Coarctati

on of
Aorta
Femoral
pulse
absent
Preductal
Ductal
Postductal
= notch
rib/collate
ral
circulation
Intermitte
nt
claudicati
on
Left to
subclavia
n artery

Before
sub
Radioradi
al delay
(left
weak,
right
normal
Poststeno
tic
dilatation
of aortic
arch
Figure 3
sign
Poststeno
tic
dilatation
of
descendi
ng aorta
Reverse
3/ E sign

ASD
Secundum
Primum
(pAVSD+TR)
Symptoms
None
Recurrent
chest
infection/whe
eze
Arrhythmias
Sign
Systolic
murmur
upper LSB
Fixed wide
split S2
(RSV=resp)
pAVSD =
apical
pansystolic
AVR

Investigati
on
CXR
Cardiomeg
aly
Pulmonary
vascular
marking
Enlarged
pulmonary
arteries
Secundum
= pRBB
pAVSD =
negative
AVF

VSD
Peri
Membra
ne
Muscular

Lesion

Left to right shunts

Right to
left
shunts

Common
mixing

Outflow
obstruction
In well child

Symptom
s
Example
s

Breathless/asympto
matics
VSD
PDA
ASD

Blue

Breathless
and blue
AVSD

Asymptoma
tic
AS
PS
Adult CoA

Maternal disorders
Rubella (PS, PDA)
SLE (Complete heart
block)
Dm (increased risk)

TOF
TGA

Maternal drugs
Warfarin (PS, PDA)
Fetal alcohol syndrome (ASD,
VSD, TOF)

Innocent murmur
Asymp, soft systolic murmur
Left sternal edge, no radiation, no
parasternal thrill, normal heart
sounds
Heart failure
Symptoms
Breathless
Sweating
Poor feed
Recurrent chest infection
Signs
Poor weight gain
Tachypnea
Tachycardia
Murmur, gallop rhythm
Enlarged heart
Hepatomegaly
Cool peripheries
Right heart failure
Ankle edema

Sick
neonate
with
obstructio
n
Collapse
with shock
CoA
HLHS

Gene
Down 21 (ASD, VSD)
Edward 18
Patau 13
Turner 45XO (AS) CoA
DiGeorge 22q112DS
(TOF)
Williams (7q11.23) (PS)
Noonan (PTPN11) (ASD,
PS)

Neonates
Obstructed systemic
Hypoplastic left
heart syndrome
Critical AS
CoA
Interrupted aortic
arch
Infant
(high pulmonary flow)
VSD
AVSD
Large PDA
Children
Eisenmenger
syndrome
Rheumatic heart
disease
Cardiomyopathies
Progression
PVR decrease

Cyanosis (Hb < 5

g/dl)
Peripheral (hand,feet)
cold/polycythemia
Central (tongue)
Normal O2 saturation
> 94% Distress (RR >
60)
Cause of cyanosis
Cardiac = cyanotic
heart disease
Respiratory disorder =
surfactant deficiency,
meconium aspiration,
pulmonary hypoplasia
PPHN = fall of
pulmonary vascular
resistance
Infection =
septicaemia of group B
strep

 Sacral edema
Ascites
Causes
Rheumatic fever
Pulmonary hypertension
Tricuspid regurgitation
Right atrial dilatation
ECG
Arrythmias
Superior QRS axis (negative in
AVF)
Right ventricular hypertrophy
(upright T wave in V1, over 1
month of age )
Left ventricular strain
(inverted T wave in V6)
Partial RBBB common in ASD
Sinus arrhythmias are normal.
Coarctation of Aorta
Femoral pulse absent
Preductal
Ductal
Postductal = notch rib/collateral
circulation
Intermittent claudication
Left to subclavian artery
Before sub
Radioradial delay (left weak, right
normal
Poststenotic dilatation of aortic
arch
Figure 3 sign
Poststenotic dilatationof
descending aorta
Reverse 3/ E sign

Left to right shunt

Increase pulmonary
flow
Pulmonary oedema
Breathlessness
Eisenmenger
syndrome
Blue
Prostaglandin
infusion=open ductus
arteriosus
ASD
Secundum
Primum (pAVSD+TR)
Symptoms
None
Recurrent chest
infection/wheeze
Arrhythmias
Sign
Ejection systolic
murmur upper LSE
Fixed wide split S2
(RVSV=resp)
pAVSD = apical
pansystolic AVR
Investigation
CXR Cardiomegaly
Pulmonary vascular
marking
Enlarged
pulmonary arteries
Echocardiogram
ECG
Secundum ASD=
pRBBB, right axis
deviation due right
ventricular
enlargement
pAVSD = A superior
(negative AVF) due to
defect in middle part

Metabolic
acidosis/shock
Heart failure case
Wheeze poor feed
poor weight
tachypnea, sternal
costal recession
pansystolic murmur
thrill enlarged liver at
two fingerbreadth
Congenital heart
disease
Antenatal US, detect
murmur, heart failure
cyanosis, shock
Symptoms
Heart failure with
dyspnoea and FTT
after 1 week old
Recurrent chest
infections
Signs
Tachypnoea,
tachycardia, and
enlarged liver from HF
Active precordium
Soft pansystolic
murmur or no murmur
Apical mid-diastolic
murmur
Loud P2 sound (raised
pulmonary arterial
pressure)
Investigation
CXR
Cardiomegaly
Hepatomegaly
Enlarged pulmonary
arteries
Increased pulmonary
vascular markings
Pulmonary oedema
ECG
Biventricular

Treatment
Cardiac catheterisation
with occlusion device
VSD
Perimembranous
Muscular
Small VSD (3mm)
Asymptomatic
Physical sign
Loud pansystolic
murmur at upper lower
LSE
Quite P2 sound
ECG, CXR = normal
Take care of dental
hygiene
Large VSD (larger than
aortic valve)

hypertrophy
Upright/Inverted T
wave= yes/no
pulmonary
hypertension
In 2 month age
Management
HF= Diuretic +
captopril
Surgery at 3 5
months
PDA
Symptoms
Continuous murmur
beneath clavicle
Bounding/collapsing
pulse
Treatment
Cardiac catheterisation

Acyanotic (Right to left

shunts)
TOF
TGA
Hyperoxia (nitrogen
washout)
Infant placed in 100% for
10 min.
If right radial arterial PaO2
from blood gas low
(<15kPa, 113 mmHg),
cyanotic is diagnosed.
Management
Stabilise ABC with artificial
ventilator
Start prostaglandin
infusion (5ng/kg/min)
TOF
Symptoms
Large VSD
Overriding aorta
Pulmonary stenosis
(RVOTO)
Right ventricular
hypertrophy
Tet spells
Squat to relieve
Irritability/inconsolable
crying due to hypoxia,
pallor, tissue acidosis
Sign
Clubbing
Loud harsh ejection
systolic murmur at LSE
Investigation
Small heart
Uptilted apex (boot
shaped) due to right
ventricular hypertrophy
Right sided aortic arch
Pulmonary artery bay
(concave left heart border)
Reduce pulmonary
vascular marking

TGA
Symptoms
Cyanosis after 2 days of
life
Second heart sound loud
single
Usually no murmur, but
systolic murmur may
present (LVOTO)
Investigation
Narrow upper
mediastinum with egg on
side appearance of
cardiac shadow (due to
anteroposterior
relationship of great
vessels, narrow vascular
pedicle and hypertrophied
right ventricle)
Increased pulmonary
marking
Management
Give prostaglandin
infusion
Balloon atrial septostomy
Eisenmenger syndrome
High pulmonary blood flow
Left to right shunt
Pulmonary arteries
becomes thick walled and
resistance increases
Shunt reverses
Blue
Common mixing (blue and
breathlessness)
cAVSD (defect in middle
with single five leaflets
valve)
Down syndrome
Symptoms
Pulmonary hypertension
Cyanosis birth
No murmur
Always superior axis on

Fontan operation connect IVS to pulmonary

artery in 3 to 5 years.
Outflow obstruction in well
child
Aortic stenosis
Leaflets fused together
Symptoms
Asymptomatic murmur
Reduce exercise tolerance
Chest pain on exertion
Syncope
Physical sign
Small volume, slow rising
pulse
Carotid thrill
Ejection systolic murmur
maximal at upper RSE
radiate to neck
Delayed and soft A2 sound
Apical ejection click
Investigation
CXR= Normal/prominent
left ventricle with post
stenotic dilatation of
ascending aorta
ECG= left ventricular
hypertrophy = Deep S
wave in V2 and tall R
wave in V6 (>45 mm
total) l
Downgoing T wave
suggest eft ventricular
strain and severe AS.
Management
Balloon valvotomy on
child with high resting
pressure (>64 mmHg)
Pulmonary stenosis
Leaflets fused partially
Symptoms
Asymptomatic
Physical sign
Ejection systolic

(oligaemic lung field)

ECG
Upright T wave in V1 with
pure R wave (no S wave)
Treatment
Blalock Taussigg shunts
(shunt from subclavian
artery to pulmonary
artery.
Balloning of RVOT
Bicarbonate (acidosis)
IV propranolol + morphine

ECG
Complex CHD (tricuspid
atresia)
Right ventricle small/non
functional
Common mixing in left
atrium
Management
Blalock Taussig shunt
Pulmonary artery banding
Palliation (Glenn or hemi
Fontan operation connect
SVC with pulmonary
artery) in 6 months

Adult CoA
Symptoms
Asymptomatic
Systemic hypertension in
right arm
Ejection systolic murmur
at upper sternal edge
Collaterals heard with
continuous murmur at the
back
Radiofemoral delay
Investigation
CXR= rib notching due to
development of collateral
intercostals arteries under
ribs
3 sign= notch in
descending aorta
ECG= deep S wave in V2
and tall r wave in V6 (45
mm total) LVH
Downgoing T wave
suggest left ventricular
strain and severe CoA
Management
Cardiac
cathetherisation/stent
Obstruction in sick infant

Cardiac arrhythmias
Sinus arrhythmias
Acceleration during
inspiration/slow on
expiration (30 beats/min)
Supraventricular
tachycardia

murmur/click in upper
LSE, may thrill
In severe, prominent right
ventricular impulse
(heave)
Investigation
CXR= normal/poststenotic dilatation of
pulmonary artery
Upright T wave in V1 RVH
Management
Trans-catheter balloon
dilatation

CoA
Physical sign
Sick baby with heart
failure
Absent femoral pulse
Severe metabolic acidosis
Investigation
CXR= cardiomegaly
ECG= normal
Management
Maintain ABC and PGE
Interruption of aortic arch
DiGeorge syndrome
Symptoms
VSD
Shock
Absent femoral pulse and
absent brachial pulse
Hypoplastic left heart
syndrome
Small atretic mitral valve
Diminutive left ventricle
Aortic valve atresia
Symptoms
Weak/absence peripheral
pulse
Norwood + Glenn
/HemiFontan