Congenital Heart Disease nysaap先天性心臟病nysaap

PediatricBoardReview

2014

PediatricCardiologyPremaRamaswamy,M.D.Co-Director,PediatricCardiology,MaimonidesInfantsandChildren'sHospitalofBrooklynPEDIATRICCARDIOLOGYInnocentMurmursCongenitalstructuralheartdiseaseRhythmproblems,syncopeetc.Peri,myo,endocarditis,RheumaticfeverSyndromesKawasakiDiseaseInnocentMurmursDiastolicmurmursareneverinnocentInnocentmurmursarepresentinatleast50%ofnormalchildrenStill’smurmur:lowpitched,vibratory,systolicejection,increaseswiththesupineposition.Venoushum:continuousmurmurinsupraclavicularregion,reducesonlyingdownorwithpressureonneck.Uponphysicalexaminationofa3yearoldgirlwhoisnewtothepractice,younoteacontinuousgrade2tograde3murmurattheupperrightsternalborderwhilesheissitting.Inthesupineposition,younoteonlyagrade2lowpitchedsystolicmurmurattheapex.MeasurementsofBP,pulsesandprecordialpalpationsaswellastheauscultationisnormal.Ofthefollowing,theMOSTappropriatenextstepisto:

reassuretheparentsaboutthebenignprognosisrequestacardiologyconsultationrequestchestradiographyrequestechocardiographyrequestelectrocardiography6CongenitalHeartDisease-StructuralPINKShunts(LtoR):ASDVSDPDAStenosis:ASPSCoarctationHLHSBLUETOFTGATricuspidatresiaTruncusTAPVREbstein’sSingleventricleNormalCardiacPressures120/<825/<5<5<8120/8025/15ATRIALSEPTALDEFECT<5<8ATRIALSEPTALDEFECTS(ASD)Threetypesexist:primum,secundumandsinusvenosusThemostcommonisthesecundumtypeSymptoms:Noneinchildhood,arrhythmiasinthe3rddecadeASD-cont...Clinicalsignsincludea2-3/6SEMattheULSBandafixedwidesplitS2AlargeASDcausesrightventricularenlargementEKG:RADandIRBBBASD-cont...ECHO:DiagnosticNaturalHistory:Arrhythmiasandpulmonaryobstructivevasculardiseaseinthe3rdand4thdecade.Treatment:Surgicalvs.transcatheterclosureVENTRICULARSEPTALDEFECT120/<825/<5VENTRICULARSEPTALDEFECTS(VSD)ThisisthemostcommonformofCHDTheVSDsaresubdividedaccordingtothepartoftheseptumtheyoccurin:Muscular,perimembranous,inlet,outletAlargeVSDcausesleftventricularenlargementWithasmallVSDthereisnormalgrowthanddevelopmentVSD-cont…..WithalargedefecttheremaybeCHF(usuallyat6-8weeks),pulmonaryinfectionsanddelayedgrowthClinicalsigns:Loud4-5/6,harshholosystolicmurmur,middiastolicrumbleandaloudP2VSD-cont…..EKG:LVHorBVHECHO:DiagnosticVSD-cont...Naturalhistory:SmallVSDsclosespontaneouslydependingonthesite.UnrepairedthelargedefectsmayleadtoEisenmenger’ssyndrome.VSD-cont…..LargeVSDsareclosedsurgicallyby6monthsofage.Diuretics,digoxinandafterloadreducingagentsareusedpriortosurgery-ifneeded.ENDOCARDIALCUSHIONDEFECTSAVSD-cont...1/3rdofbabieswiththishaveDownsyndromeEKG:Characteristicwithasuperiorleftaxis.Echo:ConfirmatoryManagement:Anticongestivemedicationsandsurgeryat4-8monthsofage.PATENTDUCTUSARTERIOSUS25/15120/80PATENTDUCTUSARTERIOSUS(PDA)Itisaconnectionbetweentheaortaandthepulmonaryartery.Verycommoninpretermbabies.Usuallyclosesinthefirst2weeksoflife.PDA-cont…..Symptoms:a)Noneifsmallb)IflargecancauseCHFat6-8weeksinaterminfantc)Inapretermbabyincreasingrespiratorysupportusuallyoccursafterday3oflife.PDASigns:Systolicmurmurinanewbornandacontinuous“traininatunnel”murmurinanolderchild.Bestheardbelowtheleftclavicle.AlargePDAcausesLAandLVenlargement.Treatment:Pretermvs.termbaby.PDA-cont...Inapretermitcanbeclosedmedicallyusingindomethacin.Inatermbabyifstillopenat3monthsofagethencoilclosurebycardiaccatherizationisthemethodofchoice.1.A3montholdgirlwhohasDownsyndromeexhibitspoorweightgain,tachypneaandalowpitchedgrade2murmur.Chestradiographyrevealscardiomegalyandincreasedpulmonaryvascularity.EKGdocumentsRVHandasuperiorfrontalplaneQRS.Ofthefollowing,theMOSTlikelydiagnosisis:A. coarctationoftheaortaB. completeatrioventricularseptaldefectC. patentductusarteriosusD. PerimembranousVSDE. secundumASD2.A5dayoldinfantbornat31weeksgestationisonventilatorysupport.Hehasagrade2holosystolicmurmurthatextendspastthesecondheartsound.Pulsesarebounding.Precordialpalpationishyperdynamic.Concentrationsofhemoglobin,electrolytesandcreatininearenormal.OfthefollowingthemostappropriateINITIALmanagementisto:A. administerfurosemideintravenouslyB. administerindomethacinintravenouslyC. performanechocardiogramD. deferinterventionbecausespontaneousclosureislikelyE. obtainasurgicalconsultationforligationoftheductus.Youareevaluatinganewborn6hoursafterhisbirth.Laboranddeliverywereuncomplicated,butamniocentesisperformedduringthepregnancyrevealedtrisomy21.Fetalechocardiographyat20weeks'gestationshowednormalfindings.Theinfantcurrentlyissleepingandiswell-perfused,withaheartrateof140beats/minandnoaudiblemurmurs.HisphysicalfeaturesareconsistentwithDownsyndrome.

Ofthefollowing,theMOSTappropriatediagnosticstudytoperformis:bariumswallowcervicalspineradiographyEchocardiographyheadultrasonographyradiographyoftheabdomen

64.Atermnewbornhastachypnea,rales,tachycardia,audiblegallopanddiminishedarmandlegpulses.Echocardiographyshowsenlargementofbothventricularchamberswithgoodsystolicfunctionandnocongenitalheartdisease.Ofthefollowing,theMOSTlikelydiagnosisis:A. CarnitinedeficiencyB. hyperthyroidismC. hypoglycemiaD. intracranialarteriovenousmalformationE. pheochromocytomaCOARCTATIONOFTHEAORTACoarctationoftheAorta(CoA)MorecommoninmalesAlmostalwaysjuxtaductal85%ofchildrenwithCoAhaveabicuspidaorticvalve.CoA-cont….SymptomsandSigns: SEVERE:Shock MODERATE:CHF, MILD:Headaches,legclaudicationDecreasedfemoralpulsesareanimportantsignesp.inneonates.BPlowerinthelowerlimbsCoA-cont….ECHO:DiagnosticTreatment:Foraninfantinshock-PGE1immediately.Surgicalvs.transcatheterrepair.HypoplasticLeftHeartSyndromeVaryingdegreesoflefthearthypoplasiaatmultiplelevelsBabiespresentincardiogenicSHOCKoncetheductuscloses.ImmediatetreatmentisPGE1intravenouslyasaninfusion.HypoplasticLeftHeartsyndromeSurgicalTreatment:NorwoodatbirthGlennat4-8mnthsFontanat2-4years3)A7-month-oldfemalehasundergonethesecondstageofsurgicalpalliation(Glennoperation)forhypoplasticleftheartsyndrome.Shewasdischargedfromthehospital1weekago,andhermotherbringshertotheofficebecauseofirritabilitythatbeganthismorning.Onphysicalexamination,theinfantisawakeandirritable,withaheartrateof150beats/minandarespiratoryrateof50breaths/min.Shehascyanosisofthefaceandmucosalsurfacesandswellingofthearmsandhead.

Ofthefollowing,theBESTexplanationforthispatient'sclinicalpresentationis

A)

polycythemiaB)

postpericardiotomysyndromeC)

protein-losingenteropathyD)

superiorvenacavasyndromeE) thoracicductinjury

Pulmonic/AorticStenosisStenosisPulmonicThismaybeatthevalve,subvalvarorsupravalvar.Symptoms:Noneinmildormoderatestenosis.CyanosisisseenonlywithcriticalPS.Signs:ejectionclickandaharshSEM,attheULSB.ECHO:DiagnosticTreatment:BallooningAorticStenosispossibleatthevalve,subvalvarorsupravalvar.ThisisamoresignificantandadangerouslesioncomparedtoPS.Morecommoninmales.ValvarASisusuallyassociatedwithabicuspidaorticvalve.Treatment:BallooningASAtypeofsubvalvarASisalsocalledHCMwhichisthecommonestcauseofsuddendeathinchildrenSymptoms: Mild:None Moderatetosevere:Chestpain,fatigability,syncope.HYPERTROPHICCARDIOMYOPATHY1. A3dayoldgirlisfoundunconsciousinhercribandisbroughttotheED.Findingsinclude:tachypnea,tachycardia,pallor;poorcapillaryrefill;hepatomegaly;cardiomegalywithincreasedpulmonaryvascularmarkings;hemoglobinconcentration17gm/dl;andhematocrit,51%.Ofthefollowing,thecardiogenicshockinthisgirlMOSTlikelyisdueto:A. criticalaorticstenosisB. erythroblastosisfetalisC. patentductusarteriosusD. severehypovolemiaE. ventricularseptaldefectA6hour-oldinfanthasincreasingpallor,tachypneaandrespiratorydistress.Physicalexaminationrevealsanenlargedliver,agalloprhythm,poorpulsesintheupperextremitiesandabsentpulsesinthelowerextremities.Inadditiontotreatingtheinfantforsepsis,themostappropriateINITIALmanagementistoadminister:adopamineinfusionaloadingdoseofdigoxina25%glucoseandwatersolutionFurosemideprostaglandinE1.6BLUELESIONSTherehastobeaRIGHTtoLEFTshunttocausecyanosisTetralogyofFallot

Mostcommoncyanoticheartdisease.Thefourabnormalitiesinclude:PulmonarystenosisRVHVSDOverridingAortaSignsincludecyanosis,murmur,squattingandspells.TOFcont..A“tet”spellconsistsofrapidbreathingandincreasedcyanosis.Anyeventlikecryingorincreasedphysicalactivitycaninitiatethespell.Treatmentincludes:holdingthebabyinakneechestpositionMorphineOxygen,betablocker,generalanesthesia,

TRANSPOSITIONOFTHEGREATARTERIESTranspositionofthegreatArteriesTheaortaarisesfromtherightventricleandthepulmonaryarteryfromtheleft.ThemixingofthebloodoccursatthePFOandthePDA.Thesignsincludecyanosisandcardiomegaly.Reversedifferentialcyanosis!Theremaybenomurmur.Anechocardiogramisdiagnostic.1.Themotherofa5montholdgirlreportsthatfollowingafeeding,thechildbegantobreathedeeply,becameincreasinglyblueandthenlostconsciousness.Afterbeingheldbriefly,theinfantregainedherusualcolorandbecamealert.Physicalexaminationrevealsaharshmurmur.OfthefollowingtheMOSTlikelydiagnosisis:A. aorticstenosisB. coarctationoftheaortaC. myocarditisD. tetralogyofFallotE. ventricularseptaldefect2.Youarecalledat3AMfromthenurserywhere36houroldBBBleuisnoticedtobecyanotic.ThenursesreportthathehadbeenfeedingwellandappearedhealthywithApgarscoresof9/9.Untiltonightheappearedpink.Theyreportnosignificanttachypnea.YouorderachestX-Rayandpulseoximetrytobedonewhileyourushtothehospital.OnarrivalthepulseoximetryindicatedO2saturationof55%andtheX-rayshowsnoincreaseinpulmonaryvascularmarkingsorinfiltrate.ThenextMOSTappropriateinterventionisto:A. obtainastatEKGtoevaluateforSVTB. intubatetheinfantandplaceon100%O2.C. startIVprostaglandininfusionat0.05-0.2mcg/kg/minD. startnitricoxideat40ppminspiredtoreducepulmonaryvascularresistanceE. arrangefortransfertoafacilitycapableofECMO.Followinganuncomplicateddelivery,a3.7kgterminfantdevelopscyanosisinthefirsthouroflife.Findingsat3hoursofageinclude:cyanosis;heartrate,140beats/min;respiratoryrate,56/min;noheartmurmurs;pulseoximeteryinroomair,70%saturationintherighthandand75%inthefoot;in100%FIO2viahead-hoodoxygen,saturationincreasesto90%inthefoot;chestradiography,normal.Thesefindingsaremostconsistentwith:

Primarypulmonaryhypertensionofthenewbornpulmonaryvalveatresiatransienttachypneaofthenewborntranspositionofthegreatarteriestruncusarteriosus

At60minutesofage,aterm3.3-kgfemaleinfantappearscyanoticbutisotherwisewell.Heroxygensaturationis79%,shehaswidespreadcyanosis,andyoucanhearafaintlow-pitchedmurmurdiffuselyacrossthechest.Theremainderoffindingsonherphysicalexaminationarewithinnormallimits.Afterplacingheronnasalcannulaoxygenat2L/min,younotenochangeinsaturation.Ofthefollowing,theMOSTlikelycauseofthischild'sfindingsis:anemiaB.hypoplasticleftheartsyndromeC.neonatalsepsisD.retainedfetallungliquidsyndromeE.tracheoesophagealfistulaCongestiveCardiacFailureTachycardiaTachypneaHepatomegalyCardiomegaly,murmur,HRtoofast/slowFAILURETOTHRIVECHD2months-VSD,PDAWithin1stmonth-Coarctation,AS,HLHSNeonatalperiod:TruncusArteriosusNormalheartMyocarditis1. Inadditiontoirritability,sweatinganddifficultybreathingwithfeeding,thesymptomthatisMOSTindicativeofcongestivecardiacfailureina3weekoldinfantis:A. ascitisB. coughC. cyanosisD. diminishedfeedingvolumeE. pretibialedemaAterminfantisbornwithalargeventricularseptaldefect.AtwhatageisthisinfantMOSTlikelytofirstdemonstrateclinicalfindingsofcongestivecardiacfailure?2days2weeks2months6months12months6RhythmAbnormalitiesEctopicbeats:prematureatrial,ventricularBenigniftheydisappearwithexerciseSeenintheneonatalandadolescentagegroupsAtrialFlutter,fibSVTVTElectrolyteImbalancesTOFHCM,LongQTsyndromeAVblock1.An8yearoldpreviouslyhealthyboypresentsforaschoolphysical.Heisactiveandhasnosymptoms.Onexam.Heappearswell.Hispulsenotedbythenursetobe80butwithperiodsofbradycardiato60andthenfollowedbymorerapidratesof90/min.Nootherabnormalitiesarenoted. HisEKG:Mostcommoncauseofirregularrhythminchildren–SINUSARRHYTHMIA–BENIGN!!!Irregularrhythminanewbornbaby-Prematureatrialcontractions–BENIGN!!!Irregularrhythmincidentallynotedinanadolescent-VentricularPrematurebeatswhichdecreasewithexercise–BENIGN!!!SVTRateabove230/min.Tachycardia–mostlikelySVTNarrowcomplextachycardiaWPWisthemostcommoncauseofreentrytachycardiainchildrenTreatmentofSVTHemodynamicallystable:VagalmaneuversAdenosineVerapamilinchildrenover1yearHemodynamicallyunstable:DCcardioversionChronicM/t:Drugs:Betablockers,digoxinRadiofrequencyablation1.A1yearoldchildisbroughttotheERbecausehisparentsthoughthisheartwaspoundingastheywereputtinghimtobed.EKGrevealsaHRof300/minthatspontaneouslyconvertstoasinusrateof100/min.Theparentsestimatethatthetachycardialasted20minutes;thechildwasasymptomaticthroughout.OfthefollowingtheMOSTappropriatemanagementofthischildis;A. administrationofabetablockerB. adminstrationofdigoxinC. administrationofprocainamideD. administrationofverapamilE. observationwithoutdrugtherapy2. A4weekoldinfantappearsinyourEDwithahistoryofirritability,increasedrespiratoryrateandpoorfeeding.Onphysicalexaminationthechildisdiaphoreticwithdecreasedperfusionandtachypneicbutstillalert.YounoticenomurmurbutthemonitorindicatesaHRof280bpm.Allbutoneofthefollowingareappropriate;A. obtaina12leadEKGB. giveverapamil0.1mg/kgpushslowlyC. giveadenosine100mcg/kgrapidpushD. fillabagwithiceandapplytoinfantsfaceE. passanesophagealprobeandpacetheheart20bpmfasterthanthetachycardiaAtrialFlutter/FibrillationSeenintwogroupsNewborns:Aftert/tBENIGN!!AfterextensiveatrialsurgerysuchasFontanop,atrialswitchforTGAetc.Treatment:DCCardioversion,AVblockingmedsAVBLOCKFirstDegree–ProlongedPRintervalRheumaticfever,ASD,PDASecondDegreeTypeI:VaryingPRintervalsanddroppedbeat,WenkebachTypeII:2ormorethan2:1blockThirdDegree:

Surgical,LymeDiseaseMomwithSLESecondDegreeAVBlock–TypeIandIIThirddegreeAVBlock4.SYNCOPEBrieflossofconsciousnesswithrapidrecoverySeeninadolescentsandintoddlers20-50%ofadolescentsexperienceatleastoneepisodeofsyncopemostcasesbenignVasovagalsyncopeisthemostcommontypeinadolescentsTypicalhistory,normalEKGBENIGNSYNCOPEVasovagalOrthostatichypotensionHyperventilationBreathholdingspellsDANGERSYMPTOMSSyncopeespeciallywithEXERTIONorEXCITEMENT-anger,fear,startleCardiacarrestwithexerciseorexcitementSuddenDeathinYoungAthletesCommotioCordisYoungchildrenBaseball,football,icehockeyForceofblowisnotunusuallyhardRonTphenomenonPrevention:?softerballs,?protectiveclothing,RoleofautomatedExternaldefibrillatorLongQTSyndromeDisorderoftheelectricalactivityoftheheartInvolvesrepolarizationCharacterizedbyQTprolongationPts.aresusceptibletosuddendeathduetoTorsadedepointesSyncopetypicallyoccurswithastartleorexertioncanbeinheritedoracquiredQTIntervalTorsadedePointesSpecialsituationswheretheQTshouldALWAYSbemeasuredSyncopeSeizurescongenitalDeafnessnearSIDS1.A5yearoldgirlisveryexcitedfollowingarideontheferriswheel.Inthemidstofherexcitementshesuddenlylosesconsciousnessandfallstotheground.Paramedicsonthescenedocumentventriculartachycardia.Familyhistoryrevealsamaternalunclewhodiedsuddenlyat16yearsofage.Followingtreatmentoftheventriculartachycardia,anelectrocardiogrammostlikelywilldemonstrateA. correctedQTintervalof0.52secB. Pwaveaxisof–30degreesC. PRintervalof0.81secD. QRSaxisof–15degreesE. QRSintervalof0.12seconds2.A12yearoldboyunderwentrepairfortetralogyofFallotat9monthsofage.Lastmonth,routinefollowupechocardiographyrevealednoresidualshunts;moderaterightventricleenlargement;a60mmHggradientfromtherightventricletothemainpulmonaryartery;andnormalLVsizeandfunction.Todayheisdizzyandhadanearsyncopalepisodeingymclass.TheMOSTlikelycauseforhissymptomsisA. leftventricularfailureB. physicaldeconditioningC. pulmonaryhypertensionD. rightventricularfailureE. ventriculararrhythmia3.Julie,anotherwisehealthy9yearoldcomestotheEDbecauseshe“passedout”.Afteraskingquestionsandexaminingthepatientallbutoneofthefollowingreassuresyouthatshehasvasovagalsyncopewhichisarelativelybenigncauseofsyncopeinchildren.A. Juliewasstandinginlinewaitingtosee“HarryPotterandtheDeathlyHallows”whenshepassedout.B. shefaintedoncebeforewhenshehadabloodtestC. afterfallingtothegroundshecametoquicklyandrememberedfeelingwarmanddizzyD. JuliewaslyingonasofawatchingTVwhenadoorslammedandshesuddenlybecameunresponsiveE. S1andS2werenormalandnomurmurswerenoted4.A14yearoldgirlfallsduringarace.Sheisunconscious,cyanoticandhasnopulsebutspontaneouslyreviveswithinseconds.Bothpatientandfamilyhistoriesarebenign.Resultsofthephysicalexamination,chestradiography,EKG,echocardiography,EEGandanexerciseECGduringatreadmillstresstestarenormal.ThemostappropriateNEXTstepinmanagementistoA. ordera30dayloopingeventrecorderB. performcardiaccatheterizationstudiesC. Perform24hourambulatoryECGmonitoringD. performtilttabletestingE. reassurethefamilythatcardiacetiologieshavebeenexcluded5. A13yearoldboywishestoparticipateincompetitivesports.Hisfatherdiedsuddenlyatage28years,andhypertrophiccardiomyopathywasfoundonautopsy.Ofthefollowing,theMOSThelpfultestforassessingtheboy’sriskis:A. echocardiographyB. electrocardiographyC. exercisemyocardialperfusionscintigraphyD.GenetictestingformyosinchainmutationsE.GenetictestingfortroponinmutationsSYNDROMESDown’s:Incidence50%.AVcanaldefects.Turner’s:10%.Coarctation,bicuspidaorticvalveWilliams’s:Supravalvaraorticstenosis,PPSAlagille:Peripheralpulmonicstenosis(PPS)Noonan:PPSandHCMMarfan’s:Aorticrootdilatation,MVPDiGeorge:TruncusArteriosus,Interruptedaorticarch.Catch22:conotruncalabn.suchasVSD,TOF,collaterals,rightaorticarchKartagener:Dextrocardia,situsinversus,immotileciliaHolt-Oram:LimbabnormalitieswithASDEllis-vanCreveld:ASDPompe’sD:HypertrophiccardiomyopathyCongenitalHeartDisease-Etiology-EnvironmentalFactors/Toxins

Lithium:Ebstein’sanomalyEthanol:ASD,VSD(FetalAlcoholSyndrome)Anticonvulsants:PS,AS,TOFRetinoicAcid:TranspositionRubella:PDA,PPSCoxsachieB:NeonatalmyocarditisMaternalDiabetes:HCM,TGAMaternalLupus:CompleteheartblockPKU:VSD,ASD,complexCHDPERICARDITISFollowsaviralURISharpchestpain,retrosternal,difficultyindeepinspirationPt.ResistslyingdownPainworsenedbypressureoverthesternumFrictionrub,pulsusparadoxusEKGisdiagnosticPericarditisPERICARDITIS-EKGTREATMENTReassuranceNSAIDSOccasionalpericardialtap,windowPostpericardiotomySyndrome:2weeksaftersurgeryInfectiveEndocarditisTheendocardiumisadeterranttoadhesionbyplateletsandorganisms.ThedenudedendotheliumisasiteforplateletadhesionandsubsequentvegetationgrowthThe“Lowpressuresink”isthesiteforvegetations.PolycythemiaIE-Lab.TestsBLOODCULTURESEchoPreventionofInfectiveEndocarditis

GuidelinesFromtheAmericanHeartAssociation

AGuidelineFromtheAmericanHeartAssociation

RheumaticFever,Endocarditis,andKawasakiDiseaseCommittee,CouncilonCardiovascular

DiseaseintheYoung,andtheCouncilonClinicalCardiology,Councilon

CardiovascularSurgeryandAnesthesia,andtheQualityofCareand

OutcomesResearchInterdisciplinaryWorkingGroup

Circulation2007;116;1736-1754;Conclusions(1)Onlyanextremelysmallnumberofcasesofinfectiveendocarditismightbepreventedbyantibioticprophylaxisfordentalproceduresevenifsuchprophylactictherapywere100%effective.(2)IEprophylaxisfordentalproceduresisreasonableonlyforpatientswithunderlyingcardiacconditionsassociatedwiththehighestriskofadverseoutcomefrominfectiveendocarditis.

(3)Administrationofantibioticssolelytopreventendocarditisisnotrecommended forpatientswhoundergoagenitourinaryorgastrointestinaltractprocedure.ConclusionsProstheticcardiacvalvesorprostheticmaterialusedforcardiacvalverepairPreviousIECongenitalheartdisease(CHD)*-UnrepairedcyanoticCHD,includingpalliativeshuntsandconduits-Completelyrepairedcongenitalheartdefectwithprostheticmaterialordevice,whetherplacedbysurgeryorbycatheterintervention,duringthefirst6monthsaftertheprocedure?-RepairedCHDwithresidualdefectsatthesiteoradjacenttothesiteofaprostheticpatchorprostheticdevice(whichinhibitendothelialization)CardiactransplantationrecipientswhodevelopcardiacvalvulopathyMyocarditis-EtiologyMyocarditis-signsandsymptomsDILATEDheartSinusTACHYCARDIA

CHFInflamedMyocardiumandconductionsystem Arrhythmias

PERI

MYO

ENDOHeart Normal Normal PathologyCause

Viral Viral BacterialSymptom

Chestpain C.pain,irr.beats FeverSigns Rub Tachycardia FeverTest EKG,echo CXR,echo B.CultureTreatmentNSAIDS ?IVIG AntibioticsCourse Benign Canbefatal insidiousJones’ModifiedCriteriaRheumaticCarditisPresentin50%cases“Sleeping”tachycardiaisanearlysignMitralandaorticvalvesmostcommonlyinvolvedRheumaticArthritisMostcommonmanifestationPain,swellinganderythemaResolveswithin1weekRF-TreatmentandPreventionBenzathinepenicillin1.2megaunitsIMAspirin75-100mg/kgfor6-8weeksSteroidsforseverecarditisDigoxin,diureticsPreventionwithBPq4weeks.1.Twoweeksafteranonspecificupperrespiratoryinfection,apreviouslyhealthy,3year-oldboyisnotedtohavearesp.rateof40breaths/min,aHRof140beats/min,hepatomegalyandagalloprhythm.Noheartmurmursaredetected.Ofthefollowing,theMOSTlikelydiagnosisis:A.acuterheumaticfeverB.infectiveendocarditisC.myocarditisD.paroxysmalatrialtachycardiaE.pericarditis2.A13yearoldboywhohasabicuspidaorticvalveandwhoreceivedtreatmentfordentalcariesabout3weeksagonowcomplainsoflethargy,decreasedenergy,andreducedappetite.Findingsonphysicalexaminationincludelowgradefever,splinterhemorrhages,splenomegalyandanewmurmurconsistentwithaorticinsufficiency.Amongthefollowing,theBESTstu