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CardiacDDx (1)

CardiacDDx (1)

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Published by Reza Abidin

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Published by: Reza Abidin on Aug 13, 2012
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04/06/2015

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CONGENITAL HEART DISEASEEC
Cyanosis NoYesVascularity increasedVascularity normalVascularity increasedVascularity decreasedLA enlargement
Aortic stenosisTGA
Cardiac enlargement (RA)
Pulmonic stenosisTruncus
YesNo
CoarctationTAPV
YesNo
IAATric atresia + TGAASDTingle ventricleEbsteinFallotECDPulmonic atresiaTric atresia
Aorta enlargedYesNo
PDAVSDPulmonary blood flow indicators:
gestalt, hepatic window, interlobar artery diameter = supraaortic tracheal diameter, bronchovascular couplet, MPA size
Acyanotic CHD with increased pulmonary vascularity:
 
VSD
– most common CHD (25%), membranous type most common,large LA/RV, LV remains normal;
ASD
– ostium secundum type most common, large RA/RV/PA;
PDA
 – premature infants,maternal rubella, large LA/LV/aorta;
ECD
– ostium primum ASD, Down’s, gooseneck deformity on angio from LV outletobstruction;
PAPVR 
 – right SVC most common, IVC (scimitar syndrome)
Acyanotic CHD with normal pulmonary vascularity:
 
PS
– large RV/MPA/LPA;
AS
– bicuspid aortic valve (most commoncongenital cardiac anomaly), LVH, large aorta;
coarctation
– assoc with bicuspid aortic valve and Turners, figure 3 sign,inferior rib notching, reverse 3 sign on esophagram;
interrupted aortic arch
– neonatal pulmonary edema, no aortic knob,large PA, usu assoc with VSD and PDA
Cyanotic CHD with decreased pulmonary vascularity:
 
Tetralogy of Fallot
– most common cyanotic CHD of childhood, pulmonic stenosis/RVH/VSD/overriding aorta, boot-shaped heart, right aortic arch in 25%, small or concave PA;
Ebstein’sanomaly
– atrialization of superior RV, assoc with maternal Li, PFO or ASD nearly always present, TR, arrhythmias, largeRA, massively large box-shaped heart;
tricuspid atresia
– PFO or ASD always present, VSD common, complete TGA in 35%,no TGA has similar appearance as Fallot, large RA/LA/LV, small RV/PA; pulmonic atresia – ASD present, large LV/RA,small RV/PA
Cyanotic CHD with increased pulmonary vascularity:
 
TGA
– most common CHD presenting with cyanosis in 1
st
24 hoursof life, D-TGA or complete (aorta from RV, PA from LV, 2 independent circulations, incompatible with life unlessASD or VSD or PDA present, “egg-on-side” cardiac contour, narrow superior mediastinum, aorta and PA not seen,right heart enlargement, aorta is anterior and to R), L-TGA or corrected (large vessels and ventricles transposed, aortaand PA not seen, LAE, abnormal aortic arch contour);
truncus arteriosus
– single outflow vessel, high VSD in all patients, right aortic arch in 35%, large LV/RV/aorta (actually truncus);
TAPVR 
– pulmonary veins to systemic veins or RA, obligatory PFO or ASD, unobstructed (large RA/RV/PA, supracardiac or type 1 most common with snowman or figure of 8 heart that is dilated left vertical vein), obstructed or infracardiac type 3 (pulmonary edema, normal size heart,cyanotic edema in 1
st
week of life);
tricuspid atresia with TGA
;
single ventricle
– LV morphology and rudimentaryRV, malposition of great vessels usu present;
DORV
– great vessels from RV, VSD always present
Aortic anomalies:
 
coarctation
;
pseudocoarctation
– aortic kinking, figure 3 sign, no pressure gradient, no rib notching, assocwith bicuspid aortic valve;
IAA
;
left arch with aberrant RSA
– most common cong AA anomaly, usu retroesophageal;
rightarch with aberrant LSA
– retroesophageal, Diverticulum of Kommerell at origin;
double arch
– most common vascular ringand most symptomatic, right arch higher and larger than left, widened superior mediastinum, posterior indentation of esophagus on lat view, bilateral indentation on AP view
Other:
 
pulmonary sling
– aberrant LPA arises from RPA and goes between trachea and esophagus;
hypoplastic left heart
– small LA/LV/MV/AV/aorta, survival requires large ASD and PDA, neonatal CHF, prominent right heart esp RA;
persistentfetal circulation
– persistent severe pulmonary HTN in neonate with R to L shunting via patent PDA;
azygos continuation of IVC
– absent intrahepatic IVC, enlarged azygos/hemiazygos vein, associated with polysplenia;
situs
– abdominal situs solitusis liver on right and stomach on left, thoracic situs is epiarterial bronchus (above PA) normally on right;
cardiosplenicsyndromes
– always consider when cardiac apex and situs are discordant, aplenia (right isomerism=2 right lungs or 2 RA), polysplenia (left isomerism);
Down’s
– ECD, 11 rib pairs, hypersegmented manubrium;
Marfan
– AD, asc aortic aneurysm,
 
dissection, aortic regurg, MVP/MR, coarctation, arachnodactyly;
Turner
– coarctation, bicuspid aortic valve;
Noonan
– maleTurner, pulmonic stenosis, pectus excavatum;
Williams
– supravalvular AS, PA stenosis, infantile hypercalcemia
ACQUIRED HEART DISEASEApproach:
pressure overload (stenosis, HTN) causes hypertrophy, normal heart size; volume overload (regurgitation, shunt)causes dilatation, large heart size; wall abnormalities (aneurysm, infarct, cardiomyopathy)
Cardiomegaly:
valvular disease, cardiomyopathy, CHD, pericardial effusion, mass
Chamber enlargement: LAE
– esophagus displaced posteriorly, double density, LA appendage bulge, splaying of bronchi;
LVE
 – downward displacement of apex, round left cardiac border;
RAE
– increased convexity lower R heart border;
RVE
 – rounding and elevation of apex, obliteration of retrosternal air space
Valvular heart disease:
 
MS
– PVH, LAE, eventually RVH, calcified valve, causes (rheumatic fever, bacterial endocarditis, prolapse of LA myxoma);
MR 
– large LA/LV, calcified mitral annulus, causes (rheumatic fever, MVP, rupture of papillarymuscle, Marfan, endocarditis);
AS
– LVH, normal heart size, poststenotic aortic dilatation, calcified aortic valve, causes(degenerative, bicuspid, rheumatic, IHSS);
AR 
– large LV/aorta, causes (rheumatic fever, HTN, aortic dissection, endocarditis,Marfan, syphilus, trauma, AS)
Complications of AMI:
papillary muscle rupture, septal perforation, pericardial tamponade, aneurysm, LV thrombus,arrythmia
LV aneurysm:
 
true
– apical, anterolateral, transmural MI, low risk of rupture, mural thrombus, embolization, CHF,arrhythmias;
false
 – posterior, diaphragmatic, MI, trauma, high risk of rupture
Cardiomyopathies:
 
hypertrophic
- obstructed LV outflow segment, causes (familial 50%, sporadic);
dilated
– systolicdysfunction, causes (infectious, metabolic, alcohol, adriamycin, CVD);
restrictive
 – diastolic dysfunction, causes (amyloid,sarcoid, hemochromatosis)
Coronary arteries:
 
RCA
– 1
st
branch is conus artery, SA nodal artery 55%, AV nodal artery 90%, PDA supplies inferior LVwall; LCA – 
LAD
– longest vessel, only vessel that extends to apex, supplies septum, anterior wall and apex;
LCx
– supplieslateral wall; 85% patients with right sided dominance – RCA larger than LCA and gives rise to AV nodal artery and suppliesdiaphragmatic aspect of interventricular septum and LV
CAD:
risk factors – DM, HTN, chol, smoking, fam hx; worse prognosis with low EF and abnormal wall motion; calcifiedcoronary arteries, LV aneurysm; stenoses occur primarly in proximal portions LAD>RCA>LCX
Pericardium:
 
congenital absence
– partial more common that total, usu on L and asx, heart shifted and rotated into L pleuralcavity, total absence looks like large pericardial effusion;
pericardial cyst
– congenital malformation at cardiophrenic angles,90% unilocular, most asx;
pericardial effusion
– subpericardial fat stripe >1cm, symmetrical enlarged cardiac silhouette(water-bottle sign), tumor (mets), inflammatory (rheumatic heart disease, CVD, Dressler syndrome, drugs), infection (viral,TB, pyogenic), metabolic (uremia, myxedema), trauma (hemopericardium, postsurgical), vascular (AMI, aortic dissection, LVrupture);
constrictive pericarditis
– pericardial thickening and calcification, dilated SVC and azygos from increased RV pressure, TB (most common), viral, pyogenic, cardiac surgery, radiation
Other Cardiac DDx:Pulmonary edema in newborns:
hypoplastic LV (large heart), TAPVR below diaphragm (normal size heart), TTN,lymphangiectasia
Massive cardiomegaly in newborn:
Ebstein’s, tricuspid atresia, pericardial effusion
Boot-shaped heart:
Tetralogy of Fallot, loculated pleural effusion, LV aneurysm, pericardial cyst
Inferior rib notching:
coarctation, IAA, Blalock-Taussig shunt, Takayasu, SVC obstruction, AVM of intercostals, intercostalneuroma, HPT
Superior rib notching:
HPT (most common), CVD, OI, Marfan
Cardiac mass:
thrombus, infectious vegetation, met, atrial myxoma (L>R), rhabdomyoma in infants (TS), pericardial cyst,angiosarcoma
High cardiac output states:
severe anemia, peripheral AVM, thyrotoxicosis, pregnancy
Calcification:
pericardial – pericarditis, pericardial cyst; myocardial – coronary arteries, calcified infarct, aneurysm, postmyocarditis; intracardiac – calcified valves (stenosis), calcified thrombus, atrial myxoma; aorta – atherosclerosis, syphilis,aneurysm
L heart border bulge:
LA appendage, LV aneurysm, congenital absence of pericardium, pericardial cyst, pleural or  pericardial mets, L coronary artery aneurysm
Coronary artery aneurysm:
atherosclerosis, congenital, polyarteritis nodosa, Kawasaki (GB hydrops), mycotic, syphilus,trauma
Pneumopericardium:
iatrogenic, cardiac surgery, barotrauma, fistula from bronchogenic or esophageal CA
PA enlargement:
 
PAH
– systolic >30mmHg, primary (young female), secondary (chronic lung dz, chronic PE, mitralstenosis, LV failure, L to R shunts, vasculitis, drugs);
PA stenosis
 – Tetralogy, Takayasu, rubella, Williams syndrome;
PAdilatation
– poststenotic jet, Osler-Weber-Rendu;
aneurysm
– Takayasu, Behcets, vasculitis, trauma, infection

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