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Common Congenital Heart Lesions - page 77 / 126

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77 / 126

77 of 126

      • o

        Hypotension

      • o

        Reflex tachy

  • Elevated systemic venous pressures

    • o

      JVD

      • o

        Hepatomegaly and ascites

      • o

        Peripheral edema

  • When pts come in w/ hepatomegaly and ascites you may think it’s hepatic cirrhosis or intra-abdominal tumor… carefully inspect jugular veins to rule out this cardiac problem

PHYSICAL EXAM

  • early diastolic “knock” following S2 Æ the ventricle suddenly stops filling when it hits the rigid pericardium

  • no pulsus paradoxus Æ this is b/c the neg intrathoracic pressure from inspiration is not transmitted thru rigid pericardial shell to right heart… thus, the blood is pulled up but can’t enter right heart so increased venous return accumulates in the intrathoracic veins Æ jugular veins become more distended during inspiration (Kussmaul’s sign)… opposite of normal physiology

TESTS and IMAGING

  • Chest x-ray Æ normal or mildly enlarged cardiac silhouette

  • ECG Æ nonspecific ST and T wave abnormalities; atrial arrhythmias are common

  • Echocardiography Æ subtle findings…

  • Computed tomography or MRI Æ superior to echo in assessment of pericardial anatomy and thickness… good for ruling out constrictive pericarditis

  • Cardiac catherization Æ confirms diagnosis… will show 3 key features:

    • o

      elevation and equalization of diastolic pressures in each of the cardiac chambers

      • o

        the RA tracing will show a prominent y descent (see prev. fig)

        • after the tricuspid opens, the RV quickly fills before it hits the pericardial restriction and stops filling… diff than in tamponade which causes an external compression throughout the cardiac cycle and so it prevents rapid filling of the ventricles and thus blunts the y descent… (think of the water balloon vs. hard container analogy if it helps)

      • o

        R and L ventricular tracings show early “dip and plateau” configuration Æ the early diastolic ventricular filling stops abruptly as the volume in each ventricle reaches the limit imposed by the constricting pericardium… (see on next page)

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