short approach.....contains both cyanotic and acynotic CHD

1. APPROACH TO CHILD
WITH CONGENITAL
HEART DISEASE
PRESENTOR : DR ANKUR PURI
MODERATOR : DR DEVENDER BARUA

2. 5 Basic questions to be answered in
every case
 1) Cyanotic or Acyanotic?
 2) Increased Pulmonary Blood Flow /
Decreased PBF ?
 3) Origin of the lesion is in the Right /Left
heart?
 4) Which is the dominant ventricle?
 5) Presence/ absence of Pulmonary
Hypertension?

3. HISTORY TAKING:
 As in the evaluation of any other system,
history taking is a basic step in cardiac
evaluation. Maternal history during pregnancy
is often helpful in the diagnosis of congenital
heart disease (CHD) because certain prenatal
events are known to be teratogenic.
 Age of Presentation-
• PDA before 6 wks,
• VSD after 6 wks,
• ASD 1year

4. CONT…
ANTE-NATAL HISTORY:
H/o infections, disease & drugs in the mother.
-- Infections :
• Maternal Rubella during the first trimester causes PDA/
PS.CMV, HSV and
• Coxsackie-B during later trimesters may cause Neonatal
Myocarditis.
-- Maternal Disease :
• Diabetes Mellitus - TGA/Cardiomyopathy.
• SLE/mixed connective tissue disease - Complete Heart Block

5. CONT…
-- Drugs/Medications:
• Lithium – Ebstein’s anomaly.
• Valproic Acid - VSD, AS, Pulmonary Atresia with intact
ventricular septum & COA.
• Phenytoin – PS, AS, COA & PDA
• Other medications suspected of causing CHD include
progesterone and estrogen (VSD, TOF, TGA)
• Excessive alcohol intake during pregnancy has been
associated with VSD, PDA, ASD, & TOF (fetal alcohol
syndrome).

6. CONT…
NATAL HISTORY:
• Birth Weight:
• If infant is SGA, this may indicate Intra-uterine infections or use of
chemicals or drugs ( e.g Rubella syndrome & fetal alcohol
syndrome)
• If infant is LGA – often seen in Diabetic Mother - TGA

7. CONT...
POST NATAL HISTORY:
• H/o poor weight gain / Failure to thrive in infants with CCF or
severe cyanosis ( weight more affected than height).
• H/o Poor feeding (i.e. suck-rest-suck cycle) due to fatigue
and dyspnoea.
• H/o Cyanosis, “Cyanotic spells,” & Squatting
• H/o tachypnoea, dyspnoea & puffy eyelids are signs of CHF.
Left
heart failure produces tachypnea with or without dyspnea.
Tachypnea becomes worse with feeding and eventually
results in
poor feeding and poor weight gain.

8. CONT...
 H/o frequent respiratory tract infections (due to Left to Right
shunt with increased PBF predispose to LRTI). Frequent
upper respiratory tract infections are not related to CHD.
 H/o decreased exercise tolerance (seen with Left to right
shunts, cyanotic lesions, valvular stenosis or regurgitation
and arrhythmias) -- Ask in terms of inability to climb
stairs/walk short distances/play outdoor games as compared
to other children of the same age.

9. HISTORY OF MODES OF
PRESENTATION:
H/o Murmur :
• Time of detection – In neonatal age(with in few hours of
birth): AS/PS/Small VSD/PDA. In Early infancy:
Large
VSD/PDA(after 6 - 8 weeks i.e. regression of the
PVR)
• If incidentally found during fever/pre-school evaluation
– innocent murmur.
• Most common conditions which may present as

10. CONT...
H/o Cyanosis :
o Presenting in the first week of life – (all ‘T’):
-TGA
-Truncus Arteriosus
-Total AV-Canal Defect
-Total Pulmonary Atresia
-Tricuspid Atresia
-Tricuspid Regurgitation with Ebstein’s anomaly of the
-Tricuspid Valve.
o After first week of life –
- Tetralogy of Fallot’s,
- Total Anomalous
- Pulmonary Venous Circulation.

11. CONT...
H/o Cardiac Failure:
o First week of life – CoA,
Critical Aortic Stenosis
Truncus Arteriosus
Hypoplastic Left Heart Syndrome.
o 1 – 4 weeks – PDA
VSD with coarctation
Severe coarctation
Transposition with large VSD or PDA
o 1 – 2 months – VSD, PDA, TAPVC
o 2 – 6 months – VSD, PDA, ALCAPA,
Endocardial cushion defcts

12. CONT...
H/o Palpitations:
Some parents and children report sinus tachycardia as
palpitation.
Most common with – MVP
- SVT
- Hyperthyroidism.

13. CONT...
H/o Cyanotic Spells:
o Classical: TOF with infundibular spasm.
o Ask about –
--Time of occurrence – common in early morning/ on
awakening / post feeds.
--Duration and Frequency of the spells – for prognosis and
early intervention.
--H/o squatting episodes /knee-chest positions by self.
o Breathing rapidly/ no breathing during the spell – to
differentiate from Breath holding spells.

14. CONT...
H/o Cerebral events viz
Convulsions/Transient Ischemic Attacks/Strokes:
-Emboli may occur with right to left shunts,
-Polycythemia may lead to cerebral thrombosis and
brain
abcess.

15. FAMILY HISTORY:
H/o Hereditary Disease –
- PS secondary to a dysplastic pulmonary valve is common in
Noonan's syndrome.
- Lentiginous skin lesion (l entigines, e lectrocardiogram
abnormalities,
ocular hypertelorism, p ulmonary stenosis, a bnormal
genitalia,
r etardation of growth, and d eafness [LEOPARD]
syndrome) is
often associated with PS and cardiomyopathy.

16. FAMILY HISTORY:
 H/o Congenital Heart Disease in parents/siblings
(risk of recurrence) –
- When one child is affected, the risk of recurrence in siblings
is about 3%.
- Lesions with a higher prevalence (e.g., VSD) tend to have a
higher
risk of recurrence, & lesionsn with a lower prevalence
(e.g. tricuspid atresia, persistent truncus arteriosus) have
a
lower risk of recurrence.

17. EXAMINATION
 As with the examination of any child, the order and
extent of
the physical examination of infants and children with
potential
cardiac problems should be individualized.
 Supine is the preferred position for examining patients in
any age

18. CONT…
Growth pattern
- Growth impairment is frequently observed in infants
with
congenital heart diseases (CHDs).
- Different patterns of growth impairment are seen in
different
types of CHD.
a) Cyanotic patients have disturbances in both height
and weight.
b) Acyanotic patients, particularly those with a large
left-to-right shunt, tend to have more problems
with weight gain than with linear growth.

19. CVS Vital Signs
 Temperature
 Respiration
 Pulse
 Blood pressure

20. Temperature
o Fever, chills and rigors
 IE
 RF
 Pericarditis, myocarditis
o Hypothermia is seen in cardiogenic failure or shock

21. Respiration
o Rate, rhythm, Type
o Breathing: dyspnea + wheezing (asthma, COPD,
LV
failure).
o Breathing: Chyne-Stokes breathing (stroke, CHF,
sedation,
uremia).

22. Pulse
o Rate
o Rhythm
o Character
o Volume
o Radio – radial delay
o Radio femoral delay
o Palpable Peripheral pulse
o Jugular venous pressure

23. Pulse
 The normal pulse rate varies with the
patient's age and status. The younger the
patient, the faster the pulse rate.

24. Pulse
Normal Heart Rate for Different Ages
Age Rate Average
Newborn 100 – 180 140
1 – 11 months 80 – 160 120
2 – 3 years 80 – 130 110
4 – 5 years 80 – 120 100
6 – 8 years 75 – 115 95
> 8 years 70 – 110 90

25. CONT…
 Every patient should have palpable pedal pulses, either
dorsalis pedis, tibialis posterior, or both. It is often easier
to feel pedal pulses than femoral pulses.
 If a good pedal pulse is felt, coarctation of the aorta
(COA) is effectively ruled out, especially if the blood
pressure in the arm is normal.

26. CONT…
o Normally femorals felt just before radial
o Radio – radial – pre subclavian COA
 If the right brachial pulse > left brachial pulse,
COA
occurring near the origin of the left subclavian
artery
or supravalvular aortic stenosis (AS)
o Radio femoral – post subclavian COA
 A weaker right brachial pulse than the left
suggests and aberrant right subclavian artery

27. CONT…
 Bounding pulses are found in aortic run-off
lesions such as PDA, aortic regurgitation
(AR), large systemic arteriovenous fistula,
or persistent truncus arteriosus (rarely).
Pulses are bounding in premature infants
because of the lack of subcutaneous
tissue and because many have PDA.

28. Blood Pressure
o Blood pressure should be measured in the legs as
well as in the arms.
o In older children, a mercury sphygmomanometer
with a cuff that covers approximately two-thirds of
the upper part of the arm or leg.
o A cuff that is too small results in falsely high
readings, whereas a cuff that is too large records
slightly decreased pressure.
o The pressure recorded in the legs with the cuff
technique is approximately 10 mm Hg higher than
that in the arms

29. CONT…
o Blood pressure varies with the age of the child and
is closely related to height and weight.
o Exercise, excitement, coughing, crying, and
struggling may raise the systolic pressure of infants
and children as much as 40-50 mm Hg greater than
their usual levels

30. CVS – Systemic Examination
 Inspection
 Palpation
 Percussion
 Auscultation

31. CONT…
 Obese child
 Pericardial effusion
 Severe cardio
myopathy
 Thin patient,
 Volume over load,
 Lt to Rt shunt ( PDA,
VSD)
Silent Precordium
Hyper dynamic
Precordium :
Inspection
A precordial bulge to the left of the sternum with increased
precordial activity suggests cardiac enlargement; such bulges can
often best be appreciated by having the child lay supine with the
examiner looking up from the child’s feet
Parasternal Lift – Severe
MR

32. CONT…
 Harrison's groove, a line of depression in the bottom of
the rib cage along the attachment of the diaphragm,
indicates poor lung compliance of long duration, such as
that seen in large left-to-right shunt lesions.

33. CONT…
Inspection
APICAL IMPULSE
o Lowest and outer most point of
cardiac pulsation
o The apical impulse is normally
at the 5th ICS in the MCL after age 7.
o Before this age, the apical impulse
is in the 4th ICS just to the lateral to the MCL.
o Shifting :
o Lateral & inferior – LVH
o Only lateral – RVH

34. CONT…
Palpation
 Confirm the position of apex beat
 Preschool – 4th ICS just lateral to MCL
 Older child – 5th ICS
 Character of apex beat
 Tapping - MS
 Heaving – force full, well sustained - LVH, pressure
over load - AS
 Hyper dynamic – ill sustained - Volume over load -
MR
 Para sternal heave
 Right ventricular enlargement – ASD, VSD
 Left atrial enlargement – MS, MR

35. CONT…
Palpation
 Thrills
Thrills are the palpable equivalent of murmurs and correlate
with
the area of maximal auscultatory intensity of the murmur.
1. Thrills in the upper left sternal border originate from the
pulmonary valve or pulmonary artery (PA) and therefore
are
present in PS, PA stenosis, or PDA (rarely).
2. Thrills in the upper right sternal border are usually of aortic
origin
and are seen in AS.
3. Thrills in the lower left sternal border are characteristic of a

36. CONT…
Palpation
 Thrills
5. The presence of a thrill over the carotid artery or arteries
accompanied by a thrill in the suprasternal notch suggests
diseases of the aorta or aortic valve (e.g., COA, AS). An
isolated thrill in one of the Carotid arteries without a thrill in
the suprasternal notch may be a carotid bruit.
6. Thrills in the intercostal spaces are found in older children
with severe COA and extensive intercostal collaterals.

37. CONT…
Percussion
 Outline cardiac borders
 Useful in
 Pericardial effusion – Dullness beyond apex
 Dextrocardia
 Dilated cardiomyopathy

38. CONT…
Auscultation
 Use the diaphragm for high pitched sounds and
murmurs
 Use the bell for low pitched sounds and murmurs.
 The entire precordium, as well as the sides and back of
the
chest, should be explored with the stethoscope.
Systematic
attention should be given to the following aspects:
a) Heart rate and regularity
b) Heart sounds
c) Systolic and diastolic sounds

39. CONT…
Auscultation
Heart sounds
 Intensity and quality of the heart sounds, especially the second
heart sound (S2), should be evaluated.
 Abnormalities of the first heart sound (S1) and the third heart sound
(S3) and the presence of a gallop rhythm or the fourth sound (S4)
should be noted. Muffled heart sounds should also be noted.
 1st Heart sound(S1) – closure of mitral & tricuspid valve. Best heard
at the apex or lower left sternal border.
 2nd Heart sound (S2) - The S2 in the upper left sternal border (i.e.,
pulmonary valve area) is of critical importance in pediatric
cardiology

40. CONT…
Auscultation

41. CONT…
Auscultation
Heart sounds
 The S2 must be evaluated in terms of the degree of splitting
and the intensity of the pulmonary closure component of the
second heart sound (P2) in relation to the intensity of the
aortic closure component of the 2nd heart sound (A2).
 Physiological split –
Normal splitting between
A2 & P2 which varies with
inspiration and expiration

42. Abnormal heart sounds – S1
 Intensity
 Loud S1-
 MS
 TS
 Sinus Tachycardia
 High output states
 Muffled S1 –
 Pericardial effusion
 Obesity
 Calcified valve

43. Abnormal heart sounds – S2
S2
A2 P2
Accentuated
Diminished
Delayed
Early
AR
Calc.AV, Aortic Atresia
AS, PDA, AR, LVF, LBBB
VSD, MR
PAH
PS, PA
PS, ASD, TAPVC, RBBB
TR

44. Spliting of Second Heart Sound
Expiration InspirationSpliting
Normal
Wide & Variable
Paradoxical
Wide & Fixed
Single Second Sound
MR, VSD, PS
ASD, TAPVC,
RBBB,MR
AS, PDA, AR
TOF,TGA,severe
AS

45. Abnormal heart sounds –
Contd..
o 3rd heart sound – due to maximal ventricular
filling
 S3 Gallop – Myocarditis, CCF
o 4th heart sound – due to rapid emptying of
atrium
 Occurs in constrictive pericarditis, hypertrophic
cardiomyopathy (HCM)

46. Additional Sounds
o Click – arise due to semi lunar valves
o Ejection systolic clicks(EC) – AS, PS
o Opening snap(OS) – due to abnormal mitral & tricuspid
leaflets -- Occurs in ASD, VSD, RHD – MS / TS
o Mid systolic Click(MC) – MVPS
o Multiple Clicks – Ebstein’s Anomaly

47. CONT…
Auscultation
MURMURS
o Caused by normal flow through a abnormal
valve or abnormal flow through a normal
valve
o Each heart murmur must be analyzed in
terms of
 intensity (grade 1 to 6)
 timing (systolic or diastolic)
 location
 transmission

48. CONT…
Auscultation
MURMURS- Intensity
 Intensity of the murmur is customarily graded from 1 to 6.
 Grade 1 Barely audible
 Grade 2 Soft, but easily audible
 Grade 3 Moderately loud, but not accompanied by a thrill
 Grade 4 Louder and associated with a thrill
 Grade 5 Audible with the stethoscope barely on the
chest
 Grade 6 Audible with the stethoscope off the chest

49. CONT…
Auscultation
MURMURS-Classification
o Based on the timing of the heart murmur in relation to
the S1 and S2, the heart murmur is classified as a
systolic, diastolic, or continuous murmur

50. CONT…
Auscultation
Systolic Murmurs
 Midsystolic (or Ejection Systolic) Murmurs.
 Holosystolic Murmurs.
 Early Systolic Murmurs.
 Late Systolic Murmurs.

51. CONT…
Auscultation
Midsystolic (or Ejection Systolic) Murmurs
 Begins after S1 and ends before S2
 Midsystolic murmurs coincide with turbulent flow through
the
semilunar valves and occur in the following settings:
(1) flow of blood through stenotic or deformed semilunar
valves (such as AS or PS).
(2) accelerated systolic flow through normal semilunar
valves,
such as seen during pregnancy, fever, anemia, or
thyrotoxicosis

52. CONT…
Auscultation
Cont…
(3) innocent (normal) midsystolic murmurs.
o The intensity of the murmur increases toward the middle and
then decreases during systole (crescendo-decrescendo or
diamond shaped in contour).
o The murmur may be short or long and is audible at the
second left or second right intercostal space.

53. CONT…
Auscultation
Holosystolic Murmurs
o Holosystolic murmurs begin with S1 and occupy all of
systole up to the S2. No gap exists between the S1and
the onset of the murmur.
o Holosystolic murmurs are caused by the flow of blood
from a chamber that is at a higher pressure throughout
systole than the receiving chamber, and they usually
occur while the semilunar valves are still closed

54. CONT…
Auscultation
Cont…
o These murmurs are associated with only the following three
conditions: VSD, MR, and tricuspid regurgitation (TR).
o None of these ordinarily occurs at the base (i.e., second left
or right intercostal space).

55. CONT…
Auscultation
Early Systolic Murmurs
o Early systolic murmurs (or short regurgitant murmurs) begin
with the S1, diminish in decrescendo, and end well before the
S2, generally at or before midsystole.
o VSD, MR, and TR

56. CONT…
Auscultation
Late Systolic Murmurs
o The term “late systolic” applies when a murmur begins in
middle to late systole and proceeds up to the S2
o The late systolic murmur of mitral valve prolapse is
prototypical

57. CONT…
Auscultation
MURMURS-Location
The following four locations are important:
(1) upper left sternal border (pulmonary valve area)
(2) upper right sternal border (aortic valve area)
(3) lower left sternal border
(4) the apex.

58. CONT…
Auscultation
MURMURS-Location
 Differential Diagnosis of Systolic Murmurs at the Upper Left
Sternal Border (Pulmonary Area) – mainly a mid systolic
murmur
o Pulmonary Valve stenosis
o ASD
o AS
o Pulmonary flow murmur of newborn
o TOF
o COA
o PDA

59. CONT…
Auscultation
MURMURS-Location
 Differential Diagnosis of Systolic Murmurs at Upper Right
Sternal Border (Aortic Area) – mostly midsystolic murmur
o Aortic Stenosis
o Subvalvular AS
 Differential Diagnosis of Systolic Murmurs at the Lower
Left Sternal Border – may be holosystolic, early, or
midsystolic type.
o VSD
o ECD
o Vibratory innocent murmur
o TR

60. CONT…
Auscultation
MURMURS-Location
 Differential Diagnosis of Systolic Murmurs at the Apex –
holosystolic, midsystolic, or late systolic murmurs.
o MR ( holosystolic )
o MVP (late systolic usually preceeded by a midsystolic click )
o HOCM ( midsystolic )

61. CONT…
Auscultation
MURMURS-Location

62. CONT…
Auscultation
MURMURS-Location
For example,
o A holosystolic murmur heard maximally at the lower left sternal
border is characteristic of a VSD.
o A midsystolic murmur maximally audible at the second left
intercostal
pace is usually pulmonary in origin. The location of the
heart
murmur often helps differentiate between a midsystolic
murmur
and a holosystolic murmur.
For example,
o A long PS murmur may sound like the holosystolic murmur of a
VSD; however, because the maximal intensity is at the
upper left

63. CONT…
Auscultation
MURMURS-Transmission
o The transmission of systolic murmurs from the site of
maximal intensity may help determine the murmur's
origin.
o For example, an apical systolic murmur that transmits
well to the left axilla and lower back is characteristic of
MR.
o whereas one that radiates to the upper right sternal
border and the neck is more likely to originate in the
aortic valve.
o A systolic ejection murmur at the base that transmits well
to the neck is more likely to be aortic in origin.

64. CONT…
Auscultation
MURMURS-Quality
o The quality of a murmur may help diagnose heart
disease.
o Systolic murmurs of MR or of a VSD have a uniform,
high-pitched quality, often described as blowing.
o Midsystolic murmurs of AS or PS have a rough, grating
quality.
o A common innocent murmur in children, which is best
audible between the lower left sternal border and apex,
has a characteristic “vibratory” or humming quality

65. When to call a Murmur as Innocent or
functional
 Blood Pressure normal
 No Cardiomegaly
 No cyanosis
 Second sound is normal
 X Ray chest is normal
 ECG is normal

66. Acyanotic Patients with continuous
murmur
 PDA
 Coronary arteriovenous fistula
 Systemic arteriovenous fistula
 Coarctation of the Aorta
 Peripheral Pulmonic stenosis
 Anomalous Left Coronary Artery From Pulmonary Artery
( ALCAPA )

67. Continuous Murmur in cyanotic Patient
 Bronchial collaterals in Anomalies of Fallots Physiology
 Patent Ductus arteriosus in patients with Fallot’s
physiology
 Total anomalous pulmonary venous connection
 Pulmonary arterovenous fistula
 Surgically created shunts

68. Approach to Congenital Heart
Disease

69. Acyanotic Heart
Increased PBF Normal PBF
LVH or BVH RVH
•VSD
•PDA
•ECD
•ASD(often
RBBB)
•PAPVR
LVH RVH
•AS or AR
•COA
•Primary
myocardial
disease
•MR
•PS
•COA(
in
Infants)
•MS

70. Cyanotic Defects
Increased PBF
LVH or BVH
•Persistent
truncus
Arteriosus
•Single
ventricle
•TGA + VSD
RVH
•TGA
•TAPVR
•HLHS
Decreased PBF
•TGA + PS
•Persistent
truncus
arteriosus
with
hypoplastic
PA
•Single
ventricle
with PS
•Tricuspid
Atresia
•Pulmonar
y atresia
with
hypoplasti
c RV
RVHLVHBVH
•TOF
•Ebstei
n’s
anomal
y (
RBBB)

71. Conditions with Pulmonary
Hypertension :
 ASD
 VSD
 PDA with Eisenmenger’s Complex (reversal of
shunt from Right to Left) ,
 Hypoplastic Left Heart Syndrome,
 TAPVC with increased Pulmonary Vascular
Resistance.

72. Approach to Congenital Heart
Disease
 When to suspected heart disease in children ?
 Symptoms of heart disease in children
 How to decide whether congenital or acquired ?
 Age of onset of symptoms and time of diagnosis
 Markers of congenital heart disease
 History of acquired heart disease

73. Once Congenital Heart Disease is
Decided
Apply NADA’s Criteria

74. NADA’S Criteria
 Systolic murmur
with thrill
 Any diastolic
murmur
 Cyanosis
 Congestive cardiac
failure
 Systolic murmur
without thrill
 Abnormal P2
 Abnormal BP
 Abnormal CXR
 Abnormal ECG
MAJOR MINOR
1 Major or 2 Minor criteria indicates Presence of
Congenital Heart Disease

75. Approach to Heart disease
Cyanotic CHDAcyanotic CHD
Patient Apply NADAS’
Criteria
Heart Disease
Present
Heart Disease
Absent
Re-evaluate
after Six months
-L to R shunt
-Obstructive
Lesions
-Regurgitant
Lesions

76. Acyanotic Heart Disease
Classificatio
n
Left to Right
Shunts
Obstructive
Lesions
Regurgitant
lesions
–Frequent Resp
Infections
–Precordial buldge
–Hyperkinetic
precordium
–Tendency for
sweating & CCF
–Shunt & Flow Murmur
–Plethric lung fields on
X Ray
–e.g ASD, VSD, PDA,
AP Window
-Forcible heaving
precordium
-Systolic thrill
-No cardiomegaly
-Delayed corresponding
component 2nd hearat
sound
-Ejection systolic
murmur
-Ventricular hypertrophy
on ECG
Generally
uncommon &
asymptomatic
e.g MR, AR, TR,
PR

78. Acyanotic CHD : L → R
Shunts
Left parasternal
impulse
Wide, fixed split S2
Pulmonary ejection
systolic murmur
Tricuspid diastolic flow
murmur
rsR‘ in V1 in ECG
Atrial Septal
Defect
Left ventricular type
apial impulse
Systolic thrill
Pansystolic murmur
Mitral diastolic flow
murmur
LV dominance in ECG
Ventricular Septal
Defect
Wide pulse
pressure
LV type impulse
Systolic or
continuous thrill
Continuous
murmur
Mitral diastolic
flow murmur
Patent Ductus
Arterious

79. CONT…
•White arrow, right atrial
border;
•Purple arrow, right ventricular
border;
•red arrow, aortic notch;
•yellow arrow, pulmonary
artery;
•blue arrow, left atrial border;
•green arrow, left ventricular
border.

80. ASD

81. ASD
Right Atrium
Right Ventricle

82. VSD

83. VSD
Left Atrium
Left Ventricle

84. PDA

85. PDA
LAE
LV Dilatation

86. Acyanotic heart disease- Obstructive
Lesions
Right sided Left sided
Left parasternal
heave
Systolic thrill
Ejection systolic
murmur in upper left
sternal border
Wide split second
sound, delayed, well
heard P2
Pulmonary
Stenosis
Narrow pulse
pressure
Systolic thrill
Ejection systolic
murmur radiating
to neck
Delayed A2
Absent or weak, delayed
femorals compared to
radials
Arm blood pressure
high
Prominent carotids,
palpable aorta in
suprasternal notch
Palpable collaterals
Ejection murmur in
inter-scapular region
Aortic
Stenosis Coarcation of
Aorta

87. Pulmonary Stenosis

88. Aortic Stenosis

89. Coarcatation of Aorta

90. COA

91. Cyanotic Congenital Heart
Disease

92. Cyanotic Congenital Heart Disease
With PS Without PS
No VSD With VSD Increased
PA pressure
Normal PA
pressure
Increased Pulm
blood flow
Decreased Pulm
blood flow
Pulm Venous
Obstruction
Cyanosis, Clubbing, Polycythemia

93. Cyanotic Congenital Heart
Disease
Cyanosis, Clubbing, Polycythemia
Pulmonary stenosis with right to left shunts at atrial level
Eg. Critical PS, Ebstein’s anomaly
Pulmonary stenosis with VSD – Fallot’s Physiology
Eg. TOF, Single ventricle, ECD, Hypoplastic RV
Increased blood flow with PAH – TGA Physiology
Eg. TGA, TAPVC, Tricuspid Atersia
Decreased pulmonary blood flow with PAH
Eg. Hypoplastic LV, Eisenmenger syndrome
Normal Pulmonary Artery pressure
Eg. TAPVC, Single Atrium, Pulmonary AV fistula.

94. CCHD - Pulmonary stenosis with
right to left shunts at atrial level
Prominent a waves – JVP
Parasternal heave
Cardiomegaly may be present
Systolic thrill ±
Cyanosis may be mild
Inter-costal retractions present
RVH with late transition in ECG
Critical Pulmonary
Stenosis
Quiet precordium
Heart size increased
Multiple sounds ± gallop rhythm
Scratchy systolic and diastolic
murmur
Characteristic ECG
Ebstein’s Disease

95. CCHD - Pulmonary stenosis with
VSD – Fallot’s Physiology
No Cardiomegaly, Mild left parasternal impulse, thrill
uncommon, S2 single, ejection murmur ends before S2,
Ischemic lungs
RAD, RVH: TOF, Single Ventricle
RAD, LVH: Single ventricle, Hypoplastic right ventricle
LAD, RVH: Single ventricle, ECD with PS
LAD, LVH: Tricuspid atersia, Single Ventricle
ECG

96. Tetrology Of Fallot

97. Differential diagnosis of Fallot’s
Physiology
 Fallot’s Tetralogy
 Transposition of great arteries
 Tricuspid atresia
 Single ventricle
 Double outlet right ventricle
 Corrected transposition of great arteries
 Atrioventricular canal defect
 Malpositions

98. Transposition of Great
Arteries

99. CCHD - Increased blood flow with
PAH – TGA Physiology
Neonate or infant, Failure to thrive,
Congestive failure
Cardiomegaly
Radioloically – Cardiomegaly with
pulmonary plethora
d-TGA, DORV, Tricuspid Atresia, Single
Ventricle, TAPVC, Misc. Malpositions

100. CCHD with Increased PBF
 Complete transposition of great vessels
 Double outlet right ventricle without pulmonary
stenosis
 Tricuspid atresia with large VSD
 Persistent truncus arteriosus
 Single ventricle without pulmonary stenosis
 Total anomalous pulmonary venous connection
 Malpositions without obstruction to pulmonary
blood flow

101. Features of Eisenmenger
Physiology
 History of frequent chest infection in infancy
 Cyanosis present from birth or appears late
 JVP – Prominent ‘a’ waves
 No cardiomegaly or thrill
 No parasternal heave
 Constant ejection click of PHT
 Second sound palpable, pulmonary component is
accentuated
 Systolic murmur in pulmonary area
 Pulmonary and/or tricuspid regurgitation murmurs may
be present

102. Bibilography
 Nelson 20th edition
 Myung K. Park’s Pediatric Cardiology 5th
edition

103. THANK YOU

105. CONT…
 Character
Normal pulse

106. CONT…
 Character
Collapsing pulse (water hammer pulse) jerky pulse with
full expansion followed by sudden collapse (AR, PDA, A-V
fistulas, anemia)

107. CONT…
 Character
Alternating pulse pulses alternans
(regular rate, amplitude varies from beat
to beat) seen in LVF

108. CONT…
 Character
Pulses bisferiens (two strong systolic
peaks separated by a midsystolic dip)
seen in HCM, AS
Anacrotic pulse slow rising pulse in
A.S. (Parvus et tardus)

109. CONT…
 Character
Pulsus paradoxus (amplitude decreases with
inspiration and increases during expiration) seen in
cardiac tamponade, COPD, massive P.E.

110. CONT…
 Volume
 Pulse Pressure – Difference between systolic and diastolic
blood pressure
 Normal: 30 – 60 mm Hg
 Bounding pulses are found in PDA, aortic regurgitation (AR),
large
systemic arteriovenous fistula.
 Low Volume pulse – cardiac failure, shock.

111. CONT…
 Delay

112. CONT…
 Jugular Venous Pressure
 Although of little use in infants, in cooperative older children,
inspection of the jugular venous pulse wave provides
information about central venous and right atrial pressure.
 The external jugular vein should not be visible above the
clavicles unless central venous pressure is elevated.
 Increased venous pressure transmitted to the internal jugular
vein may appear as venous pulsations without visible
distention; such pulsation is not seen in normal children
reclining at an angle of 45 degrees.
 Because the great veins are in direct communication with the
right atrium, changes in pressure and the volume of this
chamber are also transmitted to the veins. The 1 exception
occurs in superior vena cava obstruction, in which venous
pulsatility is lost

113. CONT…

114. Pulmonary Atresia

115. Ebstein’s Anomaly