Embryogenesis of cardiovascular system.

Physiological and anatomical

peculiarities of the heart and blood
vessels in children. Inspection, palpation,
and percussion of cardiovascular system.

Pediatrics Department # 2
MD, PhD Kovalchuk T.A.
 Embryogenesis of CVS

✓ Division of the heart into right and left halves

starts at the end of the third week of gestation
period.
✓ Interventricular septum appears at the end of the
fourth week.
✓ Interventricular aperture appears first in its upper
part and grows quickly into a membrane.
 Embryogenesis of CVS

• During the sixth week of gestation period the fetus has

a three chambered heart (atria are connected).
• Then between right and left atria near the primary
septum, the secondary septum is formed. Both of them
has foramen ovale.
• The secondary septum blocks primary foramen ovale
in the form of a valve of foramen ovale so that due to
higher blood pressure in the right atrium the
movement of blood is possible only from the right
atrium to the left one.
 Embryogenesis of CVS

• Valvular system is formed after

the formation of septums.
• Structural formation of the
heart (becoming four
chambered) and large vessel
sare completed during the
seventh and eighth weeks of
gestation period.
Embryogenesis of CVS
 Embryogenesis of CVS

Intrauterine abnormalities of cardiovascular

system arise starting from the 3rd till the 8th
week of fetus development.
Embryogenesis of CVS
Embryogenesis of CVS
 Blood circulation in fetus

During first weeks of embryogenesis the basic elements of

the conducting system are formed in heart muscles:
• Sinoatrial node of Keith-Flack (English anatomist of the 19th-20th
and English physiologist of the 20th sentury),
• Atrioventricular node of Aschoff and Tawara (German
pathologist of the 19th-20th centuries and Japanese pathologist of the 20th
century),
• His’ bundle (German anatomist of the 19th-20th centuries),
• Purkinje’s fibers (Czech physiologist of the 19th century).
Conducting system
 Placental blood circulation of the fetus,
whose all organs
receive only
mixed blood,
begins at the end
of the third week
of gestation
period
Blood flow circulation is
as follows:

(A) Well oxygenated

arterial blood saturated
with nutrients flows from
capillary network of
placenta into the umbilical
vein, which is in the
process of development
and which is constituent
of umbilical cord.
Blood flow circulation is
as follows:

(B) Wide venous Aranzi’s

duct separates from
umbilical vein below the
liver. It carries most of the
arterial blood into the
inferior vena cava where it
is mixed with venous
blood.
Blood flow circulation is
as follows:

(C) Umbilical vein

incorporates with
underdeveloped portal
vein that carries venous
blood, leading to a
mixture of blood.

The first organ of fetus –

liver – gets mixed blood.
Blood flow circulation is
as follows:

(D) Trough the recurrent

hepatic veins blood from
the liver flows into inferior
vena cava, that is one
more mixing of blood.
Blood flow circulation is
as follows:
(E) Mixed but more arterial blood
from inferior vena cava and
venous blood from the superior
vena cava enters the right atrium.
Due to the structure of atrium a
very minor degree of blood
mixing takes place in it in such a
way that more arterial mixed
blood from inferior vena cava
passed trough the foramen ovale
into left atrium and more venous
blood from superior vena cava
flows into the right ventricle.
Blood flow circulation is
as follows:
(F) Pulmonary artery
starts from right ventricle.
It is divided into: larger
arterial duct = Botallo’s
duct, which runs into
aorta (mixing of blood),
and two vessels of less
diameter through which
about 10 % 0f cardiac
output blood is directed
into lungs, which are not
functional yet.
Blood flow circulation is
as follows:

(G) Small amount of

venous blood from
pulmonary tissues flows
through the pulmonary
veins to the left atrium,
where there is one more
mixing (with well
oxygenated blood from
right atrium).
 Blood flow circulation is as follows

(H) Mixed (but well oxygenated and rich in nutrients)

blood from left atrium passes through left ventricle and
flows into aorta. Before its confluence with aorta of
Botallo’s duct, this blood supplies the brain, neck and
upper limbs of fetus. It flows through carotid and the
subclavicular arteries.

Blood gets to the lower part of body through aorta only

after passing through subclavicular artery and after its
joining with Botallo’s duct, which conteins more venous
blood.
Blood flow circulation is
as follows

Blood getting
into greater
circulation
occurs through
two shunts –
the foramen
ovale and
Botallo’s duct.
Blood flow circulation is
as follows:

(I) Part of this blood, that

is more venous in
composition, returns to
the capillary network of
placenta from descending
aorta through two
umbilicar arteries;
another part of this blood
supplies the lower part of
body with necessary
substances.
 Blood circulation in fetus

• It is performed by contractility of its

heart and is separated from the
mother’s circulatory system.
• The heart rate of embryo is 15-35 per
minute, and later increases up to 125-
130 per minute.
• During auscultation S1 and S2 are
identical in loudness.
• Intervals between S1 and S2 are equal
to intervals between S2 and S1.
 Blood circulation in newborn
Immediately after
delivery the
greater and lesser
circulations begin
functioning as a
result of the
following quick
changes
Blood circulation in newborn

(A) Pulmonary
respiration starts
functioning. This
considerably reduces
resistance of blood
circulation through the
capillaries of lungs and
increases blood
circulation through
lungs five times.
Blood circulation in newborn
(B) The start of complete
pulmonary circulation
results in substantial
increase of pressure in
the left atrium, which
influences septum and
presses it to the edge of
foramen ovale and
terminates the shunt of
blood from the right
atrium to the left one.
 Blood circulation in newborn
(C) After the first inspiration of a
newborn baby develops a spasm of
Botallo’s duct, which stops the
movement of blood through it.

❖The functional closing of the duct

lasts for 10-15 hours of the first
day of infant’s life.

❖The anatomic closing of the duct

in mature baby takes place by the
end of the third month and in
premature baby – by the end of
first year of life.
 Blood circulation in newborn
(D) Six basic structures of intrauterine blood
circulation stop functioning:
•Umbilical vein;
•Venouz Aranzi’s duct;
•Two umbilical arteries;
•Foramen ovale;
•Botallo’s duct.
 Anatomic features

• The heart of a newborn baby is relatively large compared

to an adult – 0,8% and 0,4% of body weight.
By the age of fifteen-sixteen the weight of the heart
increases by ten times.
 Anatomic features
• Right and left ventricles of a newborn baby are
more or less identical after that an intensive
growth of the left heart is observed.
At the age of 16 years the mass of the left ventricle
is almost three times heavier than the right one.
 Anatomic features

• A newborn’s heart occupies a relatively large part of

thorax.

Its projection in relation to the vertebral column

corresponds to the IV-VIII thoracic vertebrae.
 Anatomic features

• Atria and large vessels of a newborn baby are relatively

larger than the ventricles if compared to adults.

• Differentiation of the heart parts is completed by the age

of ten-fourteen years. At this age it resembles the
parameters of adult heart.
 Anatomic features

• Due to the higher position of the diaphragm, a newborn

baby’s heart is located at a higher position. Thus the
heart’s axis is almost horizontal. By the end of the first
year of life it acquires a slanting position.

• A newborn’s heart is spherical in form (the transverse

heart distance can be larger than the longitudinal size).
The heart gradually acquires a pear-shaped form.
Anatomic features
 Peculiarities of vessels
• In newborn babies the
pulmonary artery is 21 mm
and aorta is 16 mm in
diameter.
• At the age of 12 years the
vessels are approximately
equal in diameter (72-74
mm).
• Diameter of pulmonary
artery in adults is less than
the diameter of aorta (74
and 80 mm respectively).
 Functional features
• Stroke volume (SV) is the quantity blood
which is ejected during each contraction of the
heart. It characterizes force and efficiency of
heart contractions.

• Minute volume or cardiac output (CO) is

the quantity of blood which is ejected out of the
left ventricle into aorta per minute
Functional features
 Functional features

• In newborn babies stroke volume is 2.5-3.5

ml. By the end of breast feeding age it increases
up to 10 ml. By the age of sixteen it is 60 ml.

• The cardiac output increases from 340 ml to

1250ml and up to 4300 ml respectively.
 Gathering complaints
Pain on the area of heart.
• Character of pain – sharp, blunt, burning, stabbing.
• Time when it appears – at night, in the afternoon,
constant, after neuro-psychological stress or physical
exercises or in a state of rest.
• Connection of pain with position of the patient – in
position on the left or right side, change in pain while
getting up.
• Irradiation of the pain – especially to the left hand.
• Probable change after taking medicines.
 Gathering complaints
Cardiac dyspnea which leads to
take deep inspiration, stops during
climbing, sometimes with groaning.

Perceptible heartbeats (=
palpitations) in a state of rest or
during physical exertion.
 Gathering complaints
Pallor, cyanosis of skin. It is necessary to clarify
conditions at which they occur and their character.
 Gathering complaints
Pain in the area of large and small joints.
 Gathering complaints
Edema of the lower limbs and other parts of the body.
 Gathering complaints
Sharp headache, dizziness, nausea, vomiting during the
increase of blood pressure.

Complaints of general character: rise in temperature,

fatigue, weakness, headache, loss of memory, loss of
apetite, loss of body weight.
 Complains
When infants and toddlers are ill, gathered complaints are not
informative.
Attentive parents can specify certain disorders such as:
• Sudden shout, anxiety of child, which alternates with long periods
of flaccidity, flabbiness and pallor.
• Improper sucking:
✓ A child starts sucking breast, but after short time baby stops.
✓ Signs of weariness and dyspnea.
✓ After resting for a while, the child starts sucking again, but for a
short time.
• Anoxic blue spell – sudden pallor, shortness of breath and cry are
replaced by cyanosis, loss of consciousness, apnea and spasms.
• Mild sweating, sometimes with rise in body temperature.
• Cyanosis and pallor skin.
 The anamnesis of disease
• To ask the parents in details about the dynamics of
disease from the moment it started.
• To establish precisely, when and where the child was
treated, what medicines were given, their efficacy and
duration of treatment.
• To consider carefully the results of the tests done (ECG,
ultrasound cardiography, etc.)
 The anamnesis of life
Detailed anamnesis is necessary for finding out
genesis of cardiovascular disease

Congenital Acquired

CHD Rheumatic fever

 The anamnesis of life
• Obstetric anamnesis – toxicosis of pregnancy, nephropathy,
toxoplasmosis, infectious diseases of mother, professional
exposure to harmful conditions – all this can cause CHD.
• Rheumatic fever: presence of chronic infection or frequent
acute diseases in the upper respiratory tract; family
anamnesis, as susceptibility to rheumatic fever is transmitted
hereditarily; if rheumatic fever is repeated, to ask in details
about its time, course and previous treatment.
• Cardiovascular disorders of functional character can be
connected to the pathology of nervous system, especially
during puberty. In this case cardiac and vascular disorders
may be of non-rheumatic origin.
 Physical examination
✓Consciousness.
✓Dyspnea.
✓Facial expression:
o Widely opened eyes of a child fear, and suffering are
signs of severe cardiac pain.
o If patient’s face expresses apathy, it indicates dyspnea.
 Position in bed
(A) In diseases with isufficient
blood circulation, the patient
acquires a compelled
position that makes patients
condition better – half sitting
or sitting, lowering legs,
leaning with patients back to
pillows (ortopneic posture).
Such position directs flow of
blood to the love limbs,
reduces blood stagnation in
lesser circulation and improves
excursion of diaphragm.
 Position in bed
(B) In exudative pericarditis
the patient lies down or sits in
compelled knee-elbow
position that reduce cardiac
pain.
 Position in bed

(C) When a child suffers from

dyspneic cyanotic paroxysms
(pentalogy of Fallot) another
compelled position is observed
with a knee-chest position
(knee are pressed to the chest).
 Position in bed
(D) At vascular insufficiency
(collapse) the acquired position
is passive – patient just lies
down.
 Physical and neuro-psychological
development of a child
• Slow rate of development is often seen in children of
younger age; the greater the deficiency in gaining weight
and growth is, the older the disease.
 Physical and neuro-psychological
development of a child
• One of the pathognomonic features of coarctation of
aorta is the disproportion of trunk, when the child of
school age has a wide neck and large upper limbs, but
underdeveloped pelvis and lower limbs
 Skin color

Pallor:
collapse, heart diseases with arterio-venous shunt.
 Skin color
Cyanosis -
the syndrome is caused by hypoxemia.

Respiratory Circulatory
origin origin
 Cyanosis can be:
General

Local
Different kinds of rashes on skin are symptoms of
rheumatic fever
 “Clubbing” and “watch glasses”
are symptoms of chronic cirulatory isufficiency
 Cardiac edema
• First appears on the feet.
• In young children and seriously ill patients if
they lie in a horizontal position then edema can
also appear in the lumbar and sacral areas.
• Boys may have scrotal edema.
• If a patient’s condition gets worse edema is also
observed on shins, hips, puffiness of face occurs,
ascites and hydrothorax develop.
• Anasarca – general edema of whole body.
Cardiac edema
 Cardiac edema
• Accompanied by cyanosis of skin.
• Increases after physical work.
• Seen at the end of the day and decreases after sleep.
• Edema is dense – hollow formed, by pressing restores its
form slowly.
• Skin often cold.
• If the body position changes shift of edema is unlikely to
occur.
• If the condition gets worse edema spreads upward.
• First they appear on feet and then they spread to the legs
and trunk.
Cardiac edema
Renal edema
• Develops on the base of paleness.
• First appears around the eyes.
• Occurs in the morning.
• During day decreases or disappears.
• It’s not dense – easily pits on pressure.
• Skin is often warm.
• Location of edema changes if the body position changes.
• If condition gets worse renal edema spreads downward.
• First they appear around the eyes and then they spread
to lower parts of the trunk.
Renal edema
 Apex beat
• Is the thrust of heart apex against a small area of thoracic
wall during each systole.
• Apex beat can be visually determined in the form of weak
pulsation in almost all the children.
• Under condition of hypotrophy and emaciation, after
physical exercises or during emotional activation the beat
may exist as a strong pulsation
 Criteria of apex beat
• Location of apical thrust according to the horizontal line:
✓up to 1.5 years it lies in the IV intercostal space;
✓above 1.5 years in the V intercostal space.

• Location of apical thrust according to the vertical line:

✓up to 2 years – 1-2 cm lateral to the left medioclavicular
line;
✓ 2-7 years – 1 cm lateral to it;
✓7-12 years – on left medioclavicular line;
✓above 12 years – 0.5 cm to the middle from the left
medioclavicular line.
 Criteria of apex beat
• Extension (= area) of apex beat is not
more than 1x1 cm, and in older children
not more than 2x2 cm.

• Magnitude (= height) – normally

moderate height.

• Resistance (= force) – normally

moderate force.
 Disorders of apex beat
Location:
Displasement to the left – left ventricle hypertrophy,
hypertension, right pneumothorax, right hemothorax,
exudative pleurisy.
Displacement to the right - right ventricle hypertrophy,
left pneumothorax, left hemothorax, exudative pleurisy,
dextrocardia.
Displacement downwards – dilatation of left ventricle,
insufficiency of aortal valves and pulmonary emphysema.
Displasement upwards – atelectasis of lungs,
meteorism and ascites.
 Disorders of apex beat
Extension:
Expansion – left ventricular hypertrophy.
Limited – exudative pericarditis, pulmonary emphysema, descended
diaphragm.

Height:
High – hypertrophy of left ventricle, deep exhalation, weight loss,
elevated diaphragm, tumor in posterior mediastinum.
Low – deep inspiration, adiposity, pericarditis, left side exudative
pleurisy with pulmonary emphysema.
Negative – adhesive pericarditis.

Resistance:
Resistant - left ventricular hypertrophy.
Weak - left side exudative pleurisy with pulmonary emphysema.
 Apex beat
Change of borders

Cardiac diseases Respiratory diseases

Gastrointastional diseases
 Cardiac thrust
Is fluctuating movements of large area of the thorax in the
projection of the heart or beyond its limit which occurs
when walls of ventricles push thorax wall during each
systole.

➢CHD
➢Mediastinal tumor
➢Emphysema of lungs
 Cardiac hump
Is bulging of thorax in the form of deformation on the area
of heart that is determined visually.

Symptom of prolonged cardiac defect.

 Pulsation of peripheral vessels
• “Carotid shudder” or “dancing carotid” is pulsation of
carotid arteries visually observed in front of the
sternocleidomastoid muscle – insufficiency of aortal
valve and aneurysm of aorta.

• Bulging and pulsation of cervical veins which coincide

with pulsation of carotid arteries are called positive
venous pulse – tricuspid insufficiency.

• Pulsation of epigastrium – right ventricle

hypertrophy (at the end of inspiration), pathology of
aorta (during expiration).
 Palpation
• Pulse rate is determined by palpating
peripheral big vessels.

• Heart rate is established by palpation apex

beat or during auscultation of the heart.

1 pulse = 1 heart beat = 1 apex beat =

2 heart sounds
Rules for determination
of pulse rate

• The most accurate data can be obtained in the morning

right after sleep, on an empty stomach.
• A child should be calm, as excitation and physical
exercises may result in increase of heart rate.
• A child sits or lies down.
• At first, the pulse is palpated on both hands by the second
and third fingers on radial artery in the area of radiocarpal
joint.
• Pulse can be read during 15 or 20 seconds, and than the
figure obtained should be multiplied by 4 or 3
respectively.
 Places of pulse determination

• A. radialis
• A. temporalis
• A. carotis
• A. ulnaris
• A. femoralis
• A. poplitea
• A. tibialis posterior
• A. dorsalis pedis
 As the child grows
pulse rate per minute decreases

Newborn 120-140 (up to 160)

1 year 120
5 years 100
10 years 85
12 years 80
15 years 70-75
 Pulse characteristics

• Pulse rhythm – rhythmic, irregular.

Children 2-11 years old – respiratory arrhythmia.
• Tension of pulse – pulse of normal pressure, hard pulse,
soft pulse.
• Filling of pulse – satisfactory filling, full filling, low filling.
• Size of pulse – normal size, high, weak.
 Disorders of pulse rate
Tachycardia - increase in frequency by 10 % and more.

➢Intoxication bacterial and viral etiology

➢Circulatory insufficiency
➢Vegetovascular dystonia
➢Hyperthyroidism
➢Anemia
➢Paroxysmal tachycardia (above 180 per minute)
 Disorders of pulse rate

Bradycardia - decrease in frequency by 10 % and more.

➢Myocarditis
➢Malnutrition
➢Hypotension
➢Recovering after scarlet fever
 Disorders of pulse rate

• Asymmetric pulse – mitral stenosis, compressing the

arteries by tumor or lymph nodes.
• Hard pulse and soft pulse – high and low blood pressure.
• Small pulse – stenosis of the mitral and aortal valves,
cardiovascular insufficiency.
• Alternating pulse – high and low pulsations during
damage of myocardium.
• Paradoxical pulse – weakening of pulse waves during
inspiration – pericarditis, pleuritis, mediastinal tumors,
bronchial asthma.
 Blood pressure
Types of sphygmomanometer

Mercury Aneroid Electronic

Rules of the measuring blood pressure
• Preparation: give up physical activity for one hour.
• In sitting or lying position.
• The device is placed on the table or bad in such a way that the heart of a child,
arm, zero point of scale and the cuff are on the same horizontal level.
• Air should be completely removed from the cuff, which is tied around the arm
2 cm above the cubital fossa so that it would be possible to put 1-2 fingers
under it.
• Hand of the child is placed on the table with its palm upwards, muscles
relaxed.
• Localization of brachial artery in the cubital fossa is determined by palpation.
• The bell of the stethoscope is placed on the place where brachial artery is
located and air is pumped into the cuff till it reaches 40-50 mmHg above the
level where pulsation of artery stops.
• After that the pressure in the cuff is slowly reduced, - the moment of
occurrence and termination of loud and strong tones are registered on a
mercury column by auscultation.
 Normal range
of blood pressure
• Newborns: 70/35 mmHg on the upper
and lower extremities.
• 12 months: 90/60 mmHg on the upper extremities.
• 1-15 years:
systolic blood pressure = 90 + 2n
diastolic blood pressure = 60 + n, n – age of child in
years.
In children below 9 months blood pressure becomes
higher than blood pressure on the upper extremities –
by 5-20 mmHg.
 Percussion
This is a method for determination of
heart borders and size.

Limits of this zone are called borders of

absolute heart dullness.
Limits of heart zone covered with lungs
are named borders of relative heart
dullness.
 Borders of relative heart dullness
Border Up to 2 years 2-7 years 7-12 years Above 12
years
Right Right Inwards from Middle between Right sternal
parasternal line right right lines
parasternal line parasternal and
right sternal
lines
Upper II rib II intercostal III rib III rib or III
space intercostal
interval
Left 2 cm outwards 1 cm outwards 0.5 cm outwards Left
from left from left from left medioclavicul
medioclavicular medioclavicular medioclavicular ar line or o.5
line line line cm inwards
Transversal 6-9 cm 8-12 cm 9-14 cm
distance
 Borders of absolute heart dullness
Border Up to 2 years 2-7 years 7-12 years Above 12
years
Right Left sternal line
Upper II intercostal III rib III intercostal IV rib
space space
Left Closer to the On the left Closer to the left Left
left medioclavicular parasternal line parasternal
medioclavicular line line
line
Transversal 2-3 cm 4 cm 5-5,5 cm
distance
 Symptomatological percussional
disorders
Reasons of expansion of borders of relative heart dullness:

➢Congenital and acquired heart diseases

➢Myocarditis
➢Fibroelastosis
 Symptomatological percussional
disorders
Reasons of reduction of borders of the relative heart
dullness:

➢Emphysema of lungs
➢Left pneumothorax
➢Asthenic constitution of body
Thank you for attention!