Transcript Acute Rheumatic Fever

R. TANDON
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ECG, accurate physical examination and
radiology form the tripod on which rests
the clinical diagnosis in Ped. Card.
Omission of, unfamiliarity with or
misinterpretation of any of these three
tools spells disaster.
Alexander S. Nadas
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Investigations are complimentary
to each other in helping reach an
accurate clinical diagnosis.
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ECG is the quickest, safest, least
expensive and most widely
available cardiac investigative
tool.
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Electrocardiogram : Utility
 Identify cardiac malposition.
 Atrial and ventricular hypertrophy
- specific dx.
- assess severity
 Pericard. and myocard. disease.
 Electrolyte imbalance.
 Atriovent. & intravent conduction abn.
 Arrhythmias.
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In congenital heart disease interpretation of
the ECG is useful only on the patient’s
bedside.
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CONGENITAL HEART DISEASE
ECG Crucial data
 Age
 Cyanotic or acyanotic
 Heart size – x-ray
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Electrocardiogram
At Birth : RAD (+90 to +120) RVH
At 2 to 5 years :Normal axis (+30 to +75)
Normal LV dominance
Transitional period (Unstable ECG)
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CONGENITAL HEART DISEASE
CLASSIFICATION
L  R shunts Obstr. lesions
Cyanotic pts
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With PS
With PAH
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•
Atrial level
Vent. Level
PA level
Right sided
Left sided
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CONGENITAL HEART DISEASE
CYANOTIC : Subgroups
 PS, no VSD, R to L at atrial level
 PS with VSD (TOF physiology).
 pulm flow (Transposition physiol.)
 PA pr ,  pulm. flow (Eisenmenger
physiol).
 Pulm. ven. obst.
 PA pr. normal, No PS, No PAH.
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CONGENITAL HEART DISEASE
L to R Shunts : Atrial level
QRS axis-30 to +150 Atrial septal defect 2°
 QRS axis-15 to -120 Atrial septal defect 1°
 Atrial septal defect 2° - rsR1 – V1 - 95%
 RVH  PAH
 Atrial septal defect 1° - right, left, right +
left, V.H.

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CONGENITAL HEART DISEASE
L to R Shunts : Vent. & PA level
 Normal axis.
 L.V. dominance or LVH.
 RVH  PS or PAH.
 PDA : Left ventricular hypertrophy with ST
and T changes of ischaemia indicates
associated Aortic stenosis or LVEFE.
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CONGENITAL HEART DISEASE
Obstructive lesions : RVH : Right sided lesion (PS)
(Except in newborns and neonates).
 Left ventricular hypertrophy – left sided
lesion (Aortic stenosis, C of A0)
 ST and T changes in Coarct. of A0
indicates associated Aortic stenosis or
LVEFE.
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CONGENITAL HEART DISEASE
Obstructive lesions : As a rule severity of RVH or LVH is
consistent with the severity of obstruction.
 Presence of ST and T changes.
 Severe
obstr.
 Myocardial dis.
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CONGENITAL HEART DISEASE
Cyanotic :  QP, No VSD, CE+
(R  L at atrial level)
Pure
PS - Severe
Ebsteins anomaly.
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CONGENITAL HEART DISEASE
Cyanotic : TOF physiology (VSD + PS)
Clinical : No CE, S1 normal.
S2 single, eject syst. murmur.
X-ray
: No cardiomegaly.
Ischaemic lungs. Ao large.
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CONGENITAL HEART DISEASE
Cyanotic : TOF physiology
RAD RVH
TOF
RAD LVH
 RV
LAD LVH
LAD RVH
TA
AVC
SV
SV
DORV
SV
TGA
SV
DORV
DORV
(Small VSD) (Rare)
DORV
(Rare)
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CONGENITAL HEART DISEASE
Cyanotic : TOF physiology
LAD or RAD
Equiphasic complexes across.
precordium, q may be absent.
Single ventricle.
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CONGENITAL HEART DISEASE
Cyanotic : TGA physiology
CE + Congestive cardiac failure + Age - NB
RAD RVH RAD LVH LAD LVH
TGA
 RV
LAD RVH
TA
SV
TAPVC
SV
SV
AVC
DORV
PTA
SV
-
 RV
AVC
-
-
-
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CONGENITAL HEART DISEASE
Cyanotic Patients : Eisenmenger Phys.
RAD RVH
VSD, PDA,
APW
RAD LVH
 RV
LAD LVH
LAD RVH
TA
AVC
TGA
Physiol.
SV
SV
SV
ASD 2°
-
-
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CONGENITAL HEART DISEASE
Cyanotic Patients : Pulm. Ven. Obstru.
‘P’ Pulm, RAD, RVH.
 Hypoplastic
left heart
 TAPVC with PV obstru.
(Xray – Diagnostic)
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CONGENITAL HEART DISEASE
Cyanotic : Miscellaneous
(No PS, normal PA
RAD RVH
LAD RVH
Normal ECG -
pr).
TA PVC.
Single atrium
SVC to LA.
Pulm. AV fistula.
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SPOT DIAGNOSIS BY ECG

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ALCAPA
Ebstein’s anomaly
Ventricular inversion (l-loop)
Situs inversus
Hypertrophic cardiomyopathy
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Arrhythmias and conduction
defects
suggest
specific
congenital cardiac anomalies
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SSS
 ASD in Holt Oram synd.
 Sinus venosus ASD.
 AV canal defects
 Ebstein’s anomaly.
 Asplenia, polysplenia synd.
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Narrow QRS tachycardia
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Ebstein’s disease.
Cong. CTGA
LV – RA shunt
AV canal defects
Older pts of TA and ASD 2°.
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Wide QRS tachycardia
ALCAPA
 Coron. arterio-ven. fistula
 Arrhythmogenic RV dysplasia.

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Atrioventricular conduction defects
and pre-excitation syndrome

Ebstein’s disease.

Cong. CTGA
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Age
: 3 yrs, acyanotic.
Dx.
: PDA, No PAH
Shunt  2:1.
X-ray : No CE, Ao+, MPA +
Vasc : N to +.
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Age
: 2 m, cyanotic
Dx.
: Transposition physiology
X-ray : CE ++, Vasc. ++.
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Age
: 2 yrs, cyanotic
Dx.
: Fallots’ physiology
X-ray : No CE, Vasc. , Ao+.
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Age
: 12 yrs, cyanotic
Dx.
: Eisenmenger physiology
X-ray : CE +, Vasc : Prominent hilar
vasc., Ischaemic periphery.
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CONGENITAL HEART DISEASE
Electrocardiogram provides diagnostic help
only on the bedside of the patient from
whom the ECG has been taken.
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