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IntroductionChildren brought to the ER with signs of difficulty in breathing such as polypnea, accessory muscle use, flaring of the nostrils, dyspnea, wheezing, grunting, can initially misguide the doctor to a pulmonary disease, but further investigations can diagnose a cardiac malformation.Case series presentation, management and outcomeCase 1. A previously healthy 3 months old boy is brought to the ER for grunting especially during sleeping, polypnea and dry coughing. Oxygen saturation showed 84% on room air and 89% with oxygen. Chest X-ray showed cardiomegaly. Echocardiography certified totally anomalous venous drainage into the coronary sinus. He underwent surgery with favourable results.Case 2. 14 months old boy with previous history of recurrent bronchiolitis presented to the ER for dyspnea, wheezing, dry cough and rhinorrhea accompanied by pallor. Although he didn’t have heart murmur, Chest X-ray showed cardiomegaly. Echocardiography certified the diagnoses of Ebstein disease with moderate tricuspid insufficiency. He never got operated; however, he is alive with no signs of pulmonary hypertension.Case 3. 5 weeks old boy is brought to the ER for polypnea, dyspnea, dry cough and difficulty in breastfeeding. He also had pallor and bilateral crackles. Heart murmur was inaudible and oxygen saturation was 90% on room air. Echocardiography showed severe coarctation of the aorta. He got cardiac surgery with good results.Case 4. 4 months old girl presented at the ER for wheezing, cough, dyspnea and grunting. She had pallor, rhonchi and no heart murmur. Oxygen saturation showed 85% on room air and 99% with oxygen; chest X-ray showed cardiomegaly. Echocardiography diagnosed the child with dilated cardiomyopathy. He initially got specific treatment with good results and he had no indication of surgery.ConclusionsAll cases were initially presumed to be acute pulmonary diseases. Chest X-rays and oxygen saturation monitoring along with specific clinical features (failure to thrive, cyanosis, pallor and fatigue during breastfeeding) are useful for orienting towards congenital cardiac malformations. Auscultation is not a reliable evaluation since heart murmur it is not always pathologic and it depends on the severity of the heart defect and on the physician’s skills and praxis. Since echocardiography is the key in diagnosis, there should be done short courses for basic children echocardiography for ER paediatricians.