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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 venous return adequately, or a combination of the two.
Cause
CHF may result from congenital or acquired heart diseases with volume and/or pressure overload or from myocardial insufficiency.
ASD rarely causes CHF in the pediatric age group, although it causes CHF in adulthood. Large L-R shunt lesions, such as VSD and PDA, do not cause CHF before 6 to 8 weeks of age because the PVR does not fall low enough to cause a large left-toright shunt until this age. The onset of CHF resulting from L-R shunt lesions may be earlier in premature infants (within the first month) because of an earlier fall in the PVR in these infants.
MISCELLANEOUS CAUSES
Supraventricular Tachycardia (SVT) Complete heart block Severe anemia Acute hypertension Bronchopulmonary dysplasia Acute cor pulmonale caused by acute airway obstruction
Physical Examination
The following are compensatory responses to impaired cardiac function: Tachycardia, gallop rhythm, and weak and thready pulse Cardiomegaly There are signs of increased sympathetic discharges (e.g., growth failure; perspiration; cold, wet skin). Pulmonary venous congestion (left-sided failure) results in the following: Tachypnea is common. Dyspnea on exertion (poor feeding in small infants) is common. Orthopnea Wheezing and pulmonary crackles
X-ray Studies The presence of cardiomegaly should be demonstrated by chest x-ray films. The absence of cardiomegaly almost rules out the diagnosis of CHF
Electrocardiography ECGs help determine the type of defect but are not helpful in deciding whether CHF is present Echocardiography Echo may confirm an enlarged chamber or impaired left ventricle (LV) function (decreased fractional shortening or ejection fraction, increased left preejection period/left ventricular ejection time).
Management
The treatment of CHF consists of: (1) elimination of the underlying causes (2) elimination of the precipitating or contributing causes (e.g., infection, anemia, arrhythmias, fever) (3) control of heart failure state by the use of multiple drugs, usually inotropic agents, diuretics, and afterload-reducing agents.
GENERAL MEASURES
A cardiac chair or infant seat is used to relieve respiratory distress Oxygen (40% to 50%) with humidity is administered to infants with respiratory distress Sedation with morphine sulfate (0.1 to 0.2 mg/kg per dose subcutaneously every 4 hours as needed) or phenobarbital (2 to 3 mg/kg per dose by mouth or intramuscularly every 8 hours as necessary)
In older children, salt restriction (<0.5 g/day) and avoidance of salty snacks (chips, pretzels) and table salt are recommended Daily weight measurement Predisposing factors, such as fever, anemia, and infection, are eliminated Underlying causes such as hypertension, arrhythmias, and thyrotoxicosis are treated.
DRUG THERAPY
Three major classes of drugs are used in the treatment of CHF in children: inotropic agents, diuretics, and afterload-reducing agents. Rapidly acting inotropic agents (dopamine, dobutamine) are used in critically or acutely ill infants and children.
Digoxin is used in all noncritically ill patients. The use of digoxin is contraindicated in hypertrophic cardiomyopathy, complete heart block, or cardiac tamponade.
Diuretics are almost always used with inotropic agents. Afterload-reducing agents have gained popularity because they can increase cardiac output without increasing myocardial oxygen consumption.
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