i am blue: cardiac classifications

© The Children's Mercy Hospital, 2014. 03/14© The Children's Mercy Hospital, 2014. 03/14

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© The Children's Mercy Hospital, 2014. 08/14

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Am I Blue: Am I Blue: Cardiac ClassificationsCardiac Classifications

Lori Erickson MSN, CPNP

The Ward Family Heart Center

Children’s Mercy Hospital


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DisclosureDisclosure

No financial disclosures


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ObjectivesObjectives

Identify the Neonate with potential cardiac v. respiratory problem

Discuss babies prenatally diagnosed and how to manage at delivery


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OutlineOutline Overview of fetal physiology

Review of Neonatal heart disease including

– Physiology

– Clinical presentation

Cardiac Delivery Classification for prenatal diagnosis


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BackgroundBackground

Early Diagnosis

Prenatal

Postnatal


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Fetal Physiolo

gy


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Birth ChangesBirth Changes Lungs expand, 02

increased Pulmonary vascular

resistance drops Pulmonary venous

return increases Ductus arteriosus flow

reverses


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What fetal structure is kept open with the medication prostaglandin

(PGE)?A.A. Patent Foramen Patent Foramen

OvaleOvale

B.B. Ductus Ductus ArteriosusArteriosus

C.C. Ductus VenosusDuctus Venosus

D.D. Ventricular Ventricular Septal Defect Septal Defect

Patent Foramen O

vale

Ductus A

rterio

sus

Ductus V

enosus

Ventricu

lar Septal D

efect

0% 0%0%0%


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Congenital Heart Disease Congenital Heart Disease (CHD) (CHD)

Electrical– Arrhythmia

Plumbing– Blockage with any of the 4 valves have stenosis

or atresia

– Great vessels not hooked up correctly

– Holes in heart

Function


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CHD OverviewCHD Overview

Goals of CHD evaluation

– Early recognition of disease

– Knowledge of physiology

– Resuscitation and stabilization


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Delivery ClassificationDelivery Classification


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Baby

Mother

Father

Neonatologist

Cardiologist

RN1

RN2

RT

ECHO tech

Neo 2

NNP

Cath Doc

Cardiac Surgeon

3 CV nurses

2 cath nurses

Fetal Cardiac APRN

Fetal Cardiac RN

CV Perfusion (4)

Cardiac Anesthesia

OB team….


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Fetal ECHO’sFetal ECHO’s

Only primary cardiac diagnosis

See another 100 patients with multiple conditions

70% delivered at CMH

60% of Class I delivered elsewhere


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PreparationPreparation

High risk, low frequency cases


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Class IClass I

Stable Hemodynamics anticipated

Non-Ductal dependent

Examples:

CAVC

Truncus arteriosus

TOF

VSD


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Class I: BehaversClass I: Behavers

Normal NRP assessment and evaluation

Monitor for adequate pulmonary and systemic blood flow

Echo after birth when able


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Tetralogy of Fallot (TOF)


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Class I ExpectationsClass I Expectations

Cardiology consult after birth

Follow-up in outpatient clinic

No neonatal surgery planned (first 30 days of life- may need it later)


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Class II: Neonatal surgery Class II: Neonatal surgery

Stable Hemodynamics anticipated

Ductal dependent lesions

Examples:

HLHS

Single ventricle with atresia

COA

Hypoplastic aortic arch


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Hypoplastic Left Heart Syndrome (HLHS)


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Class II: Expectations Single ventricle Single ventricle

hemodynamics hemodynamics Most require PGE Most require PGE

infusioninfusion Pulmonary flowPulmonary flow Systemic flow Systemic flow

Surgery 1Surgery 1stst 1-2 weeks 1-2 weeks of life if term of life if term

Umbilical linesUmbilical lines Side effects of PGE Side effects of PGE


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Class II Evaluation Class II Evaluation Pulse oximetry

– Sat 75-85%

– Location of desaturation

Ventilation ABG

– Possible Low pO2

– No significant metabolic acidosis unless profoundly cyanotic or low cardiac output


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Class II MisbehavingClass II Misbehaving

Not acting right?

– NRP

– Evaluate hemodynamics

– Mixing appropriately

– Output getting to systemic and pulmonary blood flow


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Class III: Expecting badnessClass III: Expecting badness

Possible Hemodynamic instability

Examples:

d-TGA

TAPVR

Heart Block


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Class III ExpectationsClass III Expectations Cardiology in house for

echo

Ready for inotropic support, airway support

Communication early- Troops on stand-by

Cardiac cath on hold

CV surgery on hold

HELP!


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Clinical Presentation Clinical Presentation

Cyanotic right from birth- 50-60’s

Severe respiratory distress

Weak to normal pulses


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Class IIIClass III


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What do you think this above case is most likely? Cardiology isn’t available

yet- stuck in traffic coming to your hospital

A.A. Meconium Meconium AspirationAspiration

B.B. Pulmonary Pulmonary HypertensionHypertension

C.C. Total Anomalous Total Anomalous Pulmonary Pulmonary venous returnvenous return

D.D. Severe bilateral Severe bilateral pneumoniapneumonia

Meco

nium Aspira

tion

Pulmonary Hyp

ertensio

n

Total Anomalous P

ulmona..

Seve

re bilateral p

neumonia

0% 0%0%0%


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TAPVR Infradiaphragmatic Infradiaphragmatic

TAPVRTAPVR Pulmonary veins Pulmonary veins

return to confluence return to confluence that drains down that drains down below the below the diaphragm and diaphragm and enters inferior vena enters inferior vena cavacava


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Class IV: CalvaryClass IV: Calvary

Hemodynamic Instability expected at separation from placental circulation

Examples:

HLHS with restrictive atrial septum

d-TGA with restrictive atrial septum


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D-tga with RAS

Survival depends on Survival depends on mixing of blue and red mixing of blue and red bloodblood

Immediate Immediate septostomy septostomy


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Class IV ExpectationsClass IV Expectations

Everything for class III PLUS delivery in cardiac OR

Cardiac Anesthesia in delivery

LIFE SAVING

Only getting them stable to get to the first surgery

Long road ahead


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Is it Heart?Is it Heart? Extremely varied presentation

As pulmonary vascular resistance drops

– Pulmonary blood flow will increase

– Saturations will increase

– Pulmonary over-circulation may result in heart failure (tachypnea, grunting, retractions, tachycardia)

Generally not distressed until develop heart failure (gradual)


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Likely Heart DiseaseLikely Heart Disease

Massive cardiomegaly with poor cardiac output, gallop and/or murmur

Obvious dysrhythmia

– Bradycardia

– Extreme tachycardia

– Non-perfusing rhythm


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Possible Heart DiseasePossible Heart Disease Respiratory distress and cyanosis

– Most often pulmonary/infectious etiology

– May be cardiac (or combination)

– Chest x-ray may or may not be helpful in distinguishing between etiologies

– Support as needed and early transfer to tertiary care center for evaluation and management


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What cardiac delivery classification is a HLHS with no ASD restriction?A.A. Class IClass I

B.B. Class IIClass II

C.C. Class IIIClass III

D.D. Class IV Class IV

E.E. What’s a delivery What’s a delivery classification? classification?

Class I

Class I

I

Class I

II

Class I

V

What’s

a delivery cla

ssifi...

0% 0% 0%0%0%


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Final thoughtsFinal thoughts

High Risk, low frequency

Life saving interventions

Delivery with CMH only if have to!


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i am blue: cardiac classifications

Healthcare

heart function

prenatal diagnosis

fetal structure

fetal physiolog y

ductus venosusductus

respiratory problem

atresia great vessels

medication prostaglandin