systemic circulation – coarctation, aortic stenosis,HLHS coarctation, aortic stenosis,HLHS Deep cyanosis– Duct dependent pulmonary Deep cyanosis– Duct dependent pulmonary circulation - Pulmonary stenosis or atresia circulation - Pulmonary stenosis or atresia Blue baby with black X ray – Pulmonary atresia Blue baby with black X ray – Pulmonary atresia Start prostaglandin on an empirical basis Start prostaglandin on an empirical basis Deep cyanosis with white out lung – obstructed Deep cyanosis with white out lung – obstructed TAPVC TAPVC
- 10. Heart murmurs Heart murmurs Systolicmurmurs Systolic murmurs Early systolic – muscular VSD, large VSD with PAH, Early systolic – muscular VSD, large VSD with PAH, Mid systolic/Ejection (aortic) –PS, AS, ASD Mid systolic/Ejection (aortic) –PS, AS, ASD Late systolic – MVP, TVP Late systolic – MVP, TVP Holosystolic – VSD, MR, TR Holosystolic – VSD, MR, TR
- 11. Heart murmurs Heart murmurs Earlydiastolic murmurs – Early diastolic murmurs – AR AR (bicuspid aortic valve, subvalvar AS, VSD) (bicuspid aortic valve, subvalvar AS, VSD) PR PR (isolated or associated with TOF, VSD, PS) (isolated or associated with TOF, VSD, PS) Mid diastolic murmurs – Mid diastolic murmurs – MS MS Increased flow across nonstenotic mitral valve Increased flow across nonstenotic mitral valve (MR, VSD, PDA) (MR, VSD, PDA) TS TS Increased flow across nonstenotic tricuspid valve Increased flow across nonstenotic tricuspid valve (TR, ASD, (TR, ASD, TAPVC) TAPVC) Late diastolic murmurs – Late diastolic murmurs – Austin Flint murmur, presystolic Austin Flint murmur, presystolic accentuation of MS murmur accentuation of MS murmur
- 12. Heart murmurs Heart murmurs Continuousmurmur – Continuous murmur – PDA PDA Coronary AV fistula Coronary AV fistula RSOV RSOV Anomalous coronary artery from pulmonary artery Anomalous coronary artery from pulmonary artery Peripheral pulmonic stenosis Peripheral pulmonic stenosis Small (restrictive) ASD with MS Small (restrictive) ASD with MS Bronchial collaterals, intercostal AV fistula, intercostal Bronchial collaterals, intercostal AV fistula, intercostal collaterals in CoA, post BT shunt collaterals in CoA, post BT shunt Mammary souffle Mammary souffle Cervical Venous hum Cervical Venous hum
- 13. CXR CXR Pulmonary vasculature Pulmonaryvasculature Cardiac size Cardiac size Cardiac configuration Cardiac configuration
- 14. GENERAL RULES GENERAL RULES DecreasedPBF Decreased PBF Oligemic X ray Oligemic X ray (Small Pulmonary arteries) (Small Pulmonary arteries) -Stenosis or atresia -Stenosis or atresia Normal CT ratio Normal CT ratio Increased PBF Increased PBF Increased vascularity Increased vascularity (Dilated Pulmonary (Dilated Pulmonary arteries with severe PH) arteries with severe PH) Cardiomegaly Cardiomegaly
- 17. Prominent MPA Prominent MPA Poststenotic dilatation (valvar PS) Poststenotic dilatation (valvar PS) Increased pulmonary flow (ASD, VSD, Increased pulmonary flow (ASD, VSD, PDA) PDA) Increased PA pressure (PAH) Increased PA pressure (PAH)
- 18. Wall to wallheart – Ebsteins Wall to wall heart – Ebsteins anomaly anomaly
- 19. Snowman heart –Supracardiac Snowman heart – Supracardiac TAPVC TAPVC
- 20. No cardiomegaly, Pulmonary Nocardiomegaly, Pulmonary edema – Obstructed TAPVC edema – Obstructed TAPVC
- 21. Narrow pedicle, mild Narrowpedicle, mild cardiomegaly, normal PBF - TGA cardiomegaly, normal PBF - TGA
- 22. Normal size heartwith clear Normal size heart with clear lungs with cyanosis - TOF lungs with cyanosis - TOF Empty pulmonary bay RV apex
- 23.
- 25. All lesionswith VSD and severe PS are classified as TOF All lesions with VSD and severe PS are classified as TOF physiology – present with cyanosis, spells and squatting episodes physiology – present with cyanosis, spells and squatting episodes