Approach to chd

Congenital Heart Disease. Nadas Criteria. Second Heart Sound

1. Approach to CHD Kripasindhu Chatterjee Associate Professor, Pediatrics, GIMSH, Durgapur, Paschim Bardhaman

2. Approach to CHD Common clinical clues that help in diagnosis of CHD Nadas's criteria of diagnosis of CHD Diagnostic implication of Second heart sound Objectives

3. Approach to CHD Common clinical clues that help in diagnosis of CHD 1 . Cyanosis 2. Difficult feeding and poor growth 3. Difficult breathing 4.Frequent respiratory infections 5. Specific syndromes Nadas' criteria of diagnosis of CHD Diagnostic implication of Second heart sound Objectives

4. Approach to CHD Parents seldom report cyanosis unless, it is relatively severe (saturation <80%). It is often easier for them to notice episodic cyanosis (when the child cries or exerts). Cyanosis

5. Approach to CHD The parent may complain of difficulty in feeding. Usually a feature of congestive heart failure resulting from CHD. History may be of Slow feeding, Small volumes consumed par feed, Tiring easily following feeds and Need of periods of rest during feeds. Excessive sweating of forehead or occiput Sometimes history of feeding difficulty is not found Examination of the growth charts will reveal recent decline in growth rate Characteristically,growth failure affects weight more that height Difficult feeding and poor growth

6. Tachypnea is a characteristic feature of heart failure in newborns Respiratory rates Up to 1 month : > 60 / Min 2 – 12 months : > 50 / Min 1 – 5 years : > 40 / Min For infants, subcostal or intercostal retractions together with flaring of nostrils are frequently associated with tachypnea. Approach to CHD Difficult breathing

7. The association of respiratory infections that are Frequent, Severe and Difficult to treat With large L – R shunts Not a specific feature Frequent respiratory infections Approach to CHD

8. Approach to CHD Chromosomal anomalies or other syndromes are associated with CHD Trisomy 21 is the commonest anomaly associated with heart disease – Endocardial Cushion Defect Others include Trisomy 13 and 18 : VSD, PDA Turner : Bicuspid Aortic Valve, Coarctation of Aorta Noonan syndromes : Pulmonary Stenosis Di George syndromes : Interrupted Aortic Arch Specific Syndromes

9. Approach to CHD Common clinical clues that help in diagnosis of CHD 1. Cyanosis 2. Difficult feeding and poor growth 3. Difficult breathing 4.Frequent respiratory infections 5. Specific syndromes Nadas' criteria of diagnosis of CHD Diagnostic implication of Second heart sound Objectives

10. The assessment for presence of heart disease can be done using the Nadas' criteria. Congenital heart disease is indicated by presence of ONE MAJOR OR TWO MINOR These criteria are of limited use in newborns, where clinical signs are subtle Nadas' Criteria

11. Nadas' criteria for clinical diagnosis of CHD Major Minor Systolic murmur grade III or more Systolic murmur grade I or II Diastolic murmur Abnormal second sound Cyanosis Abnormal electrocardiogram Congestive cardiac failure Abnormal blood pressure Nadas' Criteria

12. A murmur should be interpreted by analysing many factors. Main factors are Area of Maximum intensity Timing in cardiac cycle Intensity Radiation Relation with respiration Relation with posture etc Systolic murmur grade III or more in intensity. Major Criteria

13. Area of Maximum intensity Major Criteria 1. Aortic area Systolic – AS, Carotid Bruit Continuous Flow murmur – venous hum 2. Pulmonary area Systolic – PS, ASD Continuous Flow murmur – PDA, venous hum 3. Left Upper Sternal Border Diastolic – AR, PR Systolic – Hypertrophic cardiomyopathy, Pulmonary Flow murmur 4. Left Lower Sternal Border Systolic – VSD, TR, Still's murmur Diastolic – ASD, TS 5. Apex Systolic – MR, MVP Diastolic -- MS

14. Timing in Cardiac Cycle Systolic Major Criteria Pansystolic murmur VSD, MR, TR Continuous murmur PDA Ejection Systolic murmur AS, PS, CoA Late Systolic murmur MVP Systolic murmur grade III or more usually indicate organic heart disease

15. Timing in Cardiac Cycle Diastolic Major Criteria Early Diastolic murmur AR, PR Mid Diastolic murmur MS The presence of a diastolic murmur almost always indicates the presence of organic heart disease

16. Grade I Barely audible ( softer than heart sounds ) Grade II Soft but easily audible ( as loud as heart sound ) Grade III Moderately loud murmur without a thrill ( louder than heart sounds ) Grade IV Loud murmur with a thrill Grade V Murmur heard with the stethoscope barely touching the chest Grade VI Murmur heard with stethoscope off the chest GRADES of MURMUR by INTENSITY Major Criteria

17. Radiation Major Criteria

18. Relation with Respiration Major Criteria Relation with Posture Left sided murmurs accentuate in expiration Right sided murmurs accentuate in inspiration MS murmurs better heard in Left lateral position Murmurs of base of heart is better heard on stooping forwards

19. Must meet the following criteria Child must be asymptomatic from cardiovascular point Cardiac examination should be normal Heard only in Systole except venous hum which is continuous Intensity < III / VI Innocent Murmur

20. Major Criteria Central Cyanosis ------------------------------------------------------------------------------------------------- Features Central Cyanosis Peripheral Cyanosis -------------------------------------------------------------------------------------------------- Mechanism Desaturation at Heart / Lung Increased O2 extraction by CCHD or Lung disorder peripheral tissues Site Skin + Mucosa Skin – Extremity, nose tip Blue nail, nail bed, ear lobule Mucosa – remain pink Clubbing Present Absent Extremity Warm Cold On Warming No change Disappears O2 inhalation Slight improvement No change PaO2 Low < 85% Normal > 85% -------------------------------------------------------------------------------------------------

21. Presence of CHF indicates heart disease Except Major Criteria Congestive Heart Failure Neonates and infants may show CHF due to extra cardiac causes like Anemia Hypoglycemia

22. Electrocardiogram is used to determine the Mean QRS axis Atrial hypertrophy -- R or L Ventricular hypertrophy – R or L. Criteria for ventricular hypertrophy, based only on voltage criteria are not diagnostic for the presence of heart disease. The voltage of the QRS complexes can be affected by Changes in blood viscosity, Electrolyte imbalance, Position of the electrode on the chest wall and Thickness of the chest wall. Abnormal electrocardiogram Minor Criteria

23. Why abnormal X-ray as a minor criterion ? In infants and smaller children, the heart size varies considerably in expiration and inspiration. If there is cardiomegaly on a good inspiratory film , it suggests presence of heart disease. Thymus in children in < two years , may mimic cardiomegaly. Minor Criteria Abnormal X - Ray

24. Egg on Side in TGA Case courtesy of Dr Vincent Tatco, Radiopaedia.org, rID: 43062 Minor Criteria Abnormal X - Ray Snowman sign or Figure of 8 in TAPVC Coeur en Sabot in TOF

25. It is difficult to obtain accurate blood pressure in smaller children . Appropriate sized cuffs should be used for blood pressure Abnormal Blood Pressure Minor Criteria Age group Width Length Max arm circumference cm (inch) cm (inch) cm (inch) Newborn 4 (2") 8 (3") 10 (4") Infant 6 (3 " ) 12 (5 " ) 15 (6 " ) Child 9 (4") 18(7") 20 (8") Adult 13 (5") 30(12") 35 (14")

26. It is difficult to obtain accurate blood pressure in smaller children . Appropriate sized cuffs should be used for blood pressure Abnormal Blood Pressure Minor Criteria Age group Upper Limit Lower Limit mm (Hg) mm (Hg) Newborn 90 < 60 1 Year 100 < 70 Child 100 + Age in year*2 <70 + age in year*2 (< 10 years of age) up to 120 mm Child > 120 < 90 (< 10 years of age)

27. Hypertension is defined as average systolic blood pressure (SBP) and/ or diastolic blood pressure (DBP) that is > 95th percentile for age, sex and height on 3 occasions . Elevated Blood Pressure is defined as SBP or DBP that are > 90th percentile but <95th percentile. Stage I Hypertension Children with blood pressure that is between 95 th percentile and 95 th + 12mm of Hg. Stage II Hypertension is above 95 th percentile+ 12 mm of Hg. Abnormal Blood Pressure Minor Criteria Adolescents Elevated blood pressure with 120/80 mm Hg and 129/<80 Hypertension with > 130/80 mm of Hg

28. Approach to CHD Common clinical clues that help in diagnosis of CHD 1 . Cyanosis 2. Difficult feeding and poor growth 3. Difficult breathing 4.Frequent respiratory infections 5. Specific syndromes Nadas' criteria of diagnosis of CHD Diagnostic implication of Second heart sound Objectives

29. Abnormal second sound indicate presence of heart disease. It has been included as a minor criterion only because auscultation is an individual and subjective finding. Diagnostic Implications of the S2

30. Diagnostic Implications of the S2 S2 is said to be NORMAL when it meets ALL three parts 1. Has two components: A2 and P2. 2. During quiet breathing During expiration S2 is single and During Inspiration A2 – P2 split due to early A2 and delayed P2. 3. The A2 is louder than the P2 except in infants < 3-6 Mo old. Abnormalities of the S2 might occur in each of these aspects .

31. The A2 is accentuated Systemic hypertension from any cause AR The A2 is Diminished Critical AS due to less mobile valve cusps Absent in aortic valve atresia. Abnormal Aortic Component (A2) Diagnostic Implications of the S2 Intensity -- A2 may be accentuated or diminished Timing –--- A2 may be early or late

32. Abnormal Aortic Component (A2) Diagnostic Implications of the S2 The A2 is delayed When Left ventricular ejection is prolonged due to Pressure overload - AS Volume overload PDA with a large L - R shunt, AR Left ventricular electrical activation is delayed -- LBBB and Left ventricular slow contraction -- left ventricular failure. The A2 occurs early in VSD, mitral regurgitation Intensity -- A2 may be accentuated or diminished Timing –--- A2 may be early or late

33. Diagnostic Implications of the S2 Abnormal Pulmonary Component (P2) Intensity -- P2 may be accentuated or diminished Timing –--- P2 may be delayed Although P2 may occur early in TR, it is not recognized clinically since TR as an isolated lesion is rare The P2 is accentuated Pulmonary hypertension P2 is diminished Critical PS due to less mobile valve cusps Absent in Pulmonary valve atresia. The P2 is delayed When Right ventricular ejection is prolonged due to Pressure overload - PS Volume overload -- ASD, PAPVC, PR Right ventricular electrical activation is delayed -- RBBB

34. Wide splitting-- Splitting during expiration due to an early A2 or late P2 or the A2-P2 interval 0.03 sec or more during expiration Wide and Variable Splitting (WVS) – Splitting in expiration increases in inspiration Early A2 – VSD, MR. Late P2 -- PS Wide and Fixed Splitting (WFS) – Splitting interval same in expiration and inspiration ASD, TAPVC, RBBB Abnormal Splitting of S2 Diagnostic Implications of the S2

35. The delay in A2 results in closely split, single or paradoxically split S2. Paradoxically split is P2 - A2 split Wide in expiration but narrows in inspiration Abnormal Splitting of S2 Diagnostic Implications of the S2 When Left ventricular ejection is prolonged due to Pressure overload - AS Volume overload PDA with a large L - R shunt, AR Left ventricular electrical activation is delayed -- LBBB

36. The decision whether it is aortic or pulmonic or a combination, depends on clinical profile . It is difficult to differentiate between TOF and Eisenmenger complex on auscultation alone. History and CXR can aid in distinguishing between the conditions. Abnormal Splitting of S2 Diagnostic Implications of the S2 Single S2 means that it is either A2 only and P2 inaudible – TOF, Critical PS or PA P2 only and A2 inaudible – Critical AS or AA A2+P2 in combination – Mod AS, Single Ventricle, VSD + PAH + Reversal of shunt (Eisenmenger complex)

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