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 & friedrichs ataxia Myocarditis in Kawasakis 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(g/kg) Maintenance dose(g/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. 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 dose0.080.46mg/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 Jatenes switch 26. HEART FAILURE IN SPECIAL CONDITION Ductus dependent circulation Rheumatic carditis Kawasakis disease Anthracycline toxicity Preterm PDA 27. 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