Congestive cardiac failure

1. CONGESTIVE CARDIAC FAILURE

2.  Definition
Congestive heart failure (CHF) is a clinical syndrome
in which the heart is unable to pump enough blood
to the body to meet its needs, to dispose of systemic
or pulmonary venous return adequately, or a
combination of the two.

3.  Age of Onset Cause
 At birth HLHS
 Volume overload lesions:
 Severe tricuspid or pulmonary insufficiency
 Large systemic arteriovenous fistula
 First week TGA
 PDA in small premature infants
 HLHS
 TAPVR
 Critical AS or PS
 1–4 wk COA with associated anomalies
 Critical AS
 Large left-to-right shunt lesions (VSD,PDA) in
premature
 4–6 wk Some left-to-right shunt lesions such as ECD
 6 wk–4 mo Large VSD PDA

4. Miscellaneous Causes
 Metabolic abnormalities
 Endocrinopathy such as hyperthyroidism
 Supraventricular tachycardia (SVT) causes CHF in
early infancy
 Complete heart block associated with structural
heart defects
 Bronchopulmonary dysplasia
 Severe anemia

5. Acquired Heart Disease
 Dilated cardiomyopathy
 Myocarditis associated with Kawasaki’s disease
 Patients who received surgery for some types of
CHDs
 Viral myocarditis
 Acute rheumatic carditis
 Rheumatic valvular heart diseases,

6. Pathophysiology
 Cardiac output is determined by preload, afterload,
myocardial contractility, and heart rate
1. Increase in preload
2. Increase in after load
3. Decrease contractility
4. Increase HR

7. Compensatory Mechanisms
 Activation of
1. Sympathetic nervous system
 increase in sympathetic tone secondary to increased
adrenal secretion of circulating epinephrine.
 increased neural release of norepinephrine.
2. Renin–angiotensin–aldosterone system
 Angiotensin II may cause a trophic response in
vascular smooth muscle (with vasoconstriction) and
myocardial hypertrophy, attempting to restore
wallstress to normal

8. Symptoms
 Poor weight gain
 Feeding difficulties
 Fast breathing
 Cough and wheezing
 Irritability
 Excessive sweating
 Puffiness of face
 Pedal edema

9. Signs
Right side failure Left side failure
 Facial edema
 Hepatomegaly
 Jugular venous enlargement
 Edema of feet
 Tachypnea
 Tachycardia
 Cough
 Wheezing
 Crepts in chest

10. INVESTIGATIONS
 CXR
 ECG
 2D ECHO
 CARDIAC CATHETERIZATION- Biopsy to diagnose
inflammatory disease, infections, metabolic disorder

11. Treatment
1. Elimination of the underlying causes.
2. Treatment of the precipitating or contributing
causes (e.g., infection, anemia, arrhythmias, fever)
3. Control of heart failure state.

12. GENERAL MEASURES
 Restrict activity
 Propped up position
 Humidified Oxygen
 Sedation
 Diet

13. Treatment of Underlying Causes
 1. When surgically feasible, surgical correction of
underlying CHDs and valvular heart disease is
the best approach for complete cure.
 2. If hypertension is the underlying cause of CHF,
antihypertensive treatment should be given.
 3. If arrhythmias or advanced heart block is the
cause of or contributing factor to heartfailure,
antiarrhythmic agents or cardiac pacemaker therapy
is indicated.

14.  4. If hyperthyroidism is the cause of heart failure,
this condition should be treated.
 5. Fever should be controlled with antipyretics.
 6. When there is a concomitant infection, it should
be treated with appropriate antibiotics.
 7. For anemia, a packed cell transfusion is given to
raise the hematocrit to 35% or higher.

15. Drug Therapy
 Inotropic agents
 Diuretics
 Afterload-reducing agents

16. DIURETICS
 Diuretics remain the principal therapeutic agent to
control pulmonary and systemic venous congestion.
 Diuretics reduce preload and improves congestive
symptoms, but do not improve cardiac output or
myocardial contractility
 Loop diuretics commonly used
 Aldosterone antagonists- used in conjunction with a
loop diuretic

17.  Side effects of diuretic therapy.
1. Hypokalemia
2. Hypochloremic alkalosis may result because the loss
of chloride ions is greater than the loss of sodium
ions through the kidneys

18. Rapidly Acting Inotropic Agents
 In critically ill infants with CHF, in those with renal
dysfunction (e.g., infants with coarctation of the
aorta), or in postoperative cardiac patients with heart
failure, rapidly acting catecholamines with a short
duration of action are preferable to digoxin
 dopamine,
 dobutamine
 epinephrine

19. Digoxin
 Increases CO
 Diuretic effect
 Parasympathetic action- slows HR & inhibits AV
conduction
 The pediatric dosage of digoxin is much larger than
the adult dosage- larger volume of distribution

20.  How to digitalize?
Loading doses of the total digitalizing doses are
given over 12 to 18 hours followed by maintenance
AGE DIGITALIZING
DOSE
MAINTAINANCE
PREMATURE 20 5
NEWBORN 30 8
<2YRS
40-50 10-12
>2 YRS
30-40 8-10

21. Step-by-step method of digitalization:
 1. Obtain a baseline ECG and baseline levels of serum
electrolytes.
 2. Calculate the total digitalizing dose
 3. Give half the total digitalizing dose immediately
followed by one fourth and then the final fourth of the
total digitalizing dose at 6- to 8-hour intervals.
 4. Start the maintenance dose 12 hours after the final
total digitalizing dose.
 Obtaining an ECG before starting the maintenance dose
is advised

22. Afterload-Reducing Agents
 Arteriolar vasodilators - hydralazine
 Venodilators -nitroglycerin, isosorbide dinitrate
 Mixed vasodilators include ACE inhibitors captopril,
enalapril, nitroprusside, and prazosin

23. CARNITINE
 Carnitine, which is an essential cofactor for
transport of long-chain fatty acid into mitochondria
for oxidation, has been shown to be beneficial in
some cases of cardiomyopathy
Most of these patients had dilated cardiomyopathy
 DOSE- 50 to 100 mg/kg/day, given twice a day or
three times a day orally (maximum daily dose, 3 g).
 It improved myocardial function, reduced
cardiomegaly, and improved muscle weakness.

24. THANKYOU