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Most popular medical Questions
What occurs during a "Tet spell"?"Tet spells" are cyanotic and hypoxic episodes that occur in patients with tetralogy of Fallot. The pathophysiology is felt to be related to a change in the balance of systemic to pulmonary vascular resistance. Spells may be initiated by events that cause a decrease in systemic vascular resistance (e.g., fever, crying, hypotension) or by events that cause an increase in pulmonary outflow tract obstruction. Both types of events cause more right-to-left shunting and increased cyanosis. Hypoxia and cyanosis lead to metabolic acidosis and systemic vasodilatation, which cause a further increase in cyanosis. Anemia may be a predisposing factor. Although most episodes are self-limited, a prolonged Tet spell can lead to stroke or death; therefore, such a spell is an indication that surgery may be necessary.
After what age does a presumed peripheral pulmonic branch stenosis murmur deserve more detailed study?
The murmur of peripheral pulmonic branch stenosis-a low-intensity systolic ejection murmur heard frequently in newborns-is the result of the relative hypoplasia of the pulmonary arteries as well as the acute angle of the branching of pulmonary arteries in the early newborn period. This murmur usually persists until 3-6 months of age.
When should afterload reduction be used in children?
In settings of low cardiac output (CO) as a result of myocardial dysfunction with increased peripheral vascular resistance (cool extremities and poor capillary refill) and pulmonary congestion, afterload reduction can decrease overall cardiac work and myocardial O2 consumption while increasing CO and oxygen delivery. It is often used to aid a failing heart during the immediate postoperative period and also may be of value in children with chronic ventricular dysfunction and those with mitral and/or aortic regurgitation or systemic-to-pulmonic shunts.
What agents are used to treat afterload reduction in children?
Agents that preferentially dilate arterioles (e.g., hydralazine), veins (e.g., nitrates), or both (e.g., sodium nitroprusside, captopril, other angiotensin-converting enzyme inhibitors) can be used. As a rule, arteriolar vasodilators tend to increase CO, and venous dilators tend to lessen pulmonary congestion. Afterload reduction may be of little use in shock states that occur as a result of causes other than myocardial failure. If the blood pressure remains unacceptably low (i.e., unstable shock), there is no role for afterload reduction. Volume replacement and inotropic support should first be used. Afterload reduction may also be of little benefit during the "warm phase," of septic shock when CO is actually increased and there is peripheral vasodilation.
How abnormal are premature atrial contractions?
Premature atrial beats are usually benign, with the exception of patients with an electrical or anatomic substrate for supraventricular tachycardia (SVT) or atrial flutter.
Which children are candidates for transcatheter ablation techniques for SVT?
Ablation therapy is used most commonly in children with dysrhythmias that are refractory to medical management and in those with life-threatening symptoms or possible lifelong medication requirements. Ablation is now commonly performed in children who are symptomatic from WPW or AV nodal reentrant tachycardia. Recommendations for transcatheter ablation are changing as increased experience with the safety and efficacy of the procedure are gathered. Recommendations vary with the age of the patient, the severity of the dysrhythmia, the type of lesion, the difficulty with medical control of the dysrhythmia, and the skill of the operator.
How reliable is the ECG for diagnosing bacterial endocarditis (BE)?
Echocardiography can sometimes identify an intracardiac mass that is attached either to the wall of the myocardium or to part of the valve itself. Although the yield of echocardiography for diagnosing BE is low, the likelihood of a positive finding is increased under certain conditions (e.g., indwelling catheters, prematurity, immunosuppression, evidence of peripheral embolization). BE is still a clinical and laboratory diagnosis (physical examination and blood cultures, respectively) and not an "echocardiographic" diagnosis. A negative study does not rule out BE.
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