CARDIOVASCULAR DISORDER By DR. Areefa Albahri (Alkasseh) Assistance Prof. of MCH Islamic University of Gaza 28/11/1436 DR. Areefa Albahri.

CARDIOVASCULAR DISORDER

By

DR. Areefa Albahri (Alkasseh)

Assistance Prof. of MCH

Islamic University of Gaza

/ /١٤٤٤ ١٠ ١

DR. Areefa Albahri

• Cardiovascular disease is a significant cause of chronic illness and death in children.

• Typically cardiovascular disorders in children are divided into two major categories:

• Congenital heart disease is defined as structural anomalies that are present at birth. CHD accounts for the largest percentage of birth defects

• Acquired heart disease includes disorders that occur after birth. These disorders develop from a wide range of causes, or they can occur as a complication of CHD.

Fetal Circulation

• Foramen Ovale: • Is anatomical opening between the right atrium and left

atrium which closes shortly after birth. • Higher pressure in the left atrium due to increased

pulmonary blood flow cause the foraman ovale to close.

• Ductus arteriosus: A vessel that connects the main pulmonary artery to

the aorta

The ductus arteriosus should functionally close within 15 hours and structurally within a few weeks (in mature infants)

Assessment of Cardiac Function:• History: parents usually report

• Poor weight gain, fatigue during feeding, sweating with feeding.

• Frequent respiratory infections • Cyanosis• Evidence of exercise intolerance• A previous cardiac defects in a sibling• Maternal rubella infection during pregnancy, • Children with chromosomal abnormalities are likely to

have associated congenital heart defects. • A history of viral infection or toxic exposure

(myocardities)• A history of streptococcal infection (Rheumatic fever)

Physical Examination :• Vital signs• Tachycardia or bradycardia may indicate cardiac

disease.• Tachypnea may indicate congestive heart failure• Hypertension; Differences in BP between the upper and

lower extremities may indicate coarctation of the aorta• Physical Examination Inspection:

• Skin color ( cyanosis, ruddy complexion)• Position of comfort• Presence of clubbing • Lethargy and overall

• Physical Exam; Palpation• The point of maximum intensity and the apical impulse

• The presence of a thrill/murmur should be noted.

• The quality and symmetry of all pulses• Warmth of extremities, capillary refill• Locating the hepatic and splenic borders

• Physical Exam; Auscultation• Heart sounds, heart rate and rhythm. • The presence of additional heart sounds, such as a

murmur, is noted. • Lung sounds

•Diagnostic procedures to Evaluate [ student presentation]

Types of Defects -:

• 1. Acyanotic Heart Defects: there is no mixing of unoxygenated blood with systemic circulation (Oxygenated blood), its take one of the following forms:

• a. Dextracardia ―as a part of situs inversus ― • b. Obstructive lesion as: aortic stenosis, pulmonary stenosis and coarctation of the aorta.

• c. Left to Right shunts as: patent ductus arteriosus, atrial septal defect and ventricular septal defect.

Acyanotica. Increased Pulmonary Blood Flow 1. Atrial Septal Defect (ASD)

• VI. Atrial Septal Defect • Is an abnormal opening in the septum between

two atrium.

• Altered Physiology: • The pressure in the left atrium is greatening than

that in the right one, which promotes the flow of oxygenated blood from the left to the right atrium and thus increasing the total blood flow through the lung.

• If the pulmonary resistance is great reversal the shunt with unoxygenated blood flowing from the right to left atrium and cyanosis occur.

• CM:• Many children have no symptoms and seem healthy

• If the opening is large S& S of CHF may develop and increased the risk of

endocarditis Harsh systolic MurmurAtrial dysrhythmias Pulmonary vascular obstructive diseases and emboli formation later in life from chronic condition

Enlarged right side and increased pulmonary circulation

Treatment of ASD:

• ASD may close spontaneously as the child grows

• Some children may need medication such as digoxin and diuretics

• Control infection• Catheterization may be needed to close the septum

Ventricular Septal Defect (VSD)

• An opening between left ventricle and right ventricle • Most common congenital heart defect• Can be classified as:

• Membranous VSD (located in the upper section; 80% of all VSD cases

• Muscular VSD (located in the lower section; 20% of all cases)

• Altered Physiology: The pressure in the left ventricle is greater than that of the right one promotes the flow of oxygenated blood from the left to the right ventricle increasing the total blood flow through the lungs and thus increased right ventricular and pulmonary arterial pressure.

CM:

• Fatigue• Sweating• Rapid, heavy, congested breathing• Disinterest in feeding• Poor weight gain• Murmurs• May lead to hypertrophy and enlargement of the right

side• CHF is common

• Treatment: Surgical repair

Patent Ductus Arteriosus (PDA)

• Before a baby is born, the fetus's blood does not need to go to the lungs to get oxygenated. The ductus arteriosus is a hole that allows the blood to skip the circulation to the lungs. However, when the baby is born, the blood must receive oxygen in the lungs and this hole is supposed to close. If the ductus arteriosus is still open (or patent) the blood may skip this necessary step of circulation.

•  

• CM:• Asymptomatic or signs of CHF• Murmurs• A widened pulse pressure & bounding pulses• At risk for endocarditis & pulmonary vascular obstructive disease

• Treatment• Prostaglandin inhibitor• Surgical repair

Acyanotic 

Obstruction to Blood Flow from Ventricular

• Coarctation of the Aorta (COA)• Narrowing anywhere in the aorta• Increased pressure proximal to the defect• Restricts the amount of oxygenated blood to

lower part• LT ventricle has to work harder• Risk for endocarditis• Coronary arteries may narrow due to high

pressure

Altered Physiology: the narrowing of the aorta obstructs the blood flow through the constricted

segment of the aorta, that increasing the left ventricular pressure.

• CM:• High BP and bounding pulse in arms• Low BP & Absent femoral pulse and cool extremities• Headaches, dizziness , fainting & epistaxis• Cramps in the legs• Pt at high risk for hypertension, ruptured aorta and stroke• Kidneys’ function may be altered ( decrease urine )• Treatment:• Enlargement of constricted section (surgical or

nonsurgical (Balloon angiplasty))

•  

Balloon angiplasty

II. Aortic Stenosis

• Aortic stenosis (AS) is a narrowing or a stricture of the aortic valve that results in:

• Increase left ventricular pressure to overcome the obstructed valve

• Left ventricular hypertrophy, myocardial ischemia and decreased cardiac output.

• Imbalance between the increased O2 requirements and the amount of O2 supplied.

Clinical Manifestations• Rarely symptomatic during infancy, in severe cases infant may

demonstrate evidence of decreased cardiac output such as faint peripheral pulses or exercise intolerance.

• Older children may experience chest pain, dyspnea and fatigue with exertion.

• Narrow pulse pressure and weak peripheral pulses. • X-ray may show normal heart to varying degrees of left ventricular

hypertrophy. • A harsh ejection systolic murmur is best heard in the aortic area. • E.C.G.: left ventricular hypertrophy {T. wave inversion}. • Diagnosis: Cardiac Catheterization. • Complications: CHF, MI, bacterial endocarditis and death.

• Treatment:• Balloon dilatation (via cardiac catheterization)• Valvotomy involves a surgical removal of adhesion that

preventing valve leaflets from opening• Aortic valve replacement

III. Pulmonary Stenosis

• Refers to narrowing of the opening to the pulmonic valve,

that cause obstruction to blood flow, so the right ventricle

has an additional work-load, causing the muscle to

thicken, resulting in right ventricular hypertrophy and

decreased pulmonary blood flow .

• CM:• Mild cases are asymptomatic • Cyanosis in severe cases • Murmurs• Cardiomegaly (chest X-ray)• Treatment:• Depends on the degree of the stenosis may wait for a

few years• Relieve stenosis or valve adhesion by balloon

angioplasty

•Cyanotic Congenital Heart Disease •I. Teratology of Fallot (TOF)

• The most common type of cyanotic heart disease, its involve four anatomical abnormalities :

•1 -Pulmonary stenosis .•2 -Ventricular septal defect {VSD} .

•3 -Overriding of the aorta (enlargement of the aortic valve)

•4 -Right ventricular hypertrophy .•Altered Physiology :

• Pulmonary stenosis: unoxygenated blood is shunted from the right ventricle (from the VSD) directly into the

aorta .•The right ventricle is hypertrophied because of high right

ventricular pressure .

• Clinical Manifestation: • Cyanosis: not cyanotic at birth {left to right shunt}, may

starts later, may be at 1-2 years, first observed with exertion or crying, then cyanotic even at rest.

• Clubbing of fingers. • Squatting posture is assumed to relief stressed heart by

trapping blood in lower extremities. • Slow weight gain. • Hypoxia spells (Tet spells characterized by sudden

cyanosis and syncope)

• Complication: CHF, endocarditis, CVA and iron

deficiency anemia. • Treatment: • Improve oxygenation • Emergency for Tet spells: beta-blockers as propranolol, but acute episodes may require rapid intervention with morphine are required.

• Surgical• Complete intracardiac repair of VSD and PA stenosis.• Repair the VSD with a patch.• removing the excessive muscle tissue will help to function

correctly.• Pacemaker wires are placed temporarily because of the

potential for postoperative ventricular arrhythmias. • Individual chamber pressures are then measured before

the chest is closed. The pressure readings help to determine how effective the surgery was.

• II. Transposition of the Great Arteries (TGA) • TGA occurs when the aorta arises from the right ventricle and the pulmonary artery from the left ventricle.

• Incompatible with life unless the infant has an associated defect which allows the blood to communicate between the pulmonary and systemic circulation.

• Clinical Manifestation: • Marked cyanosis since birth. • Failure to thrive, Fatigability and dyspnea with subcostal retractions at rest

• Cardiomegaly, early clubbing of fingers and C.H.F.

• Prognosis: without surgical treatment, 85 % die in the first 6 months of age.

• Treatment: • Management of C.H.F. • Palliative procedures: creation of A.S.D. with a balloon catheter during catheterization or surgical creation of A.S.D.

• Complete correction: by cardiopulmonary bypass.

• III. Tricuspid Atresia

• Is a condition in which there is a complete absence of the tricuspid valve. Therefore, there is an hypoplastic of right ventricle. Its associated with:

• Atrial septal defect. • There is usually a V.S.D. allowing some blood to enter the underdeveloped right ventricle.

• Pathophysiology:

• Blood from the systemic circulation is shunted from the right atrium through an interatrial communication to the left atrium, to the left ventricle.

• Pulmonary blood flow is established either through PDA or VSD.

• Clinical Manifestation:

• Cyanosis {marked since birth}, dyspnea on feeding and may hypoxia spells.

• Early clubbing of fingers and failure to thrive. • Right heart failure may occur.

•Treatment: • Palliative procedures: to increase the pulmonary blood flow (Anastomosis between the ascending aorta and right pulmonary artery).

• Fontan Procedure: is a palliative surgical procedure used in children with complex congenital heart defects. It involves diverting the venous blood from the right atrium to the pulmonary arteries without passing through the morphologic pulmonary ventricle

• Complete correction

•Diagnostic Evaluation for Congenital Heart Defects .

•1 .Chest x- ray shows enlargement of the affected chambers of the heart .

•2 .Cardiac catheterization: visually demonstrate the defect, demonstrate blood oxygenation in

heart chambers .•3 .E.C.G.

• Nursing care plan for the child with congenital heart

disease

• Assessment:

• Take careful health history including evidence of: poor

weight gain, unusual posturing or poor feeding

• Exercise intolerance – frequent respiratory tract infections

• Perform physical assessment with special emphases on:

color, pulse (apical and peripheral), respiration, blood

pressure, examination and auscultation of chest and

manifestations of CHD.

Hypoplastic Left Heart Syndrome (HLHS)• Is a combination of abnormalities of

the heart and the great vessels• In HLHS most structures on the left

side of the heart are small & underdeveloped

• Mitral valve, left ventricle, aortic valve, & aorta are involved.

• The newborn develops symptoms shortly after delivery

CMCyanosis, Sweating, cool skin

Increased RR & HR, heavy breathing

• Treatment is by series of surgical repair

Acquired Cardiovascular Disorders

•1. Rheumatic Heart Disease (RHD).•2. Congestive Heart Failure (CHF)

Rheumatic Heart Disease (RHD).

• Permanent damage to the heart valves is caused by RF• It develops after an infection of the upper RT with group

A β-hemolytic streptococci • The antigens of group A Streptococci bind to receptors in

the heart, muscle, brain & synovial joints, causing an autoimmune response

• The antigens produced by Streptococci are similar to the body’s own antigens thus antibodies may attack healthy body cells

• RF forms Aschoff bodies (inflammatory lesions) that causes swelling and alterations in the connective tissue

• RF major criteria: • Rheumatic Carditis• Polyarthritis• Erythema marginatum• Subcutaneous nodules• Chorea

• Rheumatic Carditis.• Involves endocardium, pericardium & myocardium

• CM: • Valvulitis • Myocardities• Pericarditis: muffled heart sound due to pericardial

effusion, chest pain, pericardial friction rub• Murmur• Tachycardia especially during sleep

• Polyarthritis:• Joints such as knees, elbows, hips, shoulders &

wrists• Joints are swollen, hot, red & painful

• Erythema marginatum:• Erythematous macule mostly found on the trunk &

extremities

• Subcutaneous nodules:• Nontender swellings mostly found on the bony

prominences areas such as feet, hands vertebrae

• Chorea:• Sudden & aimless irregular movements of the extremities

• Involuntary facial, grimaces• Speech disturbances• Emotional liability• Muscle weakness

• Other minor criteria: arthralgia (joint pain), fever, fatigue and elevated ESR

•Diagnostic test:• Throat culture-group a beta hemolytic streptococcal

• Increased ESR• Increased in WBC• Increased in C-reactive protein

• Treatment:• Bed rest until ESR decreases • Antibiotics (penicillin, erythromycin) x 10 days• Reduce inflammation (Salicylates: aspirin)• Corticosteroids (if not responding to aspirin alone)• Phenobarbital for chorea• Treatment of heart failure

• Prophylactic antibiotics (benzathine penicillin G) for 5 years or until 18 to prevent recurrence• Prevention of RHD by Treating streptococcal throat infections with a full course of antibiotic

• Complications of RHD:• Mitral valve damage• Congestive heart failure

• Hypoxemia

Acquired Cardiovascular Disorders 2. Congestive Heart Failure (CHF)

• CHF: is a condition in which the heart cannot pump enough oxygenated blood to meet the need of the body organs

• CHF often occurs in children with congenital heart defects

• Medical problems that may lead to CHF are• Rheumatic fever• Endocarditis or valuvlitis• Cardiac arrhythmias• Cardiomyopathy• Chronic lung disease• Hypertension• Hemorrhage

Causes of CHF:

• Volume overload• Pressure overload which is caused by obstructive lesion, stenosis or coarctation of the aorta

• Decreased contractility which may be caused by myocardial ischemia due to:• Severe anemia• Asphyxia• Acidemia• Low level of K, glucose, Ca , Mg• High cardiac output (such in sepsis,

hyperthyroidism or severe anemia)

• Right side failure:• Right side is unable to pump blood to the lungs• Due to the congestion in the right side of the heart the blood

flow begins to back up into the veins which causing fluid retention

• Edema can be seen in the feet, ankles, eyelids

• Left side failure:• Left side is unable to pump much blood to the body• Blood begins to back up into the vessels in the lungs,

thus lungs become stressed (increased RR and labored breathing)

• Fatigue and poor growth

• Therapeutic Management of CHF: Improve tissue oxygenation & decrease oxygen on• Improve cardiac function:• Digitalis glycosides have three actions

• Increase the force of contraction (increase cardiac output & decrease venous pressure)

• Decrease the HR & slow the conduction of the impulses through the AV node

• Increase renal perfusion (enhance diuresis)

• Digoxin (Lanoxin) is used for children because of rapid onset and decreased risk of toxicity

• Digoxin level 0.8 – 2.0 u/L • S&S of Toxicity includes nausea, vomiting, anorexia, slow HR

• Hold digoxin dose • If HR less than 100 for infant • If HR less than 80 for older children•If HR less than 60 for adolescents

• Angiotension-converting enzyme (ACE) inhibitors• Reduces the afterload on the heart• Vasodilatation results in decreased pulmonary and systemic

vascular resistance, dec. BP& dec. in right and left atrial pressures

• Renal flow improved which enhances diuresis• Capoten (captopril) most commonly used

• Side effect include hypotension, renal dysfunction

• Remove accumulated fluid & sodium (decrease preload)

• Use of diuretics; lasix , diuril aldactone, Bumex, Zaroxolyn• Potassium supplements when Lasix is used• Low level of K enhances the effect of digoxin thus increases the

risk of digoxin toxicity• High level of K diminishes the effect of digoxin

• Fluid & sodium restriction

• Decrease Cardiac Demands (lessen heart workload)• Using easy-to-suck nipples• Increase the frequency and decrease the amount of each feeding• neutral thermal environment• Treating any existing infections• Reducing the effort of breathing (semi-fowler position)• Sedation if necessary• Rest

• Improve tissue oxygenation and decrease oxygen consumption• In addition to the previous management Oxygen supplement

• Management: • Valve replacement• Cardiac catheterization• Cardiac surgery• Cardiac transplantation