CCF in paediatrics

2. DEFINITION
 Inability of the heart to maintain the cardiac
output as per the metabolic demands of the body
i) Systolic failure: inability to push the
blood into the aorta
ii) Diastolic failure: inadequate filling of the
ventricle

3. Modified Ross classification for
children

4. EPIDEMIOLOgy
 In children, the causes of heart failure are
significantly different from adults.
 Many cases are due to congenital malformations
which usually result in high output cardiac failure.
 Some children suffer from low output cardiac
failure such as cardiomyopathy.
 Congenital heart disease(CHD) occurs in around
8/1000 live births.
 Heart failure associated with CHD occurs in
approximately 20% of all patients.
 Many of the children with CHD receive early
surgical intervention and it has been estimated
that the yearly incidence of heart failure as a
result of congenital defects is between 1 and 2
per 1000 live births

5. AETIOLOGY
FETUS
 Severe anemia(haemolysis, fetal-maternal transfusion,
hypoplastic anemia)
 Ventricular tachycardia
 Supraventricular tachycardia
 Complete heart block
 Atrioventricular valve insufficiency
 High-output cardiac failure(atriovenous malformation,
teratoma)

6. PREMATURE NEONATE
 Fluid overload
 Patent ductus arteriosus
 Ventricular septal defect
 Cor pulmonale(Bronchopulmonary dysplasia)

7. FULL TERM NEONATE
 Asphyxial cardiomyopathy
 Arteriovenous malformation(vein of Galen,
hepatic)
 Left sided obstructive lesions(COA, hypoplastic
left heart, critical aortic stenosis)
 Transposition of great arteries
 Large mixing cardiac defects(single ventricle,
truncus arteriosus)
 Viral myocarditis
 Anaemia
 Supraventricular tachycardia
 Complete heart block

8. INFANT/TODDLER
 Left-to-right cardiac shunts(Ventricular septal defect)
 Haemangioma (arteriovenous malformation)
 Anomalous left coronary artery
 Metabolic cardiomyopathy
 Acute hypertension (haemolytic uraemic syndrome)
 Supraventricular tachycardia
 Kawasaki disease
 Postoperative repair of congenital heart disease

9. CHILD/ADOLESCENT
 Rheumatic fever
 Acute hypertension (glomerulonephritis)
 Viral myocarditis
 Thyrotoxicosis
 Haemochromatosis/Haemosiderosis
 Cancer therapy (Radiation, Doxorubicin)
 Sickle cell anaemia
 Endocarditis
 Cor pulmonale (Cystic fibrosis)
 Arrhythmias
 Chronic upper airway obtruction (Cor pulmonale)
 Unrepaired or palliated congenital heart disease
 Cardiomyopathy

10. PATHOGENESIS

11. Clinical Manifestation
-Infants: Poor feeding, Failure to thrive, Tachypnoea,
Diaphoresis with feeding
-Older children: Dyspnea, orthopnea, easy fatigability,
dependent edema, abdominal pain, ascites
-Physical examination findings depend on whether
pulmonary venous congestion, systemic venous
congestion or both are present.
-Tachycardia, a gallop rhythm and thready pulses may be
present with either cause.

13. DIAGNOSTIC CRITERIA

14. INVESTIGATIONS

15. MANAGEMENT
 Treatment of heart failure is actually
management of the neurohumoral mechanism
that cause the presenting signs and
symptoms.
 Initial treatment directed at improving
myocardial function and optimizing preload
and afterload.
 Other aim of treatment is reducing cardiac
work and definitive treatment of the cause.
 Apart from drugs, low-sodium diet, calorie
dense feeds and correction of anaemia helps
manage children with congestive cardiac
failure.

16. 1) General care
 Rest
 Oxygen
 Sodium,fluid restrictions
2) Diuretics
 Furosemide
 Combination of distal tubule and loop diuretics
 Spironolactone

17. 5) Other measures
 Mechanical counterpulsation
 Transplantation
 Extracorporeal membrane oxygenation
 Carvedilol
6) Newer drugs
 Niseritide
 Levosimendan
(offers mixed results based on cause of failure)

18. 3) Inotropic agents
 Digitalis
 Dopamine
 Dobutamine
 Amrinone/Milrinone
4) Afterload reduction
 Hydralazine
 Nitroprusside
 Captopril/Enalapril

19.  Cardiac transplantation is the mainstay with use of
ventricular assist devices as a bridge to the same.
 The two main devices used in patients with heart failure
are the implantable cardioverter defibrillator (ICD)
and cardiac resynchronization therapy (CRT).
 In recent years, the outcome of pediatric transplantation
has continued to improve.
 The most recent data from the The International Society
of Heart and Lung Transplantation demonstrate that the
median survival is :
i)19.7 years for infants,
ii)16.8 years for children ages 1–5 years,
iii)14.5 years for children ages 6–10 years, and
iv)12.4 years for children 11–17 years of age at the time of
transplantation

20. -Various innovations in management such as:
 Stem-cell/myocyte transplant
 Robotic procedures
 Genetic procedures
-However are in experimental stages

21. Complications
 Arrhythmias—Atrial fibrillation, ventricular
arrhythmias (ventricular tachycardia,
ventricular fibrillation), bradyarrhythmias
 Thromboembolism—Stroke, peripheral
embolism, deep venous thrombosis,
pulmonary embolism
 Gastrointestinal—Hepatic congestion and
hepatic dysfunction, malabsorption
 Musculoskeletal—Muscle wasting
 Respiratory—Pulmonary congestion,
respiratory muscle weakness, pulmonary
hypertension (rare)

22. PROGNOSIS
 Morbidity and mortality for all grades of
symptomatic chronic heart failure are high.
 20-30% one year mortality in mild to
moderate heart failure.
 Greater than 50% one year mortality in
severe heart failure.
 These prognostic data refer to patients
with systolic heart failure, as the natural
course of diastolic dysfunction is less well
defined

23. Some predictors of poor outcome in chronic
heart failure
 High NYHA functional class
 Reduced left ventricular ejection fraction
 Low peak oxygen consumption with maximal
exercise (% predicted value)
 Third heart sound
 Increased pulmonary artery capillary wedge
pressure
 Reduced cardiac index
 Diabetes mellitus
 Reduced sodium concentration
 Raised plasma catecholamine and natriuretic
peptide concentrations