1. Heart failure in children

2. Definition
Pathophysiology
Signs and symptoms
Causes by age
Management – Various options
Communication
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.

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 Infants Diagnosis
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 Left-sided Hepatomegaly
Ascites
Pleural effusion
Edema
Jugular venous distension
Left-sided
Tachypnea
Retractions
Nasal flaring or grunting
Rales
Pulmonary edema

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 > 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.

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 Ebstein’s anomaly
Mitral regurgitation from atrioventricular canal defect
Myocarditis

18. CHF on first day of life
Myocardial dysfunction secondary to asphyxia, hypoglycemia
Hypocalcemia
Sepsis
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.
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 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. Nat Clin Pract Cardiovasc Med 3: 377–386 doi:10.1038/ncpcardio0575
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: 377–386 doi: /ncpcardio0575

37. Berlin heart

39. General Measures Head end elevation,
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.

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