The document discusses congestive heart failure (CHF) in children. It defines CHF as a state of systemic and pulmonary congestion due to failure of the heart pump to meet the metabolic needs of the body. Causes of CHF include ventricular dysfunction, preserved ventricular function with volume or pressure overload. Symptoms vary with age from tachypnea and diaphoresis with feeding in infants to exercise intolerance and dyspnea in older children. Treatment involves controlling congestion through diuretics, afterload reduction with ACE inhibitors, and ionotropes like digoxin. Management of underlying cardiac lesions and advanced support with ECMO or VADs may also be required. Nutritional management is important for improving

1. Congestive Heart Failure
Current Perspectives
Arvind Sindwani
1

2. Congestive Heart Failure
Definition
“State of systemic & pulmonary congestion”
Failure of heart pump
Metabolic needs of body
2

3. Congestive Heart Failure
Reasons
 Ventricular Dysfunction
 Preserved ventricular function
with volume overload
 Preserved ventricular function
with pressure overload 3

4. Congestive Heart Failure
Compensatory mechanisms
 ↑ Contractility
 Sympathetic over activity
 Fluid retention ( RAA system)
> Compensated
> Decompensated
4

5. Congestive Heart Failure
Symptoms
 Infants – Tachypnea, diaphoresis during feeding
 Young children – FTT, easy fatigability, recurrent
cough, wheezing
 Older children – Exercise intolerance, anorexia,
wheezing, dyspnea, palpitation, chest pain,
syncope 5

6. Congestive Heart Failure
Physical Examination
 Tachycardia
 Signs of poor perfusion
 S3 gallop
 Tachypnea, Wheeze, Crepitations
 Hepatomegaly
6

7. Congestive Heart Failure
Initial Evaluation
 Chest Radiography – Cardiomegaly,
Pulmonary edema, pleural effusion etc.
 Electrocardiography- arrthymia, evidence for
myocarditis, cardiomyopathies, ALCAPA
 Echocardiography - To see anatomy and
function
 CBC, RFT, LFT 7

8. Congestive Heart Failure
Further Evaluation
 MRI Heart
 Cardiac Catheterization
 Additional Blood tests such as cTnT, CK-
MB,CRP, IL-6, TNF-α, ESR etc
 BNP and NT-pro BNP
8

9. Management of CHF
Principles
1.General measures
2.Control of congested state
- Drug management
3.Treatment of precipitating events
4.Treatment of cause
9

10. Management of CHF
General measures
 Propped up position
 Sedatives/ Morphine
 Supplement Oxygen
 Respiratory support
 Nutritional management
10

11. Drug Treatment
> Compensated stage
> Acute / Decompensated stage
11

12. Drug Treatment
> Compensated stage
Diuretics
Afterload reduction (ACE inhibitors)
Ionotropes (Digoxin)
12

13. Drug Treatment
Diuretics
‘Quick relief ’ from congestion
 Frusemide – standard prescription
 Side effects – Ototoxicity, dehydration,
electrolyte imbalance, renal stones
 Torsemide – More potent than Furosemide
13

14. Drug Treatment
Diuretics
 K sparing diuretics – Spironolactone, Eplerenone
Spironolactone has shown to improve survival in adults
 Thiazide diuretics – Hydrochlorthiazide,Metolazone
Thiazide are mainly used in mild hypertension, edema
Caution – Weight & SE monitoring
14

15. Drug Treatment
ACE inhibitors
Proven improvement in morbidity & mortality
in CHF in large scale trials
 Beneficial effects on ventricular remodeling & hypertrophy
 First line drugs
 Captopril – 0.5 - 6 mg/kg/day
 Enalapril – 0.1 - 0.2 mg/kg/day
15

16. Drug Treatment
ACE inhibitors
 Side effects - Hyperkalemia
- Hypotension
- Neutropenia
- Cough, altered taste
Caution - drug interactions, hyperkalemia
- C/I in azotemia & obstructive lesions
16

17. Drug Treatment
Digoxin
 Dosage Preterm Infants Children
>Oral Loading 0.02 mg/kg 0.04 mg/kg 0.03 mg/kg
( ½ dose initially, ¼ + ¼ in next 24 hours )
>Maintenance 0.005 mg/kg 0.01 mg/kg 0.01 mg/kg
>Intravenous - 75% of oral doses
 Side Effects - Nausea, vomiting, headache
- Arrhythmia 17

18. Drug Treatment
Digoxin
 Traditional drug, most widely prescribed
 Mechanism – Inhibition of Na - K ATPase
 Effects – Improve contractility
– Sympatholytic
– Vagotonic
– Delay in AV conduction
 Role in L → R shunt lesions – controversial 18

19. Drug Treatment
Digoxin
Caution - Hyperkalemia
- Pre – existing rhythm disturbances
- Renal dysfunction
- Drug interactions
19

20. Drug Treatment
Newer Drugs
Selective B – blockers - Carvedilol
 Extensively studied in DCM
 Important add-on drug to standard regimen
 Dose – 0.02 – 0.4 mg/kg/day, titrate up
gradually
 S/E – hypotension, bradycardia, ↓ CF 20

21. Drug Treatment
Newer Drugs
Angiotensin II receptor antagonists - Irbesartan
Losartan
 Recent metanalysis did not show any benefit
over ACE i s
21

22. Drug Treatment
> Acute / Decompensated stage
* Acute resuscitation & stabilization
* Ionotropic support
* Vasodilators
* Advanced support & other options
22

23. Drug Treatment
> Acute / Decompensated stage
Goals
* Restoration of adequate BP
* Effective perfusion
* Correction of hypoxia & acidosis
23

24. Drug Treatment
Ionotropes CHF
Decompensated / Shock
Hypotensive Normotensive
Epinephrine Dopamine
Dopamine Dobutamine
Nor epinephrine Amrinone/ Milrinone 24

25. Myocardial Dysfunction
• Milrinone (5 Phosphodiasterase inhibitors)
Dose
• 0.25 - 0.8 mcg/kg/minute IV infusion
Side effects
• Hypotension, Arrhythmia (less)
25

26. Drug Treatment
Vasodilators
 Nitroglycerine – Venodilator
 Dose – 0.5 – 1 mcg/kg/min
 Effective in pulmonary edema
 Caution – BP monitoring
 Sodium Nitroprusside – Arterial dilator
 Dose – 0.5 to 10 mcg/kg/min
 Acute LVF/ hypertension
 Caution – BP monitoring, cyanide toxicity
26

27. Drug Treatment
Vasodilators
 Nesiritide – Human type B natriuretic peptide
 Dose – 2 mcg/Kg stat f/b 0.01 mcg/kg/min
 Systemic vasodilator with modest natriuretic
properties
 Limited data in pediatric patients
27

28. Drug Treatment
Inotropes
 Levosimendan – Calcium channel sensitizer
 Does not increase myocardial O2 Consumption
 Not arrythmogenic at therapeutic levels
 Istaroxime – Nonglycoside Na K ATPase inhibitor
 Uncouples inotropy and arrythmogenicity
 Lesser tachycardia than dobutamine
28

29. Drug Treatment
Vasopressin Receptor Antagonists
2 types of vasopressin receptors V1a and V2
 Dual (V1a&V2)receptor antagonist:
Conivaptan,
 SelectiveV1areceptor antagonist:
Relcovaptan
 Selective V2 receptor antagonist :
Tolvaptan, Mozavaptan ,Satavaptan
Although provide short term benefit in hyponatremia
and edema long term results are awaited 29

30. Role of PGE 1
 Life saving drug in critically ill neonates
 Duct dependent CHDs
– CoA, HLHS, PS, TGA
 Dose – 0.05 - 0.4 mcg/kg/min infusion
 S/E – Apnea, hypotension, irritability, seizures
30

31. Severe PAH
• Sildenafil
 Dose - 0.3mg/kg – 3mg /kg / 6-8 hrly
 Caution
- Infection, Deranged LFT
- Gross CHF
Monitor
- CBC, RFT, LFT
31

32. Severe PAH
• Nitric Oxide
Dose- 5 – 80 ppm
 Problems
- Cost
- Special Equipment
32

33. Anaemia & CHF
• No structural heart defect
• Hb <6 gm%
• Acyanotic heart defect
• Hb <10 gm%
• Cyanotic heart disease
• Hb <12 gm%
33

34. Arrhythmias
Cause of CHF
– Tachyarrhythmia (common)
– Bradyarrhythmia ( rare )
Precipitating/ Contributory factor
Diagnose and treat accordingly
34

35. Arrhythmias
Tachycardia
• 8 months old/M
• Persistent CHF
• ECG
– Narrow QRS Tachycardia
• Echo
– Dilated LV,LV Dysfunction
– No Structural Heart Defect
35

36. Arrhythmias
SVT
• Treated With
– Adenosine IV bolus
Inj Adenosine
– Continued Tx with
• Digoxin
• Flecainide
– Follow up at 6 months
• Normal LV size and function
36

37. Arrhythmias - Bradycardia
• 1 year / F, Failure to thrive
• On exam – LVE, CHF
• ECG
– Complete Heart Block
• Echo
– Corrected TGA, no septal defect
• Underwent PPI
– No LVE / CHF at 1 y FU
37

38. Cardiac Lesions
L →R shunts
Obstructive Lesions
Admixture Lesions
Ventricular Dysfunction
38

39. L → R Shunts
• Patent Ductus Arteriosus
• Premature Babies –
– Indomethacin / Ibuprofen
– Surgical ligation
» Ventilator dependence
» If CHF / PAH persisting
Even in NICU setting
• Term Babies –
If CHF – Closure at presentation
39

40. L → R Shunts
• VSD
– Single large VSD
» Elective surgery at 3-6 m
» Early if indicated
– Multiple VSDs
» PA band as initial palliation
» Closure of VSDs after 1 year
• ASD
– Elective closure 2-3 yrs
– Early if CHF
40

41. L → R Shunts
• AVSD
• Elective surgery
– 8-12 weeks
– Early surgery
» Significant MR
» Persistent CHF / FTT
• Aorto-Pulmonary Window
• Surgery at 4-8 weeks
41

42. Obstructive Lesions
• Left sided lesions
• Critical AS
– Balloon Aortic Valvoplasty
• Critical CoA
– Surgery / Balloon Dilation
• Right sided lesions
• Critical PS
– Balloon Pulmonary Valvoplasty
42

43. Admixture Lesions
• TGA
• Arterial switch
– Intact Septum – 2 to 4 wks
– With VSD – 4 to 8 wks
• TAPVC
• Surgery at presentation
• Truncus Arteriosus
• Elective Surgery at 4 – 8 weeks
43

44. Myocardial Dysfunction
• ALCAPA
– Surgery at time of presentation
– Excellent results
44

45. Myocardial Dysfunction
• 45 days / M
• Clinical evaluation
• Convulsion, CHF
• Blood Inv
• Hypocalcaemia
• Echo
– LVEF-30 %,N coronaries
• Tx – Cal, Vit D, Decongestives
• Follow up – n EF after 8 wks
45

46. Myocardial dysfunction
Myocarditis
• Role of IVIG (May be helpful)
• Beta Blockers
• IV Inotropes - Milrinone
46

47. Advanced life support
 Extracorporeal Membrane Oxygenation
(ECMO)
 Ventricular Assist Devices (VADs)
 Intraaortic Balloon Pump (IABP)
 Biventricular synchronized pacing
47

48. Management of CHF
Nutritional Management
 Failure to thrive
- common
- multifactorial
 High caloric diet – up to 150 – 170 kcal / kg / day
 Low salt diet, Fluid restriction (If hyponatremic)
 Nasogastric, Transpyloric, Gastrostomy feeds
 Better nutritional care → Improved survival
48

49. Cardiac Transplantation
• Heart / Heart- Lung transplantation
• Patients with
* End stage heart disease
* Complex CHDs
* Eisenmenger’s Syndrome
49

50. Take Home Message
Presently most patients with CHF can be
salvaged, if evaluated timely and
managed appropriately
50

51. Facilities Available in
Department of Paediatrics
8 bedded Tertiary Care NICU
High end state of art neonatal ventilator
Computerized monitors for measuring
invasiveBlood pressure, Heart rate,
ECG,SpO2 etc.
51

52. Facilities Available in
Department of Paediatrics
Open care warmers.
Syringe pumps
CFL Phototherapy unit
Infant Flow driver CPAP machine
Experienced nursing staff with
neonatal training. 52

53. Facilities Available in
Department of Paediatrics
Taking care of extreme preemies,
Newborns with birth asphyxia,
Meconium aspiration, pneumonia etc
with morbidity and mortality levels
comparable to best centers in India.
53

54. Facilities Available in
Department of Paediatrics
High end state of art
PaediatricVentilator
Successfully doing various Paediatric
cardiac, surgical and urologic procedures
such as PDA ,ASD device closure, VSD
closure, TOF repair, Ureteric 54

55. 55