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Heart failure in children. 1. Definition 2. Pathophysiology 3. Signs and symptoms 4. Causes by age 5. Management – Various options 6. Communication 7.

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Presentation on theme: "Heart failure in children. 1. Definition 2. Pathophysiology 3. Signs and symptoms 4. Causes by age 5. Management – Various options 6. Communication 7."— Presentation transcript:

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. 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. The clinical picture of CHF results from a combination of “relatively low output” and compensatory responses to increase it.

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5 Heart failure results either from an excessive volume or pressure overload on normal myocardium (left to right shunts, aortic stenosis) 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). 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 Renal retention of fluid Renin-angiotensin mediated vasoconstriction Renin-angiotensin mediated vasoconstriction Sympathetic overactivity Sympathetic overactivity Excessive fluid retention Excessive fluid retention Increases the cardiac output by increasing the end Increases the cardiac output by increasing the end Diastolic volume (preload) 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 Infants Diagnosis Difficult at times (pulmonary causes, sepsis) Symptoms Symptoms Incessant cry Feeding difficulty Excessive sweating Frequent chest infection Failure to thrive

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

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

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

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

17 CHF in the fetus Supraventricular tachycardia, Supraventricular tachycardia, Severe bradycardia due to complete heart block Severe bradycardia due to complete heart block Anaemia Anaemia Severe tricuspid regurgitation due to Ebstein’s anomaly Severe tricuspid regurgitation due to Ebstein’s anomaly Mitral regurgitation from atrioventricular canal defect Mitral regurgitation from atrioventricular canal defect Myocarditis Myocarditis

18 CHF on first day of life Myocardial dysfunction secondary to asphyxia, hypoglycemia Myocardial dysfunction secondary to asphyxia, hypoglycemia Hypocalcemia Hypocalcemia Sepsis Sepsis Ebstein’s anomaly Ebstein’s 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. 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. 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 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). 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. 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. 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. 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 Any left to right shunt Left coronary artery arising from the pulmonary artery 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 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. Acquired diseases are common cause of CHF in children.

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

25 Characteristic findings in heart failure in children Cardiac rhythm disorders Cardiac rhythm disorders Volume overload Volume overload Pressure overload Pressure overload Systolic dysfunction Systolic dysfunction Diastolic dysfunction Diastolic dysfunction

26 Treatment of CHF Treatment of the cause Treatment of the cause Treatment of the precipitating events 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 pulmonary or systemic congestion (diuretics) Reducing the disproportionately elevated afterload (vasodilators including ACE inhibitors) Reducing the disproportionately elevated afterload (vasodilators including ACE inhibitors) Increasing contractility (inotropes) Increasing contractility (inotropes) Other measures Other measures

28 Diuretics Diuretics afford quick relief in pulmonary and systemic congestion. 1 mg/kg of frusemide is the agent of choice. 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 mg/kg of chlorothiazide in divided dosages are used. For chronic use 1-4 mg/kg of frusemide or mg/kg of chlorothiazide in divided dosages are used. Monitor electrolytes, urea and weight Monitor electrolytes, urea and weight Spironolactone may be added. 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. 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. 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. 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 Nitroglycerin Sodium nitroprusside Sodium nitroprusside Nifedipine – CoA, Pulm HTN Nifedipine – CoA, Pulm HTN

31 Inotropes Dopamine Dopamine Dobutamine Dobutamine Adrenaline Adrenaline Noradrenaline Noradrenaline Isoprenaline Isoprenaline

32 Phosphodiesterase inhibitors Amrinone Amrinone Milrinone Milrinone

33 Miscellaneous B Blockers - Dilated cardiomyopathy (espicially Carvidelol) B Blockers - Dilated cardiomyopathy (espicially Carvidelol) L carnitine L carnitine Prostagaldin E2 inhibitors – Prostagaldin E2 inhibitors –

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

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

36 Hetzer R and Stiller B (2006) Technology Insight: use of ventricular assist devices in children Nat Clin Pract Cardiovasc Med 3: 377–386 doi: /ncpcardio0575 Figure 3 Standard configuration of Berlin Heart Excor® (Berlin Heart AG, Berlin, Germany) biventricular support

37 Berlin heart

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39 General Measures Head end elevation, Head end elevation, Judicious use of sedation and temporarily denying oral intake Judicious use of sedation and temporarily denying oral intake

40 Nutrition Infants with CHF require Kcal/kg/day of caloric intake and 2-3 mEq/kg/day of sodium. Infants with CHF require 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 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 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. 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 Definition of heart failure Presentation of CHF. Presentation of CHF. Various causes Various causes Management Management

44 Thank you


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