Congenital heart disease as Underlying Causes of Pneumonia in Children at a

Referral Hospital in Indonesia

ABSTRACT
OBEJECTIVE: Congenital heart disease (CHD) is the most common disease in
neonates and children. The incidence of congenital heart disease is about 8 –
10/1000 live births. In Indonesia, the annual average of birth is about 4.6
millions/year and its predicted 36.000 neonates with CHD. Children with CHD have
many complications concerning all of the organ systems, but pneumonia being the
most important.. This study objective was to know prevalence of children with
CHD, type of CHD in children with pneumonia, complication of CHD at pneumonia
patient, comorbidity and outcome children with CHD.
METHOD: This was a retrospective study of pneumonia children hospitalized in
Hasan Sadikin Bandung during 2012 – 2016. The eligble children with pneumonia
were indentifid by typical history, physical findings and confirmed on chest
radiographic findings of pneumonic infiltrates in either or both lung fields. The
biodata of each patient was documented. CHD children were diagnosed by natural
history, physical diagnosis and echocardigraphy done by pediatic cardiologist.
Other parameters for each patient, complication, duration of admission, comorbid
and outcome were noted.

RESULT:
According to characteristic of congenital heart disease and pneumonia patients
which eligible to perform this study (100%; n=410) were aged by mean 15.6
months old. By sex patients are mostly boys (80.2%; n=329) with 19.8% girls
(n=81). Most of the patients had normal nutritional status condition (50.7%; n=208),
while the rest were had abnormal nutritional status condition such as severe
malnutrition (24.4%; n=100), moderate malnutrition (18.8%; n=77), overweight
(2.4%; n=10), obese (1%; n=4), and 3 patients data were missed (0.7%). These
patients were hospitalized by mean 11.6 days. Then, the outcome, 71.9% (n=295)
had recovered, 19.8% (n=81) against medical advice, while 8.3% (n=34) died.

By type of congenital heart disease, L to R shunt CHD (74.8%; n=305) is the most
common type, followed by cyanotic CHD (18.1%; n=74), post correction CHD
(2.7%; n=11), obstructive lession CHD (1.7%; n=7), and the least with the other
types (3.9%; n=16) such as mitral regurgitation trivial, pulmonary hypertension,
dekstrokardia, cardiomyopathy, and persistent foramen ovale.

Several of the pneumonia patients who had congenital heart disease weren’t had
complications (37.2%; n=152), while the rest were complicated by pulmonary
hypertension (36.5%; n=149), followed by heart failure (24.6%; n=101), and the
least are essenmenger (1%; n=4) and endocarditis (0.5%; n=2)

From the planning for congenital heart disease and pneumonia patients
underwent, more than half patients were planned by surgery (59.3%; n=242),
followed by cardiology intervention (23.4%; n=96), observation (16.2%; n=66), and
conservative intervention (0.7%; n=3). All the planned data underwent were
missed by 1 patient.

The presence of comorbidity for congenital heart disease and pneumonia by these
patients were down syndrome (12%; n=49), cerebral palsy (11%; n=45),
hypothyroid (10.2%; n=42), and TORCH (6.3%; n=26), while the rest (60.5%;
n=248) weren’t had comorbid.

CONCLUSION:

INTRODUCTION

Congenital heart disease (CHD) is the most common disease in neonates and children.
The incidence of congenital heart disease is about 8 – 10/1000 live births. In
Indonesia, the annual average of birth is about 4.6 millions/year and its predicted
36.000 neonates with CHD. Children with CHD have many complications concerning
all of the organ systems, but pneumonia being the most important. The mechanism of
pneumonia happened in children with CHD, because of there is hemodinamically
significant lession from L to R shunt, such as VSD, ASD, PDA and complete AVSD.
There is overcirculation blood flow to pulmonal circulation that caused by the defect.
This phenomenon leads to pulmonary hypertension and congerstive heart failure
which of the risk of pneumonia. In cyanotic CHD, such as persistent truncus arteriosus
a single arterial blood vessel (truncus arteriosus) arises from the heart. The
Pulmonary Arteries or its branches arise from the truncus arteriosus, and the truncus
continues as the aorta. A large VSD is always present with pressures in both ventricles
are identical 
 and makes increase pulmonary blood flow and leads to congestive
heart failure which is the risk factor of pneumonia. Congestive heart failure and
pneumonia may increase the mortality in children with CHD. This study objective was
to know prevalence of children with CHD, type of CHD in children with pneumonia,
complication of CHD at pneumonia patient, comorbidity and outcome children with
CHD.
METHOD
This was a retrospective study of pneumonia children hospitalized in Hasan Sadikin
Bandung during 2012 – 2016. The eligble children with pneumonia were indentifid
by typical history, physical findings and confirmed on chest radiographic findings of
pneumonic infiltrates in either or both lung fields. The biodata of each patient was
documented. CHD children were diagnosed by natural history, physical diagnosis and
echocardigraphy done by pediatic cardiologist. Congenital heart disease classification
is devided to 1) L to R shunt 2) obstructive lession 3) cyanotic myung 4)post coreection
CHD 4) others. Other parameters for each patient, complication, duration of
admission, comorbid and outcome were noted . Ethical approval was given by he
Ethics Committee of Hasan Sadikin.

Result

Table 1. Characteristic CHD and pneumonia patient

 Charactrrictic Data n (%)
Age (month) Mean 15,9
Median 7
Gender Male 329 (80,2)
Female 81 (19,8)
Status gizi Severe Malnutrition 100 (24,4)
Moderate 77 (18,8)
Malnutrition
Normal 208 (50,7)
Overweight 10 (2,4)
Obese 4 (1)
Missing data 3 (7)
Duration of Mean 11,6
hospitalization
(days)
Median 9
Outcome Recovery 295 (71,9)
Died 34 (8,3)
Against medical 81 (19,8)
advice

Table 1. Type of CHD

Type of CHD n (%)

 L to R shunt 305 (74.8)
o Isolated VSD 114 (27.9)
o Isolated ASD 38 (9.3)
o Isolated PDA 85 (20.8)
o Complete AVSD 5 (1.2)
o Aorta pulmonary window 1 (0.2)
o other 58 (14.2)
 Obstructive lession 7 (1.7)
o Pulmonary stenosis 4 (1)
o Aorta stenosis 0
 o Hypoplastic left heart 1 (0.2)
syndrome
o others 3 (0.7)
 Cyanotic CHD 74 (18.1)
o Tetralogy fallot 15 (3.7)
o Transposition great artery 10 (2.5)
o Double outlet right ventricle 10 (2.5)
o Truncus arteriousus 3 (0.7)
o Pulmonal Atresia 17 (4.2)
o other 17 (4.2)
 Post Correction 11 (2.7)
o PDA
o VSD
 Others 16 (3.9)
o Persistent foramen ovale 7 (43.7)
o cardiomyopathy 2 (12.5)
o dekstrokardia/no CHD 4 (25)
o pulmonary hipertention/ no 1 (6.25)
CHD
o Mitral regurgitation trivial 2 (12.5)

Table 2. Complication of CHD at pneumonia patient

Complication n (%)
Heart failure 101 (24,6)
Pulmonary Hypertension 149 (36.5)
Essenmenger 4 (1)
Endocarditis 2(0,5)
No complication of heart/other 152 (37,2)

Table 3. Planning for CHD and pneumonia patients

Planning n (%)
 Intervention 96 (23,4)
cardiology
 Surgery 242 (59,3)
 konservatif 3 (0,7)
 Other/observasi 66 (16,2)
*Semua ada missing data 1

Table 4. Comorbid for CHD and pneumonia patients

Comorbid n (%)
Down syndrome 49 (12)
 Torch 26 (6,3)
Hypothiroid 42 (10,2)
Celebral Palsy 45 (11,0)

DISCUSION

CONCLUSION
ASD Porter CJ, Feldt RH, Edwards WD, Seward JB, Schaff HV. Atrial septal defects.

Dalam: Allen HD, Gutgesell HP, Clark EB, Driscoll DJ, penyunting. Moss and Adam’s

heart disease in infants, children, and adolescents. Edisi ke-6. Philadelphia: William &

Wilkins; 2001.h.603-17.

Vick GW. Defects of the atrial septum including atrioventricular septal defects.
Dalam: Garson A, Bricker JT, Fisher DJ, Neish SR, penyunting. The science and
practice of pediatric cardiology. Edisi ke-2. Baltimore: Williams & Wilkins; 1998.h.