Paediatric Cardiology- after one year of age Jon Skinner

Topics to cover Murmur in a well four year old ECG in diagnosis of CHD CXR in diagnosis of CHD

Murmur in a well four year old What are the possibilities?

Murmur in a well four year old What are the possibilities? Innocent murmur

Murmur in a well four year old What are the possibilities? Innocent murmur Atrial septal defect

Murmur in a well four year old What are the possibilities? Innocent murmur Atrial septal defect Ventricular septal defect

Murmur in a well four year old What are the possibilities? Innocent murmur Atrial septal defect Ventricular septal defect Valvar stenosis

Murmur in a well four year old What are the possibilities? Innocent murmur Atrial septal defect Ventricular septal defect Valvar stenosis Aortic coarctation

Murmur in a well four year old What are the possibilities? Innocent murmur Atrial septal defect Ventricular septal defect Valvar stenosis Aortic coarctation Patent arterial duct

Murmur in a well four year old What are the possibilities? Innocent murmur Atrial septal defect Ventricular septal defect Valvar stenosis Aortic coarctation Patent arterial duct Miscellaneous rare stuff- HCM, valvar regurg etc

Murmur in a well four year old No. 1 What is this? Pulses normal, BP 95/60 RV lift 2-3/6 ESM at upper LSE ECG- CXR

Murmur in a well four year old No. 1

Murmur in a well four year old No. 1

Murmur in a well four year old No. 1 What is this? Pulses normal, BP 95/60 RV lift 2-3/6 ESM at upper LSE ECG- normal axis IRBBB CXR-mild cardiomeg, plethora, prominent PA

Murmur in a well four year old No. 2 No. 2 What is this? Pulses normal, BP 95/60 Normal precordium 2-3/6 vibratory ESM at upper and lower LSE ECG- normal axis IRBBB CXR-normal

Murmur in a well four year old No. 2- murmur disappears doing this

Murmur in a well four year old No. 2 No. 2 What is this? Pulses normal, BP 95/60 Normal precordium 2-3/6 vibratory ESM at upper and lower LSE murmur disappears on stretching the neck ECG- normal axis IRBBB CXR-normal

Murmur in a well four year old No. 3 What is this? History of recurrent chest infections Pulses normal, BP 100/65 RV lift. 2-3/6 ESM at upper LSE, fixed split of second sound ECG- IRBBB CXR- Cardiomeg, plethora, prominent PA

Murmur in a well four year old No. 3

Murmur in a well four year old No. 3 No. 3 What is this? Pulses normal, BP 100/65 RV lift. Harrison’s sulci 2-3/6 ESM at upper LSE, fixed split of second sound ECG- IRBBB CXR- Cardiomeg, plethora, prominent PA Diagnosis--

Murmur in a well four year old No. 4 No. 4 What is this? Pulses normal, BP 100/65 Parasternal thrill 4/6 PSM at lower LSE, ECG- CXR- Normal

Murmur in a well four year old No. 4

Murmur in a well four year old No. 4

Murmur in a well four year old No. 4 No. 4 What is this? Pulses normal, BP 100/65 Parasternal thrill 4/6 PSM at lower LSE, ECG- Borderline LVH CXR- Normal Diagnosis?

Murmur in a well four year old No. 5 No. 5 What is this? Slim child, recurrent chest infections Pulses normal, BP 95/60 Overactive precordium 2/6 low pitched PSM at lower LSE, 2/4 diastolic murmur at apex ECG- CXR-

Murmur in a well four year old No. 5

Murmur in a well four year old No. 5

Murmur in a “well” four year old No. 5

Murmur in a well four year old No. 5 No. 5 What is this? Slim child, recurrent chest infections Pulses normal, BP 95/60 Overactive precordium 2/6 low pitched PSM at lower LSE, 2/4 diastolic murmur at apex ECG- RVH, LVH CXR- Cardiomegally and plethora Diagnosis?

ECG diagnosis of atrial hypertrophy?

ECG diagnosis of atrial hypertrophy? Lead II

Conditions causing Atrial hypertophy on the ECG RAH LAH

Murmur in a well four year old No. 6 No. 6 What is this? BP 130/90 Soft ESM at upper RSE ejection click ECG- LVH with strain CXR- unavailable

Murmur in a well four year old No. 6 No. 6 What is this? BP 130/90 Soft ESM at upper RSE ejection click ECG- LVH with strain CXR- unavailable What do you wish to examine now?

Murmur in a well four year old No. 6 No. 6 What is this? BP 130/90 Soft ESM at upper RSE ejection click ECG- LVH with strain CXR- unavailable What do you wish to examine now? Diagnosis?- what might the CXR show?

Normal blood pressure values in children Boys Girls Paediatrics (suppl) 59:797, 1977

Murmur in a well four year old No. 7 What is this? Pulses normal, BP 90/65 RV lift. 2-3/6 ESM at upper LSE, fixed split of second sound ECG- CXR-

Murmur in a well four year old No. 7

Murmur in a well four year old No. 7

Murmur in a well four year old No. 7 What is this? Pulses normal, BP 90/65 RV lift. 2-3/6 ESM at upper LSE, fixed split of second sound ECG- LAD IRBBB CXR- CM plethora Diagnosis?

Types of ASD

What does this ECG show? 2 year old, loud systolic murmur, mild cyanosis (88%)

What does this CXR show? 3 month cyanotic infant

What does this CXR show?

Topics we have covered (superficially!) Murmur in a well four year old ECG in diagnosis of CHD chamber hypertrophy QRS axis RBBB in ASD CXR in diagnosis of CHD L-R shunts-> cardiomegally and plethora oligaemia

Useful texts Essential paediatrics- Hull and Johnstone, Church Liv Pediatric Cardiology for practitoners- Myung K Park, Mosby How to Read Pediatric ECGs- Park and Guntheroth, Mosby Heart Disease in Paediatrics- Jordan and Scott, Butterworths

Paediatric ECGs the rules Jon Skinner Green Lane Hospital

Criteria for chamber enlargement RA p wave amp >3mm LA bifid p wave and prolonged >.10 secs - ie 2.5 squares (.08 secs in infants) RV - use Davignon charts. R in V1>20v (4 squares) >25v in neonates or S in V6 >7v. OR upright T wave in V1 after 72 hours and up to 5 years. Severe RVH- ST and T wave now invert with ST depression, and small Q wave in lead V1. LV R in V6 >25v (5 squares). Severe- ST depression and T wave inversion V6.

Q- waves Are allowed (usual) in 1,2, 3 and aVf, V5 and V6 and are narrow and up to 7mm deep in 2 and 3 Are pathological in V1 (except occasional newborns) and indicate LTGA, single ventricle, severe RVH or anterior MI (deep and wide).

QT interval QTc = QT (ms)/ sq root R-R interval (ms) is less than 0.45sec Refer to Normal reference values Measure in lead 2 and V5 (and particularly not in V2- V4)

Abnormal ST segment (up or down) Up to 1mm is normal Up to 2 mm is normal in V2- V4 Causes?