Pediatric Cardiology

In our Pediatric Cardiology unit, we provide care to children with congenital or acquired heart disease and to babies in the womb, offering diagnosis and treatment with appropriate diagnostic and testing tools.

• Fetal (in the womb) and Congenital Heart Diseases
• Chest Pain in Children
• Palpitations and Arrhythmias in Children
• Unexplained Fainting, Cyanosis and Easy Fatigue in Children
• Acquired Heart Diseases
• Rheumatic Heart Disease
• Diseases of the Heart Muscle and Pericardium
• Heart Valve Diseases
• Pre-Participation Cardiac Evaluation for Sports

Congestive Heart Failure

What Is Heart Failure?

Congestive heart failure is a clinical syndrome reflecting the heart’s inability to meet the metabolic needs of the tissues. When the heart cannot pump enough blood to the periphery, ventricular end-diastolic pressure and atrial pressure rise and congestion develops. This occurs either when the heart muscle is normal but faces an excessive increase in workload (volume and/or pressure), or with an impairment of the pumping capacity of the myocardium itself.

What Causes Heart Failure?

Heart failure has various causes. The main contributing factors can be grouped into three categories:

1. Mechanical Abnormalities: Supravalvular, valvular and subvalvular stenoses (of the mitral, tricuspid, aortic and pulmonary valves), shunts (VSD, ASD, PDA), ventricular aneurysm and pericardial diseases.

2. Myocardial Failure: Cardiomyopathies, inflammation of the myocardium, and ischemic and metabolic disorders.

3. Arrhythmias: Tachyarrhythmias, bradyarrhythmias

Apart from these three main factors, heart failure due to less common non-cardiac causes can be examined in two groups:

• Conditions that increase venous return and cause high-output heart failure: arteriovenous fistulas, thyrotoxicosis (causes peripheral vasodilation), severe anemia, excessive and rapid transfusion, and hormonal causes (especially aldosterone).
• Conditions that decrease venous return: tumors of the IVC and SVC, and peripheral vascular diseases.

In childhood, the age at which congestive heart failure begins can offer clues about its cause. Age groups can be examined in three categories: the fetal period, the period from birth to 1 year of age, and childhood and adolescence:

What Are the Signs of Heart Failure?

Most clinical signs of heart failure are explained by the side effects of the mechanisms that develop to compensate for overload or myocardial dysfunction. Clinically, heart failure is divided into right-sided and left-sided heart failure.

Signs of right-sided heart failure: Systemic venous hypertension, hepatomegaly, right-sided hydrothorax, right-sided hydropericardium, splenomegaly, edema, ascites and oliguria.

Signs of left-sided heart failure: Weakness, fatigue, exertional dyspnea, orthopnea, cardiac asthma, pulmonary edema, chronic cough, rales, gallop rhythm and pulsus alternans.

However, in most cases failure of both sides is present at the same time, and it is often impossible to distinguish these signs from one another. For example, peripheral edema is usually recorded as a sign of right-sided heart failure. Yet whether or not there is disease in the left ventricle, left ventricular output has also decreased, kidney function has become impaired, and water and salt retention has occurred in the body.

However, in most cases failure of both sides is present at the same time, and it is often impossible to distinguish these signs from one another.

Dyspnea is regarded as a sign of left-sided heart failure. However, dyspnea can also be seen in pulmonary stenosis, which causes right-sided heart failure. For these reasons, the signs of heart failure can be examined in three categories: signs of impaired myocardial performance, pulmonary congestion and systemic venous congestion.

How Is Heart Failure Treated?

Treatment of heart failure is examined in two groups: treatment of the underlying disease causing heart failure, and symptomatic treatment.

1. Treatment of the underlying disease

Some cases with structural anomalies, such as congenital heart disease and rheumatic heart disease, require surgical intervention. In non-structural conditions such as anemia, hypervolemia, infection, acute rheumatic carditis and, especially in newborns, hypoglycemia, hypocalcemia and hypomagnesemia, heart failure can be corrected with red blood cell transfusion, treatment of the infection, phlebotomy in polycythemia, corticosteroid therapy in acute rheumatic fever, and magnesium, calcium and glucose supplementation in metabolic disorders.

2. Symptomatic treatment

Rest

Rest significantly reduces the workload of the heart. In cases with mild symptoms, heart failure can sometimes be controlled with rest alone. In moderate and severe heart failure, prolonged rest is usually required. In this situation, venous stasis and the resulting pulmonary embolism and stasis pneumonia may occur. To prevent this, passive leg exercises should be done and the patient’s position should be changed frequently.

Position

An infant with heart failure should be seated in a cardiac chair, or a pillow should be placed behind the back and a rolled blanket under the knees. In older children, the head of the bed should be raised and the legs allowed to hang down. This allows blood to pool in the lower extremities and reduces the load on the circulation.

Sedation

Among sedative drugs, morphine and phenobarbital can be used. They do not need to be used for long periods. Morphine used for 1–2 days can sometimes be very beneficial.

Oxygen and humidity

Giving oxygen provides at least symptomatic benefit. A mixture of 50% oxygen and 80% humidity is ideal. However, if the sick child or baby refuses oxygen, it should not be forced.

Diet

In most cases, heart failure can be controlled with diuretics and digitalis without changing the diet. In young children, especially in severe cases, oral feeding is initially stopped to prevent aspiration and/or regurgitation, and the stomach is emptied with a nasogastric tube. Intravenous 10% glucose solution may be given to prevent hypoglycemia. As heart failure improves, the child should be fed with adequate but not excessive calories. Care is needed with high-protein and concentrated foods, as they increase the osmotic load on the kidneys. In older children with signs of systemic venous congestion, a salt-free diet and mild fluid restriction should be applied. Salt intake should be adjusted according to the child’s response. A cheerful child whose salt balance is managed with medication is preferable to an unhappy child who has lost their appetite because of unsalted food.

Digitalization

In the pediatric age group, digitalis glycosides are the most commonly used drugs in the treatment of heart failure. In practice, the most widely used digitalis glycosides are obtained from Digitalis purpurea and Digitalis lanata. Digitoxin (Digimerck, digitoxin) is obtained from Digitalis purpurea, while digoxin (Natigoxin) and lanatoside C (Cedilanid) are obtained from Digitalis lanata.