Common Cardiac disorders among Children.ppt

Dealing with a child with cardiac
dysfunction is often disconcerting and
we are often unsure of how to proceed
this lecture aims to provide an overview
of common heart pathology in children
and the physiotherapy management
thereof

Background
 Congenital heart defects (CHD) occur in 1% of the live
births (6 of every 1 000)
 Most common congenital abnormality seen
 Approximately 1/3 of these children will require
surgery, whilst the rest of the cases resolve
spontaneously or are deemed haemodynamically
insignificant
 Early surgical intervention is recommended to limit
CVS and neurodevelopmental complications. Most
children are operated on before 1 year of age

Background
 Mortality for children with CHD has decreased
significantly ( ≤ 5 %) as a result of medical
and surgical advances, and many of these
children are surviving well into adulthood.
 The decreasing mortality rates has resulted in
the shift in focus to the neurodevelopmental
status of these children and ways of
addressing the associated developmental
delays

Background
 As PT’s we will encounter children with CHD in
all clinical settings we work in
 Acute care setting – pre/postoperatively
 Sub-acute care setting in the ward
 Out patient department
 As PT’s we need to know:
 What CHD is
 Types of cardiac disorders
 How the child’s CVS system is affected during
exercise
 Prevalent complications associated CHD

Aetiology
 In most cases of CHD the aetiology is multi-
factorial and include
 genetic inheritance (patterns not yet clear)
 Maternal conditions
 Environmental factors
 Above factors interact during the first 8-10
weeks of gestation a critical development
phase of the heart

Cardiac Physiology in the
infant

Normal foetal circulation
 Foetal heart in not dependant on the lungs for
respiration. Instead the placenta is used for
gaseous exchange.
 The R and L ventricles exist in a parallel circuit
 Blood travels through the umbilical vein through
the ductus venosus to the foetal heart via the IVC
to the RA and through the foramen ovale to the LA
 The SVC leads to the RA to the RV to the
pulmonary artery to the lungs or ductus arteriosus
bypassing the lungs into the descending aorta to
perfuse the lower extremities and the body,
travelling back to the placenta via the umbilical
arteries.

Normal foetal circulation
 The blood travelling through the left ventricle
to the aorta perfuses the upper extremities and
the brain.
 All of the blood flowing through the chambers
of the heart, arteries and veins is rich in
Oxygen
 The vessels for pulmonary circulation in the
foetus are vasoconstricted. All blood travelling
in the arteries to the lungs is oxygen rich and
contributes to the nourishment of the lung
tissue

Changes in the circulatory system
at birth
 As the baby takes its first breath the lungs expand,
causing the lung P to fall. This allows the blood to
move more easily into the lung.
 After reaching the lungs and being oxygenated the
blood is moved to the LA. The P on the L side of the
atrial septum becomes higher than on the R causing
the foramen ovale to gradually close (closed by 3/12)
 Once the lungs are filled with air and the oxygen level
in the child’s blood rises the muscle wall of the ductus
arteriosus contracts no longer allowing blood to flow
through the ductus. The ductus arteriosus closes 10-
15 hours after birth.
 Now child has separate oxygenated and de-
oxygenated blood and relies fully on the lungs for
gaseous exchange

Normal circulation after birth

Common heart disease in
children

Congenital heart defects
 At any point in the development of the cardiac
system problems can arise leading to
congenital heart disease.
 CHD can be classified into two main groups:
 Cyanotic lesions ( ↓O2 saturation in the blood)
 Acyanotic lesions (O2 saturation unaltered, but
can result in pressure or volume related issued)

Common cardiac conditions seen in children

Acyanotic Congenital Heart
Defects

Classification of Acyanotic
heart lesions
 Coarctation of aorta
 Pulmonary stenosis obstructive in nature
 Aortic stenosis
 Patent ductus arteriousus
 Atrial septal defects
 Ventral septal defects increased pulmonary
bloodflow
 Atrioventricular septal defects with shunting O2 rich blood
from
left to right
“PINK BABY”

Patent Ductus Arteriosus (PDA)
 The ductus arteriousus is the foetal vascular
connection between the main pulmonary trunk and the
aorta which under normal circumstances closes soon
after birth (usually within the first week of life).
 If it stays open excessive blood shunts from the aorta
ton the lungs
 Causing pulmonary oedema and in the long run
pulmonary vascular disease
 Symptoms may vary from mild to severe depending
on the magnitude of the shunt
 Very common in premature infants and may further
complicate weaning from the ventilator and result in
CHF

 clinical signs and symptoms of significant PDA
 Poor feeding
 Failure to thrive (below weight for and height for
age)
 Sweating with crying or play
 Persistent tachypnoea or breathlessness
(dyspnoea)
 Easy tiring
 Tachycardia
 Frequent lung infections
 A bluish or dusky skin tone
 Developmental delay

 Management Closing of PDA can be induced
using medication
(indomethacin)
Surgically
 Surgical correction is done via a thoracotomy

Atrial Septal Defect (ASD)
 An ASD is an opening or whole in the wall
separating the atria
 This permits free communication of blood
between the two atria.
 Seen in 10% of all congenital heart disease
 Rarely presents with signs of congestive
heart failure or other cardiovascular symptom
 Most are asymptomatic but may have easy
fatigability or mild growth failure. The right
atrium and ventricle may enlarge over time
 Cyanosis does not occur unless pulmonary
hypertension is present.

Atrial Septal Defect (ASD)
Management:
 Surgical or catheterization closure is usually
indicated
 Closure is performed electively between ages 2 &
5 yrs if the whole has not closed in order to avoid
late complications. Children may be on
anticoagulant therapy for 6 months to prevent
clotting
 Surgical correction is done earlier in children with
congestive heart failure or significant pulmonary
hypertension

Venticular Septal Defect (VSD)
 A VSD is an abnormal opening in the ventricular
septum, which allows free communication
between the right and left ventricles ventricles.
 Oxygen rich blood in the left ventricle is then
pumped into the right ventricle through the
opening instead of to the body. In a large VSD
excessive blood is pumped to the lungs resulting
in congestion and shortness of breath.
 In return excessive amounts of blood are pumped
back from the lungs to the left heart
overburdening and enlarging it resulting in CHF

 In case of a small VSD most children are
asymptomatic and 50% will close spontaneously
by age 2yrs
 In the case of a moderate or large VSD the child
will be symptomatic. This may include
dyspnoea, feeding difficulties, failure to thrive
recurrent respiratory infections and profuse
sweating

Management
 In case of a small VSD 50% will close
spontaneously
by age 2yrs
 Large VSD’s are usually closed surgically

Atrioventricular Septal Defect
(AVSD)
 AVSD results from the incomplete fusion of the
tendocardial cushions, which help to form the
lower portion of the atrial septum, the
membranous portion of the ventricular septum
and the septal leaflets of the triscupid and mitral
valves.
 They account for 4% of all CHD
 Commonly associated with chromosomal
disorders Down Syndrome
 Clinical findings include CHF in infancy,
recurrent respiratory infections, failure to thrive,
exercise intolerance and easy fatigability.

(AVSD)

(AVSD)
Treatment
 Surgery is always required.
 Prior to surgery congestive symptoms are
treated.
 Pulmonary banding maybe required in
premature infants or infants < 5 kg.
 Correction is done during infancy to avoid
irreversible pulmonary vascular disease.

Pulmonary artery banding
 The primary is to
reduce excessive
pulmonary blood flow
and protect the
pulmonary
vasculature from
hypertrophy and
irreversible (fixed)
pulmonary
hypertension.

Truncus arteriosus
 Defect characterised by a
single arterial trunk arising
from both ventricles from
which the aorta and
pulmonary arteries arise
from a single semi-lunar
valve

Pulmonary hypertensive crisis
 Can be a severe complication post operatively
 Children at risk of pulmonary hypertension are those
with excessive shunting of blood from left to right e.g.
VSD, AVSD
 This results in excessive bloodflow to the lungs
resulting in distension and damage to the pulmonary
artery wall which becomes muscularised
 Unable to dilate and vulnerable to reactive
vasoconstriction
 Hypoxaemia, hypercapnea, metabolic acidosis as well
as relentless handling (including by the
physiotherapist) and tracheal suctioning may
predispose the child to a hypertensive crisis.
 In children at risk physiotherapy should be indicated,
treatment must be quick and effective and vitals need

Pulmonary hypertensive crisis
 In the case of a crisis the
pulmonary arteries
constrict resulting in an
increase in pulmonary
artery pressure and CVP.
The systemic blood
pressure will drop
suddenly resulting in
cardiac arrest.
 Treatment includes
sedation, paralysis and the
administration of Nitric
Oxide and 100% oxygen to
try and facilitate pulmonary
vasodilatation

Coarctation of the aorta
 Congenital narrowing of the aorta as it leaves
the heart anywhere from the transverse arch to
the iliac bifurcation.
 Resulting in increased pressures in the arteries
nearest the heart, head and arms and
decreased circulation in lower extremities.
 7 % of all CHD
 Male: Female ratio 3:1

 This is often not evident in the newborn until
the ductus arterious closes causing a
constriction. The blood in the left ventricle has
then to be pumped out against the constriction.
 Child presents with symptoms of left
ventricular hypertrophy and left ventricular
failure, with congestive heart failure. Changing
a healthy baby into a baby that has hard
breathing, is sweaty and wheezing.

Management:
 With severe coarctation maintaining the ductus with
prostaglandin E is essential
 Early surgical repair and resection of the stenosis
is imperative
 Simple coarctation repair have a extremely low
mortality but in complex cases mortality might be
higher
 A rare complication of surgical repair is paraplegia
(longer cross clamping times during surgery)
 In 18% of children undergoing surgery re-
coarctation occurs

Obstructive causes
 Is an obstruction to the
outflow from the left
ventricle at or near the
aortic valve.
 Resulting in left
ventricular overload and
hypertrophy
 Accounts for 7% of
CHD.
 Is obstruction in the
region of either the
pulmonary valve or the
sub-pulmonary
ventricular outflow tract.
 Pulmonary circulation
decreased
 Work of the RV increased
 RV hypertrophy
 ↓ cardiac output
 Accounts for 7-10% of
all CHD.
Aortic Stenosis Pulmonary Stenosis

Obstructive causes
 Asymptomatic in mild
cases, in more severe
cases fatigue, syncope
and dyspnoea
 Treatment is surgical
repair
 Symptoms include
dyspnoea, exercise
intolerance, fatigue CHF
and hypoxaemia
 Treatment is surgical
repair

Obstructive causes

Cyanotic Congenital Heart
Defects

Classification of cyanotic
heart lesions
Cyanotic heart lesions include:
 Tetralogy of Fallot
 Hypoplastic left heart
 Trasposition of the great vessels

Tetralogy of Fallot (TOF)
 Most common cyanotic heart lesion
 Has 4 components:
 A high VSD
 Pulmonary stenosis
 Anomalous position aorta
 RV hypertrophy
 Results in a right to left shuntting of blood with low
oxygen levels in the artieires and in the body tissues
 Resulting in cyanosis, easy fatigability, fainting and
shock.
 Clubbing may be observed

Tetralogy of Fallot (TOF)
 Early surgical intervention (TOF repair) is
usually required
 Palliative care by means of anestomosis and
pulmonary valvotomy can be done

Hypoplastic Left Heart Syndrome
(HLHS)
 Most serious congenital heart malformation
with the poorest of prognosis
 Means that the left ventricle is extremely small
and the mitral valve and aortic valves may be
missing
 Symptoms usually minimal until the ductus
arteriosus closes causing shock and multi-
organ failure

(HLHS)
 Treatment prpstaglandin E1 until surgery
 Initial palliative surgeries
 Heart transplant is often the suggested option

(HLHS)

Other Congenital Heart
Defects

Transposition of the great
vessels
 Aorta arises from the RV and the pulmonary
arteries arise from the LV
 The 2 circulations namely the systemic and
pulmonary are in parallel instead of in series
 Venous blood circulates around the body and
oxygenated blood around the lungs
 May be dyspnoea, cyanosis and syncope

vessels

vessels
 Treatment
 Palliative surgeries including pulmonary
banding or atrial septum excision
 Corrective surgery

Cardiomyopathy
 Primary heart muscle disease
 Cardiomyopathy is a chronic and sometimes
progressive disease in which the heart muscle is
abnormally enlarged, thickened and/or stiffened.
 The condition typically begins in the walls of the
ventricles and in more severe cases also affects
the walls of atria)
 The actual muscle cells as well as the
surrounding tissues of the heart become
damaged.
 Hallmark is depressed cardiac functioning.
Eventually, the weakened heart loses the ability to
pump blood effectively and heart failure or
irregular heartbeats (arrhythmias or dysrhythmia)

Cardiomyopathy
 "primary cardiomyopathy" where the heart is
predominately affected and the cause may be
due to infectious agents or genetic disorders
 "secondary cardiomyopathy" where the heart
is affected due to complications from another
disease affecting the body e.g. HIV, cancer,
muscular dystrophy or cystic fibrosis

Cardiomyopathy
 Cardiomyopathy can affect a child at any stage
of their life. It is not gender, geographic, race
or age specific.
 Rare disease in infants and young children.
 Cardiomyopathy continues to be the leading
reason for heart transplants in children.
 Complications may include arrythmias, heart
block, blood clots, congestive heart faiulure,
endocarditis and sudden death

Heart transplant
 Heart transplantation is used only as an option in
end stage heart failure in children with heart
defects or cardiomyopathies that are
unresponsive to surgery or medication
 Heart failure may occur in children with CHD post-
operatively due to the nature of their artificial
circulations
 Individual units have their own transplant
protocols
 A heart transplant presents a ling risk of organ
rejection and infection
 The transplant half life of children is estimated at
18 years

Assessment of the child with
CHD
History
Will need to conduct an interview
with the family:
 Children often have a very long and
complicated medical and often
surgical history that has to be well
document
 Medications that the child is taking
e.g. blood thinners, and
immunosuppressant drugs
 Social, economic and family
circumstsances need to be
determined (CHF highly stressful to
the family unit- high divorce rate)
 Developmental history –these
children often present with
developmental delays
 Is child receiving any early
intervention services e.g.
physio/OT
 Child’s general health
 Sleeping patterns’
 Current and previous level of
functioning
 ADL – if child of schoolgoing age
is he attending school.
 What is their chief complaint with
the child:
 Most common complaint from
parent with children awaiting
surgery is failure to thrive and
poor feeding. I
 In older children it is often
lethargy, fatigue

CHD
Interview with paediatric
cardiologist
 Nature of the CHD
 Intervention and treatment
planning
 Precautions
 Need for physiotherapeutic
intervention

heart disease
Oxygenation –laboratory
results
 Arterial blood gas values
and saturation monitor
reading are incredibly
important when assessing
a patient with cardiac
dysfunction
 Cyanotic lesions the ABG
may be reduced due to the
mixing of arterial and
venous blood
Vital sign parameters
 The following reading need
to be taken manually or
read off the monitor HR,
RR, BP prior to your
assessment to serve as
baseline values
 Important to retake vital
signs during assessment
and after as well

Assessment of the child
with heart disease
PaO2
60-80 mmHg
= SaO2 90-95%
PaO2
40-60 mmHg
= SaO2 60-90%
Mild hypoxaemia
PaO2 ≤
40 mmHg
= SaO2 ≤ 60%
Severe
hypoxaemia

heart disease
General observations
 Child’s LOC – is he sedated,
on a neuromuscluar blocker
(paralysis) in children where
any movement or position
changing has a negative
impact on the CVS function)
 Equipment and indwelling
devices
 Pain
 Integrity of the skin
 Surgical sites and wounds
e.g. sternotomy/
thoracotomy
 Clubbing
 Oedema
 Capillary refill
 Cyanosis central and
peripheral

heart disease
Respiratory system
 Chest shape
 Chest deformities
 Chest expansion
 Thoracic mobility;
flexion, extension, lateral
flexion, rotation
 Breathing pattern
 Shoulder girdle tightness
and mobility
 Shortness of breath
(tachypnoea)
 Dyspnoea and grade
 Cough
 Sputum
 Auscultation
 If ventilated –ventilator
settings

heart disease
Musculoskeletal
system
 Posture
 ROM
 Muscle strength
Functional ability &
ADL
 Functional and ADL
tasks appropriate for
age need to be
assessed in line with
the child’s condition

heart disease
Aerobic capacity,
endurance and
exercise tolerance
 In younger children
observe during
activity and play-
monitor HR
 In older child can do
the 6 min. walk test
 Shortness of breath
can objectively be
monitored through
the ventilatory index
in older children
 Can also use the
dyspnoea index or
Borg scale but it is
often subjective and
difficult in children

Ventilatory index
child must inhale deeply and count to 15 (8 seconds)
0
• Count aloud to 15 without taking a breath
1
• Count aloud to 15 taking 1 breath
2
• Count aloud to 15 taking 2 breaths
3
4

Dyspnoea Index
1
• Breathlessness barely noticeable
2
• Breathlessness moderately bothersome
3
• Breathlessness severe and very
uncomfortable
4
• Most severe breathlessness ever
experienced

Borg scale of perceived exertion
6-8 • Very, very light
8-10 • Very light
10-12 • Fairly light
12-14 • Somewhat hard
14-16 • Hard
16-18 • Very hard
18-20 • Very, very hard

Preoperative physiotherapy
 Seeing the child prior to surgery affords the
physiotherapist the opportunity to get to know the
child and their family, makes the post-operative period
far easier.
 Provides an opportunity to do a quick respiratory,
developmental and functional assessment
 In other cases it might be a child you know well from
previous inpatient/out patient visits to adress
recurrent respiratory tract infections and
neurodevelopmental delays
 Explain the operation in simple terms and tell him/her
and the parents about the post operative stay in PICU
(lines, ventilator ,ET tubes etc.). Also indicate the
post-operative role of the physiotherapist.

Preoperative physiotherapy
aims
 Maintain joint ROM, circulation and function
pre-operatively
 Correct posture and positioning in bed
 CPT if indicated to clear secretions and
breathing exercises
 Teach older child how to cough with
wound/chest support
 Maintain functional abilities as cardiovascular
status allows

Postoperative physiotherapeutic
problems
 Pain –see child has adequate sedation
 Decreased air entry
 Retained secretions
 Ineffective cough –must cough with wound
support
 Reduced UL movements
 Decreased mobility
 Family and caregiver education

Postoperative physiotherapy
 Avoid physiotherapy in the first few hours after
surgery as they are aiming to stabilise the child and
achieve haemodynamic stability
 The exception to the rule here may be in the case of
a lobar collapse on the post-operative CXR or poor
ABG. In this case careful physiotherapy is to be
done avoiding any deterioration in haemodynamic
status

Postoperative physiotherapy
When not to treat
Confidence in treating cardiothoracic patient only
comes with experience, but accurate assessment
will reveal the needs of the child:
Treatment should be avoided in the following cases:
 Haemodynamic instability
 Tachycardia or bradycardia
 Hyper/hyptensive
 Child in a pulmonary hypetensive crisis

intervention
 Localised breathing exercises if child awake and of
age or tactile neurophysiological stimulation
 Modified postural drainage positions are used
as the head down position may compromise
cardiac output and diaphragm functioning
 Mechanical vibrations, gentle percussions (ensure
adequate analgesia) and suctioning to remove
secretions
 Must give chest support when coughing
 Bilateral UL mobility above 90 degrees
 Correct positioning for ventilation and posture
Intubated in the ICU

intervention
 Children are usually extubated quickly unless
underlying lung pathology or secondary infection.
 Teach huffing & coughing with chest support
 Localised and lateral basal breathing exercises or
can use blowing pin-wheel, bubbles, incentive
spirometry
 Manual CPT techniques if indicated
 Functional activities e.g. teaching log rolling, coming
up into sitting
 Active bed exercise programme
 Older child can sit out in a chair in the unit
Extubated in the ICU

intervention
Exercise rehabilitation in paediatric patients
 Mobilisation can be start once inotropic drugs
stopped and some of drains removed
 Studies in children show an improvement in work
capacity & VO2 max following a 6-8 week
rehabilitation exercise programme
 Not much research has been done on rehabilitation
exercise programmes in children
Ward

intervention
Exercise rehabilitation in paediatric patients
An at risk group for exercise.....
 There is a small population of children who are at
risk of sudden death ( hypertrophic cardiomyopathy,
coronary artery anomalies, Marfan Syndrome, Aortic
valve stenosis and long QT syndrome)with physical
activity and sport participation.
 These children need to be identified and restriction
placed on competitive sport and high intensity
physical activity
Ward

intervention
 Start with activity and endurance training
 Allow older child to walk, cycle and stair climb (can be
taught to monitor own HR)
 Smaller children uses play and functional activities
 Pay attention to the following principles
 mode : walking, cycling
 Duration (sick children shorter intensity e.g. 3-5 minutes
 Frequency (3-5/wk)
 Intensity: monitor exhaustion, dyspnoea and HR (not a
rise of ≥ 20 beats)
 In older children where stress ECG can be done, the
child can exercise at 60 -65% of maximal HR
Ward

intervention
Aerobic and endurance training
 Not all patients e.g. Left to right shunt have
impaired exercise tolerance where in some
cases children with cyanotic heart lesions and
severe abnormalities may have impaired
exercise tolerance due to the hypoxemia
 Exercise tolerance is also often affected by
recurrent hospitalisations, inactivity and periods
of bed rest
 Therefore post operatively there must be a
progressive exercise plan aiming to improve the
child’s cardiovascular fitness and endurance
Ward and out patient basis

intervention
Aerobic and endurance training
 Over time children that have had a complete defect
repair at an early age should have normal
cardiovascular functioning-with normal age expected
exercise tolerance and endurance
 In cases where complete repair was not possible and
cardiac functioning still impaired the child have to
monitor HR and signs of fatigue can aim at improving
endurance and at least maintaining it where possible
 Sporting activity in cases of impaired cardiac function
needs to be reviewed by the interdisciplinary team

intervention
Strength training
 General strength training may be undertaken
pre- and postoperatively although there is a
6-8 week postoperative restriction on lifting
activities for children
 Important that children breathe correctly
during resistance training in order not to
increase the blood pressure

intervention
Neurodevelopmental outcomes in children with heart
disease:
CHD often has a significant impact on a child’s
development
 Cause of delays are often multifactorial
 Child with CHD may have brain insults prior to surgery
due to prolonged hypoxaemia
 Studies have found that children with CHD show
delays in all main areas of development as well as
tonal abnormalities (hypotonia), abnormal posture
emotional and behavioural difficulties
 Following open heart surgery children may suffer from
mild hypotonia, motor problems and CMD may occur

intervention
Neurodevelopmental outcomes in children with heart
disease:
 language development also delayed in many cases.
Even at one year after surgery most children were still
behind for age. Delayed gross and fine motor
development also impacted negatively on perceptual
skills.
 Children often exhibited behavioural problems and
greater caregiver dependency

intervention
Neurodevelopmental therapy
 Age appropriate play is an important activity that can
be used in order to get a child to move
 In cardiac patient it is often important to then try and
get the child accustomed to prone over towel enven on
a caregivers lap during awake, play time. Prone is an
important developmental position.
 Nerodevelopmental assessment and therapy to aid the
child in catching up on his age appropriate milestones
is often essential post operatively especially in
younger children who were acutely ill and failed to
thrive.
 Regular developmental monitoring would also be

Family and caregiver support
 A family suffers huge amounts of anxiety and
stress in the case of having a child with CHD
 The distress, frustration and reaction shown by
the mother may affect the relationship with the
child
 Often over-restriction and over-observation of
children with CHD by parents
 The child’s reaction and adjustment to their illness
is largely related to the emotional and behavioural
reaction of the family
 Physiotherapist can play an important role by
providing support and encouraging more positive
interactions within the family

References
 Ammani Prasad, S. & Main, E. Paediatrics in Physiotherapy
for respiratory and cardiac Problems. Adults and children 4th
ed. Pryor, J.A. & Ammani Prasad, S. (eds.)358-363
 E-medicine. 2010. pulmonary artery banding.
Available online at:
http://emedicine.medscape.com/article/905353-overview
 Hendon. K.L. Not dated. Congenital Heart Disease
(slideshow)
 Children’s Cardiomyopathy Foundation. 2010. About the
disease.
Available online at:
http://www.childrenscardiomyopathy.org/site/description.php

References
 Pepper, J.R.; Anderson, J.M. & Innocenti, D.M. 1992. Cardiac
surgery in Cash’s Textbook of chest, Heart and Vascular
disorders for Physiotherapists. 4th ed. Downie, P.A. (ed).
Mosby, london pp 407-429
 Bar-Or, O. & Rowland, T.W. 2004. Cardiovascular disease in
Paediatric exercise medicine. From physiological principles to
healthcare application. Human Kinetics, USA Pp177-217
 Brossman, H. 2008. Cardiac disorders in Pediatric Physical
Therapy. 4th ed. Telin, J.S. (ed.). Lippincott williams Wilkins,
Baltimore pp 589-609

References
 Main, E. 1998. Paediatric Cardiothoracic Surgery in Paediatric
Management in Cardiovascular/Respiratory Physiotherapy.Smith,
M. & Ball,V. (eds.).Mosby, London pp291-298
 Image courstey of GOOGLE images (2010)

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