St Johns case discussion.ppt Mudhal Nee Mudivum Nee, Moondru Kalam Nee, You are the beginning. You are the end. You are all three manifestations of time. Kadal Nee Karaiyum Nee, Katru Kooda Nee, You are the ocean. You are also the shore. Manadhoaram O

Mudhal Nee Mudivum Nee, Moondru Kalam Nee, You are the beginning. You are the end. You are all three manifestations of time.

Kadal Nee Karaiyum Nee, Katru Kooda Nee, You are the ocean. You are also the shore.

Manadhoaram Oru Kayem, Unai Yennadha Nalillaye, You are even the wind. I was hurt in the side of my heart. There’s not a day I don’t think of you.

Nanage Nanum Illaye,Vazhiyenghum Pala Bimbum, I am hardly myself anymore.

Adhil Nan Sayeh Thoalillaye, Un Pola Yarum Illaye, I see yoour beaming ... - Full article: Mudhal Nee Mudivum Nee Lyrics English Meaning Dhoora Desathil - https://lyricsraag.com/mudhal-nee-mudivum-nee-title-track-darbuka-siva/Mudhal Nee Mudivum Nee, Moondru Kalam Nee, You are the beginning. You are the end. You are all three manifestations of time.

Kadal Nee Karaiyum Nee, Katru Kooda Nee, You are the ocean. You are also the shore.

Manadhoaram Oru Kayem, Unai Yennadha Nalillaye, You are even the wind. I was hurt in the side of my heart. There’s not a day I don’t think of you.

Nanage Nanum Illaye,Vazhiyenghum Pala Bimbum, I am hardly myself anymore.

Adhil Nan Sayeh Thoalillaye, Un Pola Yarum Illaye, I see yoour beaming ... - Full article: Mudhal Nee Mudivum Nee Lyrics English Meaning Dhoora Desathil - https://lyricsraag.com/mudhal-nee-mudivum-nee-title-track-darbuka-siva/Mudhal Nee Mudivum Nee, Moondru Kalam Nee, You are the beginning. You are the end. You are all three manifestations of time.

Kadal Nee Karaiyum Nee, Katru Kooda Nee, You are the ocean. You are also the shore.

Manadhoaram Oru Kayem, Unai Yennadha Nalillaye, You are even the wind. I was hurt in the side of my heart. There’s not a day I don’t think of you.

Nanage Nanum Illaye,Vazhiyenghum Pala Bimbum, I am hardly myself anymore.

Adhil Nan Sayeh Thoalillaye, Un Pola Yarum Illaye, I see yoour beaming ... - Full article: Mudhal Nee Mudivum Nee Lyrics English Meaning Dhoora Desathil - https://lyricsraag.com/mudhal-nee-mudivum-nee-title-track-darbuka-siva/Mudhal Nee Mudivum Nee, Moondru Kalam Nee, You are the beginning. You are the end. You are all three manifestations of time.

Kadal Nee Karaiyum Nee, Katru Kooda Nee, You are the ocean. You are also the shore.

Manadhoaram Oru Kayem, Unai Yennadha Nalillaye, You are even the wind. I was hurt in the side of my heart. There’s not a day I don’t think of you.

Nanage Nanum Illaye,Vazhiyenghum Pala Bimbum, I am hardly myself anymore.

Adhil Nan Sayeh Thoalillaye, Un Pola Yarum Illaye, I see yoour beaming ... - Full article: Mudhal Nee Mudivum Nee Lyrics English Meaning Dhoora Desathil - https://lyricsraag.com/mudhal-nee-mudivum-nee-title-track-darbuka-siva/Mudhal Nee Mudivum Nee, Moondru Kalam Nee, You are the beginning. You are the end. You are all three manifestations of time.

Kadal Nee Karaiyum Nee, Katru Kooda Nee, You are the ocean. You are also the shore.

Manadhoaram Oru Kayem, Unai Yennadha Nalillaye, You are even the wind. I was hurt in the side of my heart. There’s not a day I don’

1. Clinical Cardiovascular Clinical Cardiovascular
ExaminationExamination
Dr Usha MKDr Usha MK
Associate Professor of pediatric cardiologyAssociate Professor of pediatric cardiology
Sri Jayadeva institute of Cardiovascular sciencesSri Jayadeva institute of Cardiovascular sciences
BangaloreBangalore

2. Clinical pearls to CHDClinical pearls to CHD

Child with failure to thriveChild with failure to thrive

Persistent tachypnea and retractionsPersistent tachypnea and retractions

Fever of prolonged duration – 1 weekFever of prolonged duration – 1 week

Genetic malformationsGenetic malformations

Newborn who has failed screeningNewborn who has failed screening

First degree relative with CHDFirst degree relative with CHD

HypertensionHypertension

Syncope, palpitations, breathlessnessSyncope, palpitations, breathlessness

3. Five basic questionsFive basic questions

Is the patient acyanotic or cyanotic?Is the patient acyanotic or cyanotic?

Is the pulmonary arterial flow increased?Is the pulmonary arterial flow increased?

Does the malformation originate in the left or Does the malformation originate in the left or
right side of the heart?right side of the heart?

Which is the dominant ventricle? VOLUME Which is the dominant ventricle? VOLUME
OR PRESSURE?OR PRESSURE?

Is pulmonary hypertension present or not?Is pulmonary hypertension present or not?

4. INCREASED PBF – can be INCREASED PBF – can be
both cyanotic or acyanoticboth cyanotic or acyanotic

Failure to thrive – emaciated Failure to thrive – emaciated
childchild

Recurrent LRTIRecurrent LRTI

Feeding difficulty, sweatingFeeding difficulty, sweating

Fast breathing and retractionsFast breathing and retractions

Mild cyanosis even in cyanotic Mild cyanosis even in cyanotic
CHDCHD

Palpitations or increased Palpitations or increased
precordial activityprecordial activity
REDUCED OR NORMAL PBFREDUCED OR NORMAL PBF

Good growth - usuallyGood growth - usually

Cyanotic spellsCyanotic spells

Squatting episodesSquatting episodes

Deep cyanosisDeep cyanosis

Syncope Syncope

Exercise intoleranceExercise intolerance
GENERAL RULES

5. 
Volume overloadVolume overload

PalpitationsPalpitations

FatigueFatigue

Brisk PulseBrisk Pulse

Palpable impulsePalpable impulse

Hyperdynamic Hyperdynamic
precordiumprecordium

AR,MR,VSD,PDAAR,MR,VSD,PDA

Pressure OverloadPressure Overload

Decresed exercise Decresed exercise
tolerance or fatiguetolerance or fatigue

Slow rising , low volume Slow rising , low volume
pulsepulse

Sustained or heaving Sustained or heaving
apex/parasternal heaveapex/parasternal heave

Reduced systolic pressureReduced systolic pressure

AS,PS,COAAS,PS,COA

6. 
Right heart failureRight heart failure

Pedal edemaPedal edema

AscitesAscites

Tender abdomen – Tender abdomen –
congestive hepatomegalycongestive hepatomegaly

Elevated JVPElevated JVP

Left heart failureLeft heart failure

Dyspnea on exertionDyspnea on exertion

OrthopneaOrthopnea

PNDPND

Sweating while feeding Sweating while feeding
and tachypneaand tachypnea

7. Heart Failure - ClassHeart Failure - Class

8. Does the child have heart Does the child have heart
disease?disease?
Dr Alexander Nadas
1 major or 2 minor

9. Newborn presentationNewborn presentation

Shock – most common D/d – Septic shock – Shock – most common D/d – Septic shock –
think of duct dependant systemic circulation –think of duct dependant systemic circulation –
coarctation, aortic stenosis,HLHScoarctation, aortic stenosis,HLHS

Deep cyanosis– Duct dependent pulmonary Deep cyanosis– Duct dependent pulmonary
circulation - Pulmonary stenosis or atresiacirculation - Pulmonary stenosis or atresia

Blue baby with black X ray – Pulmonary atresiaBlue baby with black X ray – Pulmonary atresia
Start prostaglandin on an empirical basisStart prostaglandin on an empirical basis

Deep cyanosis with white out lung – obstructed Deep cyanosis with white out lung – obstructed
TAPVCTAPVC

10. Heart murmursHeart murmurs
Systolic murmursSystolic murmurs

Early systolic – muscular VSD, large VSD with PAH, Early systolic – muscular VSD, large VSD with PAH,

Mid systolic/Ejection (aortic) –PS, AS, ASDMid systolic/Ejection (aortic) –PS, AS, ASD

Late systolic – MVP, TVPLate systolic – MVP, TVP

Holosystolic – VSD, MR, TR Holosystolic – VSD, MR, TR

11. Heart murmursHeart murmurs
Early diastolic murmurs – Early diastolic murmurs –

AR AR (bicuspid aortic valve, subvalvar AS, VSD)(bicuspid aortic valve, subvalvar AS, VSD)

PR PR (isolated or associated with TOF, VSD, PS)(isolated or associated with TOF, VSD, PS)
Mid diastolic murmurs –Mid diastolic murmurs –

MSMS

Increased flow across nonstenotic mitral valve Increased flow across nonstenotic mitral valve (MR, VSD, PDA)(MR, VSD, PDA)

TSTS

Increased flow across nonstenotic tricuspid valve Increased flow across nonstenotic tricuspid valve (TR, ASD, (TR, ASD,
TAPVC) TAPVC)
Late diastolic murmurs –Late diastolic murmurs – Austin Flint murmur, presystolic Austin Flint murmur, presystolic
accentuation of MS murmuraccentuation of MS murmur

12. Heart murmursHeart murmurs
Continuous murmur – Continuous murmur –

PDAPDA

Coronary AV fistulaCoronary AV fistula

RSOVRSOV

Anomalous coronary artery from pulmonary arteryAnomalous coronary artery from pulmonary artery

Peripheral pulmonic stenosisPeripheral pulmonic stenosis

Small (restrictive) ASD with MSSmall (restrictive) ASD with MS

Bronchial collaterals, intercostal AV fistula, intercostal Bronchial collaterals, intercostal AV fistula, intercostal
collaterals in CoA, post BT shuntcollaterals in CoA, post BT shunt

Mammary souffleMammary souffle

Cervical Venous humCervical Venous hum

13. CXRCXR

Pulmonary vasculaturePulmonary vasculature

Cardiac sizeCardiac size

Cardiac configurationCardiac configuration

14. GENERAL RULESGENERAL RULES
Decreased PBFDecreased PBF

Oligemic X rayOligemic X ray

(Small Pulmonary arteries) (Small Pulmonary arteries)
-Stenosis or atresia-Stenosis or atresia

Normal CT ratioNormal CT ratio
Increased PBFIncreased PBF

Increased vascularityIncreased vascularity

(Dilated Pulmonary (Dilated Pulmonary
arteries with severe PH)arteries with severe PH)

CardiomegalyCardiomegaly

17. Prominent MPAProminent MPA

Poststenotic dilatation (valvar PS)Poststenotic dilatation (valvar PS)

Increased pulmonary flow (ASD, VSD, Increased pulmonary flow (ASD, VSD,
PDA)PDA)

Increased PA pressure (PAH)Increased PA pressure (PAH)

18. Wall to wall heart – Ebsteins Wall to wall heart – Ebsteins
anomalyanomaly

19. Snowman heart – Supracardiac Snowman heart – Supracardiac
TAPVCTAPVC

20. No cardiomegaly, Pulmonary No cardiomegaly, Pulmonary
edema – Obstructed TAPVCedema – Obstructed TAPVC

21. Narrow pedicle, mild Narrow pedicle, mild
cardiomegaly, normal PBF - TGAcardiomegaly, normal PBF - TGA

22. Normal size heart with clear Normal size heart with clear
lungs with cyanosis - TOFlungs with cyanosis - TOF
Empty pulmonary bay
RV apex

23. CLASSIFICATIONCLASSIFICATION

25. 
All lesions with VSD and severe PS are classified as TOF All lesions with VSD and severe PS are classified as TOF
physiology – present with cyanosis, spells and squatting episodesphysiology – present with cyanosis, spells and squatting episodes