Swischuk Notes Chapter 3 Cardiovascular system Cardiac problems: Neonates congenital Older children acquired NORMAL HEART AND

T AND VARIATIONS Neonates: o Cardiac size does not vary with respiration o Transient cardiac enlargement is common o Causes of enlargement: 1. Placental-to-fetal transfusion 2. Hypoglycemia 3. Excessive cord stripping 4. Hypocalcemia 5. Myocardial ischemia 2O to hypoxia Older children o Heart size varies substantially with respiration o Pathologic cardiac enlargement

LV and aorta posterior LAO most used LA, LV, interventricular septum, RV, aorta and pulmonary artery Mitral and tricuspid valves PHYSIOLOGIC CONSIDERATIONS IN CHD Systolic (pressure) and diastolic (volume) ventricular overloading Diastolic overload ventricular dilatation (1), enlargement, reactive hypertrophy left to right shunt valvular insufficiency Systolic overload concentric hypertrophy (little to no chamber enlargement; obstruction to normal flow: aortic stenosis pulmonary stenosis coarctation of the aorta Postnatal pulmonary vascular and right ventricular involution (days to weeks) thick pulmonary arteriolar walls increased pulmonary resistance RVH Primary pulmonary hypertension (persistent fetal circulation syndrome), if persistent o Right to left shunt cyanosis BASIC PULMONARY VASCULAR PATTERNS 1. Increased pulmonary vascularity Active congestion o LR shunt: ASD, VSD, PDA o To lower pressure pulmonary circulation: TGA, PTA, single ventricle o Uniform in upper and lower lobes o Involves both veins (not visible) and arteries (dilated, tortuous and extends to periphery with distinct walls) o Visible on x-ray only when RV output is 2x greater than LV or 2.5:1 cardiac output Normal: RDPA and trachea = same +/2 mm Significant shunt: RDPA > trachea Passive congestion o Pulmonary venous HPN, and PVHPN 2O to left sided obstructive lesions or left-side myocardial dysfunction o Dilated pulmonary veins pulmonary interstitial edema (fuzzy vessels) o Arteries do not dilate and enlarge o Mimickers: HMD, 1O pulmonary lymphangiectasia, TAPVR (III), pulmonary vein atresia, hypoplastic left heart syndrome

Normal variants: 1. Prominent SVC Produces unilateral mediastinal widening, right No displacement of trachea (same with normal thymus) 2. Left atrial silhouette Different with enlarged double silhouette (seen further to the right, lower) 3. Ductus bump Limited to newborn as it disappears with age Only seen in neonatal period o If persistent, suspect ductus arteriosus aneurysm Represents dilated ductal infundibulum of the closing ductus 4. Calcified ligamentum arteriosum Located between aortic knob and pulmonary artery NORMAL ROENTGENOGRAPHIC ANATOMY View: frontal projection NORMAL ANGIOCARDIOGRAPHIC ANATOMY Views: frontal, lateral and both oblique Frontal all chambers RV midline and trabeculated LV left RA crescent shaped LA medial and oval Lateral RV and great vessels RV and PA anterior

2. Decreased pulmonary vascularity RL shunt: right outflow tract-obstructing lesions Cyanosis o TOF, hypoplastic right heart syndrome, severe PS with RL atrial shunt (trilogy of Fallot), Ebsteins anomaly Pulmonary oligemia (hyperlucent lung) Blood vessels are thin and stringy 3. Unequal pulmonary blood flow TOF left lung is diminished PTA diminished in either lung or 1 lobe PS towards LPA (then enlarges) increased flow to left lung (on nuclear scintigraphy) 4. Pulmonary hypertension with increased pulmonary blood flow LR shunt or intracardiac mixing lesion Eisenmengerization o Peripheral pulmonary arterioles constrict (transient PH) muscular hypertrophy permanent PH decreased peripheral pulmonary blood flow prominent (dilated) MPA and proximal R/LPA o Ddx: hilar lymphadenopathy SPECIFIC CHAMBER ENLARGEMENT 1. Increased pulmonary vascularity