essential of paediatric cardiology
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Essential of paediatric cardiology
Robyn SmithDepartment of Physiotherapy
UFS2011
Causes of CHD
Genetic
Maternal Environmental
First 8-10 weeks of gestation critical in development of the
heart
CHD affects 1% of children
Foetal circulation • Not dependant on the lungs
for respiration• Placenta is used for gaseous
exchange• All of the blood flowing
through the chambers of the heart, arteries and veins is rich in Oxygen
• Pulmonary vessels are vasoconstricted
Change in circulation after birth• As the baby takes its first breath the
lungs expand, causing the lung P to fall and air enter lungs.
• Once the lungs are filled with air and the oxygen level in the child’s blood rises resulting muscle wall of the ductus arteriosus contracts no longer allowing blood to flow through it (10-15 hours after birth)
• This forces pulmonary circulation into action
• Now child has separate oxygenated and de-oxygenated blood and relies fully on the lungs for gaseous exchange
Classification of CHD
CHD
Cyanotic lesions
↓O2 saturation in the blood
Acyanotic lesions
O2 saturation unaltered, pressure or volume related
issued
Acyanotic lesions
Left to right shunting of blood
PDA
ASD
VSD
AVSD
Obstructive
Coarctation
Pulmonary stenosis
Aortoc stenosis
Conditions where there is a left to right shunting of blood
Patend Ductus Arteriousus (PDA)
Patend Ductus Arteriousus (PDA)
• Ductus arteriousus open in the foetal circulation
• Vascular connection between the main pulmonary trunk and the aorta
• Closes soon after birth • If it stays open excessive blood shunts from the
aorta ton the lungs• Resulting in pulmonary oedema• Common in premature infants
Patend Ductus Arteriousus (PDA)
Clinical signs and symptoms of a PDA:
Poor feedingFailure to thrive (below weight for and height for age) Sweating with crying or play Persistent tachypnoea or breathlessness (dyspnoea)Easy tiring Tachycardia Frequent lung infections A bluish or dusky skin toneDevelopmental delay
Medical management PDA
• Management Closing of PDA:
• Medication (indomethacin) induces closure• Surgical closing via a thoracotomy
Atrial Septal Defect (ASD)
Atrial Septal Defect (ASD)
• Opening or whole in the wall separating the atria• Free communication of blood between the two
atria. • Seen in 10% of all congenital heart disease• Rarely presents with signs of congestive heart
failure or other cardiovascular symptoms• The right atrium and ventricle may enlarge over
time• Cyanosis does not occur unless pulmonary
hypertension is present.
Clinical signs and symptoms of ASD
• Most are asymptomatic • May have easy fatigability or mild growth
failure.
Atrial Septal Defect (ASD)
Medical management of ASD
• Surgery of catheterization
Venticular Septal Defect (VSD)
Venticular Septal Defect (VSD)
• Abnormal opening in the ventricular septum.• Allows free communication between the right and left
ventricles • Oxygen rich blood in the left ventricle pumped into the
right ventricle instead of to the body. • In a large VSD excessive blood is pumped to the lungs
resulting in congestion and shortness of breath.• In return excessive amounts of blood are pumped back
from the lungs to the left heart overburdening and enlarging it resulting in CHF
Venticular Septal Defect (VSD)
Clinical signs and symptoms of VSD
• Small VSD most children are asymptomatic • In the case of moderate to large VSD the child
will be symptomatic. dyspnoeafeeding difficultiesfailure to thrive recurrent respiratory infections profuse sweating
Medical management of VSD
• In case of a small VSD 50% will close spontaneously by age 2yrs
• Large VSD’s are usually closed surgically
Atrioventricular Septal Defect (AVSD)
Atrioventricular Septal Defect (AVSD)
• Result from incomplete fusion of :tendocardial cushions which help to form the lower
portion of the atrial septum, the membranous portion of the ventricular septum
and the septal leaflets of the triscupid and mitral valves.
• 4% of all CHD• Commonly associated with chromosomal
disorders such as Down Syndrome
Atrioventricular Septal Defect (AVSD)
Clinical signs and symptoms of an AVSD
• The child may present with:CHF in infancyrecurrent respiratory infectionsfailure to thriveexercise intoleranceeasy fatigability
Medical management of AVSD
• Surgery is always required.
Prior to surgery congestive symptoms are treated.Pulmonary banding maybe required in premature
infants or infants < 5 kg.Correction is done during infancy to avoid
irreversible pulmonary vascular disease.
What is pulmonary banding?
• Primary aim procedure is to reduce excessive pulmonary blood flow
• In order to protect the pulmonary vasculature from hypertrophy and
• irreversible (fixed) pulmonary hypertension.
Other less common conditions
Surgical complications: Pulmonary hypertension
• Can be a severe complication post operatively• Children at risk of are those with excessive
shunting of blood from left to right e.g. VSD, AVSD• This results in excessive blood flow to the lungs
resulting in distension and damage to the pulmonary artery wall which becomes muscularised
• Pulmonary artery is then unable to dilate and vulnerable to reactive vasoconstriction
May predispose the child to a hypertensive crisis.
The following may predispose a child to a hypertensive crisis:
• Hypoxaemia• Hypercapnea• Metabolic acidosis as well as • relentless handling (including by the physiotherapist) • Tracheal suctioning may predispose the child to a
hypertensive crisis.
Surgical complications: Pulmonary hypertension
• In the case of a pulmonary hypertensive crisis the pulmonary arteries constrict resulting in an increase in pulmonary artery pressure and CVP.
• The systemic blood pressure drops suddenly resulting in cardiac arrest.
• Treatment includes sedation, paralysis and the administration of Nitric Oxide and 100% oxygen to try and facilitate pulmonary vasodilatation
Pulmonary hypertension
and PT
Only do PT if clearly indicated
Adequate sedation
Muscle relaxant
/paralysisO2
supplementation
BE QUICK and effective !!!!
Monitor vitals
Conditions where there is a obstructive cause
Coarctation of the aorta
Coarctation of Aorta
• Congenital narrowing of the aorta as it leaves the heart.
• Resulting in:increased pressures in the arteries nearest the heart,
head and arms decreased circulation in lower extremities.
• 7 % of all CHD• Male: Female ratio 3:1
Coarctation of Aorta• This is often not evident in
the newborn until the ductus arterious closes
• The blood in the left ventricle has then to be pumped out against the constriction.
• Resulting in :left ventricular hypertrophy left ventricular failure with
congestive heart failure (CHF)
Clinical signs and symptoms of coarctation
• The child may present with:CHF“Hard” breathing”WheezingExcessive sweating
Coarctation of Aorta
Medical management of a Corarctation of Aorta
• With severe coarctation maintaining the ductus with prostaglandin E is essential
• Early surgical repair and resection of the stenosis is imperative
• Simple coarctation repair have a extremely low mortality but in complex cases mortality might be higher
• A rare complication of surgical repair is paraplegia (longer cross clamping times during surgery)
• In 18% of children undergoing surgery re-coarctation occurs requiring further surgical intervention
Obstructive causes
• Asymptomatic in mild cases, • More severe cases fatigue,
syncope and dyspnoea
• Treatment is surgical repair
• Symptoms include dyspnoea, exercise intolerance, fatigue, CHF and hypoxaemia
• Treatment is surgical repair
Aortic Stenosis Pulmonary Stenosis
Obstructive causes
Aortic Stenosis Pulmonary Stenosis
Cyanotic heart lesions
Cyanotic lesions
Tetrallogy of Fallot
Hypoplastic left heart
Transposition of great vessels
Tetrallogy of Fallot (TOF)
Tetrallogy of Fallot (TOF) • Most common cyanotic heart lesion
• Has 4 components:– A high VSD– Pulmonary stenosis– Anomalous position aorta– RV hypertrophy
• Results in a right to left shunting of blood with low oxygen levels in the arteries and in the body tissues
• Resulting in cyanosis, easy fatigability, fainting and shock.• Clubbing may be observed
Tetrallogy of Fallot (TOF)
Medical management of TOF
• Early surgical intervention (TOF repair) is usually required
• Palliative care by means of anestomosis and pulmonary valvotomy can be done
Hypoplastic Left Heart Syndrome
Hypoplastic Left Heart Syndrome (HLHS)
• Most serious congenital heart malformation• Poorest of prognosis• Means :
left ventricle is extremely small and under-developed mitral valve and aortic valves may be missing
• Symptoms usually minimal until the ductus arteriosus closes causing shock and multi-organ failure
Hypoplastic Left Heart Syndrome (HLHS)
Medical management of Hypoplastic Left Heart Syndrome
• Treatment prpstaglandin E1 until surgery • Initial palliative surgeries• Heart transplant is often the suggested option
Transposition of the great vessels
Transposition of the great vessels• big vessels are in the wrong place –aorta and pulmonary artery
are switched:Aorta arises from the RV Pulmonary arteries arise from the LV
• The 2 circulations namely the systemic and pulmonary are in parallel instead of in series
• Venous blood circulates around the body and oxygenated blood around the lungs
• May be dyspnoea, cyanosis and syncope
Medical management of Transposition of the great vessels
• Palliative surgeries including pulmonary banding or atrial septum excision
• Corrective surgery
Non-congenital heart diseases
Cardiomyopathy
• Primary heart muscle disease• chronic and (sometimes progressive disease) in
which the heart muscle is abnormally enlarged, thickened and/or stiffened.
• The condition typically begins in the walls of the ventricles and in more severe cases also affects the walls of atria
• The actual muscle cells as well as the surrounding tissues of the heart become damaged.
Clincal signs and symptoms of cardiomyopathy
• Hallmark is depressed cardiac functioning.• Eventually, the weakened heart loses the
ability to pump blood effectively leading to: heart failure or irregular heartbeats (arrhythmias or dysrhythmia)
Cardiomyopathy
"primary cardiomyopathy“ where the heart is
predominately affected cause may be due to infectious
agents or genetic disorders
"secondary cardiomyopathy" where the heart is affected due to complications from another
disease affecting the body e.g. HIV, cancer, muscular dystrophy or cystic fibrosis
Cardiomyopathy
• Cardiomyopathy can affect a child at any stage of their life.
• It is not gender, geographic, race or age specific.
• Rare disease in infants and young children.• Cardiomyopathy continues to be the leading
reason for heart transplants in children.
Complications related to
CardiomyopathyArrhythmias'
CHF
Blood clots
Endocarditis
Sudden death
Heart transplantation
LAST OPTION/RESORT in end stage heart failure in children
with heart defects or cardiomyopathy that are
unresponsive to surgery or medication
Heart transplant
• Heart failure may occur in children with CHD post-operatively due to the nature of their artificial circulations
• Individual units have their own transplant protocols• A heart transplant presents a high risk of organ
rejection and systemic infection• The transplant half life of children is estimated at 18
years
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