Cardiac
Function
RNSG 2201
& Dysfunction
Heart begins beating at ~3 weeks
Development complete by 8-10 weeks
Fetal
Circulatio
n
Adaptation
s
Patent Ductus
(PDA)
Arteriosus
Patent Foramen Ovale
(PFO)
Transitio
n
• Lung fluid is expelled at birth
• Oxygen concentration
increases
• Pulmonary vessels dilate
⚬ Resistance decreases in
vessels
⚬ Blood flow to lungs
increases
• Gas exchange begins in lungs
• Systemic vascular resistance
Circulatory Changes at Birth
The Normal
Heart
Right Left
Atriu Atriu
m m
Right Left
Ventricl Ventricl
e e
Pediatric
Cardiology
Right ventricle dominant
Smaller cardiac dimensions
Increasing cardiac output with age/size
Immature electrophysiology
Utilize glucose as fuel source
Congenital Heart Defect
Etiology: Maternal
(CHD)
• Factors
Age
• Medication use
• Environmental toxins
• Insulin-dependent diabetes
• Perinatal infection (esp.
Rubella)
• Alcohol use/Fetal Alcohol
Congenital Heart Defect
Etiology
(CHD)
(cont.)
Genetic Multi- Unkno
• Inheritance • Combination of
s
• Chromosomal
factorial
genetic / wn
abnormalities environmental
factors
Diagnostic
Echocardiogram
• Produces picture of the heart
s
Ech
Electrocardiogram
• Produces wave like diagram
o
(Mechanical
)
Cardiac Catheterization
• Utilized for intervention
• Obtains pressure readings
EKG
(Electrical)
Cardiac MRI
Risks of Cardiac
Catheterization
• Infection
• Dysrhythmias
• Embolism/Stroke
• Arterial
obstruction
• Cardiac
perforation
• Reaction to
contrast
Cardiac Catheterization
Post-Operative
(cont.)
Care
• Monitor vital signs
• Monitor temperature and color of
extremities
• Monitor distal pulses
• Assess site for bleeding
• Bed rest/positioning
• Encourage fluid intake
• Blood glucose levels
Cardiac Surgical
Pre-Op
Care
Care
• Provide respiratory
• Monitor vital signs
• Monitor intake and support as needed
• Cluster care
output
• Monitor labs ⚬ Conserve energy /
⚬ Hematology oxygen
⚬ Chemistry • Provide for increased
caloric needs
• Parental education
Cardiac Surgical
Post-Op Care
Care
• Monitor VS
• Monitor I&O
• Pain management
• Provide for caloric
needs
• Cluster care/activity
• Gradually increase
activity
• Monitor for S&S of
infection
Discharge After
Bathin Surgery
Activit Infection
• Avoid rubbing incision
g • Avoid pick child up
y Preventio
site under the arms • Avoid ill contacts
• Do not use oils, creams, • Avoid contact activities n
• No immunizations for 4-
lotions or powders for 2 months after 6 weeks
• Observe and report S&S surgery • Will likely require
of infection prophylaxis for invasive
• Otherwise, protect from procedures
excessive moisture
Consequences of
Increased CHD Pulmonary
• Tachycardia • Fatigue
Hypertension
Workload
• Hypertrophy • Dyspnea
• Tachypnea
Cardiac Output • Right ventricular
• Inability to meet hypertrophy
physiologic demands Metabolic
• Poor feeding
• Activity/exertion Demands
intolerance • Failure to thrive
• Poor intake • Increased caloric needs
Consequences of CHD
(cont.)
Hypoxia
• Cyanosis
• Clubbing
• Polycythemia
• Metabolic acidosis
Congestive Heart Failure
• Weakness/failure of (CHF)
pump (ventricles)
• Decreased stroke
volume leads to
“backup”
• Symptoms vary by
location (left vs
right)
• Volume overload
CHF
Right- (cont.) Left-
• sided:
Circulatory • sided:
Pulmonary
congestion congestion
⚬ Dependent ⚬ Bloody / pink
edema sputum
• Liver enlargement • Dyspnea /
• Possible ascites orthopnea
• Hypertension • Tachypnea
• Weight gain • Restlessness
• Crackles
CHF
Workloa
Treatment
Fluid Volume
• Provided:
rest Overload:
• Restrict fluids
periods • Administer diuretics
• Administer oxygen • Monitor intake and
prn output
• Position of comfort • Monitor electrolytes
⚬ Semi-fowlers ⚬ Potassium
• Calm environment • Monitor weight
⚬ Maintain ⚬ Same scale Same
boundaries time
CHF Treatment:
Improve Goals
Contractility:
• Administer positive inotropes
⚬ Digoxin
￭ + inotropic -
chronotropic
⚬ Milrinone (in hospital)
⚬ Dopamine (in hospital)
• Maintain electrolyte
imbalance
⚬ Avoid hypokalemia (nml
CHF Treatment:
Goals
Improve Cardiac
Output:
• ACE inhibitors (Enalapril,
Captopril)
⚬ Monitor BP closely
• Angiotensin II Receptor Blockers
⚬ Losartan
4Ds
Acyanoti
c Obstructive
Increased
Defects:
Pulmonary Blood
Impede Blood Flow
Flow Defects
from Ventricles
• AS • Coarctation of the
D Aorta
• VS • Aortic Stenosis
D • Pulmonic Stenosis
L to R Shunting
Lesions
• Atrial Septal Defect (ASD)
• Ventricular Septal Defect
(VSD)
• Patent Ductus Arteriosus
Oxygenated
(PDA) & deoxygenated blood
mix
Increases blood flow to lungs
Patent Ductus Arteriosus
(PDA)
Surgical Repair:
• Failed closure of ductus
arteriosus
• Increased pulmonary blood
flow
• Higher incidence in
preemies
• Loud machine-like murmur
PDA
Management
Non-
Pharmacologic:
• Fluid restriction
• Respiratory support
Pharmacologic:
• Prostaglandin inhibitors
⚬ Indomethacin
⚬ Ibuprofen
• Diuretics
PDA Management
(Cont.)
Surgical Ligation
• Clip, Coil, Patch
Who is a
•Failedcandidate?
drug management
• Difficulty weaning respiratory
support
• Signs of CHF
• Failure to thrive
Atrial Septal Defect
(ASD)
• Defect in septal wall between
atria
• May spontaneously close
• CHF can occur- unlikely
ASD
Closure
Non-Surgical:
• Patch (via cardiac cath)
• Avoids invasive surgery
• Requires aspirin
therapy
⚬ low-dose
Ventricular Septal Defect
(VSD)
• Septal defect between
ventricles
• Loud, harsh systolic murmur
• Pulmonary hypertension results
in:
⚬ Dyspnea, tachypnea,
grunting, wheezing
• May have spontaneous closure
• Moderate risk for endocarditis
• CHF is common
VSD
Treatment
Pharmacologic:
• Diuretics to manage CHF
• Digoxin if poor ventricular
function
⚬ Monitor apical heart rate!!
Non-Surgical
• Patch viaRepair:
cardiac catheter
VSD
Repair
Surgical
• Repair:
Requires general
anesthesia
• Requires
cardiopulmonary
bypass
• Patch manually
sutured
Coarctation of the
Aorta
• Narrowed aortic arch
• Blood pressure disparity
⚬ upper vs lower - take all
extremities!
• High pressures in head / upper
extremities
Shunting occurs if ductus arteriosus
• Low pressures / pulses - lower is
extremities open!
Coarctation of the Aorta
(cont.)
Cyanoti
c
Decreased
Mixed Blood Flow
Pulmonary Blood
Flow Defects
• Tetralogy of • Transposition of Great
Fallot Arteries
• Tricuspid • Truncus Arteriosus
Atresia • Hypoplastic Left Heart
R to L Shunting
Lesions
• Transposition of the Great
Arteries
• Tetralogy of Fallot
• Truncus Arteriosus
• Tricuspid Atresia
• Hypoplastic Left Heart
Deoxygenated blood re-enters
circulation
Truncus
Arteriosus
• Single main artery
⚬ Harsh systolic murmur with
thrill
⚬ Bounding pulse & widened
pulse pressure
• Pulmonary overload
⚬ Severe CHF
⚬ Poor feeding --> FTT
⚬ Poor activity tolerance
• Surgical repair
Transposition of the Great
Arteries
• Diagnosed in neonatal period
• Significant cyanosis at
birth
• Failure to respond to
oxygen
• Needs PDA/PFO to
oxygenate
• May require ASD creation
• Prostaglandin continuously
Tetralogy of
Fallot4 Defects:
• Displaced (Overriding) aorta
• Right ventricular
hypertrophy
• Opening in septum (VSD)
•• Pulmonary stenosis
Mixed blood causes hypoxia
• Repair based on oxygenation
Tetralogy of
Fallot
Tetralogy of Fallot
(cont.)
"Tet Spells" = Hypoxic
• Caused by agitation / events
episodes
requiring increased oxygen
requirements
Tet Spell
• Intervention
Knee-chest / squat position
• May require oxygen
• Calm environment
• Control pain
Tetralogy of Fallot
(cont.)
Polycythemia
• Response to hypoxia
⚬ Body's attempt to
increase oxygen carrying
capacity.
⚬ Monitor H&H, RBCs
⚬ HYDRATION!
Risk for
• Due endocarditis:
to repair / shunt
• Prophylaxis for procedures
⚬ Amoxicillin 1hr before
dental or surgical
Hypoplastic Left
Heart
• Left ventricular / aortic
hypoplasia
• Dysplastic mitral and /or aortic
valves
• Decreased cardiac output
• Mild cyanosis / signs of HF until
PDA closes, thus must
maintain PDA
• Surgical repair is staged:
⚬ Norwood
Hypoplastic Left Heart
(cont.)
Norwood
Glenn Fonta
(Blalock-
n
Taussig)