Midterm

• Atrial Septal Defect (ASD)


  • Abnormal opening between atria → blood from higher pressure (LA) to flow into lower pressure (RA)
  • Increase O2 blood into R side of heart
  • RA & RV enlargement
  • Cardiac failure is unusual in uncomplicated ASD

  
• Atrial Septal Defect (ASD)

  • May be asymptomatic if small defect
  • Dyspnea
  • Fatigue and poor growth
  • Soft systolic murmur in pulmonic area (splitting S2)

  
• Diagnostic Exams for ASD

  • 2D Echo: reveals enlarged right side of the heart and ↑ pulmonary circulation
  • Cardiac catheterization: demonstrates separation of RA and the↑ O2 saturation in the RA

  
• Treatments for ASD


  1. Surgical treatment: Pericardial patch or Dacron patch closure

  2. Non-surgical: may be closed using devices during cardiac catheterization (Amplatzer Septal Occluder)

  3. Low-dose aspirin for 6 months
• Nursing Management for ASD

  • Explain to parents the purpose of tests and procedures
  • Teach parents ways to support nutrition, reduce stress on heart, promote rest, and support growth and development during preoperative period
  • Teach parents signs of congestive heart failure and infection
  • Prepare parents and child for surgery by visiting intensive care unit, explaining equipment and sounds
  • Prepare older child for post-operative experience, including coughing and deep breathing and need for movement
  • Teach need for antibiotic prophylaxis to prevent subacute bacterial endocarditis
• Ventricular Septal Defect (VSD)

  • Defect in ventricular septum – error in early fetal development
  • Abnormal opening between the right and left ventricles
  • Location: membranous (80%) or muscular
  • Pinhole to absence of septum
  • Spontaneous closure may occur during the first year of life

  
• Ventricular Septal Defect (VSD)

  • Pressure LV → RV and systemic arterial circulation resistance → pulmonary circulation, blood flows through the defect and into the pulmonary artery
  • RV becomes enlarged (Hypertrophied), over time the RA may also become distended

  
• Symptoms of VSD


  • Tachypnea, dyspnea
  • Poor growth, reduced fluid intake
  • Palpable thrills
  • Loud holo-systolic murmur at left lower sternal border
  • May develop HF
  • At risk for BE and pulmonary vascular obstructive disease

  
• Treatments for VSD


  1. Medications: Furosemide, Digoxin, Angiotensin-converting enzyme (ACE) inhibitor

  2. Surgical repair with CP Bypass (procedure of choice): Small defects by suture while large defects by knitted Dacron Patch

  3. Pulmonary artery banding (for infants with multiple muscular VSD)
• Patent Ductus Arteriosus (PDA)

  • Ductus SHOULD close by about age 15 hours after birth
  • Some shunting of blood may occur up to 24 hours of life
  • DUCTUS closes because increase in arterial oxygen concentration that follows initiation of pulmonary function
  • Prostaglandin inhibitors leads to closure of PDA
  • Allows blood to flow from left to right and pulmonary blood flow
• Patent Ductus Arteriosus (PDA)

  • Small PDA : asymptomatic
  • Bounding peripheral pulses
  • Widened pulse pressure (>25)
  • Loud machinery-like murmur at upper left sternal border (Left intraclavicular area)
  • Complication for Large PDA : CHF with tachypnea, dyspnea, and hoarse cry
• Treatments for PDA


  1. Medical: (Premature) INDOMETHACIN to close PDA's

  2. Surgical: Surgical division or ligation via left thoracotomy, Video-assisted thoracoscopic surgery

  3. Non-surgical: Coiling through cardiac catheterization (contraindicated in preterm and small infants, and with large PDAs)
• Defects of Decreased Pulmonary Blood Flow

  • Obstruction of pulmonary blood flow + anatomic defect (ASD/ VSD) between R & L side of heart
  • Difficulty of blood exiting R heart via pulmonary artery → increase R side pressure > L pressure → desaturated blood shunt R to L → desaturated blood in systemic circulation
  • Hypoxemia, usually cyanotic

  
• Tetralogy of Fallot


  Involves four heart defects: Ventricular Septal Defect, Pulmonary stenosis, Right ventricular hypertrophy, Overriding aorta

  
• Tetralogy of Fallot


  • Hemodynamics vary widely
  • Depends on extent of pulmonic valve stenosis & size of VSD
  • If VSD is large, pressures are equal in R and L ventricles. Blood is shunted in the direction of the least resistance (pulmonary or systemic vascular resistance)
  • PVR is > than systemic vascular resistance, shunt will be R to L
  • Clinical manifestations: "TET SPELLS" or "blue spells" with acute episodes of cyanosis and hypoxia, Anoxic after feeding or with crying. RISK of emboli, LOC, sudden death, seizures
• Treatments for Tetralogy of Fallot

  1. Stage 1: Blalock or modified Blalock shunt >> blood to pulmonary arteries from L or R subclavian artery

  2. Complete repair: usually in 1st year of life. Repair of VSD, resect stenosed area, and patch R ventricular outflow

  
• Endocarditis (Bacterial Infective Endocarditis)


  • BE, IE or subacute bacterial endocarditis (SBE)
  • Infection in valves and endocardium
  • Sequelae of sepsis in child with cardiac disease of congenital anomaly
  • Affects children with valvular abnormalities, prosthetic valves, recent heart surgery with invasive lines and RHD with valve involvement, drug abuse
• Endocarditis (Bacterial Infective Endocarditis)


  • Staph aureus, strep viridians (most common), candida albicans, gram negative bacteria
  • Enter blood system thru: dental (most common), UTI, cardiac catheterization, surgery, etc.
  • Organism in endocardium vegetations (verrucae) → fibrin deposits → platelet thrombi → invade adjacent tissues (mitral/aortic valves) → breaks off and embolize elsewhere (spleen, kidney, CNS) → death
• Diagnostic Exams for Endocarditis

  • Based on clinical manifestations
  • Blood c/s: definitive diagnosis
  • ECG/CXR (cardiomegaly)
  • Increased ESR, increased WBC, anemia, microscopic hematuria
  • 2D-echo – vegetations, valve function

  
• Clinical Manifestations of Endocarditis

  • Insidious onset, unexplained fever (low grade, intermittent)
  • Anorexia, malaise, weight loss
  • Extracardiac emboli
  • Splinter hemorrhage– thin black lines under nails
  • Osler nodes – red, painful, intradermal nodes on pads of phalanges
  • Laneway lesions – painless hemorrhage on panes and soles
  • Petechiae on oral mucous membrane
  • May be present: CHF, dysrhythmia, new murmur

  
• Therapeutic Management of Endocarditis

  1. High dose antibiotics: Penicillin, ampicillin, methicillin, cloxacillin, streptomycin, or gentamycin

  2. IV/IM x 4 weeks at least

  3. Amphoterecin or flucytosine for fungal infections

  4. Treat 2-8 weeks. If antibiotics is unsuccessful >> CHF develops, vulvular damage
• Therapeutic Management of Endocarditis

  • Should be instituted immediately
  • Blood c/s periodically to evaluate responseto antibiotics
  • Prophylaxis before dental procedures, bronchoscopy, T&A, surgeries, childbirth
  • Prophylaxis: 1 hour before procedures (IV) or may use PO in some cases
  • Family dentist should be advised of existing heart problems
• Rheumatic Heart Disease


  • Inflammatory disease occurs after Group A Beta-haemolytic streptococcal throat infection
  • Self-limiting
  • Affects joints, skin, brain, serious surfaces, and heart

  
• Risk Factors for Rheumatic Heart Disease

  • Age and sex: (5-15 years old) female
  • Housing and socioeconomic status
  • Season: rainy season
  • Genetic predisposition

  
• Clinical Manifestations of Rheumatic Heart Disease

  • Acute febrile-like illness (2-3 weeks after streptococcal throat infection)
  • Non-specific: Fever, Joint pain, Loss of appetite, Muscle ache
  • Specific: Joints (swelling and pain of larger joints like knee, ankle, elbow and wrist occurring in rapid succession – "migratory arthritis")
  • Heart (causes inflammation of the whole layers of the heart – PANCARDITIS) – Palpitation, chest pain, shortness of breathe, leg swelling, etc.
  • Skin & subcutaneous tissues (non-itching macular rash and painless mobile nodules over joints and spines)
  • Central Nervous System (a late manifestation) – abnormal movements of the limbs with muscle weakness and emotional labiality

  
• Diagnostic Approach: Modified Jones Criteria

  • 2 major or 1 major + 2 minor manifestations + strep infection
  • Major: Carditis, Polyarthritis, Erythema marginatum, Subcutaneous nodules, St. Vitus Dance
  • Minor: Arthralgia, Fever
• Laboratory Findings for Rheumatic Heart Disease

  • Increased ESR, CRP
  • Supporting evidence of antecedent group A Strep Infection: Throat c/s, rapid Ag test, ASO titer (most reliable – 80% children), AntiDNAse, ESR, CRP
  • ECG, CXR – evidence of heart involvement

  
• Treatment for Rheumatic Heart Disease

  Step 1 – Primary Prevention: Eradication of streptococci, Treatment of streptococcal tonsillitis / pharyngitis with Penicillin G(parenteral) – IM x 1, Penicillin V(oral) – oral x 10 days, Erythromycin (if allergic to above)

  
• Bony prominences


  • Hands
  • Feet
  • Elbows
  • Scalp
  • Scapulae
  • Vertebrae
• Bony prominences


  • Persistent indefinitely after onset of the disease and resolve with no resulting damage
• St. Vitus Dance


  The Fifth Manifestation (Sydenham's Chorea)
• St. Vitus Dance (aka, chorea)


  Reflects CNS involvement
• Chorea


  Sudden, aimless movements of extremities, involuntary facial grimaces, speech disturbances, emotional lability and muscle weakness
• Chorea


  • Worse with anxiety and relieved by rest
• MAJOR


  • Bony prominences
  • St. Vitus Dance
• MINOR


  • Arthralgia
  • Fever
• LABORATORY


  • Increased ESR, CRP
  • Supporting evidence of antecedent group A Strep Infection
  • Throat c/s, rapid Ag test
  • ASO titer (most reliable – 80% children)
  • AntiDNAse, ESR, CRP
  • ECG, CXR – evidence of heart involvement

  
• TREATMENT - STEP 1 Primary Prevention of RHD

  1. Eradication of streptococci

  2. Treatment of streptococcal tonsillitis / pharyngitis

  3. Penicillin G(parenteral) – IM x 1

  4. Penicillin V(oral) – oral x 10 days

  5. Erythromycin (if allergic to above) – oral x 10 days
• TREATMENT - STEP 2 Anti-Inflammatory treatment

  Salicylates (ASA) – control inflammatory process esp. joints, dec fever and discomfort
• TREATMENT - STEP 3 Supportive management

  Bed rest – during febrile phase but need not be strict