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Common Congenital Heart Lesions - page 98 / 126

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98 / 126

98 of 126

  • o

    Risk factors for sudden death = history of syncope, family history of sudden

death, high risk mutations and extreme hypertrophy of the LV wall

PHYSICAL EXAM

  • May be normal if asymptomatic

  • S4 Æ from left atrial contraction into the stiffened LV

  • Double apical impulse Æ palpable presystolic impulse over the cardiac apex from the forceful atrial contraction

  • For those with systolic outflow obstruction:

    • o

      Carotid pulse rises briskly in early systole, but then quickly declines as obstruction to cardiac outflow appears

      • o

        LV outflow obstructive murmur (cresc-decresc) Æ heard best at L lower sternal border

        • Heard best when using some maneavers to differentiate it from an aortic stenosis murmur:

Valsalva

Preload

Decr

Afterload

Decr

HCM murmur

Incr

AS murmur

Decr

Squatting

Standing

Incr

Decr

Incr

Decr

Decr

Incr

Incr (usually)

Decr

    • FYI: valsalva method is when pt “bears down” like if they were pooping… causes HCM murmur to increase in intensity…

  • o

    Mitral regurg murmur (holosystolic) Æ heard best at apex

TESTS and IMAGING

  • ECG

    • o

      LV hypertrophy an LA enlargement

      • o

        Prominent Q waves common in inferior and lateral leads b/c of depolarization thru hypertrophied septum

      • o

        Diffuse T waves inversions Æ can predate clinical, echo, or other manifestations of HCM

      • o

        Atrial and ventricular arrhythmias common

  • Echocardiography Æ most helpful

      • o

        Degree of LV hypertrophy can be measured

      • o

        Identify regions of asymmetric wall thickness

      • o

        Signs of ventricular outflow obstruction and imaging of the mitral valve

      • o

        Doppler recordings during echo Æ quantify regurg

      • o

        Used as serial assessment in children with mild HCM to monitor

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