Summary of "Session 1 e-Pediatric Cardiology"

Summary of “Session 1 e-Pediatric Cardiology”

This session is part of a 12-week online pediatric cardiology masterclass organized by the Indian Pediatrics (IP) Delhi chapter. It is aimed at pediatricians, students, and healthcare providers to upgrade their knowledge in pediatric cardiology. The session primarily focuses on clinical evaluation, diagnosis, and management of congenital heart diseases (CHD) using clinical criteria, chest X-rays, pulse oximetry, and ECG—especially in settings where echocardiography (echo) is not immediately available.

Main Ideas and Concepts

1. Introduction and Course Overview

The program continues IP Delhi’s master classes in various pediatric subspecialties.
The pediatric cardiology course is coordinated by Dr. Niraal, Dr. Muril Agraal, and Dr. J. Relan from Gangaram Hospital.
The course targets practical knowledge for private practitioners and pediatricians managing congenital heart diseases (CHD).

2. Initial Clinical Assessment of CHD

Use of Nadas Criteria to clinically suspect heart disease:
- Major criteria:
  - Systolic murmur > grade 3
  - Diastolic murmur
  - Central cyanosis
  - Congestive heart failure (CHF)
- Minor criteria:
  - Systolic murmur < grade 3
  - Abnormal second heart sound
  - Abnormal blood pressure (BP), ECG, or X-ray
Diagnosis is suspected if one major or two minor criteria are present.

3. Classification of CHD

A stepwise approach includes:

Confirm presence of heart disease.
Classify as cyanotic or acyanotic based on central cyanosis (detected clinically and confirmed by pulse oximetry).
Further classify based on pulmonary blood flow:
- High pulmonary blood flow (Qp): Usually seen in large left-to-right shunts (e.g., VSD, PDA, AP window).
- Low or normal pulmonary blood flow: Typically obstructive lesions (e.g., pulmonary stenosis, aortic stenosis, TOF).
Identify ventricular dominance (right ventricular [RV] or left ventricular [LV]) based on X-ray cardiac silhouette (cardiophrenic angle).

4. Clinical Features of Pulmonary Blood Flow States

High pulmonary blood flow: Recurrent chest infections, failure to thrive, sweating, hyperactive precordium, shunt murmur, cardiomegaly.
Low pulmonary blood flow: Good weight gain, absence of chest infections, exertional dyspnea, chest pain, quiet precordium, harsh murmur without cardiomegaly.

5. Chest X-ray Interpretation in CHD

Assess cardiothoracic ratio (CTR) to evaluate cardiomegaly.
Evaluate pulmonary vascularity:
- Pulmonary vascularity extending beyond medial 2/3 of lung field indicates high pulmonary blood flow (“white lung”).
- Reduced or absent distal pulmonary vascularity indicates low pulmonary blood flow (“black lung”).
Identify right lower pulmonary artery prominence as a sign of increased pulmonary blood flow.
Determine ventricular dominance via cardiophrenic angle:
- Acute angle = RV apex.
- Obtuse angle = LV apex.
Use X-ray findings to differentiate common CHD types (e.g., TOF, VSD, ASD, PDA).

6. Role of Diuretics

Indicated in symptomatic heart failure with high pulmonary blood flow (e.g., large VSD).
Contraindicated in low pulmonary blood flow/obstructive lesions (e.g., TOF, pulmonary stenosis, aortic stenosis).
Clinical signs guiding diuretic use include tachypnea, tachycardia, hepatomegaly, and poor weight gain.
In neonates, avoid loop diuretics like Lasix if PDA is suspected, as they may keep PDA open.

7. Pulse Oximetry in CHD

Essential tool to detect central cyanosis.
Saturation <85% usually indicates cyanotic heart disease.
Recommended for all suspected CHD patients in OPD, IPD, and NICU.
Devices like Masimo and Nellcor are preferred; pulsatility index is useful in NICU for assessing perfusion.

8. Electrocardiogram (ECG) in CHD

Useful mainly for:
- Detecting arrhythmias.
- Assessing ventricular hypertrophy and axis deviation.
- Differentiating RV vs. LV dominance.
- Diagnosing specific lesions like TOF (RV hypertrophy, right axis deviation) and tricuspid atresia (LV hypertrophy, left axis deviation).
Less useful than X-ray for shunt lesions but important for obstructive lesions and cyanotic heart diseases.

9. Case Discussions

Clinical scenarios illustrated:
- Differentiation of cyanotic vs. acyanotic CHD.
- Use of X-ray and pulse oximetry in diagnosis.
- Interpretation of murmurs and clinical signs.
- Decision-making about diuretic therapy.
- Recognition of rare and complex lesions (e.g., TAPVC with white lung, absent pulmonary valve syndrome).

10. Additional Points

Importance of blood pressure measurement in older children to detect coarctation of the aorta.
X-ray accuracy for CHD diagnosis is about 78–80%; clinical correlation is essential.
Differentiation of thymus shadow from cardiac pathology on X-ray.
White lung TAPVC is a cardiac emergency and can be misdiagnosed as respiratory distress syndrome.

Methodology / Stepwise Approach to CHD Assessment and Management

Clinical suspicion using Nadas criteria.
Confirm cyanosis with pulse oximetry.
Classify as cyanotic or acyanotic.
Assess pulmonary blood flow clinically and radiologically (X-ray).
Determine ventricular dominance by cardiophrenic angle on X-ray.
Use ECG to confirm ventricular hypertrophy and axis deviation.
Decide medical management:
- Start diuretics in symptomatic high pulmonary blood flow cases.
- Avoid diuretics in low pulmonary blood flow/obstructive lesions.
- Use beta blockers in cyanotic spells (e.g., TOF).
Refer for echocardiography and specialized care as needed.

Speakers / Sources Featured

Dr. Pankage Gag – Opening remarks, course introduction.
Dr. Niraal (Dr. Niraal Zagaral) – Course coordinator, main lecturer on clinical and radiological assessment of CHD.
Dr. Muril Agraal (Dr. Midul / Dr. Mul) – Senior consultant, future sessions and interventions.
Dr. J. Relan (Dr. J.) – Pediatric cardiologist, expert on X-ray and ECG interpretation.
Dr. Shivan Sar (Dr. Shivanand Goss) – Chairperson, pediatric cardiologist from Goa.
Dr. Naven (Dr. Navin) – Chairperson, pediatrician from Karnal.
Dr. Ajay Gupta – Scientific coordinator for master classes.
Dr. Shamina – Program backbone (mentioned, not present).
Other panelists and moderators participated in Q&A and discussion.

This session provides a comprehensive foundational framework for pediatricians to clinically assess and manage congenital heart diseases, emphasizing practical tools like clinical criteria, pulse oximetry, chest X-ray, and ECG to guide early diagnosis and treatment decisions before echocardiography is available.