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The Pedi-Cardiac Lecture


Part 2

• Pediatric Cardiovascular Disorders
• Jerry Carley MSN, MA, RN, CNE

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Concept Map Pediatric Cardiac Conditions
Congenital
Acquired
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Distribution of Congenital Heart Defects
by anatomical location
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• PDA

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PDA
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Persistent Ductus Arteriosus

• PDA
• Incidence 10 of all reported CHDs
• One of the most common benign defects
• Ductus normally closes within hours of birth
• Connection between the pulmonary artery (low
  pressure) and aorta (high pressure)
• High risk for pulmonary hypertension

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Pulmonary Artery
Ductus Arteriosus
Fetal Structure, Connecting
Aorta
Function
Allows Blood to Bypass Lungs
Blood from (R)) Ventricle
Reenters Aorta
Persistent Ductus Arteriosus (PDA)
Pulmonary Artery
Tachypnea
FTT
Difficulty Feeding
Dyspnea
Tires Easily
Effects / Symptoms
Bounding Pulse
Infective Endocarditis
Heart Failure
Pulmonary Hypertension
Recurrent Pneumonia
Treatments
Cardiomegaly
Murmurs
Spontaneous Closure
Usually by 2 years
Nursing Care
Medication
Indomethacin (Indocin)
Ibuprofen (Motrin)
Surgery
Heart Catheterization
Closed Heart Surgery
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Diagnosis and Treatment

• Diagnosis by
• Chest x-ray enlarged heart and dilated
  pulmonary artery
• Echo-cardiogram show the opening between
  pulmonary artery and aorta

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Treatment

• Indomethocin (Indocin) given po constricts the
  muscle in the wall of the PDA and promotes
  closure
• Cardiac Catheterization coil is placed in the
  open duct and acts like a plug
• Closed heart surgery small incision made
  between ribs on left hand side and PDA is ligated
  or tied and cut

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• ASD

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Atrial Septal Defect

• ASD
• 10 of defects
• Blood in left atrium flows into right atrium
• Pulmonary hypertension
• Reduced blood volume in systemic circulation
• If left untreated may lead to pulmonary
  hypertension, congestive heart failure or stroke
  as an adult.

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Lower Pressure In Atrium
Blood recirculates back to the lungs Via
pulmonary arteries
Oxygenated blood From lungs shunted To Atrium
from (L) d/t ASD
Pathophysiology
Atrial Septal Defect (ASD)
Short Stature
Heat Murmur
Effects / Symptoms
Dyspnea
Pulmonary Hypertension
Cardiomegaly
Treatments
Patching
Arrhythmia
Large ASDs Surgical Closure
Suturing
Heart Catheterization
Nursing Care
Transcatheter Balloon
R L
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ASD
Left
Right
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Diagnosis and Treatment

• Diagnosis heart murmur may be heard in the
  pulmonary valve area because the heart is forcing
  an unusually large amount of blood through a
  normal sized valve.
• Echocardiogram is the primary method used to
  diagnose the defect it can show the hole and
  its size and any enlargement of the right atrium
  and ventricle in response to the extra work they
  are doing.

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Treatment

• Surgical closure of the atrial septal defect
• After closure in childhood the heart size will
  return to normal over a period of four to six
  months.
• No restrictions to physical activity post closure

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• VSD

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Ventricular Septal Defect

• VSD
• 30 of congenital heart defects
• Opening in the ventricular septum
• Left-to-right shunt
• Right ventricular hypertrophy
• Deficient systemic blood flow

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Increased Pulmonary Flow Pressure
Hole in Ventricular Septum
Pathophysiology
R L Shunting
Frequently seen With other anomalies, e.g., TOF
Tachypnea
Ventricular Septal Defect (VSD)
Tachycardia
Eventually, will become R
L Shunt if Not Treated !
Enlarged Pulmonary Arteries
Pulmonary Hypertension
Effects / Symptoms
Dyspnea
Paleness
Pulmonary Edema
Congestive Heart Failure
FTT
Recurrent Pneumonia
Treatments
Digoxin
Sweating While Feeding
Diuretics
Cardiomegaly
Medication
Captopril (ACE Inhibitor)
Murmurs
Nursing Care
Heart Catheterization
Surgery
Open-Heart Septal Plasty
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VSD

• Small holes generally are asymptomatic
• Medium to moderate holes will cause problems when
  the pressure in the right side of the heart
  decreases and blood will start to flow to the
  path of least resistance (from the left ventricle
  through the VSD to the right ventricle and into
  the lungs)
• This will generally lead to CHF

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Diagnosis and Treatment

• Diagnosis heart murmur clinical pearl a
  louder murmur may indicate a smaller hole due to
  the force that is needed for the blood to get
  through the hole.
• Electrocardiogram to see if there is a strain
  on the heart
• Chest x-ray size of heart
• Echocardiogram shows size of the hole and size
  of heart chambers

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Treatment VSD

• CHF diuretics of help get rid of extra fluid in
  the lungs
• Digoxin if additional force needed to squeeze the
  heart
• FTT or failure to grow may need higher calorie
  concentration
• Will need prophylactic antibiotics before dental
  procedures if defect is not repaired

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Surgical Repair

• Over a period of years the vessels in the lungs
  will develop thicker walls the pressure in the
  lungs will increase and pulmonary vascular
  disease
• If pressure in the lungs becomes too high the
  un-oxygenated blood with cross over to the left
  side of the heart and un-oxygenated blood with
  enter the circulatory system.(Becomes a Right
  Left Shunt)
• If the large VSD is repaired these changes will
  not occur.

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• COA

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Coarctation of Aorta

• COA
• 7 of defects
• Congenital narrowing of the descending aorta
• 80 have aortic-valve anomalies
• Difference in BP in arms and legs (severe
  obstruction)

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Diagnosis and Treatment

• In 50 the narrowing is not severe enough to
  cause symptoms in the first days of life.
• When the Ductus Arteriosis closes a higher
  resistance develops and heart failure can
  develop.
• Pulses in the groin and leg will be diminished
• Echocardiogram will show the defect in the aorta

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Treatment

• Prostaglandin may be given to keep the DA open to
  reduce the pressure changes
• The most common repair is resection of the
  narrowed area with re-anastomosis of the two ends
• Surgical complications kidney damage due to
  clamping off of blood flow during surgery
• High blood pressure post surgery may need to be
  on antihypertensives
• Antibiotic prophylactic need due to possible
  aortic valve abnormalities.

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• PS

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Pulmonary Stenosis

• PS
• 7 of defects
• Obstruction of blood flow from right ventricle
• Hypertrophy of right ventricle
• If severe cyanosis due to right-to-left shunt

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Pulmonary Valvular Stenosis

• In pulmonary valvar stenosis the pulmonary valve
  leads to narrowing and obstruction between the
  right ventricle and the pulmonary artery.
• Thickened tissue become less pliable and
  increases the obstruction
• Right ventricle must work harder to eject blood
  into the pulmonary artery.

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Pathophysiology
Abnormality of Pulmonary Valve Leaflets
Leakage of Pulmonary Valve When closed
Sometimes part of DiGeorge Syndrome
Asymptomatic (usually)
Pulmonary Stenosis (PS)
Ventricular Hypertrophy
Potential Ventricular Failure
Dilated Pulmonary Artery
S/S Heart Failure
Effects / Symptoms
Pulmonary Hypertension
Feeding Problems
FTT
Dyspnea
Treatments
Tires Easily
Usually by 2 years
Surgery
Transcatheter Balloon
Nursing Care
Indomethacin (Indocin)
Stenting
Ibuprofen (Motrin)
Heart Catheterization
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Diagnosis and Treatment

• Diagnosis heart murmur is heard clicking sound
  when the thickened valve snaps to an open
  position.
• Electrocardiogram would be normal
• Echocardiogram most important non-invasive test
  to detect and evaluate pulmonary stenosis
• Cardiac Catheterization to measure pressures
  and measure the stenosis

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Treatment

• Cardiac Catheterization to dilate the valve and
  open up the obstruction.
• Open- heart procedure would only needed for more
  complex valve anomaly.

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• TOF

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Tetralogy of Fallot (TOF)

• 6 of all CHD defects
• Most common cardiac malformation responsible for
  cyanosis in a child over 1 year

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1. Narrowing of the Pulmonic Valve
3. Displacement of Aorta over ventricular septal
defect
4. Ventricular Septal defect

• Thickening of
• Right Ventricular
• Wall

Right Left
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Pulmonic Valve Narrowing
Pathophysiology
(R) Ventricle Hypertrophy
R L
Displacement of Aorta
Ventricular Septal Defect (VSD)
Tetralogy Of Fallot (TOF)
Tachypnea
Difficulty Feeding
Dyspnea
Effects / Symptoms
Tires Easily
Central CYANOSIS
FTT
Heart Failure
Tet Spells
Usually Self- Limiting
Cardiomegaly
Treatments
Finger Clubbing
Harsh Systolic Ejection Murmur
Surgery
Nursing Care
Close VSD
Relieve Ventricular Outflow
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TOF

• Four Components
• VSD
• Pulmonary stenosis narrowing of pulmonary valve
• Overriding of the aorta aortic valve is
  enlarged and appears to arise from both the left
  and right ventricles instead of the left
  ventricle
• Hypertrophy of right ventricle thickening of
  the muscular walls because of the right ventricle
  pumping at high pressure

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Clinical Manifestations

• Dependent on degree of right ventricular outflow
  obstruction.
• Right-to-left shunt
• Clubbing of digits
• tet spells - hyper-cyanotic episodes treated
  by flexing knees forward and upward
• Severe irritability due to low oxygen levels

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Children with T.O.F. exhibit cyanosis during
episodes of crying or exertion.
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Knee-chest Position
Nurse puts infant in knee-chest position.
Child with a cyanotic heart defect squats
(assumes a knee-chest position) to
relieve cyanotic spells. (tet spells )

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Diagnosis

• Cyanosis (central)
• Oxygen will have little effect on the cyanosis
• Loud heart murmur
• Echocardiogram demonstrates the four defects
  characteristic of tetralogy

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Treatment

• If oxygen levels are extremely low prostaglandins
  may be administered IV to keep the PDA open
• Complete repair is done when the infant is about
  6 months of age
• Correction includes
• Closure of the VSD with dacron patch
• The narrowed pulmonary valve is enlarged
• Coronary arteries will be repaired
• Hypertrophy of right heart should remodel within
  a few months when pressure in right side is
  reduced

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Long Term Outcomes

• Leaky pulmonic valve that can lead to pulmonary
  insufficiency
• Arrhythmias after surgery
• Heart block occasionally a pacemaker is
  necessary
• Periodic echocardiogram and exercise stress test
  or Holter monitor evaluation

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• End of Part 2