Heart Failure

Tachypnoea is an early feature of heart failure in children.

The diseases implicated are very different in the first week of life relative to those presenting after this time:

Up to 7 days, most infants with heart failure have an obstructed left heart, especially with duct dependent lesions (most likely to be coarctation of the aorta)

After 7 days, this is most likely to be due to left to right shunt (most likely to be VSD)

Specific features of heart failure

• Poor feeding
• Excessive weight gain
• Tachypnoea, breathlessness
• Respiratory distress
• Fine crepitations on auscultation
• Poor peripheral perfusion
• Sweating
• Mottled, clammy, cool skin
• Tachycardia
• Hyperdynamic precordium
• Gallop rhythm
• Hepatomegaly
• Cardiomegaly and increased pulmonary vascularity on chest radiograph
• Specific signs due to underlying cause

Children do not present in heart failure with left to right shunt due to CHD after 1 year, since they have developed pulmonary vascular disease by this time. The thickening of the pulmonary artery walls in response to the left-to-right shunt will limit the pulmonary blood flow and the signs of heart failure.

Management

The principles of managing heart failure in the first week of life are to administer prostaglandin with or without inotropes

The principles of managing heart failure after the first week of life are to reduce preload with diuretics and reduce afterload with ACE inhibitors (use of ACEi somewhat controversial) whilst maintaining optimal nutritional intake.

During the first year of life, the pulmonary vascular resistance continues to rise, such that the features of cardiac failure gradually resolve. Patients will be developing pulmonary hypertension and pulmonary vascular disease.

Specific features of managing heart failure include the following:

• Resuscitate as appropriate, but be careful: do not administer too much fluid
• Evaluate whether the infant is improving with each bolus of fluid
• If not, then consider that an inotrope or other infusion may be needed
• Consider commencing a prostaglandin infusion even before an exact diagnosis has been made if there is suspicion of a duct-dependent lesion
• Discuss with a cardiologist early if cause unknown
• Correct anaemia if present
• Consider inotropes if there is evidence of myocardial dysfunction
• Give furosemide IV 1 mg/kg 6 to 12 hourly, if there are good femoral pulses

Learning Bite

Prostaglandin is likely to be beneficial for infants with heart failure in the first week of life; pre-load and after-load reduction with diuretics and ACE Inhibitors are used for heart failure presenting beyond 1 week, once outflow tract obstruction is excluded.