Peds Cardio

1. 4 hour old term male infant is seen because of "duskiness" as well as a heart murmur. The infant's mother is 30 years of age and has three other children who are healthy. This pregnancy was uncomplicated and the baby was delivered at term with a birth weight of 3.9 kg. Although pink and well-perfused at birth, over the last several hours the infant has become cyanotic especially when crying. Why does he become more cyanotic when crying?

He is more upset

Increased oxygen demand

He is hungry

He needs his diaper changed

2. Match the findings with the appropriate cardiac disorder: Normal S1, single S2, no murmur or soft systolic ejection murmur. ECG: normal rhythm and axis, may be left ventricular enlargement

Tetralogy of Fallot

Truncus

Transposition of Great Arteries

Repair: develop heart failure early as high pressure flow to pulmonary arteries. Repair early (close VSD, create a conduit from the RV to the pulm arteries using a goretex tube)

Explanation

Repair: develop heart failure early as high pressure flow to pulmonary arteries. Repair early (close VSD, create a conduit from the RV to the pulm arteries using a goretex tube)

3. Match the findings with the appropriate cardiac disorder: Normal S1 and S2, loud grade 3-4/6 systolic ejection murmur (may also be holosystolic murmur if significant valve regurgitation). ECG: normal rhythm, left axis deviation, biventricular enlargement/hypertrophy

ASD

VSD

AVSD

PDA and AP window

4. 4 hour old term male infant is seen because of "duskiness" as well as a heart murmur. The infant's mother is 30 years of age and has three other children who are healthy. This pregnancy was uncomplicated and the baby was delivered at term with a birth weight of 3.9 kg. Although pink and well-perfused at birth, over the last several hours the infant has become cyanotic especially when crying. What is the significance of the heart murmur?

Suggests cardiac cause

Suggests pulmonary cause

Probably benign

5. A 4-week old girl presents with poor feeding and tachypnea. The infant was born at term after a normal pregnancy. At 2 weeks of ago, a cardiac murmur was noted, but the baby was otherwise well. However, over the last week she has become more tachypneic and is feeding poorly. Her family is concerned that she takes up to 50 minutes to feed and becomes sweaty and tachypneic during feedings. There is no history of cough or fever. On physical exam, weight 3.2kg (>5th %ile), length 53cm (~25th %ile), temp 36.5, HR 160, RR 64, BP (right arm) 80/40, O2 sat 92%. She is pale and diaphoretic. There is subcostal indrawing. The cardiac apex is just lateral to the mid-clavicular line at the 5th left intercostal space, and the precordial activity is increased. The heart sounds are normal, a harsh 3/6 pansystolic murmur is present. The liver is 4cm below the right costal margin. Are you concerned about hepatomegaly?

Yes

No

Splenectomy!

yes, 4cm below is ENORMOUS considering total torso size of a 4-week old baby!

Explanation

yes, 4cm below is ENORMOUS considering total torso size of a 4-week old baby!

6. Match the findings with the appropriate cardiac disorder: Normal S1 and S2, harsh grade 2-4/6 pansystolic murmur, ECG normal rhythm, normal axis, biventricular enlargement/hypertrophy

ASD

VSD

AVSD

PDA and AP window

7. Assessing upper limb vs. femoral pulses and 4 limb BPs would help you steer away from which cause of CHF?

Left heart obstruction

Arrhythmia

Myocardial disease

Shunt

8. 4 hour old term male infant is seen because of "duskiness" as well as a heart murmur. The infant's mother is 30 years of age and has three other children who are healthy. This pregnancy was uncomplicated and the baby was delivered at term with a birth weight of 3.9 kg. Although pink and well-perfused at birth, over the last several hours the infant has become cyanotic especially when crying. What is the significance of the timing of the cyanosis?

Probably a congenital defect

Physiological changes take place shortly after birth

Differentiates from cyanosis at birth

All of the above

9. Match the findings with the appropriate cardiac disorder: Normal S1, single or narrowly split S2, harsh grade 3-4/6 systolic ejection murmur. ECG: normal rhythm, right axis deviation, right ventricular hypertrophy.

Tetralogy of Fallot

Truncus

Transposition of Great Arteries

Repair: If very cyanotic, will need a BT shunt to augment pulmonary blood flow in first few days of life, with prostin to maintain ductal patency until surgery. Some centers do complete repair as a neonate even if the baby is tiny. Otherwise, get them to a good size, 4-6 months ideally, and then do complete repair (close VSD with a patch, and place patch over the R ventricular outflow tract to open up the pulm artery)

Explanation

Repair: If very cyanotic, will need a BT shunt to augment pulmonary blood flow in first few days of life, with prostin to maintain ductal patency until surgery. Some centers do complete repair as a neonate even if the baby is tiny. Otherwise, get them to a good size, 4-6 months ideally, and then do complete repair (close VSD with a patch, and place patch over the R ventricular outflow tract to open up the pulm artery)

10. A 4-week old girl presents with poor feeding and tachypnea. The infant was born at term after a normal pregnancy. At 2 weeks of ago, a cardiac murmur was noted, but the baby was otherwise well. However, over the last week she has become more tachypneic and is feeding poorly. Her family is concerned that she takes up to 50 minutes to feed and becomes sweaty and tachypneic during feedings. There is no history of cough or fever. On physical exam, weight 3.2kg (>5th %ile), length 53cm (~25th %ile), temp 36.5, HR 160, RR 64, BP (right arm) 80/40, O2 sat 92%. She is pale and diaphoretic. There is subcostal indrawing. The cardiac apex is just lateral to the mid-clavicular line at the 5th left intercostal space, and the precordial activity is increased. The heart sounds are normal, a harsh 3/6 pansystolic murmur is present. The liver is 4cm below the right costal margin. Is this a cyanotic lesion?

Yes

No

Hold on, I'll check Wiki...

11. Match the findings with the appropriate cardiac disorder: Normal S1, single S2, no murmur. ECG: normal rhythm and axis, may see predominant right-sided forces.

Tetralogy of Fallot

Truncus

Transposition of Great Arteries

cyanotic shortly after birth as systemic and pulm circulation in parallel. Need mixing of blue and red blood to survive initially, in the form of a big patent foramen ovale (PFO). If the PFO has closed or is very small, the baby will need an urgent balloon septostomy to open up a good sized interatrial communication to stabilize the baby and increase the saturations (often in the 50-60% at birth, stabilize in 70-80% range). Complete repair with an arterial switch procedure in the first 2 weeks of life.

Explanation

cyanotic shortly after birth as systemic and pulm circulation in parallel. Need mixing of blue and red blood to survive initially, in the form of a big patent foramen ovale (PFO). If the PFO has closed or is very small, the baby will need an urgent balloon septostomy to open up a good sized interatrial communication to stabilize the baby and increase the saturations (often in the 50-60% at birth, stabilize in 70-80% range). Complete repair with an arterial switch procedure in the first 2 weeks of life.

12. 4 hour old term male infant is seen because of "duskiness" as well as a heart murmur. The infant's mother is 30 years of age and has three other children who are healthy. This pregnancy was uncomplicated and the baby was delivered at term with a birth weight of 3.9 kg. Although pink and well-perfused at birth, over the last several hours the infant has become cyanotic especially when crying. Weight 3.6kg, RR 55, HR 140. BP 73/41, O2 sat on room air 74%. Pulses are normal. The precordium is quiet. The right ventricular activity is increased. There is a harsh grade 3/6 systolic ejection murmur along the upper left sternal border. The second heart sound appears single. There are no crackles or wheezes. all of the following are seen on the CXR EXCEPT

"boot-shaped" heart

Edema

Reduced pulmonary vascularity

No consolidation

13. Echocardiogram shows large perimembranous VSD. Moderate biventricular hypertrophy with normal function and mild RV/LV dilation. Increased flow velocity within main pulmonary artery secondary to VSD shunt, small PFO. When do most small VSDs require repair?

Never - often close spontaneously

4-6 months of age

6-8 months of age

8-12 months of age

most large VSDs require repair around 4-6 months of age (definitely before 1 year of age) or around 5kg in weight. Medical management is used to control CHF to allow adequate weight gain pre-op. The latter includes the use of diuretics (lasix, aldactazide) to reduce pulmonary edema. NG tube feedings to optimize caloric intake and reduce the work of feeding. Some use digoxin as that may improve heart failure symptoms. Note: CHF in patients with L-R shunts differs from patients with pump failure, such as in the case of myocarditis and cardiomyopathy. The cardiac contractility in the former is usually normal. Small VSDs often close spontaneously and do not cause heart failure as the shunting is minimal. A murmur is heard until the VSD closes.

Explanation

most large VSDs require repair around 4-6 months of age (definitely before 1 year of age) or around 5kg in weight. Medical management is used to control CHF to allow adequate weight gain pre-op. The latter includes the use of diuretics (lasix, aldactazide) to reduce pulmonary edema. NG tube feedings to optimize caloric intake and reduce the work of feeding. Some use digoxin as that may improve heart failure symptoms. Note: CHF in patients with L-R shunts differs from patients with pump failure, such as in the case of myocarditis and cardiomyopathy. The cardiac contractility in the former is usually normal. Small VSDs often close spontaneously and do not cause heart failure as the shunting is minimal. A murmur is heard until the VSD closes.

14. Match the findings with the appropriate cardiac disorder: Normal S1, fixed split S2, grade 2-3/6 systolic ejection murmur, on ECG normal rhythm, normal axis, incomplete right bundle branch block

ASD

VSD

AVSD

PDA and AP window

15. A 4-week old girl presents with poor feeding and tachypnea. The infant was born at term after a normal pregnancy. At 2 weeks of ago, a cardiac murmur was noted, but the baby was otherwise well. However, over the last week she has become more tachypneic and is feeding poorly. Her family is concerned that she takes up to 50 minutes to feed and becomes sweaty and tachypneic during feedings. There is no history of cough or fever. What physiological change takes place at approximately 4 weeks of age that could be important to consider in this case?

Closing of ductus arteriosus

Closing of foramen ovale

Closing of ductus venosus

Decline in pulmonary vascular resistance

closing of foramen ovale occurs at, or shortly after, birth. Closing of ductus arteriosus and ductus venosus occur shortly after birth. The decline in pulmonary vascular resistance can take a few weeks.

Explanation

closing of foramen ovale occurs at, or shortly after, birth. Closing of ductus arteriosus and ductus venosus occur shortly after birth. The decline in pulmonary vascular resistance can take a few weeks.

16. A 4-week old girl presents with poor feeding and tachypnea. The infant was born at term after a normal pregnancy. At 2 weeks of ago, a cardiac murmur was noted, but the baby was otherwise well. However, over the last week she has become more tachypneic and is feeding poorly. Her family is concerned that she takes up to 50 minutes to feed and becomes sweaty and tachypneic during feedings. There is no history of cough or fever. On physical exam, weight 3.2kg (>5th %ile), length 53cm (~25th %ile), temp 36.5, HR 160, RR 64, BP (right arm) 80/40, O2 sat 92%. She is pale and diaphoretic. There is subcostal indrawing. The cardiac apex is just lateral to the mid-clavicular line at the 5th left intercostal space, and the precordial activity is increased. The heart sounds are normal, a harsh 3/6 pansystolic murmur is present. The liver is 4cm below the right costal margin. All of the following are causes of a pansystolic murmur EXCEPT

Ventral septal defect

Mitral valve regurgitation

Pulmonary stenosis

Tricuspid valve stenosis

17. A 4-week old girl presents with poor feeding and tachypnea. The infant was born at term after a normal pregnancy. At 2 weeks of ago, a cardiac murmur was noted, but the baby was otherwise well. However, over the last week she has become more tachypneic and is feeding poorly. Her family is concerned that she takes up to 50 minutes to feed and becomes sweaty and tachypneic during feedings. There is no history of cough or fever. On physical exam, weight 3.2kg (>5th %ile), length 53cm (~25th %ile), temp 36.5, HR 160, RR 64, BP (right arm) 80/40, O2 sat 92%. She is pale and diaphoretic. There is subcostal indrawing. The cardiac apex is just lateral to the mid-clavicular line at the 5th left intercostal space, and the precordial activity is increased. The heart sounds are normal, a harsh 3/6 pansystolic murmur is present. The liver is 4cm below the right costal margin.Where should the pediatric cardiac apex be?

3rd intercostal space

4th intercostal space

5th intercostal space

6th intercostal space

18. Match the findings with the appropriate cardiac disorder: Normal S1 and S2, harsh continuous "machinery" type murmur, ECG: normal rhythm and axis, left atrium and/or ventricular enlargement/hypertrophy

ASD

VSD

AVSD

PDA and AP window

19. A 4-week old girl presents with poor feeding and tachypnea. The infant was born at term after a normal pregnancy. At 2 weeks of ago, a cardiac murmur was noted, but the baby was otherwise well. However, over the last week she has become more tachypneic and is feeding poorly. Her family is concerned that she takes up to 50 minutes to feed and becomes sweaty and tachypneic during feedings. There is no history of cough or fever. On physical exam, weight 3.2kg (>5th %ile), length 53cm (~25th %ile), temp 36.5, HR 160, RR 64, BP (right arm) 80/40, O2 sat 92%. She is pale and diaphoretic. There is subcostal indrawing. The cardiac apex is just lateral to the mid-clavicular line at the 5th left intercostal space, and the precordial activity is increased. The heart sounds are normal, a harsh 3/6 pansystolic murmur is present. The liver is 4cm below the right costal margin. What could be the cause of this baby's problem?

Left heart obstruction

Arrhythmia

Myocardial disease

Shunt

All of the above

The broad differential diagnosis should include shunts (ASD, VSD, AVSD, large PDA, aortopulmonary window, arterio-venous fistula, etc.), left heart obstruction (coarctation, severe aortic stenosis, HLHS, etc.), arrhythamias (especially SVT), and myocardial disease (myocarditis, cardiomyopathy)

Explanation

The broad differential diagnosis should include shunts (ASD, VSD, AVSD, large PDA, aortopulmonary window, arterio-venous fistula, etc.), left heart obstruction (coarctation, severe aortic stenosis, HLHS, etc.), arrhythamias (especially SVT), and myocardial disease (myocarditis, cardiomyopathy)

20. Echocardiogram shows large perimembranous VSD. Moderate biventricular hypertrophy with normal function and mild RV/LV dilation. Increased flow velocity within main pulmonary artery secondary to VSD shunt, small PFO. When do most large VSDs require repair?

Never - often close spontaneously

4-6 months of age

6-8 months of age

8-12 months of age

21. You do a hyperoxic test: on 100% oxygen, O2 sat goes from 74% on room air to 80%. What is the significance of this result?

Pulmonary cause of cyanosis

Cardiac cause of cyanosis

Both cardiac and pulmonary involvement

In a cardiac R-L shunt, systemic venous blood bypasses the lung and is not oxygenated no matter how much inspired oxygen is given to teh patient, so there is little or no increase in PaO2 with 100% oxygen.
1. Measure Pa)2 in room air (21% O2)
2. Give 100% O2 for 10 minutes
3. Re-measure PaO2.
Interpretation: Normal before 90, after >500,
lung disease before 60-90, after >150,
R-L shunt before

Explanation

In a cardiac R-L shunt, systemic venous blood bypasses the lung and is not oxygenated no matter how much inspired oxygen is given to teh patient, so there is little or no increase in PaO2 with 100% oxygen.
1. Measure Pa)2 in room air (21% O2)
2. Give 100% O2 for 10 minutes
3. Re-measure PaO2.
Interpretation: Normal before 90, after >500,
lung disease before 60-90, after >150,
R-L shunt before

22. A 4-week old girl presents with poor feeding and tachypnea. The infant was born at term after a normal pregnancy. At 2 weeks of ago, a cardiac murmur was noted, but the baby was otherwise well. However, over the last week she has become more tachypneic and is feeding poorly. Her family is concerned that she takes up to 50 minutes to feed and becomes sweaty and tachypneic during feedings. There is no history of cough or fever. On physical exam, weight 3.2kg (>5th %ile), length 53cm (~25th %ile), temp 36.5, HR 160, RR 64, BP (right arm) 80/40, O2 sat 92%. She is pale and diaphoretic. There is subcostal indrawing. The cardiac apex is just lateral to the mid-clavicular line at the 5th left intercostal space, and the precordial activity is increased. The heart sounds are normal, a harsh 3/6 pansystolic murmur is present. The liver is 4cm below the right costal margin. This CXR shows all of the following EXCEPT

Cardiomegaly

Increased pulmonary vascularity

Mild pulmonary edema

NG tube

Tracheal deviation

the CXR shows mild cardiomegaly with increased pulmonary vascularity, and mild pulmonary edema. Bone and soft tissues are normal. There is a nasogastric tube in stomach.

Explanation

the CXR shows mild cardiomegaly with increased pulmonary vascularity, and mild pulmonary edema. Bone and soft tissues are normal. There is a nasogastric tube in stomach.

23. This ECG shows which of the following?

Right atrial enlargement

Left atrial enlargement

Left ventricular enlargement

Abnormal axis

right atrial enlargement and right ventricular hypertrophy with strain.

Explanation

right atrial enlargement and right ventricular hypertrophy with strain.

24. Which of the following is seen in this ECG (check all that apply)

Sinus tachycardia

Right ventricular hypertrophy

Left ventricular hypertrophy

Abnormal T waves

Normal axis

sinus tachycardia (HR 150-160 bpm) and biventricular hypertrophy (large voltages throughout the precordial leads). Upright T wave in v6 mandatory, inverted T waves in v1-v3 are appropriate. V1 will be the last one to flip upright, well into puberty. Normal baby axis between II and II (R heart dominant)

Explanation

sinus tachycardia (HR 150-160 bpm) and biventricular hypertrophy (large voltages throughout the precordial leads). Upright T wave in v6 mandatory, inverted T waves in v1-v3 are appropriate. V1 will be the last one to flip upright, well into puberty. Normal baby axis between II and II (R heart dominant)

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PEDS Cardio

2.

What first name or nickname would you like us to use?

2. Match the findings with the appropriate cardiac disorder: Normal S1, single S2, no murmur or soft systolic ejection murmur. ECG: normal rhythm and axis, may be left ventricular enlargement

3. Match the findings with the appropriate cardiac disorder: Normal S1 and S2, loud grade 3-4/6 systolic ejection murmur (may also be holosystolic murmur if significant valve regurgitation). ECG: normal rhythm, left axis deviation, biventricular enlargement/hypertrophy

6. Match the findings with the appropriate cardiac disorder: Normal S1 and S2, harsh grade 2-4/6 pansystolic murmur, ECG normal rhythm, normal axis, biventricular enlargement/hypertrophy

7. Assessing upper limb vs. femoral pulses and 4 limb BPs would help you steer away from which cause of CHF?

9. Match the findings with the appropriate cardiac disorder: Normal S1, single or narrowly split S2, harsh grade 3-4/6 systolic ejection murmur. ECG: normal rhythm, right axis deviation, right ventricular hypertrophy.

11. Match the findings with the appropriate cardiac disorder: Normal S1, single S2, no murmur. ECG: normal rhythm and axis, may see predominant right-sided forces.

13. Echocardiogram shows large perimembranous VSD. Moderate biventricular hypertrophy with normal function and mild RV/LV dilation. Increased flow velocity within main pulmonary artery secondary to VSD shunt, small PFO. When do most small VSDs require repair?

14. Match the findings with the appropriate cardiac disorder: Normal S1, fixed split S2, grade 2-3/6 systolic ejection murmur, on ECG normal rhythm, normal axis, incomplete right bundle branch block

18. Match the findings with the appropriate cardiac disorder: Normal S1 and S2, harsh continuous "machinery" type murmur, ECG: normal rhythm and axis, left atrium and/or ventricular enlargement/hypertrophy

20. Echocardiogram shows large perimembranous VSD. Moderate biventricular hypertrophy with normal function and mild RV/LV dilation. Increased flow velocity within main pulmonary artery secondary to VSD shunt, small PFO. When do most large VSDs require repair?

21. You do a hyperoxic test: on 100% oxygen, O2 sat goes from 74% on room air to 80%. What is the significance of this result?

23. This ECG shows which of the following?

24. Which of the following is seen in this ECG (check all that apply)