Cardiac Problems in Children

Dr S Bandi
Slides courtesy of Dr M Rajimwale

Cardiac Problems in Children

Congenital heart disease

Myocardial/pericardial,
endocardial

Arrhythmias

Congenital heart disease

Incidence - 0.8% live births
10% in still born/ abortus
< 10% chromosomal abnormality/genetic
mutations
25% have extracardiac abnormality

Syndromes
Chromosomes
Downs (Trisomy 21) AVSD,VSD,TOF
Edwards (Tris.18)
VSD, various defects
Patau (Tris.13)VSD, various defects
Turner (XO) Coarct.,AS
de-George (22q11deletion) Truncus,IAA,TOF
Williams (7q del)
Supravalvar AS

More associations
Maternal Disease
Diabetes Mellitus TGA,VSD, HOCM
SLE - Heart block
Associations
Oesophageal Atresia VSD, TOF
Anorectal malformationAny
Diag. Hernia Any
Exomphalos Any
Pierre Robin VSD

Teratogens
Teratogenic Exposure
Rubella
Alcohol
Phenytoin
Lithium
Warfarin

Coarct, VSD, PDA

VSD
ASD
Ebsteins anomaly
VSD, TOF

FOETAL
CIRCULATION
Two intracardiac
communications

Ventricles
working in
parallel

Right
heart

Left
heart
75%

LA

RA
75%

3mm
RV
25/3

25/10

>95%

>95%

LV
75%

75%

PA

>95%

>95%

Aorta

100/8

100/60

VSD

30.5%

ASD

9.8%

PDA

9.7%

PS

6.9%

Coarctation of aorta

6.8%

AS

6.9%

TOF

5.8%

TGA

4.2%

Truncus

2.2%

TA

1.3%

Clinical Manifestations
Cardiac failure
(Lt to Rt shunt first few months
LV outflow obstruction few
days/weeks
Functional failure-cardiomyopathy)

tachypnoea
tachycardia
poor feeding, sweating
failure to thrive
hepatomegaly

Central Cyanosis duct dependant acutely unwell neonate

cyanotic spells - TOF
CHD causing cyanosis5 Ts
TOF
TGA
Tricuspid atresia
TAPVD
Truncus Arteriosus
Pulm atresia

Clinical Manifestations...
Incidental detection of murmur on routine
examination

MURMUR OFTEN ABSENT IN CYANOTIC

CONGENITAL HEART DISEASE

Clinical manifestations ...

Palpitation, dizziness,
fainting - arrhythmia,
long QT syndrome

Infective endocarditis
- rare < 2 years

Chest pain - rare,

ischaemia - aortic
stenosis, anomalous
origin of coronary artery
pericarditis

Sudden death - rare,

HOCM, severe AS,
long QT

Examination
General exam
growth, dysmorhism, well/unwell
colour, perfusion, pulse (including femorals) , BP,
post-ductal SaO2

CVS
inspection
palpation

auscultation (supine
and standing)

 Auscultation
heart sounds (intensity, splitting of 2nd sound)
systolic murmurs - intensity I - VI, phase of
cardiac cycle, area best heard, radiation (listen to
neck, axilla, back), change with posture,
diastolic murmurs - I - IV

Other systems - respiratory, abdomen

Commonest cardiac problem a

general paediatrician will see?

Innocent murmurs

Innocent murmurs
30% of all children on routine auscultation may have
one.
Stills murmur- commonest age group 3-7yr
vibratory/musical in quality
pulmonary flow, venous hum, peripheral pulmonary
stenosis
Change in intensity with posture
Always systolic (except venous hum continuous)
ASYMPTOMATIC

Investigations
Chest X-ray cardiac size, lung vascularity,
ECG chamber enlargement
Hyperoxia test - to differentiate between cardiac
and pulmonary cause of cyanosis in neonate
Echocardiography - definitive diagnosis
Consider chromosomal analysis ( T21, 22q11)

Acyanotic
Normal pulmonary
vascularity
PS (mild/moderate)
AS
Coarctation of aorta

Pulmonary plethora

VSD
ASD
PDA
Severe LV outflow
obstruction/
hypoplastic left heart

Cyanotic
Pulmonary oligaemia

severe PS/atresia
TOF
TA
complex lesion with
PS

Pulmonary plethora
- TGA with VSD
- Truncus Arteriosus
- Total anomalous
pulmonary venous
drainage (TAPVD)

Conduction disorders
Heart block
maternal SLE
complex congenital
defect

Tachy-arrhythmias
supraventricular
tachcardia
long QT syndrome prone to ventricular
tachycardia

Other cardiac problems

Myocardial - cardiomyopathies (genetic,
metabolic), myocarditis - viral
Endocardial - infective (bacterial)
endocarditis
Pericardial - pericarditis, pericardial effusion

Management strategies
MEDICAL
Cardiac failure - rest, may need O2

afterload reduction - arteriolar dilators (Captopril), diuretics

Inotropes - Digitalis, Dopamine/Dobutamine
arrhythmia - treat
Supportive - nutrition, avoid fluid overload

 Antibiotic prophylaxis
all heart defects causing high velocity
turbulence, prosthetic material
NOT REQUIRED IN ASD

Dental, surgical/endocsopic, ENT

procedures

 Cyanosis acute presentation in neonate - likely to

be a duct dependant lesion
KEEP DUCT OPEN WITH PGE1
INFUSION
may need urgent surgical intervention
(atrial septostomy in TGA, balloon
dilatation of pulm/aortic valve, TAPVD)

 Cyanotic spells in
TOF (pulmonary
stenosis, large VSD,
overriding aorta,
RVH)
calm the baby
knee chest position
O2, Morphine

 Conduction disorders - permanent pacing

for congenital complete heart block
Medication for tachyrrhythmias

Repair of defect
Interventional cardiac catheterisation
PDA, ASD, VSD occlusion with device placement
PS, AS balloon dilatation

Definitive surgical repair

Palliative surgical repair in some complex lesions
Long term cardiology follow-up