1. The Child with Cardiovascular Dysfunction
Lecture 2

2. Congenital Heart Disease
Are anatomic abnormalities of the heart that are present at the birth and impair cardiac function.
Two main clinical manifestation HF
Hypoxia

3. Location of the Heart
The heart is located in the chest between the lungs behind the sternum and above the diaphragm. It is surrounded by the pericardium. Its size is about that of a fist, and its weight is about g.

6. Pediatric differences
Cardiac functioning:
Infants have a great risk of heart failure than older child because the immature heart is more sensitive to volume or pressure overload.
Heart muscle fully developed at five year.
Metabolic rate and oxygen requirements double at birth so the HR is high

7. Congenital Heart Disease
Incidence: 5-8 per 1000 live births
About 2-3 of these are symptomatic in first year of life.
Major cause of death in first year of life (after prematurity)
Most common anomaly is VSD (Ventricular septal defect )
85% with newborn are expected to survive.

8. Risk factors Maternal rubella during pregnancy.
Maternal alcoholism, drug use.
Maternal age
Maternal type one diabetes.
Several genetics factors, down syndrome , turner syndrome

9. Down Syndrome
is a genetic abnormality. It is the most common single cause of birth defects, This syndrome occurs because of an extra copy of chromosome 21.
Sign and symptom
flat facial features
small head and ears
short neck
bulging tongue
eyes that slant
upward
oddly shaped ears
poor muscle tone.
impulsive behavior
poor judgment
short attention span
slow learning capabilities

10. Turner's Syndrome
Cause: Turner's Syndrome is caused by a condition known as Monosomy (absence of entire chromosome) of X chromosome for females.
Primarily Affects: Females
Discovered By: Dr. Henry H. Turner
Symptoms: Low-set ears, webbed neck, broad chest, non-working ovaries, hypothyroidism, diabetes, vision problems, neuro/cognitive deficiency, congenital heart disease, etc.
Turner's Syndrome occurs in approximately 1 of every 2,000 female births.

11. Changes at Birth
Foramen ovale
Ductus arteriosus
Ductus venosus

13. Pediatric Indicators of Cardiac Dysfunction
Poor feeding
Tachypnea/ tachycardia
Failure to thrive/poor weight gain/activity intolerance
Developmental delays
+ Prenatal history
+ Family history of cardiac disease

14. Fetal Circulation
During pregnancy blood is transferred from placenta through umbilical vein into the ductus venosus (opining into the inferior vena cava).
Then blood is carried to the right atrium in which is forced into the left atrium by an opining between the two atriums called foramen ovale.
Blood is transferred into the left ventricles and to the whole body through aorta.
Some blood pass into the right ventricle, in which it moved to the lungs by the pulmonary artery.
But, the majority of this blood pass into the aorta by an opining between aorta & pulmonary artery called ductus atreriousus

15. Fetal Circulation
After birth, the newborn start breathing which increase the lung expansion, helping in shifting of blood into the lungs by the pulmonary artery not into the aorta by the ductus arteriosus as during pregnancy.
This will lead to increase pulmonary blood flow & decrease pulmonary vascular resistance.
Also leading to increase blood returned to the left atrium through pulmonary veins & this leads to increase pressure in the left atrium.
The increasing pressure stimulate the closure of the foramen ovale and. Ductus arteriosus close in response to increase O2saturation after hours and permanently after days.

17. Two Types of Cardiac Defects
Congenital
Anatomic>abnormal function
Acquired
Disease process
Infection
Autoimmune response
Familial tendencies

18. Diagnostic procedure Cardiac catheterization Chest X ray Echo ECG
Treadmill Test
Holter monitor
Hyperoxi test
MRI

19. Newer Classification of CHD
Increased pulmonary blood flow
Decreased pulmonary blood flow
Obstruction of blood flow out of the heart
Mixed blood flow

20. 1. Increased Pulmonary Blood Flow Defects
Abnormal connection between two sides of heart
Either the septum or the great vessels
Increased blood volume on right side of heart
Increased pulmonary blood flow
Decreased systemic blood flow

21. Increased Pulmonary Blood Flow Defects
Examples:
Atrial septal defect - ASD
Ventricular septal defect - VSD
Patent ductus arteriosus - PDA

22. Atrial Septal Defect - ASD
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 atrium.
S&S: CHF, poor growth with large ASD, murmur.
Surgical treatment Surgical Dacron Patch Closure or open heart surgery
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.

24. ASD Three types: Ostium primum ASD1 ( lower end of the septum )
Ostium secundum ASD2 ( center of the septum )
Sinus venosus defect (opening near junction of SVC & right atrium)
Complication: arrhythmias, Murmur, emboli

25. ASD patch or device

26. 2) VSD, Ventricular Septal Defect:
VSD 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. Increase number of pulmonary Infection , pulmonary hypertention
Surgical treatment: complete repair.
Non-surgical treatment: closure device is usually implanted during cardiac catheterization

28. VSD Device

29. (3) PDA: Patent Ductus Arteriosus
it’s failed to closed at birth ,blood will shunt from the aorta to the pulmonary artery.
S & S: dyspnea, tachycardia, tachypnia widening pulse pressure, hypotension CHF, Intercostals retraction, High risk to respiratory infection

31. Treatment
Observation . In a premature baby, a PDA often closes on its own. The doctor will monitor your baby's heart to make sure the open blood vessel is closing properly.
Medications. In a premature baby, nonsteroidal anti-inflammatory drugs (NSAIDs) — such as ibuprofen (Advil, Infant's Motrin, others) or indomethacin (Indocin) — might be used to help close a PDA. NSAIDs block the hormonelike chemicals in the body that keep the PDA open.

32. Treatment
Open-heart surgery. If medications aren't effective and your child's condition is severe or causing complications, open-heart surgery might be recommended. A surgeon makes a small cut between child's ribs to reach child's heart and repair the open duct using stitches or clips.

33. 2. Obstruction of blood flow out of the heart
Coarctation of the Aorta (COA)
Localized narrowing near the insertion of the ductus arteriosus resulting an increase the pressure proximal to defect.
Sign and symptom:
Pulse in the arms strong, weak or abcsent in the lower extremities, hypotensive, acidosis, headache and fainting

34. Treatment 1. Resection with end-to-end anastomosis:
This method involves removing the narrowed segment of the aorta (resection) followed by connecting the two ends of the aorta together (anastomosis).
2. Bypass graft repair. This technique involves bypassing the narrowed area by inserting a plastic tube called a graft between the portions of the aorta.
3. Patch aortoplasty. treat coarctation by cutting across the narrowed area of the aorta and then attaching a patch of synthetic material to widen the blood vessel. Patch aortoplasty is useful if the coarctation involves a long segment of the aorta.

35. Treatment cont … 4. Balloon angioplasty and stenting
Balloon angioplasty is an option for initially treating aortic coarctation or for treating re-narrowing (re-coarctation) that has occurred after surgery.
During this procedure, the doctor inserts a thin, flexible tube (catheter) into an artery in your groin and threads it through your blood vessels to your heart using X-ray imaging.
doctor places an uninflated balloon through the opening of the narrowed aorta. When the balloon is inflated, the aorta widens and blood flows more easily.

36. COA

37. 3. Decreased pulmonary blood flow
Obstruct the pulmonary blood flow result in little or no blood reaching the lung to get oxygenated.

38. 3.Decreased pulmonary blood flow
Tetralogy Of Fallot (TOF):
The classic form includes:
Ventricular septal defect.
Pulmonary stenosis.
Overriding aorta.
Right venticular hypertrophy.

40. Tetralogy Of Fallot (TOF):
Pathophysiology:
the altered hemodynamic status depends on the size of the VSD and 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. Pulmonary stenosis decreases blood flow to lungs & consequently the oxygenated blood that returns to Lt side of the heart.
Surgical treatment: complete repair is required, open heart surgery& VSD closure

41. Tetralogy Of Fallot (TOF):
Sign and symptom: cyanosis, murmur, hypoxia, clubbing of fingers, poor growth
Patient at risk of: emboli, CVA, seizures and sudden death.
Surgical intervention: complete repair in the first year of the life.

42. The nurse instruct the mother to place the infant in knee chest position to facilitate breathing.

43. 4. Mixed defect
Transposition of the great arteries (TGA)

44. Transposition of the great Arteries
The aorta arises from the right ventricle and the pulmonary artery from the left.
The mixing of the blood occurs at the PDA.
The signs include cyanosis and cardiomegaly.
There may be no murmur.
An echocardiogram is diagnostic
Or X ray. 44

45. What are the symptoms of TGA?
Cyanosis is noted in the first hours of life
Rapid breathing
Hypoxia, CHF developed
labored breathing
Rapid heart rate
Cool, clammy skin

46. Diagnostic test Chest x-ray Electrocardiogram Echocardiogram (echo)
Cardiac catheterization

47. Echocardiogram

48. Treatment
Prostaglandin is ordered to maintain a patent ductus arteriosus.
Oxygen administered
Surgery before 1 week.
Survival with out surgery is impossible.

49. Congestive Heart Failure (CHF)
CHD Most Common Cause of CHF in Infants
S/S: Tachycardia, Diaphoresis, Tachypnea,
Feeding problem, Crackles & Respiratory Distress, Edema, weight gain.
CXR Shows Large Heart.
Echocardiogram is Diagnostic.

50. Congestive Heart Failure (CHF)
Medical Management:
Digoxin To Make Heart Work More Efficiently
Not given if HR less than 90 for infant.
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

51. CHF Nursing care Monitor physiologic functions: BP, HR, RR
Assess crackels
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 of Caregiver for Patient; Refer-Parent-to-Parent Support Groups.
CHF

52. Nursing Process Overview for the Child with CHD
Assessment
Health History
pregnancy, feeding problems, siblings , respiratory difficulty and family history.
Physical Examination
Sign and symptom (respiratory distress and poor feeding.
Growth problems.
Edema
Cyanosis, murmur 52 52

53. Assess for sign and symptoms of hypoxemia
Polycyethemia
Clubbing
Cyanosis
Assess the tongue and buccal membrane
Assessment (cont’d)
Laboratory and Diagnostic Testing
Cardiac Catheterization

54. Nursing Diagnosis:
Activity intolerance related to decreased tissue oxygenation.
Anxiety related to hypoxia
Decrease cardiac out put related to increased cardiac workload.
Delayed growth and development related to hypoxia.
Risk for infection related pulmonary stasis.

55. Nursing intervention of the Child with CHD
Improving Oxygenation.
Promoting Adequate Nutrition.
Offer frequent high calorie every three hrs.
Provide iron supplements
Maintain hydration
Blood transfusion
Assisting the Child and Family to Cope.
Preventing Infection.
Providing Care for the Child Undergoing Cardiac Surgery
Providing Preoperative Care
Providing Postoperative Care.
Providing Patient and Family Education. 55 55

56. Rheumatic fever
is an inflammatory disease that may develop after an infection with group A Streptococcus bacteria (such as strep throat). The disease can affect the heart, joints, skin, and brain
Rheumatic fever mainly affects children ages 5 -15, and occurs approximately 14-28 days after strep throat.

57. Signs and symptoms Abdominal pain Fever
Heart (cardiac) problems, which may not have symptoms, or may result in shortness of breath and chest pain
Joint pain, arthritis(mainly in the knees, elbows, ankles, and wrists)
Joint swelling; redness or warmth
Nosebleeds (epistaxis)
Skin nodules
Skin rash (erythema)

58. Arthritis in several large joints (polyarthritis)
The Major criteria for diagnosis include:
Arthritis in several large joints (polyarthritis)
Heart inflammation (carditis)
Nodules under the skin (subcutaneous skin nodules)
Skin rash (erythema marginatum)

59. Treatment
antibiotics such as penicillin, sulfadiazine, or erythromycin) over the long term to prevent strep throat from returning
Anti-inflammatory medications such as aspirin or corticosteroids reduce inflammation to help manage acute rheumatic fever.