1. Approach to child with heart disease
Pushpa Raj Sharma
Professor of Child Health
Institute of Medicine

2. Diseases of heart
Blood vessels
Endocardium
Myocardium
Pericardium

3. Prevalence Acquired Congenital Cyanotic: 22% Acyanotic: 68%
Kawasaki disease
Rheumatic
Tubercular
Collagen
Congenital
Cyanotic: 22%
Acyanotic: 68%
VSD 25%
ASD 6%
PDA 6%
TOF 5%
PS 5%
AS 5%
Ceylon Med J 2001 Sep; 46 (3): 96-8; Indian J Pediatr Aug;68 (8):757-7
Nelson’s Textbook of pediatrics; 17 ed.

4. Common acyanotic lesions
Ventricular septal defects
Atrial septal defects
Atrio-ventricular septal defects
Patent ductus arteriosus
Truncus arteriosus
Pulmonary stenosis
Aortic stenosis
Mitral stenosis/incompetence
Coarctation of aorta
Tricuspid regurgitation

5. Common Cyanotic Lesions
Decreased flow
1. Tetralogy of Fallot
2. Tricuspid Atresia
3. Severe Pulmonic Stenosis
4. Ebstein’s anamoly
Increased Flow
5. Transposition of great vessles
6. VSD with pulmonary atresia

6. Common Lesions producing cyanosis
7. Truncus Arteriosus
8. Hypoplastic left heart
9. Single ventricle
10. TAPVR with infradiaphragmatic obstruction

7. Presenting complaints/signs
Fast breathing
Oedema
Hepatomegaly,
spleenomegaly
Clubbing
Cyanosis
Focal neurological lesion
Other organ defects
Chromosomal anomalies
Failure to thrive
Exercise intolerence
Easy fatigability
Chest indrawing
Sweating during feeding
Bluish spells
Fever with rigor
Palpitation
Convulsion

8. Cyanosis: is it a cardiac cause or lung cause
Hyperoxia test
Neonates with cyanotic congenital heart disease usually do not have significantly raised arterial Pao2 during administration of 100% oxygen.

9. Ventricular Defect Small VSD Large VSD Asymptomatic
A loud, harsh, or blowing holosystolic murmur.
Large VSD
dyspnea, feeding difficulties, poor growth, profuse perspiration, recurrent pulmonary infections, and cardiac failure in early infancy.
80%
Syndromes associated with this condition

10. VSD: ECG is normal but may show right ventricular hypertrophy, if present indicates defect is large and presence of pulmonary hypertension or pulmonry stenosis

11. Ventricular Septal Defect (VSD)
Small VSDs, the chest radiograph is usually normal
Large VSD: The presence of right ventricular hypertrophy, olegeimic lung fields (pulmonary hypertension or an associated pulmonic stenosis), gross cardiomegaly with prominence of both ventricles, the left atrium.

12. Ventricular Septal defects
30–50% of small defects close spontaneously, most frequently during the 1st 2 yr of life.
Small muscular VSDs are more likely to close (up to 80%) than membranous VSDs are (up to 35%).
infants with large defects have repeated episodes of respiratory infection and heart failure despite optimal medical management.
Surgical repair prior to development of an irreversible increase in pulmonary vasculalr resistance (usually prior to the patient's second birthday).

13. Atrial Septal Defects: secundum
Most common form of ASD (fossa ovalis)
In large defects, a considerable shunt of oxygenated blood flows from the left to the right atrium.
Mostly asymptomatic
The 2nd heart sound is characteristically widely split and fixed.
Secundum

14. Atrial Septal Defects:primum
Situated in the lower portion of the atrial septum and overlies the mitral and tricuspid valves. In most instances, a cleft in the anterior leaflet of the mitral valve is also noted.
Combination of a left-to-right shunt across the atrial defect and mitral insufficiency
C/F similar to that of an ostium secundum ASD

15. Atrial Septal Defect Enlargement of the right ventricle
Enlargement of atrium
Large pulmonary artery
increased pulmonary vascularity is.

16. The electrocardiogram in patients with a complete AV septal defect is distinctive. The principal abnormalities are (1) superior orientation of the mean frontal QRS axis with left axis deviation to the left upper or right upper quadrant, (2) counterclockwise inscription of the superiorly oriented QRS vector loop, (3) signs of biventricular hypertrophy or isolated right ventricular hypertrophy, (4) right ventricular conduction delay (RSR′ pattern in leads V3 R and V1 ), (5) normal or tall P waves, and (6) occasional prolongation of the P-R interval

17. Atrial Septal Defects
Secundum ASDs are well tolerated during childhood.
Antibiotic prophylaxis for isolated secundum ASDs is not recommended.
Surgery or transcatheter device closure is advised for all symptomatic patients and also for asymptomatic patients with a Qp:Qs ratio of at least 2:1.
Ostium primum defects are approached surgically

18. Patent Ductus Arteriosus
Small defect no symptoms.
Large defect:
Wide pulse pressure
Enlarged heart
Thrill in L second IS
Continuous murmur
X-ray: prominent pulmonary artery with increased vascular markings.

19. Primary Pulmonary Hypertension
Prominent pulmonary artery.
Prominent right ventricle
Prominent vascularity in the hilar areas
Decreased vascualr marking in the periphery.
No treatment
PPrimary pulmonary hypertension is characterized by pulmonary vascular obstructive disease and right-sided heart failure. It occurs at any age, although in pediatric patients the diagnosis is initially made in the teenage years. Chest roentgenograms reveal a prominent pulmonary artery and right ventricle. The pulmonary vascularity in the hilar areas may be prominent, in contrast to the peripheral lung fields, in which pulmonary markings are decreased.

20. Mitral insufficiency: Rheumatic
High volume load
Inflammatory process
Enlarged left ventricles
Dilatation of the left atrium
Pulmonary congestion
Symptoms of left sided failure
Spontaneous improvement
Repeated insult
Chronic mitral insufficiency
Raised Pulmonary AP
Symptoms of right heart failure
Enlarged right ventricle and atrium

21. Mitral insufficiency: Rheumatic
Signs of heart failure
Heaving apical impulse
Apical systolic thrill
Accentuated 2nd sound
Holosystolic murmur radiating to axilla
ECG: bifid P waves and left ventricular hyertrophy
X-ray: prominent left atrium and ventricle (straight left border)
Prophylaxis against recurrence of rheumatic fever

22. Rheumatic valvular disease: Mitral stenosis
Takes 10 years to develop
Symptoms proportionate to severity
Left ventricular failure right ventricular failure
Loud first heart sound with opening snap.
Diastolic murmur
Absent murmur if heart failure.
Surgical intervention if symptomatic

23. Mitral Stenosis Loud 1st sound Diastolic murmur
left atrial enlargement
prominence of the pulmonary artery
enlarged right-sided heart chambers;
ECG: prominent notched P wave.

24. Pericardial Effusion Presenting complaint Signs: Precordial pain Cough
Dyspnoea
Abdominal pain
Vomiting
Fever
Other organs involvement
Signs:
Position: leaning forward.
Puffy face
Friction rub
Absent apical impulse
Muffled heart sounds
Pulsus paradoxus
Distended neck veins
Low QRS complex, T inversion

25. Pericardial Effusion
A relatively large pericardial effusion must be present to cause an enlarged cardiac shadow with the usual “water bottle” configuration on a chest roentgenogram

26. The test that differentiates
The cardiac seize and the vascularity in the chest X-ray

27. Cardiac disease with normal/decreased vasculature
Viral myocarditis
Tetralogy of Fallot
Pulmonary atresia
Tricuspid atresia
Endocardial fibroelastosis
Aberrant left coronary artery
Cystic medial necrosis
Diabetic mother

28. Tetralogy of Fallot Ventricular septal defect Pulmonic stenosis
Overriding aorta
Right ventricular hypertrophy
Cyanotic

29. Cardiac disease with increased vasculature
Atrioventricular septal defects
Congestive cardiac failure
Transposition of great arteries with VSD
Total anomalous pulmonary venous drainage
Truncus arteriosus
Single ventricle without pulmonary stenosis
Hypoplastic left heart syndrome

30. Congestive Cardiac Failure
Enlarged heart
Plethoric lung fields specially at bases