Heart Murmurs Part 2-Congenital Heart Disease

PA Study Sesh

Heart murmurs continue with congenital heart diseases.
A Picmonic is available for EVERY topic in today’s episode. Start by checking out our first topic here.
Ventricular Septal Defect
* #1 type of congenital heart disease
* Loud, high-pitched harsh, holosystolic murmur at LLSB
* Typically a left to right shunt (restrictive)
* May switch to right to left 2/2 pulmonary HTN (non-restrictive)
* “Eisenmenger’s syndrome”
* Dx: echocardiogram
* Tx:
* Observe if small
* Most close by age 10
* Surgery
* Symptomatic
* CHF
* Growth Delay
* Large VSDs repaired by age 2
Atrial Septal Defect
* Ostium secundum fails to close
* Often asymptomatic until >30y.o.
* Systolic ejection crescendo-decrescendo flow murmur @ pulmonic area (Left sternal border)
* Mimics pulmonic stenosis
* Widely split, fixed s2
* Does not vary with inspiration
* It’s not on either side of the heart
* Surgery if symptomatic
Coarctation of the aorta
* Narrowing of descending thoracic aorta
* Males>females
* 70% also have bicuspid aortic valve
* Symptoms
* Systolic murmur that radiates to the back/scapula/chest
* HTN (secondary)
* BP upper>lower extremities
* Delayed/weak femoral pulses
* Diagnosis
* Angiogram=gold standard
* CXR:
* Rib notching
* Increased flow in intercostal aa.
* 3 sign
* Narrowed aorta looks like the notch of a 3
* Tx: surgical
Patent Ductus Arteriosus (PDA)
* Connection between descending thoracic aorta & pulmonary artery
* Continuous, machinery murmur loudest @ pulmonic area
* Wide pulse pressure, bounding peripheral pulses
* Dx: echocardiogram
* Tx: indomethacin
* Inhibits prostaglandin production=closes PDA
Hypertrophic Cardiomyopathy
* Subaortic outflow obstruction secondary to hypertrophied septum
* Harsh, systolic, crescendo-decrescendo murmur at LLSB (similar to AS)
* DECREASES with INCREASED venous return
* Squatting, lying supine, etc
* Increased blood pushes septum out of the way
* INCREASES WITH DECREASED VENOUS RETURN
* Valsalva/standing
* Symptoms:
* Dyspnea usually 1st
* Chest pain
* Sudden cardiac death
* Especially during extreme exertion
* Secondary to v fib.
* Dx: echocardiogram
* Management:
* Avoid dehydration & extreme exertion
* B blockers 1st line medical
* Increases diastolic filling time
* Caution with digoxin, nitrates, and diuretics
* Surgical: myomectomy or alcohol septal ablation
Tetralogy of Fallot
* #1 cyanotic congenital heart disease
* Definition
* RV hypertrophy
* Rv outflow obstruction
* Pulmonary artery stenosis
* Overriding aorta
* VSD
* Right to left shunt=cyanotic
* “tet spells”
* Episodes of cyanosis
* Relieved by squatting
* Harsh,