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
Physiolog
y

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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 ForamenPatent Foramen
OvaleOvale
B.B. DuctusDuctus
ArteriosusArteriosus
C.C. Ductus VenosusDuctus Venosus
D.D. VentricularVentricular
Septal DefectSeptal Defect
PatentForam
en
OvaleDuctusArteriosus
DuctusVenosus
VentricularSeptalDefect
0% 0%0%0%

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Congenital Heart DiseaseCongenital 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 surgeryClass 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 ventricleSingle ventricle
hemodynamicshemodynamics
 Most require PGEMost require PGE
infusioninfusion
 Pulmonary flowPulmonary flow
 Systemic flowSystemic flow
 Surgery 1Surgery 1stst
1-2 weeks1-2 weeks
of life if termof life if term
 Umbilical linesUmbilical lines
 Side effects of PGESide effects of PGE

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Class II EvaluationClass 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 PresentationClinical 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. MeconiumMeconium
AspirationAspiration
B.B. PulmonaryPulmonary
HypertensionHypertension
C.C. Total AnomalousTotal Anomalous
PulmonaryPulmonary
venous returnvenous return
D.D. Severe bilateralSevere bilateral
pneumoniapneumonia
M
econium
Aspiration
Pulm
onary
Hypertension
TotalAnom
alousPulm
ona..
Severe
bilateralpneum
onia
0% 0%0%0%

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TAPVR
 InfradiaphragmaticInfradiaphragmatic
TAPVRTAPVR
 Pulmonary veinsPulmonary veins
return to confluencereturn to confluence
that drains downthat drains down
below thebelow the
diaphragm anddiaphragm and
enters inferior venaenters 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 onSurvival depends on
mixing of blue and redmixing of blue and red
bloodblood
 ImmediateImmediate
septostomyseptostomy

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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 IVClass IV
E.E. What’s a deliveryWhat’s a delivery
classification?classification?
ClassI
ClassII
ClassIII
ClassIV
W
hat’sa
deliveryclassifi...
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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