94 Heart Problems in Children

the child had a narrow valve that might need surgery. Nowadays, such children are usually referred to a cardiologist early on; the family can see the valve on the echo tape and discuss with the cardiologist how severe the narrowing is and whether and how often follow-up will be necessary. In earlier years, a condition such as aortic valve stenosiswhich is more frequent in boys than in girlspresented a great problem, especially for children eager to go out for sports; it was known that the narrowing of the valve became more severe over time, but there was no good way of monitoring the change other than by repeated catheter tests. Now the severity of the narrowing can be accurately assessed with the echo-Doppler, and if it is not severe, unnecessary restrictions on a childs activity can be avoided. Occasionally, in about one in twenty children who have aortic valve stenosis, the valve is severely narrowed and badly formed. Such a baby will have a heart murmur, will be breathing fast, and will be restless and irritable; uid is accumulating in the lungs, often leading to wheezing and diculty in feeding. Emergency surgery will be necessary in the rst days or weeks of life. If the aortic valve is thickened there is a drop in pressure, also called a gradient, between the left ventricle and the aorta. This gradient can be measured accurately with the Doppler test; such measurement allows an understanding of how severe the obstruction is and provides a way of monitoring its progression over time. When the aortic valve is greatly thickened, with a narrow opening, the left ventricular pressure may be between and when pressure in the aorta is around . Maintaining a higher than normal pressure is a strain on the left ventricle. The muscle of the ventricle, the myocardium, thickens in order to maintain the needed pressure. This thickening (hypertrophy) is well tolerated if it is mild, but if the myocardium becomes greatly thickened, the blood supply from the coronary arteries to the muscle becomes inadequate, particularly during strenuous exercise. In general, a cardiologist will follow a child with aortic valve stenosis and recommend treatment if the pressure is . times greater (or more) in the left ventricle than in the aorta (for example, mm Hg in the ventricle, mm Hg in the aorta). The child with aortic valve stenosis will not need any medication other than BE prophylaxis but will usually need to be checked annually during the childhood years of rapid growth to make sure that the opening in the valve is growing and keeping up with the needs of the growing body. Checkups should continue throughout life, because problems may arise in middle age or later years.