Heart failure in children

1
Heart failure in children
2

1. Definition
2. Pathophysiology
3. Signs and symptoms
4. Causes by age
5. Management Various options
6. Communication
7. Summary

3

• Inability of the heart to pump as much blood as
  required for the adequate metabolism of the body.
  
• The clinical picture of CHF results from a
  combination of relatively low output and
  compensatory responses to increase it.

4
(No Transcript)
5

• Heart failure results either from an excessive
  volume or pressure overload on normal myocardium
  (left to right shunts, aortic stenosis)
• Or from primary myocardial abnormality
  (myocarditis, cardiomyopathy).

6

• Decrease in cardiac output triggers a host of
  physiological responses aimed at restoring
  perfusion of the vital organs .
• Renal retention of fluid
• Renin-angiotensin mediated vasoconstriction
• Sympathetic overactivity
• Excessive fluid retention
• Increases the cardiac output by increasing the
  end
• Diastolic volume (preload)

7
Vasoconstriction (increase in afterload) tends to
maintain flow to vital organs, but it is
disproportionately elevated Sympathetic
over-activity results in increase in
contractility, which also increases myocardial
requirements.
8
An understanding of the interplay of the four
principal determinants of cardiac output -
preload, afterload, contractility and heart rate
is essential in optimising the therapy of CHF
9
CHF in Neonates and InfantsDiagnosis

• Difficult at times (pulmonary causes, sepsis)
• Symptoms
• Incessant cry
• Feeding difficulty
• Excessive sweating
• Frequent chest infection
• Failure to thrive

10

• Signs
• Tachycardia
• S3
• Respiratory distress
• Wheeze, rales
• Hepatomegaly
• Signs of shock
• cardiomegaly

11

• Tachycardia
• Venous congestion
• Right-sided
• Hepatomegaly
• Ascites
• Pleural effusion
• Edema
• Jugular venous distension
• Left-sided
• Tachypnea
• Retractions
• Nasal flaring or grunting
• Rales
• Pulmonary edema

12
(No Transcript)
13
A precise description of feeding history, heart
rate, respiratory rate and pattern, peripheral
perfusion, presence of S3 and the extent of
hepatomegaly should perhaps be considered in this
evaluation.
14
Heart failure in infants -General points

• Heart rates above 220/min indicate
  supraventricular tachycardia as the cause.
• On chest X-ray a cardiothoracic ratio of gt 60 in
  the newborn and gt 55 in older infants with CHF
  is the rule.
• Hepatomegaly of gt 3 cm below the costal margin is
  usually present, even in the primarily left sided
  lesions.

15
(No Transcript)
16

• The time of onset of CHF holds the key to the
  aetiological diagnosis in this age group

17
CHF in the fetus

• Supraventricular tachycardia,
• Severe bradycardia due to complete heart block
• Anaemia
• Severe tricuspid regurgitation due to Ebsteins
  anomaly
• Mitral regurgitation from atrioventricular canal
  defect
• Myocarditis

18
CHF on first day of life

• Myocardial dysfunction secondary to asphyxia,
  hypoglycemia
• Hypocalcemia
• Sepsis
• Ebsteins anomaly

19
CHF in first week of life

• Peripheral pulses and oxygen saturation (by a
  pulse oximeter) should be checked in both the
  upper and lower extremities.
• A lower saturation in the lower limbs means
  right to left ductal shunting and occurs due to
  pulmonary hypertension, coarctation of aorta or
  aortic arch interruption.

20
CHF in first week of life

• An atrial or ventricular septal defect (ASD/VSD)
  does not lead to CHF in the first two weeks of
  life.
• An additional cause must be sought
  (eg.coarctation of aorta or left hypopoplastic
  heart syndrome).

21

• Premature infants have a poor myocardial reserve
  and a patent ductus arteriosus (PDA) may result
  in CHF in the first week in them .
• Adrenal insufficiency due to enzyme deficiencies
  or neonatal thyrotoxicosis could present with CHF
  in the first few days of life.

22
CHF beyond second week of life

• The most common cause of CHF in infants is a
  ventricular septal defect that presents around
  6-8 weeks of age.
• Any left to right shunt
• Left coronary artery arising from the pulmonary
  artery

23
CHF beyond Infancy

• Onset of CHF beyond infancy is unusual in
  patients with congenital heart disease and
  suggests a complicating factor like valvular
  regurgitation, infective endocarditis,
  myocarditis, anaemia
• Acquired diseases are common cause of CHF in
  children.

24

• left-sided obstructive disease (aortic stenosis
  or coarctation)
• myocardial dysfunction (myocarditis or
  cardiomyopathy)
• hypertension
• renal failure
• more rarely, arrhythmias or myocardial ischemia

25
Characteristic findings in heart failure in
children

• Cardiac rhythm disorders
• Volume overload
• Pressure overload
• Systolic dysfunction
• Diastolic dysfunction

26
Treatment of CHF

• Treatment of the cause
• Treatment of the precipitating events
• Rheumatic activity,
• Infective endocarditis,
• Intercurrent infections,
• Anaemia, electrolyte imbalances,
• Arrhythmia, pulmonary embolism,
• Drug interactions,
• Drug toxicity or non-compliance
• Other system disturbances etc.

27
Treatment of congested state

• Reducing the pulmonary or systemic congestion
  (diuretics)
• Reducing the disproportionately elevated
  afterload (vasodilators including ACE inhibitors)
• Increasing contractility (inotropes)
• Other measures

28
Diuretics

• Diuretics afford quick relief in pulmonary and
  systemic congestion. 1 mg/kg of frusemide is the
  agent of choice.
• For chronic use 1-4 mg/kg of frusemide or 20-40
  mg/kg of chlorothiazide in divided dosages are
  used.
• Monitor electrolytes, urea and weight
• Spironolactone may be added.

29
Vasodilators

• Several trials in adults have shown that ACE
  inhibitors prolong life in patients with CHF and
  improve quality of life.
• These drugs should not be used in patients with
  aortic or mitral stenosis.
• Enalapril in a dose from 0.1 to 0.5 mg/kg/day has
  been used in children . Captopril is used in a
  dosage of upto 6 mg/kg/day in divided doses.

30

• Nitroglycerin
• Sodium nitroprusside
• Nifedipine CoA, Pulm HTN

31
Inotropes

• Dopamine
• Dobutamine
• Adrenaline
• Noradrenaline
• Isoprenaline

32
Phosphodiesterase inhibitors

• Amrinone
• Milrinone

33
Miscellaneous

• B Blockers - Dilated cardiomyopathy (espicially
  Carvidelol)
• L carnitine
• Prostagaldin E2 inhibitors

34

• Digoxin
• Controversial
• Still used in some centres.
• Highly toxic and low therepeutic margin

35
Other options

• ECMO
• LV assist devices
• A combination of external implantable pulsatile
  and continuous-flow external mechanical support
  as a bridge to transplantation
• Biventricular pacing
• Cardiac transplantation

36
Figure 3 Standard configuration of Berlin Heart
Excor (Berlin Heart AG, Berlin, Germany)
biventricular support
Hetzer R and Stiller B (2006) Technology Insight
use of ventricular assist devices in children Nat
Clin Pract Cardiovasc Med 3 377386
doi10.1038/ncpcardio0575
37

• Berlin heart

38
(No Transcript)
39
General Measures

• Head end elevation,
• Judicious use of sedation and temporarily denying
  oral intake

40
Nutrition

• Infants with CHF require 120-150 Kcal/kg/day of
  caloric intake and 2-3 mEq/kg/day of sodium.

41

• It is not generally appreciated that oxygen may
  sometimes worsen the CHF in patients with left to
  right shunts due to its pulmonary vasodilating
  and systemic vasoconstrictor effects
• Detrimental in duct dependent lesions

42
Communication

• In dealing with parents, it is preferable to use
  words like pulmonary congestion, liver
  congestion rather than heart failure, since
  heart failure, is likely to be misunderstood by
  the parents and this may hamper useful
  interaction.

43
Summary

• Definition of heart failure
• Presentation of CHF.
• Various causes
• Management

44
Thank you