Transcript Patent ductus arteriosus

Childhood Cardiac Conditions
Lydia Burland
Learning Outcomes
By the end of the session you should;
 Recognise common heart murmurs present in
childhood
 Be able to list the risk factors for cardiac disease
in childhood
 Be able to define innocent murmurs and explain
to parents
 Be able to answer exam-based questions
Case 1
 A 5 year old girl attends A+E with a 2 day
history of watery eyes, cough and runny nose
 She is also pulling at her left ear intermittently
and is off her food and drinks
 She has no relevant medical history, though
there is a family history of epilepsy
Case 1
 Observations: HR 124, RR 28, Sats 97%, T 37.9
 On examination:
Red, watery eyes and coryzal, inflamed left TM
HS I + II + systolic murmur
Chest: good AE with transmitted sounds and mild
wheeze bilaterally
Abdo: SNT, no masses or organomegaly
What do you think about the observations?
What else would you want to ask/examine?
Case 1
 Murmur loudest at the upper left sternal edge,
no radiation, thrills or heaves
 Brachial and femoral pulses present, with good
volume
 No other stigmata of cardiac disease
What are your differential diagnoses?
Do you want any further investigations or F/U?
Innocent Murmurs
 Innocent murmurs are common in childhood
 They are;
Systolic
Soft (or musical)
Localised with no radiation
Alter with changes in position and respiration
 As there is no underlying cardiac abnormality
there are no other associated symptoms
Innocent Murmurs
 Flow murmur:
 HR and blood flow within the heart increase in response to
increased oxygen demand
 Turbulent blood flow results in an audible murmur
 Loudest at the left sternal edge
 Venous hum:
 Around 20% of cardiac output flows to the brain, which in
turn drains into the internal jugular veins
 The flow of blood results in ‘vibration’ of the vessel walls,
resulting in an audible ‘hum’
 Loudest beneath the clavicle, and obliterated on lying flat
Innocent Murmurs
 No investigation is needed in a well child with
otherwise normal examination/observations
 Follow up should be arranged in 6-8 weeks when
the child is well to review the murmur
 If still present reassure parents
 Echo if any doubt regarding murmur/red flags
Case 2
 A 6 month old attends paediatric outpatients
with failure to thrive and recurrent LRTIs
 He was born on the 50th centile, and now sits
below the 2nd
 His intake is adequate for his age and he is
otherwise developing normally
Case 2
On examination:
 Bright, good colour and tone, mild tachypnoea
 Small, but no evidence of dysmorphism
 HS I + II + continuous murmur loudest in the
infraclavicular area
 Bounding brachial and femoral pulses
 Chest: good air entry with no added sounds
 Abdo: SNT, 2cm liver edge palpable
Patent Ductus Arteriosus
 In utero the ductus allows diversion of blood
away from the lungs (pulmonary artery to aorta)
 It usually closes on day 1-2 of life, and disappears
by week 3
 Risk factors:
Female sex
Congenital rubella
Prematurity
Downs syndrome
Maternal valproate exposure
Patent Ductus Arteriosus
 Small PDAs are usually asymptomatic
 Large PDAs present with failure to thrive and
recurrent LRTIs in childhood
 Continuous ‘machinery murmur’ in the
infraclavicular area or upper left sternal edge
 Associated systolic thrill and bounding pulses
 Echo confirms diagnosis and shunt size
Patent Ductus Arteriosus
Symptomatic patients:
 Preterm: ibuprofen or indometacin
 Diuretics for heart failure
 Surgical ligation
Asymptomatic patients:
 Regular echo review and catheter closure if still
patent at 1 year
Case 3
 A 2 year old girl is referred to paediatric
outpatients with a heart murmur
 It was found on routine examination by her GP
 She is otherwise well and developing normally
 Mum’s only concerns is that she is much
shorter than her nursery friends and siblings
Case 3
 On examination:
Short, with low set ears
Pink and well perfused, CRT <2 secs
HS I + II + systolic murmur loudest in L infraclavicular
area and radiating into the back
Femoral pulses are present, but weak
Is there anything else you want to check?
What is the most likely diagnosis?
Aortic Coarctation
 Narrowing of the aortic arch
 Usually distal to left subclavian artery, near the
ductus arteriosus
 Results in proximal hypertension, ventricular
hypertrophy and eventually heart failure
 Risk factors:
Males
Turner’s syndrome
Positive family history
Aortic Coarctation
 Investigation includes:
CXR
Echo
ECG
U+E
MRI
+/- cardiac catheter
 Management depends on presentation:
Critical stenosis in neonates – prostaglandin
Heart failure – diuretics
Hypertension – anti-hypertensives
 Definitive management is surgical
Case 4
 A 6 week old boy is referred with poor feeding,
failure to thrive and increased WOB
 Mum did not attend antenatal clinics, but reports
no pregnancy problems other than her ‘age’ (42)
 He was born by normal vaginal delivery, did not
require resuscitation and has been well since
 There is no family history of note
Case 4
 On examination:
Pink and active, mild hypotonia and low set ears
CRT <2 secs, RR 62, sats 95%, pulse normal
HS I + II + pansystolic murmur at lower LSE
Left parasternal heave, no thrills
Chest clear, abdo SNT
What are your differential diagnoses?
VSD
 Most common form of congenital heart disease
 One or more defects in the interventricular
septum
 Most VSDs occur in the perimembranous area
 Risk factors;
The trisomies (13/18/21)
Maternal diabetes
Turners syndrome (45XO)
Fetal alcohol syndrome
VSD
 Presentation depends on;
 Size of VSD
 Right/left ventricular pressures
 Size of shunt across defect
 Small: asymptomatic, murmur on examination
(pansystolic, loudest at LSE)
 Moderate: SOB on feeding from 5-6 weeks of life,
increased WOB and poor weight gain
 Large: as above, but may lead to irreversible
pulmonary hypertension and cyanosis
VSD
 Diagnosis confirmed on echo
 Many small VSDs close spontaneously <2yrs
 Management if symptomatic;
 Medical: diuretics and high-calorie feeds
 Surgical: open-heart surgery or catheter closure
Other Conditions
Congenital (acyanotic);
 ASD
 AVSD (Downs syndrome)
Congenital (cyanotic);
 Tetralogy of Fallot
 Transposition of the Great Arteries
Acquired;
 Coronary artery aneuryms (Kawasaki disease)
 Carditis/mitral valve disease (rheumatic fever)
Key Learning Points
 Murmur in an asymptomatic child is most likely
innocent
 Innocent murmurs do not need investigating, and
family should be reassured
 Congenital heart disease may present with cyanosis,
heart failure, feeding issues and respiratory distress
 Echo is the key investigation, and acute management
should follow an ABCDE approach
Practice Questions
MCQs
1. The most common form of congenital heart disease is...
a. Atrial septal defect
b. Atrioventricular septal defect
c. Ventricular septal defect
d. Pulmonary stenosis
2. Which of the following presents with cyanosis?
a. VSD
b. ASD
c. Tetralogy of fallot
d. Coarctation of the aorta
MCQs
3. Which of the following are risk factors for congenital heart
disease?
a. Maternal diabetes in pregnancy
b. Congenital rubella infection
c. Down’s syndrome
d. All of the above
4. Which of the following is associated with coronary artery
aneurysm?
a. Rheumatic fever
b. Type 1 diabetes mellitus
c. Kawasaki disease
d. Downs syndrome
EMQs
a. Venous hum
c. Patent ductus arteriosus
e. Tetralogy of fallot
b. Flow murmur
d. VSD
f. Aortic stenosis
5. A 28 weeker has had several failed attempts at
extubation on NNU. On examination he has a
continuous murmur in the left infraclavicular area.
6. A 5 year old presents to her GP with an URTI. She is
found to have a systolic murmur at the lower LSE. She
is pink and well perfused, pulses are normal and there
is no other evidence of cardiac disease.
EMQs
a. Venous hum
c. Patent ductus arteriosus
e. Tetralogy of fallot
b. Flow murmur
d. VSD
f. Aortic stenosis
7. A 14 year old presents with repeated collapses
on exertion. There is an ejection systolic murmur
at the LSE on examination.
8. A 4 year old is noted to frequently ‘squat’ when
running around with friends. Her mum thinks she
looks ‘blue’ sometimes when she does this.
EMQs
a. Downs syndrome
c. Rheumatic fever
e. Kawasaki disease
b. Turners syndrome
d. Patau syndrome
f. Congenital rubella
9. A 15 year old presents with delayed puberty,
short stature and a murmur radiating to her back.
10. A 11 month old is found to have a murmur. On
echo he is diagnosed with an AVSD.
EMQs
a. Downs syndrome
c. Rheumatic fever
e. Kawasaki disease
b. Turners syndrome
d. Patau syndrome
f. Congenital rubella
11. A premature infant has evidence of IUGR,
microcephaly and a continuous machinery
murmur.
12. A 2 year presents with 6 days of fever, red lips,
cervical lymphadenopathy and a new murmur.
Clinical Image
13. This baby presents with
cyanosis.
a. What does the image
show?
b. How does it improve
the cyanosis?
c. What is the underlying
diagnosis?
Answers
MCQs
1. The most common form of congenital heart disease is...
a. Atrial septal defect
b. Atrioventricular septal defect
c. Ventricular septal defect
d. Pulmonary stenosis
2. Which of the following presents with cyanosis?
a. VSD
b. ASD
c. Tetralogy of fallot
d. Coarctation of the aorta
MCQs
1. The most common form of congenital heart disease is...
a. Atrial septal defect
b. Atrioventricular septal defect
c. Ventricular septal defect
d. Pulmonary stenosis
2. Which of the following presents with cyanosis?
a. VSD
b. ASD
c. Tetralogy of fallot
d. Coarctation of the aorta
MCQs
3. Which of the following are risk factors for congenital heart
disease?
a. Maternal diabetes in pregnancy
b. Congenital rubella infection
c. Down’s syndrome
d. All of the above
4. Which of the following is associated with coronary artery
aneurysm?
a. Rheumatic fever
b. Type 1 diabetes mellitus
c. Kawasaki disease
d. Downs syndrome
MCQs
3. Which of the following are risk factors for congenital heart
disease?
a. Maternal diabetes in pregnancy
b. Congenital rubella infection
c. Down’s syndrome
d. All of the above
4. Which of the following is associated with coronary artery
aneurysm?
a. Rheumatic fever
b. Type 1 diabetes mellitus
c. Kawasaki disease
d. Downs syndrome
EMQs
a. Venous hum
c. Patent ductus arteriosus
e. Tetralogy of fallot
b. Flow murmur
d. VSD
f. Aortic stenosis
5. A 28 weeker has had several failed attempts at
extubation on NNU. On examination he has a
continuous murmur in the left infraclavicular area.
6. A 5 year old presents to her GP with an URTI. She is
found to have a systolic murmur at the lower LSE. She
is pink and well perfused, pulses are normal and there
is no other evidence of cardiac disease.
EMQs
a. Venous hum
c. Patent ductus arteriosus
e. Tetralogy of fallot
b. Flow murmur
d. VSD
f. Aortic stenosis
5. A 28 weeker has had several failed attempts at
extubation on NNU. On examination he has a
continuous murmur in the left infraclavicular area.
6. A 5 year old presents to her GP with an URTI. She is
found to have a systolic murmur at the lower LSE. She
is pink and well perfused, pulses are normal and
there is no other evidence of cardiac disease.
EMQs
a. Venous hum
c. Patent ductus arteriosus
e. Tetralogy of fallot
b. Flow murmur
d. VSD
f. Aortic stenosis
7. A 14 year old presents with repeated collapses
on exertion. There is an ejection systolic
murmur at the LSE on examination.
8. A 4 year old is noted to frequently ‘squat’ when
running around with friends. Her mum thinks she
looks ‘blue’ sometimes when she does this.
EMQs
a. Venous hum
c. Patent ductus arteriosus
e. Tetralogy of fallot
b. Flow murmur
d. VSD
f. Aortic stenosis
7. A 14 year old presents with repeated collapses
on exertion. There is an ejection systolic murmur
at the LSE on examination.
8. A 4 year old is noted to frequently ‘squat’ when
running around with friends. Her mum thinks
she looks ‘blue’ sometimes when she does this.
EMQs
a. Downs syndrome
c. Rheumatic fever
e. Kawasaki disease
b. Turners syndrome
d. Patau syndrome
f. Congenital rubella
9. A 15 year old presents with delayed puberty,
short stature and a murmur radiating to her
back.
10. A 11 month old is found to have a murmur. On
echo he is diagnosed with an AVSD.
EMQs
a. Downs syndrome
c. Rheumatic fever
e. Kawasaki disease
b. Turners syndrome
d. Patau syndrome
f. Congenital rubella
9. A 15 year old presents with delayed puberty,
short stature and a murmur radiating to her back.
10. A 11 month old is found to have a murmur. On
echo he is diagnosed with an AVSD.
EMQs
a. Downs syndrome
c. Rheumatic fever
e. Kawasaki disease
b. Turners syndrome
d. Patau syndrome
f. Congenital rubella
11. A premature infant has evidence of IUGR,
microcephaly and a continuous machinery
murmur.
12. A 2 year presents with 6 days of fever, red lips,
cervical lymphadenopathy and a new murmur.
EMQs
a. Downs syndrome
c. Rheumatic fever
e. Kawasaki disease
b. Turners syndrome
d. Patau syndrome
f. Congenital rubella
11. A premature infant has evidence of IUGR,
microcephaly and a continuous machinery
murmur.
12. A 2 year presents with 6 days of fever, red lips,
cervical lymphadenopathy and a new murmur.
Clinical Image
13. This baby presents with
cyanosis.
a. What does the image
show? Child being placed in
knee-to-chest position
b. How does it improve the
cyanosis? Increases venous
return to the heart
c. What is the underlying
diagnosis? Tetralogy of
fallot (tet spell)
Exam Resources
 Get Ahead! Specialities
 Masterpass SBAs and EMQs in Paediatrics for Medical
Students
 Masterpass SBAs and EMQs in Obstetrics and
Gynaecology for Medical Students
 Pastest OSCEs for Medical Students Vol 1/2/3
 Macleod’s Clinical OSCEs (available May 15th)
Any Questions?