Coarctation and other cardiac anomalies.

Objectives
1. To understand the principles of functional anastomoses, shunts and blue baby
syndromes.
2. To understand the principal factors contributing to a right left or left right shunt
and its physiological consequences.
3.
Case 1
13 year old girl is brought to you by her mother complaining of headaches. s a good
!" you perform a thorough clinical e#amination and note that she has a high blood
pressure 1$%&1%% but a 'ea( femoral pulse.
)urther e#amination of her shoulders sho' bilateral pulsating scapulae and an old
chest *+ray film ta(en t'o years ago sho'n irregular borders on the underside of the
ribs. ,ou ma(e a diagnosis of coarctation, start the child on antihypertensive
medication and refer her to a cardiac surgeon for revie'.
1. -escribe the anomaly of cooartation and 'hy this comes about.
.arro'ing of the aorta / ductus arteriosus tissue e#cessive and at childbirth
'hen it normally constricts, the aorta constricts 'ith it. 0sually just distal to left
subclavian artery and the limb pressure is high but femoral pressure is lo'.
1pulsation of scapula1
2. 2hat is the characteristic sound heard on e#amining the precordium 3anterior
chest45
6urmur / a sound created by turbulent flo' eg 'hen heart beats too fast. 7f
aortic valve is narro'ed8 'e 'ill hear turbulent flo' during systole
.arro'ing of mitral valve8 murmur heard in diastole
-istinguish bet'een them99 1 use carotid pulse and auscultate at the same
time
-uring coarctation the murmur 'ill be heard during both systole and diastole.
The elastic recoil of artery maintains the blood flo' constantly / continuous
murmur.
3. :o' does the child develop pulsating scapulae and notched lo'er rib borders5
-ue to narro'ing after left subclavian in aorta / blood must still be supplied
efficiently to lo'er half of body. -orsal scapular, subscapular, surprascapular
arteries anastomose 'ith posterior intercostal arteries 1 body finds bypasses to
allo' it to supply lo'er half of the body, 'hole blood supply of the lo'r body
passes through scapular arteries.
7nternal thoracic artery gives off anterior intercostals + high blood pressure
through them and feeds bac( to aorta / bypass.
.otched lo'er rib borders8 curving, meandering intercostal arteries and lo'er
ribs get a curved or notched border
;. 2hy do you thin( the child has severe hypertension / use your physiology to
come to a conclusion.
<idney plays a role in altering blood pressure / filtering using arterial pressure /
sectretes renin, angiotensin and causes vasoconstriction.
=lood pressure > flo' # resistance 1
?asoconstriction increases and blood pressure increases above the
vasoconstriction / (idney (eeps secreting more renin and angiotensin / (eep
increasing the pressure / massive and the pressure causes a stro(e as brain
arteries pop.
7f not stro(e, they get hypertrophic heart and coronary arteries cannot cope /
causes many heart attac(s etc.
$. :o' do these children die if untreated5
@. 2hat happens in the related anomaly of patent ductus arteriosus. -oes this
patient also suffer from high blood pressure5
-uctus arteriosus remains open after birth8 blood pressure of aorta goes in the
pulmonary blood pressure. Catch the condition early before cardiac
hypertrophy in right side of heart happens
=efore birth pressure is lo'er in ductus arteriosus / as lungs open up blood
pressure drops and blood flo's to the lungs.
O#ygenated blood from aorta moves into the lungs / gradient in the lungs 'ill be
smaller.
7t 'ill be a blue baby / o#ygenated blood is preventing the deo#ygenated from
being o#ygenated.
A. :o' do 'e treat patients 'ith a patent ductus arteriosus5
.on steroidal anti inflammatory drugs + eg ibuprofen
nd then surgery to tie it do'n or angioblasty / put a balloon inside it to bloc(
Case 2
five month old baby is being e#amined in a 'ell baby clinic 'hen you become a'are
of a considerable pan+systolic murmur together 'ith the normal heart sounds. 7n fact
you can barely hear the first heart sound.
,ou as( the mother about the babyBs general health and she admits she has often seen
the baby a poor colour / 'hich she describes as grayish, especially after the baby has
been crying a 'hile.
2ell baby clinic / e#amine a baby a fe' days after it is born to catch things 'hich
might have been missed after birth
1. 2hich common cardiac anomalies could give a pan systolic murmur5
"an systolic / means over the 'hole of syctole
6itral valve shunts / can cause a pan systole murmur related to a valve though
its not as common in congenital anomalies
Cjection systolic murmur is heard at the end of systole
2 chambers connected8 flo' happens do'n a pressure gradient.
=et'een 2 ventricles8 ventricular septal defect8 abnormal flo' bet'een them as
there is a large pressure difference+ and there 'ill be a pan systolic murmur
2. 2hat is the basis of a pan systolic murmur5 2hy does it happen5 2hat forces
are involved5
3. 2hich common cardiac conditions therefore 'ould most probably not give much
of a murmur and 'hy5
trial pressure is very lo' / murmur 'ith a patent fossa ovalis doesnBt occur
"robe patent fossa ovalis / it closed but never fused
;. 2hich cardiac conditions give rise to a blue+baby syndrome5
?sd / most common 3ventricular septal defect4
"da / patent ductus arteriosus
$. C#plain 'hy the baby becomes =lue 3 or grey4 in colour5
@. 2hat is the common treatment for these conditions.
Durgery
Cool stuff8