1. The Child with Cardiovascular Dysfunction
Prepared by /miss:Amira Ali

2. Out line over view on Fetal circulation Physiological changes at birth
Congenital Heart Disease (CHD)
Cyanotic heart disease
A cyanotic heart disease

3. Objectives At the end of these lecture all student will be able to
Identify Fetal circulation
mention the main Physiological changes at birth
define causes of Congenital Heart Disease (CHD)
Identify Cyanotic heart disease
Identify A cyanotic heart disease

4. Fetal Circulation

6. Fetal Circulation
Fetal circulation (prenatal circulation) differs from adult circulation in several ways and is designed to ensure a high oxygen blood supply to the brain and myocardium of the fetus.

7. Characteristics of fetal circulation
Placenta is the source of oxygen for the fetus, it has 2 arteries and 1 vein.
Fetal lungs receive less than 10% of the blood volume ; lung don’t exchange gas.
Right atrium of fetal heart is the chamber with the highest oxygen concentration.

8. The three openings that close at birth are:
Ductus Arteriosus connects the pulmonary artery to the aorta, bypassing the lungs
Ductus Venosus connects the umbilical vein and the inferior vena cava bypassing the liver.
Foramen Ovale is the opening between right and left atrias of the heart , bypassing the lungs.

9. Pattern of fetal circulation
Oxygenated Blood is carried from placenta through the umbilical vein and enters the inferior vena cava thought the Ductus Venosus .
This permits most of the highly oxygenated blood to go directly to the right atrium , bypassing the liver.

10. ….. Continue pattern
This right atrial blood flows directly into the left atrium through the foramen ovale an opening between the right and the left atriums .

11. ….. Continue pattern
From the left atrium blood flows directly into left ventricle and the Aorta through the subclavian arteries , to the cerebral and coronary arteries , resulting in the brain and the heart receiving the most highly oxygenated blood .

12. ….. Continue pattern
Deoxygenated blood returns from the heart and the arms through the superior vena cava, enters the right atriums and passes into the right ventricle.

13. Blood from the right ventricle flow into pulmonary artery, but because fetal lungs are collapsed, the pressure in the pulmonary artery is very high .

14. ….. Continue pattern
Because pulmonary resistance is high , most of the blood passes into the distal aorta through the Ductus Arteriosus, which connects the pulmonary artery and the aorta distal to the origin of the subclavian arteries.
From the aorta blood flows to the rest of the body.

15. Normal circulatory changes at birth

18. Physiological changes at birth
Foramen Ovale: Opening Between Atria; Allows Blood to Bypass Lungs intrauterinely; Closes With Increased Left-Sided Pressure
Ductus Arteriosus: Opening Between Pulmonary Artery & Aorta; Allows Blood to Bypass Lungs intrauterinely; Closes Within Hours After Birth With Permanent Closure By Days of Life

19. ….. Physiological changes
Cyanosis results from 5 or more Grams of Unoxygenated Hemoglobin per 100 ml of Blood: So, If Hemoglobin is Low, You Won’t See Cyanosis In Spite of Low PaO2!

20. ….. physiologic
Polycythemia: Increase in Production of Erythrocytes To Compensate for Chronic Hypoxemia; If Hemoglobin Greater Than 20 g/dl & Hematocrit Greater Than 55-60%, Increased Risk for thromboembolism
Infants Respond to Severe Hypoxemia With BradyCardia

21. Normal vital signs at birth
Heart rate= beat/min
Blood pressure= 65/41 mmHg
Respiratory rate= breath/min
Temperature= Axillary oC.
Oxygen saturation (SpO2 )= >93%

22. Congenital Heart Disease (CHD)
Approximately 5-8 Per 1000 Live Births; Combination of Genetic & Environmental Factors : X-ray exposure
Maternal Rubella
Maternal alcoholism
Maternal type 1 diabetes
Maternal over 40 of age
Occur EARLY in Gestation (3-8 Weeks) in the first trimester

23. CHD Classification of CHD: Acyanotic versus cyanotic Acyanotic
Pulmonary
Blood flow
Obstruction to
Blood flow
from ventricles
Pulmonary
blood flow
Mixed
blood flow
Atrial septal defect (ASD)
Ventricularr septal defect (VSD)
Coarctation of Aorta
Aortic stenosis
Tetrology of Fallot
Tricuspid atresia
Transposition
Of great vessels
Truncus arteriosus

24. Selected Acyanotic defects
(1) ASD, or atrial septal defect:
Abnormal opening between atria, allowing blood from Lt atrium (higher pressure) to go to right atrium (lower pressure).
Pathophysiology:
the new volume in the right ventricle is tolerable because it was sent by a low pressure from the right artium.
S&S: Patients may be asymptomatic they may develop heart failure, atrial arrhythmias are present.
Surgical treatment: Surgical Dacron Patch Closure .
Non-surgical Repair: in catheterization, a repair pad is implanted.
Patients with ASD may live several decades without S&S and the prognosis after operation is very high.

25. …. Cont. acyanotic (2) VSD, or Ventricular Septal Defect:
It is an abnormal opening between the right and
the left ventricles, resulting in a common ventricle.
its found that 20% of all VSDs close
spontaneously during the first year of life
Pathophysiology: the blood turns from
the left ventricle (higher pressure) to the
right ventricle(lower pressure) causing
left-to-right shunt , then to pulmonary
Artery, which increases RV pressure causing
RV hypertrophy and by time RV failure.
S&S : congestive heart failure is common.
Surgical treatment: complete repair.
Non-surgical treatment: closure devise is usually implanted during cardiac catheterization

26. -Aortic Stenosis
Stenosis of the aortic valve prevents blood from passing from the left ventricle into the aorta, leading to hypertrophy of the left ventricle
S/S
Usually asymptomatic but with murmur
May have chest pain and even sudden death
Therapeutic Management
Stabilization with a Beta Blocker or Calcium Channel Blocker
Balloon valvuloplasty
Valve replacement
Figure 41.13
Aortic stenosis:
Read slide….S/S: most children are asymptomatic. A rough systolic murmur is heard loudest in the aortic space and may radiate to the right shoulder, clavicle, and up the neck. If the stenosis is severe, the child may show signs of decreased cardiac output and develop chest pain during activity. Sudden death may also occur. DX by echo. Treatment with Beta blockers or Calcium channel blockers is used to reduce cardiac hypertrophy before the defect is corrected. Balloon valvuloplasty is the treatment of choice; however, surgery may be indicated in which case a valve replacement may be performed.

27. Coarctation of the Aorta
Narrowing of the lumen of the aorta
S/S
Absence of palpable femoral pulses; headache, vertigo, nosebleeds, CVA; leg pain
Therapeutic Management
Surgery or angiography
Figure 41.14
Coarctation of the aorta is a narrowing of the lumen of the aorta due to a constricting band. This makes if difficult for blood to pass through the narrowed lumen of the aorta, causing increased blood pressure in the heart and upper portions of the body. The child may have a headache and vertigo due to the increased pressure. With younger children, irritability may be the only sign that there is a problem. Nosebleeds and cerebrovascular accidents (CVAs) may also occur due to the high pressure. Older children may complain of leg pain. Depending upon the degree of coarctation, the child may exhibit absence of palpable brachial and/or femoral pulses. Treatment involves either interventional angiography or surgery.

28. Selected cyanotic defect: - Tetrology of Fallot (TOF)
- Tricuspid Atresia
- Transposition of the Great Arteries or Vessels
- Truncus Arteriosus

29. Tetrology of Fallot (TOF)
The classic form includes four defects: (1) ventricular Septal Defect, (2) pulmonic stenosis,(3) overriding aorta, (4) right ventricular hypertrophy.
Pathophysiology: the altered hemodynamic status depends on the size of the pulmonary stenosis, blood get shunted from right to left, if the pressure in the pulmonary is higher than the systemic pressure, and blood gets shunted from left to right if the systemic pressure is higher than pulmonary. S&S: cyanosis, clubbing fingers, poor growth. crying during or after feeding.
Surgical treatment: complete repair is required, open heart surgery& VSD closure.

30. Defects with decreased pulmonary blood flow
Tricuspid Atresia
The tricuspid valve is closed, blood flows through the patent foramen ovale into the left atrium, bypassing the lungs. Then it is shunted back through a PDA into the lungs. When these structures close, cyanosis, tachycardia, and dyspnea occur. Surgery must correct.
Treatment: IV infusion until surgery
Figure 41-18
With Tricuspid Atresia, the tricuspid valve is completely closed, allowing no blood to flow from the right atrium to the right ventricle. Since blood cannot flow in the normal pattern, blood crosses through the patent foramen ovale into the right atrium, bypassing the lungs and the step of oxygenation. It is then shunted back through the PDA (patent ductus arteriosis) into the lungs. As long as these structures remain open, the child can obtain adequate oxygenation; however, once these structures close, the child will develop severe cyanosis, tachycardia, and dyspnea. Treatment consists of an IV infusion of PGE (prostaglandin) to keep the ductus open until surgery can be performed.

31. CONAL–TRUNCAL DEFECTS
Conal–truncal defects develop during the formation of the trunk dissection. Embryologically, the pulmonary artery and the aorta begin as a large “trunk.” The ventricles then fold on themselves, the atria rise into position, and the great vessels form when the trunk twists around and separates (having a dividing wall). Transposition of the great vessels(TGA) and truncus arteriosus occur in children when there is a disruption in this process.

32. Transposition of the Great Arteries or Vessels
SIGNS AND SYMPTOMS. Symptoms appear at birth or soon afterwards and include cyanosis, shortness of breath, poor feeding, and clubbing of the fingers and toes.
DIAGNOSIS. Diagnosis is based on signs and diagnostic testing including pulse oximetry, ECG, echocardiogram, chest x-ray exam, and cardiac catheterization. If an echocardiogram is done before birth, it is called a fetal echocardiogram.
Surgical treatment. TGA in all cases must be surgically corrected

33. Truncus Arteriosus
SIGNS AND SYMPTOMS. Clinical signs and symptoms of truncus arteriosus include cyanosis, congestive heart failure, and low cardiac output.
DIAGNOSIS. Diagnosis is based on signs and diagnostic testing that includes pulse oximetry, ECG, echocardiogram, chest radiograph, and cardiac catheterization.
Surgical treatment. TGA in all cases must be surgically corrected

34. Cardiac Diseases SUBACUTE BACTERIAL ENDOCARDITIS
(SBE) occurs subsequent to a bacterial infection or introduction of an infective agent into the child’s blood stream
The infection may be caused by an invasive procedure such as surgery, urological procedures, or most often dental cleaning.
(SBE) is most commonly seen in patients with an unrepaired congenital heart defect or valve disease, but can also occur in normal hearts

35. low-grade fever : malaise, loss of appetite, and muscle aches
SIGNS AND SYMPTOMS
low-grade fever : malaise, loss of appetite, and muscle aches
A high fever: chills, sweating, stiff joints, or back pain can indicate that acute illness has occurred
DIAGNOSIS. thorough medical history and a physical exam are essential to diagnosis. Which contain
1- symptoms 2- valve replacement
3- bacterial or fungal infection(dental procedures)

36. Treatment:
SBE is treated with antibiotics, but the most effective approach is prevention.

37. CARDIAC SURGERY Discharge Teaching:
Activity Tolerance;
No Bike Riding Until Sternotomy Healed
Signs & Symptoms of Wound Infection
Return to School in 2 Weeks
Usually, No Further Cardiovascular Problems
ALLOW THE CHILD TO LIVE A NORMAL AND ACTIVE LIFE!

38. Congestive Heart Failure (CHF)
Cardiac Output (CO) Inadequate to Support Circulatory & Metabolic Needs
Causes: volume overload, pressure overload, decreased contractility, high cardiac output demands
Infant Tires During Feeding (OFTEN FIRST Indication of CHF)
Symptoms Increase With Progressing Disease
Cardiomegaly Occurs As Heart Attempts to Maintain Cardiac Output
If Tachycardia Greater than BPM; Ventricles Unable to Fill & CO Falls

39. CHF CHD Most Common Cause of CHF in Infants
S/S: Tachycardia Diaphoresis, Tachypnea,
Feeding problem, Crackles & Respiratory Distress; Edema, increase weight
CXR Shows Large Heart.
Echocardiogram is Diagnostic.

40. CHF Medical Management: Digoxin To Make Heart Work More Efficiently
Lasix/Diuretics To Remove Excess Fluid
Oxygen: Potent Vasodilator which decreases pulmonary vascular resistance.
Rest, a neutral thermal environment, semi- Fowler position, cluster care to promote uninterrupted rest

41. CHF Nursing care Monitor physiologic functions: BP, HR, RR
Prevent infection; Group care; Semi-Fowler position.
Adequate Nutrition: Feeding Techniques: 45 Degree Angle; Rest Frequently.
Promote Development: Play, Age Appropriate Toys, Physical Activities With Rest Periods
Emotional Support: Prevent Hypoxia From Agitation or Distress; Consistency(suport) of Caregiver for Patient; Refer-Parent-to-Parent Support Groups.

42. RHEUMATIC FEVER
Inflammatory Disease Following Initial Infection by Group A Beta Hemolytic Streptococci; Cause Changes in Heart, Joints, Skin & CNS.
Diagnosis: ESR( erythrocyte segmentation rate), CRP(C- reactive protein), ASLO (anti-streptolysin O- titers)
Treatment With Antibiotics To Treat Strep Infection
Aspirin To Control Joint Pain & Inflammation
Prevention is Best
Treatment: Throat Culture & Treat With Antibiotics for 10 Days

43. The End