Heart Failure in pediatrics

Investigations

& TreatmentJenan muhammed8th termESIC MC PGIMSR

Chest radiography

• High specifity and negative predictive value

• Cardiomegaly- suggestive of ventricular dilatation or hypertrophy

• Large right to left shunts-exaggerated pulmonary arterial vessels marking towards periphery

• Cardiomyopathy- lung fields normal

• Severe HF- fluffy perihilar pulmonary markings suggestive of pulmonary edema

Laboratory investigations

• Symptomatic HF- associated with perturbations of electrolyte and fluid balance, renal function, liver function, thyroid function

• Hyponatremia due to renal water retention

(chronic Diuretic treatment still worsens tht)

ECG

• Nonspecific but frequently abnormal in pediatric HF patients

• With findings of LV hypertrophy, low voltage QRS morphology with ST-T wave abnormalities (myocardial inflammatory disz,also pericarditis), MI patterns, AV blocks,

• Best tool for evaluating rhythm disorders

Echocardiography

• Std technique for assessing ventricular function

• Commonly used parameter in children Fractional shortening- ED diametr-ES diameter

ED diameter

normal – 28%to 42%

Ef normal – 55-65%

Essential for identifying

• Causes of HF such as structural heart disease

• Ventricular dysfunction (both systolic and diastolic)

• Chamber dimensions

• Effusions (both pericardial and pleural)

Biomarkers

• Serum B type ntriuretic peptide- elevated in HF due to systolic dysfunction(CM) as well as with volume overload

• Cardiac troponin-elevated in cases of mycarditis, ischemic injury due to coronary anomaly, cardiomyopathy

• Pulse oximetry or hyperoxia test- 100% oxygen given and oxygen saturation is determined

• Metabolic and genetic testing

• Endomyocardial biopsy for acute myocarditis

• MRI cardiac- left n right ventricular function

treatment

• Underlying cause

• Cardiac anomaly amenable to surgery – medical treatment to prepare the patient for surgery

• Lesion s nt reversible- medical treatment allows the child to b back to normal activities for some period and delay need for heart transplantion

• Treatment of the precipitating events• Rheumatic activity, • Infective endocarditis, • Intercurrent infections, • Anaemia, electrolyte imbalances, • Arrhythmia, pulmonary embolism..

General measures

• Bed rest and limit activities• Nurse propped up or in sitting position• Control fever• Expressed breast milk for small infants• Fluid restriction in volume overloaded• Pulmonary edema – positive pressure

ventilation• Neonates with HF- nursed in an incubator, baby

s kept propped up at 30 degree• Child s restless or dyspneic- sedatives r used

Diet

• Usually fail to thrive- increased metabolic demands and decreased caloric intake

• Increase calorie intake supplement breast milk

• Severely ill- not able to suck, nasogastric tube

• Older children- no added salt diet

Goals of medical therpay

• Reducing preload

• Enhancing cardiac contractility

• Reducing afterload

• Improving oxygen delivery

• Enhancing nutrition

• Medical management of CCF should be tailored to specific details of each case

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 2 divided doses of 2mg/kg/day

Afterload reducers-

• ACEI and ARBs• Decreases peripheral vascular resistance and thereby

improving mycardial performance• Especially useful-HF secondary to cardiomyopathy n

severe aortic n mitral insufficiency• Additional benefits on preventing cardiac

remodeling • Captopril-0.3 to 6mg/kg ,Enalapril-0.05to

0.5mg/kg/day• Nitrates- venodilators• Hydralazine arterial dilators• Nitroprusside used in icu settings

Beta blockers

• Used in dialated cardiomyopathy

• Improve symptoms n survival

• Metoprolol selctive beta blocker

• Carvediol both alpha n beta blocker

•CCBs

• Should b avoided unless indicated for systemic HTN

Phosphodiesterase inhibitor

• Milrinone- refractory to std therapy n post operative period in open heart surgery

• Positive inotropy n peripheral vasodialtaion

• IV 0.25to 1 microgm/kg/min

Augmenting myocardial contractility

• Digoxin-

• Digitalization schedule- half total immediately subsequent 2 quarters at 12 hrs intervals

• ECG closely monitored

• maintenance digitalis after 12 hrs- daily dosage one quarter of digitalising dosage s divided into 2 n given at 12 hrs intervels

Inotropes

• Usually administered in ICU settings• Dopamine – beta adrenergic agonists(alpha

adrenergic at higher doses)• Selective renal vasodilatation( useful in patients

compromised kidney functions)• 2 to 10 micro gm/kg/min• Fenoldopam – DA1 agonists • Dobutamine – causes moderate reduction in

peripheral vascular resistance 2 to 20 microgm/kg/min

• Isoproterenol- pure beta agoinists in patients with slow heart rates & less commonly used( chances of arrhythmias)

• Epinephrine in cardiogenic shock

Manging acute CCF

• Admit to ICU• Neoneates nursed in incubator• Baby kept propped up at 30 degree• Humidified oxygen• Child is restless- morphine 0.05mg/kg SC • Treat precipitating factors• Diuresis with furosemide• Significant hypotention- given dopamine

infusion• Reduce preload- nitrates• After stabilisation look into cause

Electro physiologic approach

• Biventricular resynchronisation pacing

• Improves cardiac output by maintaining normal synchrony between right n left ventricle contraction

Correct underlying cause

Surgical approach

Thank you