Cardiology

The Cascade Hospital

Last updated May 26, 1999

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Divison of Cardiology

~ diseases of the heart and circulatory system ~

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Congenital heart disease that doesn't appear until a child is older
Vasovagal syncope (fainting from emotional stress)

Congenital heart disease that doesn't appear until a child is older

It is possible to have a heart problem that isn't discovered until the child is older. Obviously these are the less severe kinds of heart disease, otherwise the problem would have been discovered earlier in life. The ones that first come to mind are called ASD and VSD -- atrial septal defect and ventricular septal defect. Both basically involve an abnormal hole in the heart from the right side to the left side, resulting in some blood "backwashing" from the left side to the right side. (Normal blood flow goes from the right side of the heart to the lungs to the left side of the heart to the body). If the defect is relatively small, it may not be detected till the child is older. The only symptom may be a heart murmur (and if you're not good at listening for a heart mumur, it can be missed). Some patients remain asymptomatic throughout life; others develop easy fatigability as older children or adults. With mild ASD, if the person is going to get worse, they usually don't until age 30 or 40.

With mild VSD, children may get frequent respiratory infections (colds, pneumonia) in infancy and early childhood. Children with severe VSD also grow slowly and have poor weight gain (thus their problem gets picked up earlier). Shortness of breath, exercise intolerance, and fatigue are very common. ASD and VSD are definitively diagnosed by an echocardiogram which shows the blood flow going through the "hole". The child may also undergo cardiac catheterization to determine the actual pressure and oxygen saturation in the cardiovascular system, particularly if surgery is being considered. The definitive treatment for ASD and VSD is surgical repair of the hole. Children as young as 2 years old are now being repaired to prevent the potential deadly complication of pulmonary hypertension -- a lung problem that can occur if the defect is large and isn't repaired (the abnormally high blood flow through the lungs eventually causes problems with oxygen exchange). If a child develops pulmonary hypertension (this kind is called the "Eisenmenger Complex", they are no longer surgical candidates and need a heart-lung transplant to be cured. Children who are repaired do very well and usually have normal exercise capacity and do not need physical restrictions.

Okay, the last congenital heart problem I'll throw out for you is called "Coarctation of the Aorta." The aorta is the main blood vessel coming out of the heart. "Coarctation" means the aorta is narrowed in one spot, thus impeding the blood flow. There are two kinds of coarct; the 2nd type is not as bad and may not be diagnosed until the child is older (approximately preteen or teenaged). Children may or may not have cardiovascular symptoms; they may develop decreased exercise tolerance and fatigability in childhood. These children are usually diagnosed at a check-up or sports physical. The blood pressure in their arms is elevated compared to the blood pressure taken in their legs (the arms should be lower or the same as the legs), and they also often have a murmur. An echocardiogram should confirm the problem. Surgery is also the definitive treatment (bypass the narrowed portion) and is usually done around age 3-5 if they've been diagnosed. If they get through infancy without developing heart failure, they usually do well. Children with coarct can have other complications from the elevated blood pressure (rare) and problems from other heart defects (more common when you have coarct) such as valve problems. Associated valve problems predispose them to getting bacterial endocarditis -- a serious infection of (usually malformed) heart valves requiring antibiotics, sometimes long-term. They are also at high risk for heart dysfunction and high blood pressure. They need to have careful exercise testing before participating in athletic activities.

Vasovagal syncope -- fainting from emotional stress

Vaso-vagal syncope refers to any kind of fainting when a person gets *very* scared or surprised or excited or whatever (some people pass out when they hear very bad or good news, have a lot of pain, or when they get their blood drawn, etc.). Syncope is the fancy medical term for fainting and losing consciousness temporarily. Vaso-vagal refers to the mechanism by which the person passes out. Somehow the emotional stress triggers a neural response via neurotransmitters which cause the heart to slow down significantly (this is the "vagal" response). When your heart slows down that much, you don't get enough blood to your brain and you pass out. If you took the person's pulse immediately after they passed out, you would find that it would be *very* slow -- maybe in the teens or 20s, especially if they're an athletic, healthy person. This usually makes the person fall down, at which point their prostrate position is perfect for getting blood back to their brain, and they wake up in a few seconds to a minute or so. Vaso-vagal syncope is more common in younger and otherwise perfectly healthy people.

Most people wouldn't call 911 for this unless they were really freaked out and the person didn't "come to" right away. A lot of people wouldn't even go to the hospital for this, especially if they're healthy and not some old person with heart problems. The fainted person should wake up quickly and should be fine afterwards. If 911 was called, the paramedics would be obligated to take the person to the hospital even though they looked fine. They would do all the standard stuff when they arrive: check the person's breathing and pulse and blood pressure, maybe give them some oxygen. All of this would be overkill because the person would be fine, but it's just standard procedure. At the hospital, the doctor might do an EKG (which would be normal), look the person over and say they were fine and it was just vaso-vagal syncope and tell them to go home.

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