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2. - Circulation >> delivery of oxygen and
metabolites to various tissues >> maintain:-
1- cellular integrity
2- specialized function
3- and growth
3. Controlled by :-
1- intrinsic control, predominantly by:-
- The Frank-Starling mechanism
- Autoregulation of peripheral vascular tone
2- Extrinsic control, mainly through:-
- Neural regulation of heart rate
- AV conduction
- Peripheral vascular resistance { afterload }
- Peripheral venous capacitance { preload }
6. - C.O. = stroke volume X HR
[ c.o. particularly HR-dependent in early
infancy >> so in presence of significant
heart disease >> bradycardia poorly tolerated
]
- In infancy >> AV node less rate-limiting
>> HR up to 200 bpm are well tolerated
7. - mainly under adrenergic control
- In infancy, myocardium particularly
sensitive to negative-inotropic factors:
= hypoxia
= acidosis
= hypocalcemia
= hypoglycemia
8. - Distribution is under neural and autoregulatory
or local control
- When C.O. falls:-
>>> blood flow to vital organs with greatest
metabolic demand [ heart and brain ] is
preferentially maintained.
>>> increased adrenergic neurohumoral tone
>> reduces flow to skin, kidneys, GI tract >>
increases heart rate { in severe tachycardia >
pallor, cold skin, pyrexia and oliguria }
9. - In presence of fever, sepsis, or anemia >>
associated with normal c.o.
- Early signs: anxiety, restlessness, tachycardia
cool and pale extremities
- Early decompensation characterized by:
tachypnea, metabolic acidosis, oliguria
- Finally:
impaired consciousness, hypotension and
periodic breathing
10. - Presents most frequently in neonates and
young infants
- Not unusual for mild circulatory failure to
precede an acute episode especially in
anomalies with left-to-right shunting
- Dehydration, hypovolemia, anemia and
sepsis >> primary cause or make existing
HF worse
12. - Varied, complex, and depend on primary
etiology
- Include:
= LV systolic and diastolic dysfunction
= Elevated LA &/or pulmonary venous pressure
= Raised pulmonary artery pressure & PVR
= RV systolic and diastolic dysfunction
- Right HF & hepatic congestion occurs in the
majority
- Emergency management is similar in most
groups
13. - Rapid endo-tracheal intubation
- Artificial ventilation with increased inspired O2
fraction
- Intravenous sedatives, opiates, and muscle
relaxants
- IV infusion of Prostaglandin E [if uncertainty
about CHD in newborn] >> duct-dependent
systemic circulation [ from MPA to AO ]
14. - For neonates with persistent pulmonary
hypertension:
= inhaled Nitric oxide
= high inspired O2 levels
= maintenance of low-normal systemic arterial
CO2
= Very few >> ECMO support
15. Persistent congestive HF:-
- Choice of inotropic agent remains
controversial , with Dopamine or Dobutamine
used most frequently
- Caution: use of large IV fluid volumes in
initial resuscitation [aggravating HF]
16. Signs of therapeutic success :-
- return of spontaneous urine output
- resolution of metabolic acidosis
N.B.
some patients required IV diuretics [bolus or
infusion ]
17. - Combination of fluid restriction with
diuretics carries risk of dehydration, and
should be used with caution
- After stabilization : urgent treatment of
underlying heart malformation
18. - Definition: A situation where symptoms such as
FTT, breathlessness or effort intolerance are
improved or remain stable with drug treatment.
- If caused by un-correctable underlying
condition >> can lead to acute circulatory
collapse at any time.
- Many infants or children with short-lived CHF
are best managed by surgical treatment of
underlying condition.
19. - Excessive pulmonary blood flow
- Ventricular volume overload [ semilunar or AV
valve incompetence
- Recurrent or incessant arrhythmia
- Primary myocardial failure
N.B. :
Congenital HD >> leading cause in developed
world
Rheumatic HD >> predominates in developing
countries
20. 1- Acyanotic conditions with left-to-right shunt:
= Complete AVSD
= Moderate-to-large VSD
= Moderate-to-large PDA
- Commonest causes during first 6 months of life
- Onset of symptoms usually from 4-6 weeks of age
[coincides with gradual fall of PVR after birth]
- Onset earlier in premature infants [much more rapid fall in
PVR]
- High PBF >> LA & LV overload >> pulmonary venous
congestion >> pulmonary edema >> dilated pulmonary arteries
21. 2- Valve insufficiency :
= Aortic regurgitation
= Mitral regurgitation
= AV valve regurg. in AVSD
- AR frequently seen in rheumatic HD
- Congenital AR usually associated with bicuspid aortic valve
- In Marfan syndrome >> ascending aortopathy >> AR
- MR : common in rheumatic HD, dilated CMP, congenital
- Mechanism : dysplastic leaflets, prolapse, isolated cleft, arcade
lesion.
22. 3- Cyanotic conditions without pulmonary
stenosis(TOF) or atresia(tricuspidatresia):
= Common arterial trunk
= DORV with sub-aortic or sub-pulmonary VSD
= TGA with large VSD
= Hearts with uni-ventricular AV connections
= TAPVC
- Cyanosis usually mild
- Pulmonary blood flow increases as PVR gradually
falls after birth >> symptoms begin at 4-6 weeks
28. 1- Diuretics:
- Mainstay of treatment
- Usually used in combination [ spironolactone combined with
furosemide or chlorthiazide ]
- Chlorthiazide is weaker and longer acting than furosemide
- Major complication: dehydration and hypovolemia , electrolyte
loss in urine
- Spironolactone unique in :
1- potassium-sparing effect
2- influence on myocardial remodeling due to aldosterone
antagonism and direct myocardial effect
29. 2- ACE inhibitors:
- Used in combination with diuretics
- Most frequently: captopril, enalapril, lisinopril [ single daily dose, not
used in infancy]
- Action:
1-reduce SVR & BP >> decrease left-to-right shunting + decrease
severity of MI/AI
2- reduce LV pressure overload >> benefit patients with heart muscle
disease
- Contraindicated in left heart obstructions
- Complications: dizziness, hyperkalemia, skin rash, irritable dry cough,
and risk of potassium retention [ attention when used with
spironolactone ]
30. 3- Beta-blockers:
- Carvedilol or Metoprolol, particularly patients with
relative resting tachycardia
- Action: reduce HR >> increase ventricular filling
time >> improve c.o. >> improve symptoms
- Contraindicated in:
1- HR-dependent cardiac output patients,
2- patients in whom beta-blockade further depresses
ventricular function >> sudden deterioration
31. 4- Oxygen:
- The temptation to give supplemental
oxygen should be avoided in:
1- left to right shunt
2- increased PBF
- Increased inspired oxygen concentration
>> drop in PVR >> marked increase in PBF
>> more severe congestive HF
32. 5- other treatments:
- little evidence of any benefit from use of
digoxin or sodium restriction
- Fluid restriction in combination with diuretics
in patient whose fluid intake already reduced [
SOB ] >> potentially dangerous >> lead to
dehydration >> acute deterioration
- Heart failure with dehydration and hypovolemia
is potentially lethal
33. 6- Nutrition:
- FTT and malnutrition
- Also malabsorption
- increase calorie intake
- with or without NG, NJ, or even temporary
parenteral feeding may help
