This document discusses heart failure in pediatrics. It defines heart failure as the heart's inability to pump enough blood to meet the body's needs. The main causes in children are congenital heart defects and acquired conditions like cardiomyopathy. Common congenital defects that can lead to heart failure include single ventricle, hypoplastic left heart syndrome, and atrioventricular septal defects. Symptoms depend on the age of onset and include poor feeding, fast breathing, cough, and failure to gain weight. Evaluation involves history, exam, echocardiogram, and blood tests. Treatment consists of diuretics, digoxin, and other inotropes to improve cardiac function, along with addressing any precipitating

1. DR. SANDIP GUPTA
PGT,PEDIATRICS
B.S.M.C.H.
HEART FAILURE IN PEDIATRICS

2. DEFINITION
 HEART FAILURE: It is syndrome in which heart is
unable to provide the output required to meet the
metabolic demands of the body(systolic failure)
and/or inability to receive blood in to the
ventricular cavities at low pressure during diastole
(diastolic failure).

3. Causes of heart failure
 congenital
 acquired

4.  Volume overload
 Left-to-right
shunting
 Ventricular septal
defect
 Patent ductus
arteriosus
 Valvular
insufficiency
 Aortic regurgitation in
bicuspid aortic valve
 Pulmonary
 Pressure overload
 Left sided
obstruction
 Severe aortic stenosis
 Aortic coarctation
 Right-sided
obstruction
 Severe pulmonary
stenosis
Causes of Heart Failure in
Children
congenital heart disease

5. Cont.
 CYANOTIC CHD WITH INCREASED PBF
 TGA
 TAPVC
 TRUNCUS ARTERIOSUS
 TRICUSPID ATRESIA WITHOUT PS
 OTHRES
 Single ventricle
 Hypoplastic left heart syndrome
 Atrioventricular septal defect
 Systemic right ventricle
 L-transposition (“corrected transposition”) of the great
arteries

6. TIMING OF ONSET OF HEART
FAILURE
• At birth: HLHS, large A-V fistula,
pulmonary atresia
• 1st wk: TGA, TAPVR, preterm PDA, critical AS or
PS
• 1-4 wk: COA with associated anomalies, critical AS,
PretermVSD/PDA
• 4-6 wk: endocardial cushion defect
• 6 wk-4 mth: large VSD, large PDA,ALCAPA.

7. 2.Acquired Heart Disease
 Primary cardiomyopathy
Dilated
Hypertrophic
Restrictive
 Viral myocarditis
 Acute rheumatic carditis & RHD
 Anthracycline induced cariomyopathy
 Post-op repaired cyanotic CHD
 Cardiomyopathy with muscular dystrophy &
friedrich’s ataxia
 Myocarditis in Kawasaki’s disease
 Hypertensive heart failure in PSGN

8. WHEN TO SUSPECT CCF
• Poor wt gain
• Difficulty in feeding
• Breathes too fast
• Persistent cough and wheezing
• Excessive perspiration, irritability,
restlessness
• Puffiness of face
• Pedal edema
• Diaphoresis

9. APPROACH TO PATIENT
 HISTORY
 PHYSICAL EXAMINATION
 INVESTIGATION
 TREATMENT

10. ClinicalHistory
NEONATES & INFANTS
• Poor feeding
• Tachypnoea worsening during feeding
• Cold sweet on forehead
• Poor weight gain
OLDER CHILDREN
• Fatigue
• Exercise intolerance
• Dyspnoea
• Puffy eyes & pedal edema
• Growth failure

11. Physical examination
Initial investigations
Right sided failure:
•Hepatomegaly
•Facial & pedal edema
•Jugular venus
engorgement
Left sided failure:
•Tachypnoea
•Tachycardia
•Cough
•Wheezing & Rales
Either side failure:
•Cardiomegaly
•Gallop rhythm
•Cyanosis
•Low vol.pulse
•Absence of wt.gain
•CXR
•Cardiac enlargement
•Pulmonary edema
•12-lead ECG
•Pulse-oximetry, CBG,
hyperoxia test
•Echocardiography
•CBC, U&E, calcium,
creatinine, and LFT
•Blood tests
•Thyroid function

12. Clinical diagnosis of CHF
E c h o c a r d i o g r a m
Structural diagnosis
(eg myopathic, valvular)
Pathophysiological diagnosis
Systolic dysfunction (LVEF < 40%)
Diastolic dysfunction (LVEF > 40%)
Proceed to
treatment guidelines

13.  MODIFIED ROSS CLASSIFICTION.
 Class I Asymptomatic
 Class II Mild tachypnea or diaphoresis with feeding in infants
Dyspnea on exertion in older children
 Class III Marked tachypnea or diaphoresis with feeding in infants
Marked dyspnea on exertion
Prolonged feeding times with growth failure
 Class IV Symptoms such as tachypnea, retractions,grunting,
or Diaphoresis at rest

14. NYHA CHF classification for infants
 NYHA I - NO SIGN
 NYHA II - RR>50 , WITH OR WITHOUT HEPATOMEGALY
 NYHA III- ALL ABOVE WITH RIB RETRACTION
 NYHA IV- RR>60/min H/R>160/ min,
WITH HEPATOMEGALY,RIB RETRACTION
WITH OR WITHOUT POOR PERFUSION.

15. Treatment of heart failure state
• General measures
• Medical management
• Treatment of precipitating factors
• Treatment of special condition

16. General measures
• Propped –up position
• Oxygen
• Adequate calories
• Salt restriction
• Bed rest
• Daily wt
• Mx respiratory failure

17. Precipitating factors
• Hypertension
• Anemia
• Arrhythmia
• Hyperthyroidism
• Infection
• Fever

18. Medical management
1.Diuretics
- 1st line of drugs
- ↓ pre-load
- Do not improve
CO
or myocardial
contractility
- Hypokalemia and
hypochloremic
alkalosis
2.Inotropic
agents
-Digoxin
-Dobutamine
-Dopamine
-Amrinone
/milrinone
3.Afterload ↓
agents
Dilators:
Arteriolar-
Veno-
Mixed-
4.B -blockers

19. DIURETICS
 Act by ↓venous return ,end diastolic
volume, ↓ pulmonary edema & work of
breathing.
 Furosemide is diuretic of choice.
 Spironolactone(2-4mg/kg/d) may be
used as add on drug.
 Metolazone(0.1-0.2mg/kg) has been
tried in frusemide resistant edema.

20. Mechanism of action
DIGITALIS : special role in heart failure by ↑
contractility at the same time depressing SA
node & AV node.
•Its half-life of 36hrs, so given
once or twice daily.
•Its absorbed well by GIT,60-
85%.even in
infants,elixir>tablets.
•Initial effect can be seen
within 30min after oral
administration and within
15min after IV.
•Adjust the dose in patients
with renal failure.

21. How to dizitalize the heart ?
1. Baseline ECG & Serum electrolytes
2. Calculate the oral digoxin dosage :
Age Total dizitalizing
dose(μg/kg)
Maintenance
dose(μg/kg/D)
Prematures 20 5
Newborns 30 8
< 2yrs 40-50 10-12
> 2yrs 30-40 8-10
Maintenance dose is 25% of the total dig.dose in 2 divided doses
I.V. dose is 75% of the oral dose.
3. Give one half of the TDD immediately ,then 1/4th & then the final 1/4th
at 6- to 8-hr intervals.
4. Start the maintenance dose 12hrs after the final TDD but before this do
ECG

22. Other ionotropes:
Phosphodiesterase
inhibitors:
Milrinone/amrinone
• Low cardiac output
refractory
to standard therapy
• After open heart surgery
• Adjunct to DA / Dobutamine
• S/E-thrombocytopenia
Adrenergic agents:
Dopamine
• Inotropic,peripheral
vesodilatation,
increased renal blood flow-
natriuresis
• 5-10mcg/kg/min
• In higher doses- peripheral
vesoconstriction
Dobutamine
•2.5-40mcg/kg/min
•Dose is gradually increased

23. Afterload ↓ agents
• Long term trials with Captopril(0.5-6mg/kg) &
Isosorbide dinitrate(0.1mg/kgq6hr) shown
improvement in symptoms & exercise
capacity.
• Used as add on with diuretics & digoxin.

24. ß BLOCKERS
 Effacious in CHF in children due to CHD,
Anthracycline induced cardiomyopathy ,
dilated cardiomyopathy.
 Improved left ventricular function & exercise
tolerance, decreased need for heart transplant.
 It has been shown to improve clinical symptoms
& neurohormonal markers in infants with CHF
due to Lt to Rt shunts.
 Dose should titrated upwards
 Avoid in decompensated heart failure.
 Carvedilol(initial dose0.08→0.46mg/kg)

25. Nonpharmacological treatment
modalities
Cadiac resynchronization
therapy:
BiVP
• cardiomyopathy
• LBBB
LV assist device
Surgery:
(depends on the type of defect)
 Blalock Taussig
shunt
 Balloon
septoplasty
 Mustard Senning
 Jatene’s switch

26. HEART FAILURE IN SPECIAL
CONDITION
 Ductus dependent circulation
 Rheumatic carditis
 Kawasaki’s disease
 Anthracycline toxicity
 Preterm PDA

27. THANK YOU