CONGESTIVE CARDIAC

FAILURE
Dr Romila Chimoriya
Lecturer
Department of pediatrics
CONGESTIVE CARDIAC FAILURE

Inability of the heart to maintain an output, at rest or

during stress, necessary for the metabolic needs of the
body (systolic failure) and inability to receive blood
into the ventricular cavities at low pressure during
diastole (diastolic failure).
ETIOPATHOGENESIS

a) Left to right shunts

- Develop C.C.F at around six to eight weeks of life.
- At birth the pulmonary vascular resistance is high.
So pulmonary artery pressure more or less equals the systemic
pressure.
- Hence left to right shunt is small.
- After few weeks of life, the pulmonary vascular resistance falls
and the size of shunt gradually increases and reach its
maximum around the age of 6 weeks.
- So at this time baby can develop C.C.F on the basis of large
shunt.
- b) Right to left shunt
- Have either pulmonic stenosis or pulmonary arterial
hypertension at ventricular or pulmonary arterial level.
- Since, the right ventricular is decompressed by the right
to left shunt, C.C.F does not occur.
- Right to left shunt at the atrial level can be secondary to
obstruction at the right ventricular outlet or inlet.
- The former presents with C.C.F , if obstruction is severe
or there is atresia.
Obstructive lesion:
- C.C.F late phenomenon.
- However, atresia or critical stenosis of aortic, pulmonary
or mitral valve can results in C.C.F within the first few
days of life.

Transpositions:
- TGA manifest C.C.F within the first two to three month
of life.
1-4 years: -Carditis, Anemia, Nephrotic Syndrome and Acute Nephritis
>4 years: -All above cases plus Myocardits ,
Cardiomyopathy, Pericarditis
CLINICAL FEATURES

Symptoms
- Slow weight gain.
- Puffiness of face.
- Swelling of limbs.
- Difficulty in feeding.
- Suck rest suck cycle.
- Easily fatigability.
- Fast breathing, cough.
- Persistent hoarse crying.
- Excessive perspiration.
TREATMENT
- Reducing cardiac work

- Augmenting myocardial contractility

- Improving cardiac performance by reducing the heart

size

- Correcting the underlying cause.

REDUCING CARDIAC LOAD
- bedrest - propped up position at 30 degree.
- Neonates - keep in incubator.
-minimally handled.
-temperature maintain at 36 to 37 c.
- Humidified oxygen
- Sedatives - morphine 0.05mg/kg s.c or
-Diazepam
- Infection - Antibiotics
- Anemia – 10 to 20ml/kg of PRBC slowly with frusemide.
- Fever - Antipyretics- paracetamol.
-Vasodilators - by reducing the arteriolar and enous
vasoconstriction, reduce the work of heart.
e.g Isosorbide Nitrate - venodilator
Hydralazine -arteriolar dilator

- ACE inhibitor - suppress renin angiotensin/aldosterone

system, thus reducing vasoconstriction as well as sodium
and water retention also prevent potassium loss.
- Persisyent cough major side effect
- First dose hypotension
 Beta blockers
 -might precipitate CCF

-Selected for patients with dilated cardiomyopathy with

tacycardia
-metoprolol and carvedilol

Other drugs
-sodium nitroprusside
-milrinone
Calcium sensitizers(levosimendan)
2) Augmenting myocardial contractility
i) Digitalis - Digoxin- Improves cardiac output by decrease the
heart rate and increase the myocardial contractility.
Dose:
Age Total digitalizing dose maintainance dose
-Premature& 0.04mg/kg 1/4th
neonates
-1monthto 1 year 0.08mg/kg 1/3rd to 1/4th
-1 to 3yr 0.06mg/kg 1/3rd to 1/4th
-Above 3 years 0.04mg/kg 1/3 rd
Digitalization:
- 1/2 of the calculated digitalizing dose as the first dose,
- Another 1/4th in 6 to 8 hours.
- And remaining 1/4th in another 6 to 8 hours.
- Maintenance dose varies from 1/4th to 1/3 rd of the
digitalizing dose every day, started at least 24 hours after
the first dose.
- Look for E.C.G changes if prolong PR interval to one and
half times of the initial PR interval, than digitalis toxicity
is present.
New inotropic Agents:
- Inotropism with peripheral vasodilation
i) Dopamine and Dobutamine - Catecholamine inotropic
agents.
ii) milrinone - non catecholamine non digitalis glycoside
In patient with congestive cardiac failure with low
blood pressure.
- Use dopamine
If Dopamine is not able to increase the blood pressure
adequately, one should add dobutamine.
3) Improving cardiac performance by reducing the
heart size
- by digitalis and diuretics.
Diuretics frusemide - oral - 2-3mg/kg/day
I.V -1mg/kg/dose
-give potassium supplements
or
Frusemide with
Potassium sparing diuretics e.g Amiloride or
Triamterene or spironolactone
- Diuretics reduce the blood volume, decrease venous
return and ventricular filling hence reduce the heart
size.
Also reduce the total body sodium, thus reduce the blood
pressure and reduce the peripheral vascular resistance.
This help in increasing cardiac output and reduce the
work of the heart.
4) Correcting the underlying cause
- For diagnosis of congenital lesion.
-Echocardiography / Cardiac catheterization with
angiocardiography may be necessary.
-Tackled by curative or palliative operations.
Supraventricular tachycardia
-

-Coarctation of aorta
-obstructive aortitis
-anomalous origin of left coronary artery from pulmonary
artery
-hypocalcemia
-Dilated cardiomyopathies
- Betablockers
- Steroids and
- Immunosuppressant

-uncommon causes of CCF in infants

Upper respiratory obstruction
Hypoglycemia
Neonatal asphyxia
hypocalcemia