heart chf

1. Heart Failure in
Pediatrics
Dr Keval and Bhadra - 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. Two Types of Heart Diseases
• Congenital Heart Diseases
• Acquired Heart Diseases

4. CONGENITAL HEART
DISEASE
Ventricular septal defect Atrial septal defect TOF
Pulmonary Stenosis Aortic Stenosis
PDA TGA TAPVC Truncus Arteriosus
Tricuspid Atresia DORV DILV APW
Coarctation of Aorta Interrupted Aortic Arch
HLHS Hypoplastic right heart
Pulmonary Atresia Ebstein’s anomaly
ALCAPA TOF-APV
C-TGASingle ventricle Parachute MV
Supra-Mitral Membrane Shone Complex

5. 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.

6. ACQUIRED HEART DISEASE
DCM HOCM Restrictive CM
Viral Myocarditis RHD
MR MV stenosis AR AS
Post OP CM KAWASAKI DISEASE
HYPERTENSIVE PSGN TRAUMATIC
DRUG INDUCED IMMUME/SLE

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

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

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

10. Physical Examination
Left sided failure:
Tachypnoea
Tachycardia
Cough
Wheezing & Rales
Right sided failure:
Hepatomegaly
Facial & pedal edema
Jugular venus engorgement
Either side failure:
Cardiomegaly
Gallop rhythm
Cyanosis
Low vol.pulse
Absence of wt.gain

11. Investigation
• CXR - Cardiac enlargement and Pulmonary edema
• 12-lead ECG
• Pulse-oximetry, ABG, hyperoxia test
• Echocardiography
• CBC, U&E, calcium, creatinine, and LFT
• Thyroid function

12. NYHA and Modified Ross Heart Failure Classification
NYHA Ross
Class I No limitations of physical activity No limitations or symptoms
Class II May experience fatigue, palpitations,
dyspnea, or angina during moderate
exercise but not during rest
Infants: Mild tachypnea or diaphoresis with
feeding
Older children: Mild to moderate dyspnea on
exertion
Class III Symptoms with minimal exertion that
interfere with normal daily activity
Infants: Growth failure and marked
tachypnea or diaphoresis with feeding
Older children: Marked dyspnea on exertion
Class IV Unable to carry out any physical activity
because they typically have symptoms of
HF at rest that worsen with any exertion
Symptoms at rest such as tachypnea,
retractions, grunting, or diaphoresis

13. Treatment Options – Exam Troubles
• General measures
• Medical management
• Treatment of precipitating factors
• Treatment of special condition

14. 1. General Measures
• Propped –up position
• Oxygen
• Adequate calories
• Salt restriction
• Bed rest
• Daily wt
• Mx respiratory failure

15. 2. Medical Treatment
• Hypertension
• Anemia
• Arrhythmia
• Hyperthyroidism
• Infection
• Fever

16. Aims of Medical Management
Treatment
Plan
-Diuretics - 1st line of drugs. ↓ pre-load. Do not improve CO or
myocardial contractility. Hypokalemia and hypochloremic alkalosis
Inotoprope, Chronotrope- Epinephrine, Nor-epinephrine, Digoxin,
Dobutamine, Dopamine, milrinone
Arterio & Venous Dilator

17. Diuretics – Reduce the syllabus
• Loop Diuretics - Furosemide
• Potassium Sparing Diuretics - Spironolactone
• Angiotensin Converting Enzyme blocker– Enalepril
• Aldostarone Receptor 2 – blocker - Losartan

18. Increase Force of Contraction – Support
Study Period
• Digoxin
• Epinephrine
• Nor-epinephrine
• Dobutamine
• Dopamine
• Milrinone
• Levosimendan

19. Arterio – Venous – Mix – Dilators - Extension
• Calcium Channel Blockers
• Nitroglycerine
• Sodiumnitroprusside
• ACE inhibitors
• AT 2 blockers

20. ß BLOCKERS
 Effacious in CHF in children due to CHD, Anthracycline induce
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.
 Carvedilol

21. HEART FAILURE IN SPECIAL
CONDITION
Treating the Cause – Studying Timely
 Ductus dependent circulation
 Rheumatic carditis
 Kawasaki’s disease
 Anthracycline toxicity
 Preterm PDA