Congenital Heart Defects Craig T. Carter, D.O. Assistant Professor – EM/Peds University of Kentucky
Mar 26, 2015
Congenital Heart Defects
Craig T. Carter, D.O.
Assistant Professor – EM/Peds
University of Kentucky
A nurse approaches you -
“Doctor, Doctor” - a kid just checked in with a history of Hypoplastic Left Heart syndrome – What is that again??”
You reply …..
“ I need to go to the bathroom, as soon as I get back, I will tell you all about it....”
So you sit and think…..
And think some more….
Back to Basics-Fetal Circulation
Four shunts of blood flow : placenta, ductus venosus, foramen ovale and ductus arteriosus
Back to Basics-Fetal Circulation
Changes after birth:
Shift of blood flow for gas exchange, from the placenta to the lungs.
Closure of ductus venosus :no placenta increase in pulmonary blood flow functional closure of foramen ovale
(increased LA pressure) Closure of ductus arteriosus (^O2)
Newborn Cardiac Exam
Vital signs: RR, HR, BP respiratory effort color palpate point of maximal impulse (PMI)
of heart palpate pulses of all extremities auscultate
Case 1: 2 day old infant
2 day old baby girl is being examined for discharge physical.
Vitals: HR:120 RR:40 BP: r arm 75/40 Gen : low hairline, webbed neck,
edemetous dorsum of feet
Case 1: cardiac exam
Normal PMI, no thrill No hepatosplenomegally unable to palpate pulses in lower
extremities BP’s all four extremities: both legs
systolic BP lower 40/30
Case 1: Auscultation
S2 splits normally ejection click systolic ejection murmur III/VI at the
URSB and LLSB systolic murmur radiates to the back early diastolic decrescendo murmur at
3LICS
Case 1:
What do you think is the congenital defect?
Case 1:
What further evaluation do you need?
Coarctation of Aorta (COA)
Coarctation of Aorta (COA)
Incidence: 8% of all congenital heart defects
Turner’s syndrome: 30% have COA
Preductal: 40% associated with other cardiac defects,symptomatic early in life
Postductal: less likely to have symptoms early
COA
EKG: LVH (but may be normal in 20%)
X-rays: heart size may be normal or slightly enlarged
Rib notching in older children
Echo: can see narrowing
Bicuspid aortic valve Doppler:disturbed
flow
COA complications
COA can cause CHF, HTN (intracranial bleeding,hypertensive encephalopathy)
Bicuspid aortic valve: stenosis or regurg LV failure infective endocarditis
Preductal COA in Newborn
80% of infants with preductal COA develop CHF by 3 months of age!
Symptoms of CHF: poor feeding, poor weight gain, dyspnea in first 2-6 weeks of life.
Case 2: Two week old with murmur Two week old infant, who you saw as a
newborn with normal exam, now is noted to have a heart murmur.
PMI LSB, not hyperdynamic pulses equal all extremities No HSM
Case 2: Cardiac exam
Grade III/VI holosystolic murmur at LLSB
Case 2: What would you like to do next? EKG: LVH,LAH Blood pressures all four extremities Xray: look for cardiomegally and
increase in pulmonary vascularity oxygenation Echo: VSD
Ventricular Septal Defect (VSD)
The most common form of congenital heart disease: 20-25%
may be located in different anatomical locations
may be associated with many other cardiac defects ( in many cases essential for survival)
may be small or large (can cause CHF)
Case 3: One day old infant
One day old infant with tachypnea and cyanosis
Gen: cyanotic RR:65, HR 140, BP 40/20 pulse ox on RA: less than 80
Case 3: Respiratory and Cardiac
Lungs clear, no retractions, RR rapid Cardiac: PMI at LSB pulses palpable all extremities S2 single and loud. No heart murmur.
What would you like to do?
ABG: before oxygenation Give 100% O2 and then repeat ABG EKG, 4 extremity BP CXR
Results of ABG
Before O2: PH: 7.15,PaCO2 30 and Pa O2 40
After 100% O2: PH: 7.12, PaCO2 25 and PaO2 50
Transposition of Great Arteries
Transposition of Great Arteries
5% of all congenital heart defects Aorta arises anteriorly from RV, PA
arises posteriorly from LV defects (VSD,ASD,PDA) that permit
mixing of the two circulations are necessary for survival
TGA:
ABG:hypoxemia is unresponsive to O2
EKG: RVH X-rays: egg-on-a-
string silhouette cardiomegally with
increased pulmonary vascularity
Echo: PA from LV associated
anomalies:VSD,ASD,PDA
Immediate Treatment
Prostaglandin E1 to reopen PDA Oxygen cardiology/surgery referral
DDX of Cyanotic Heart Dz
Transposition of the Great Arteries Tetralogy of Fallot Total Anomalous Pulmonary Venous
Return Tricuspid Atresia Pulmonary Atresia Truncus Arteriosus
Other congenital cyanotic defects
Ebstein’s anomaly single ventricle Double-outlet right ventricle (depends
on associated defects…if cyanotic or not)
Tetralogy of Fallot
Tetralogy of Fallot (TOF)
Large VSD RV outflow obstruction right ventricular hypertrophy overriding of the aorta
Tetralogy of Fallot
10% of all congenital heart defects The MOST COMMON CYANOTIC
cardiac defect beyond infancy
TOF: physical exam
Varying degrees of cyanosis and clubbing
systolic thrill LSB S2 single with ejection click loud III-V/VI SEM LSB continuous murmur of PDA
TOF
EKG: RAD, RVH Xray: “boot-shaped”
heart (hypoplastic MPA)
Echo: image of four defects associated
Tetralogy of Fallot
TOF complications
Hypoxic spells growth retardation with severe cyanosis brain abscess and CVA infective endocarditis polycythemia
Hypoxic Spell ( “TET Spell”
Paroxysm of hyperpnea (rapid and deep)
irritability and prolonged cry increasing cyanosis decreased intensity of heart murmur (may lead to limpness, convulsion,CVA
or death)
Treatment of “TET Spell”
Knee-chest (squat )position morphine sulfate treat acidosis oxygenation
Total Anomalous Pulmonary Venous Return One percent of all congenital heart
defects Defect: no direct communication
between the pulmonary veins and the left atrium (they can drain: supracardiac,cardiac,infracardiac or mixed)
Total Anomalous Pulmonary Venous Return
TAPVR findings
S2 widely split and fixed
S3 or S4 gallop SEM: III-IV/VI middiastolic rumble
at LLSB
Xrays: cardiomegally
“Snowman” Echo can define
anatomy EKG:RAD
Tricuspid Atresia
1-2% of all congenital heart disease in infancy
tricuspid valve is absent and RV is hypoplastic
associated defects of VSD,ASD or PDA are necessary for survival
Tricuspid Atresia
Tricuspid Atresia: findings
Exam: cyanosis S2 single, often syst murmur of VSD,
and occ of PDA present early CHF
Tricuspid Atresia
EKG: superior QRS between O and -90
LVH
Pulmonary vascularity is decreased
Echo: defines minimal RV, and large LV
Pulmonary Atresia
Less than 1% of congenital heart diseases
valve is atretic, RV cavity is hypoplastic need other defects: ASD,PDA for
survival
Pulmonary Atresia
Pulmonary Atresia: findings
PE: S2 is single murmur of PDA
EKG: normal axis,LVH
Xray: decreased pulmonary vascularity
Echo:atretic pulmonary valve and hypoplastic RV
Pulmonary Atresia
Prostaglandin E1 cardiac surgery
Truncus Arteriosus
Less than 1% of all congenital heart Dz Only a single arterial trunk leaves the
heart and gives rise to the pulmonary, systemic and coronary circulations
large VSD is always present
Truncus Arteriosus
PE: cyanosis wide pulse pressure
and bounding pulses
harsh VSD murmur LSB
EKG:normal axis,LAH
Xrays: cardiomegally and increased pulm vascularity
50% R aortic arch Echo:single great
artery,VSD
Hypoplastic Left Heart
Hypoplastic Left Heart
Hypoplastic left heart syndrome refers to underdevelopment of the left side of the heart.
This syndrome may include: – Small aorta: This is the major blood vessel
from the left ventricle to the body.
Hypoplastic Left Heart
May Include:
– Aortic valve atresia (absence): This valve normally opens and closes to let blood flow from the left ventricle to the aorta. When atresia is present, there is no connection between the left ventricle and aorta, and no forward blood flow.
– – Mitral valve stenosis or atresia: This valve normally
opens and closes to let blood flow between the left atrium and left ventricle. Stenosis causes little blood flow; atresia causes no blood flow. Either atresia or stenosis may be present.