Rotator'S Lecture: Pediatric Cardiology

PEDIATRIC CARDIOLOGY Cybelle E. Caramba, M.D.
ROTATOR’S LECTURE Third Year Pediatric Resident

ACQUIRED HEART DISEASES:
INFECTIVE ENDOCARDITIS
ETIOLOGY Approximately 6% of cases are
blood culture negative.
EPIDEMIOLOGY
EPIDEMIOLOGIC FEATURE COMMON MICROORGANISMS
Injection drug use (IDU) Staphylococcus aureus , including community
acquired
oxacillin-resistant strains
Coagulase-negative staphylococci
β-Hemolytic streptococci
Fungi
Aerobic gram-negative bacilli, including
Pseudomonas aeruginosa
Polymicrobial
Indwelling cardiovascular medical devices S. aureus
Coagulase-negative staphylococci
Fungi
Aerobic gram-negative bacilli
Corynebacterium spp.
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EPIDEMIOLOGY
Genitourinary disorders, infection, and Enterococcus spp.
manipulation, including pregnancy, delivery, Group B streptococci (S. agalactiae )
and abortion Listeria monocytogenes
Neisseria gonorrhoeae
Chronic skin disorders, including recurrent S. aureus
infections β-Hemolytic streptococci S. aureus
Poor dental health, dental procedures Viridans group streptococci
Nutritionally variant streptococci
Abiotrophia defectiva
Granulicatella spp.
Gemella spp.
HACEK organisms
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EPIDEMIOLOGY
Alcoholism, cirrhosis Bartonella spp.
Aeromonas spp.
Listeria spp.
Streptococcus pneumoniae
Burns S. aureus
Aerobic gram-negative bacilli, including P.
aeruginosa
Fungi
Diabetes mellitus S. aureus
S. pneumoniae
8/4/22 6
EPIDEMIOLOGY
Early (≤1 yr) prosthetic valve placement Coagulase-negative staphylococci
S. aureus
Fungi
Legionella spp.
Late (>1 yr) prosthetic valve placement Coagulase-negative staphylococci
S. aureus
Viridans group streptococci
Enterococcus spp.
Fungi
8/4/22 7
EPIDEMIOLOGY
Dog or cat exposure Bartonella spp.
Pasteurella spp.
Capnocytophaga spp.
Contact with contaminated milk or infected Brucella spp.
farm animals Coxiella burnetii
Erysipelothrix spp.
Homeless, body lice Bartonella spp.
HIV/AIDS Salmonella spp.
S. pneumoniae
S. aureus
Pneumonia, meningitis S. pneumoniae
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EPIDEMIOLOGY
Solid-organ transplantation S. aureus
Aspergillus fumigatus
Enterococcus spp.
Candida spp.
Gastrointestinal lesions Streptococcus gallolyticus (bovis )
Enterococcus spp.
Clostridium septicum
8/4/22 9
CLINICAL MANIFESTATIONS
HISTORY
Prior congenital or rheumatic heart disease
Preceding dental, urinary tract, or intestinal procedure
Intravenous drug use
Central venous catheter
Prosthetic heart valve
8/4/22 12
SYMPTOMS
Fever
Chills
Chest and abdominal pain
Arthralgia, myalgia
Dyspnea
Malaise, weakness
Night sweats
Weight loss
CNS manifestations (stroke, seizures, headache)
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SIGNS
Elevated temperature  Arthritis
Tachycardia  Heart failure
Embolic phenomena (Roth spots,  Arrythmias
petechiae, splinter nail bed  Metastatic infection (arthritis,
hemorrhages, Osler nodes, CNS or meningitis, mycotic arterial
ocular lesions) aneurysm, pericarditis, abscesses,
Janeway lesions septic pulmonary emboli)
New or changing murmur  Clubbing
Splenomegaly
8/4/22 14
ROTH SPOTS
SPLINTER HEMORRHAGES
OSLER NODES
JANEWAY LESIONS
DIAGNOSIS
LABORATORY STUDIES
Positive blood culture
Elevated erythrocyte sedimentation rate; may be low with
heart or renal failure
Elevated C-reactive protein
Anemia
Leukocytosis
20
DIAGNOSIS
BLOOD CULTURE
 increase in volume  can increase sensitivity
 smaller volumes for neonates and small children  single AEROBIC
blood culture may be taken
 2 – 12.7kg: 4ml (1st specimen); 2ml (repeat culture)
 12.8 - 36.3kg: 10ml (initial and repeat)
 >36.3kg: 20-30ml (initial and repeat)
 3 to 5 separate blood collections
 Notify lab if endocarditis is suspected to culture on enriched media
>7 days if necessary
21
DIAGNOSIS
LABORATORY STUDIES
Immune complexes
Hypergammaglobulinemia
Hypocomplementemia
Cryoglobulinemia
Rheumatoid factor
22
DIAGNOSIS
LABORATORY STUDIES
Hematuria
Renal failure: azotemia, high creatinine
(glomerulonephritis)
Chest radiograph: bilateral infiltrates, nodules, pleural
effusions
Echocardiography
23
DIAGNOSIS
LABORATORY STUDIES
 Echocardiography: Transthoracic + Transesophageal
 enhances enhances the ability to diagnose endocarditis
 with Doppler: checks for presence of valve dysfunction and effect
on left ventricular performance
 helpful in predicting embolic complications, given that lesions
>1cm and fungating masses are at greatest risk for
embolization.
24
27
DIAGNOSIS
Diagnostic Approach to Uncommon Pathogens Causing Endocarditis
PATHOGEN DIAGNOSTIC PROCEDURE
Brucella spp. Blood cultures; serology; culture, immunohistology, and PCR of surgical
material
Coxiella burnetii Serology (IgG phase I > 1 in 800); tissue culture, immunohistology, and
PCR of surgical material
Bartonella spp. Blood cultures; serology; culture, immunohistology, and PCR of surgical
material
Chlamydia spp. Serology; culture, immunohistology, and PCR of surgical material
Mycoplasma spp. Serology; culture, immunohistology, and PCR of surgical material
Legionella spp. Blood cultures; serology; culture, immunohistology, and PCR of surgical
material
Tropheryma whipplei Histology and PCR of surgical material
28
MODIFIED DUKE CRITERIA
MAJOR CRITERIA MINOR CRITERIA
1. Positive blood culture • Predisposing heart condition (valvular disease
• Typical organisms for IE from >2 cultures, or with stenosis or regurgitation, prosthetic valves,
• Persistently positive cultures, defined as: congenital heart defects, prior endocarditis,
• At least 2 blood cultures drawn >12hrs apart, hypertrophic cardiomyopathy) or injection drug
or use
• All of 3 or a majority of >4 separate cultures • Fever >38C
with first and last drawn at least 1 hour apart • Vascular phenomena: major arterial emboli,
• Single positive blood culture for Coxiella burnetiid septic pulmonary infarcts, mycotic aneurysms,
or phase 1 IgG antibody titer of >1:800 intracranial hemorrhage, conjunctival
2. Evidence of endocardial involvement hemorrhages, Janeway lesions
• Positive echocardiogram for IE: • Immunologic phenomena: glomerulonephritis,
• Oscillating intracardiac mass on valves or Osler’s nodes, Roth’s spots, rheumatoid factor
supporting structures • Microbiologic evidence: positive blood culture but
• Abscess, or not meeting major criterion or serologic evidence
• New dehiscence of prosthetic valve of active infection with organism consistent with
• New valvular regurgitation IE
DEFINITIVE INFECTIVE ENDOCARDITIS
PATHOLOGIC CRITERIA
• Microorganisms demonstrated by results of cultures or histologic
examination of a vegetation, a vegetation that has embolized, or an
intracardiac abscess specimen; or
• Pathologic lesions; vegetation, or intracardiac abscess confirmed by
results of histologic examination showing active endocarditis
CLINICAL CRITERIA
• 2 major criteria, or
• 1 major criterion and 3 minor criteria, or
• 5 minor criteria
Modified from Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective
endocarditis, Clin Infect Dis 30:633, 2000. 35
POSSIBLE INFECTIVE ENDOCARDITIS
CLINICAL CRITERIA
• 1 major criteria and 1 minor criterion, or
• 3 minor criteria
REJECTED DIAGNOSIS OF INFECTIVE ENDOCARDITIS
• Firm alternate diagnosis explaining evidence of suspected IE, or
• Resolution of IE syndrome with antibiotic therapy for ≤4 days, or
• No evidence of IE at surgery or autopsy, on antibiotic therapy for ≤4
days, or
• Does not meet criteria for possible IE
PROGNOSIS AND
COMPLICATIONS
 Morbidity and mortality remains high
 most commonly from heart failure caused by vegetations involving
the aortic or mitral valve
 Other causes of heart failure:
 myocardial abscesses
 toxic myocarditis
 life threatening arrythmias
38
PROGNOSIS AND
COMPLICATIONS
 Complications
 Systemic emboli
 CNS manifestations
 Pulmonary embolism (rare)
 Mycotic aneurysms
 Rupture of a sinus of Valsalva
 Valve obstruction from large vegetations
 Acquired ventricular septal defects
 Heart block (from involvement of conducting system)
 Meningitis, osteomyelitis, arthritis, renal abscess, purulent pericarditis, and
immune complex-mediated glomerulonephritis
39
TREATMENT
 Start antibiotics once definitive diagnosis is made.
 Empiric treatment: Vancomycin + Gentamicin
 Maintain high serum bactericidal levels long enough to
eradicate organisms that are growing in relatively
inaccessible avascular vegetations
 A total of 4 – 6 weeks treatment may be required.
40
TREATMENT
Therapy of Native Valve Endocarditis Caused by Highly Penicillin-
Susceptible Viridans Group Streptococci and Streptococcus bovis
REGIMEN DOSAGE AND ROUTE DURATION
Aqueous crystalline penicillin G sodium 12-18 million U/24 hr IV either 4 weeks
continuously or in 4 or 6 equally divided
doses
OR
Ceftriaxone sodium 2 g/24 hr IV/IM in 1 dose 4 weeks
Pediatric dose:
Penicillin 200,000 U/kg/24 hr IV in 4-6 equally divided
doses;Ceftriaxone 100 mg/kg/24 hr IV/IM in 1 dose
Aqueous crystalline penicillin G sodium 12-18 million U/24 hr IV either 2 weeks
continuously or in 6 equally divided doses
OR
Baddour LM, Wilson WR, Bayer AS, et al: Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications,
Circulation 111:e394–e433, 2005; correction: Circulation 112:2373, 2005. 41
TREATMENT
Therapy of Native Valve Endocarditis Caused by Highly Penicillin-
Susceptible Viridans Group Streptococci and Streptococcus bovis
Ceftriaxone sodium 2 g/24 hr IV/IM in 1 dose 2 weeks
plus
Gentamicin sulfate 3 mg/kg/24 hr IV/IM in 1 dose, or 3 2 weeks
equally divided doses
Pediatric dose :
Penicillin 200,000 U/kg/24 hr IV in 4-6 equally divided doses;
Ceftriaxone 100 mg/kg/24 hr IV/IM in 1 dose;
Gentamicin 3 mg/kg/24 hr IV/IM in 1 dose or 3 equally divided doses
Vancomycin hydrochloride 30 mg/kg/24 hr IV in 2 equally divided 4 weeks

doses, not to exceed 2 g/24 hr
unless concentrations in serum are inappropriately low
Pediatric dose : 40 mg/kg/24 hr IV in 2-3 equally divided doses
TREATMENT
Therapy for Endocarditis Caused by Staphylococci in the Absence of
Prosthetic Materials
OXACILLIN-SUSCEPTIBLE STRAINS
Nafcillin or oxacillin 12 g/24 hr IV in 4-6 equally divided doses 6 weeks
with
Optional addition of gentamicin sulfate 3mg/kg/24hr IV/IM in 2 or 3 equally 3-5 days
divided doses
Pediatric dose: nafcillin or oxacillin 200
mg/kg/24 hr IV in 4-6 equally divided
doses; gentamicin 3 mg/kg/24 hr IV/IM in 3
TREATMENT
Therapy for Endocarditis Caused by Staphylococci in the
Absence of Prosthetic Materials
OXACILLIN-SUSCEPTIBLE STRAINS (Penicillin-allergic but non-anaphylactoid type
patients)
Cefazolin 6 g/24 hr IV in 3 equally divided 6 weeks
doses
with
Optional addition of gentamicin 3mg/kg/24hr IV/IM in 2 or 3 equally 3-5 days
sulfate divided doses
Pediatric dose : Cefazolin 100mg/kg/24hr IV in 3
equally divided doses; gentamicin 3 mg/kg/24 hr
IV/IM in 3
TREATMENT
Therapy for Endocarditis Caused by Staphylococci in the Absence of
Prosthetic Materials
OXACILLIN-RESISTANT STRAINS
Vancomycin 30 mg/kg/24 hr IV in 2 equally divided 6 weeks
Doses
Pediatric dose : 40 mg/kg/24 hr IV in

2 or 3 equally divided doses
TREATMENT
 Medical management for heart failure
 Diuretics
 Afterload reducing agents
 Digitalis
46
TREATMENT
 Surgical intervention
 Severe aortic, mitral or prosthetic valve involvement with intractable
heart failure
 mycotic aneurysm, rupture of an aortic sinus, intraseptal abscess
causing complete heart block, or dehiscence of an intracardiac patch
 failure to sterilize the blood despite adequate antibiotic levels in 7-10
days in the absence of extracardiac infection, myocardial abscess,
recurrent emboli, and increasing size of vegetations while receiving
therapy
47
TREATMENT
Echocardiographic Features that Suggest Potential Need for
Surgical Intervention
VEGETATION
• Persistent vegetation after systemic embolization
• Anterior mitral valve leaflet vegetation, particularly if it is highly mobile with size >10 mm*
• One or more embolic events during the 1st 2 wk of antimicrobial therapy*
• Increase in vegetation size despite appropriate antimicrobial therapy* †
VALVULAR DYSFUNCTION
• Acute aortic or mitral insufficiency with signs of ventricular failure †
• Heart failure unresponsive to medical therapy †
• Valve perforation or rupture †
PERIVALVULAR EXTENSION
• Valvular dehiscence, rupture, or fistula †
• New heart block
• Large abscess or extension of abscess despite appropriate antimicrobial therapy
ANTIBIOTIC PROPHYLAXIS
Cardiac Conditions Associated with Highest Risk of Adverse Outcome from
Infective Endocarditis for Which Prophylaxis with Dental Procedures Is
Reasonable (2007 AHA Statement)
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Previous infective endocarditis
Congenital Heart Disease (CHD)
• Unrepaired cyanotic CHD, including palliative shunts and conduits
• Completely repaired CHD with prosthetic material or device, whether placed by surgery or
catheter intervention, during the 1st 6 mo after the procedure
• Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch, or
prosthetic device (which inhibit endothelialization)
• Cardiac transplantation recipients who develop cardiac valvulopathy
Wilson W, Taubert KA, Gewitz M, et al: Prevention of infective endocarditis: guidelines from the American Heart Association, Circulation 116:1736–1754, 2007.
Cardiac Conditions Associated with Highest Risk of Adverse Outcome from
Infective Endocarditis for Which Prophylaxis with Dental Procedures Is
Reasonable (2007 AHA Statement)
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Previous infective endocarditis
Congenital Heart Disease (CHD)
Patients with permanently damaged valves
• Unrepaired cyanotic CHD, including palliative shunts and conduits
• Completely repaired CHD with prosthetic material or device, whether placed by surgery or
from rheumatic heart disease should also
catheter intervention, during the 1st 6 mo after the procedure
• Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch, or
be considered for prophylaxis.
prosthetic device (which inhibit endothelialization)
• Cardiac transplantation recipients who develop cardiac valvulopathy
WHAT PROCEDURES IS PROPHYLAXIS
NEEDED TO BE GIVEN?
1. Dental procedures requiring manipulation of the

gingival or periapical region of the teeth or
perforation of the oral mucosa
2. Invasive respiratory procedures that may
cause bacteremia
3. Undergoing cardiac surgery with placement
of prosthetic material
Prophylactic Antibiotic Regimen for a Dental Procedure (2007 AHA Statement)
SITUATION AGENT ADULTS CHILDREN
Oral Amoxicillin 2g 50mg/kg
Unable to take oral Ampicillin 2g IM or IV 50mg/kg IM or IV
medications or
Cefazolin or Ceftriaxone 1g IM or IV 50mg/kg IM or IV
Allergic to penicillins or Cephalexin 2g 50mg/kg
ampicillin – oral or
Clindamycin 600mg 20mg/kg
or
Azithromycin or Clarithromycin 500mg 15mg/kg
Allergic to penicillins or Cefazolin or ceftriaxone 1g IM or IV 50mg/kg IM or IV
ampicillin and unable to take or
oral medications Clindamycin 600mg IM or IV 20mg/kg IM or IV
CARDIAC THERAPEUTICS:
HEART FAILURE
HEART
FAILURE
“A clinical and pathological
syndrome that results from
ventricular dysfunction, volume,
or pressure overload, alone or in
combination. It leads to
characteristic signs and
symptoms, such as poor growth,
feeding difficulties, respiratory
distress, exercise intolerance,
and fatigue, and is associated
with circulatory, neurohormonal,
and molecular abnormalities.
Heart failure has numerous
etiologies that are a consequence
of cardiac and noncardiac
disorders, either congenital or
acquired.”
Preload Contractility Afterload
Stroke Volume
Synergistic LV Contraction
Wall Integrity Heart Rate
Valvular Competence
Cardiac Output
PATHOPHYSIOLOGY
• Clinical manifestations of HF depend in part on the
degree of the child’s cardiac reserve
• comfortable at rest but may be unable to increase cardiac output
• if critically ill (and exhausted compensatory mechanisms) 
cardiogenic shock
• History taking is still important in diagnosis

and evaluation of etiology.
• Feeding difficulties  failure to • Elevated systemic venous
thrive pressure (by JVP measurement)
• Fatigue and activity intolerance • Cardiomegaly
• Dyspnea • Liver enlargement
• Orthopnea • Basilar rales
• Increased respiratory effort • Gallop rhythm (S3)
• Cough • Holosystolic murmur from mitral
• Abdominal symptoms (abdominal or tricuspid regurgitation
pain, nausea, anorexia) • Edema
CLINICAL
MANIFESTATIONS
Proposed HF Classification for Infants and Children
STAGE DEFINITION EXAMPLES
A Patients with increased risk of developing HF but who Previous exposure to cardiotoxic agents,
family history of heritable cardiomyopathy,
have normal cardiac function and no evidence of univentricular heart, congenitally corrected
cardiac chamber volume overload. transposition of the great arteries.
B Patients with abnormal cardiac morphology or cardiac Aortic insufficiency with LV enlargement,
history of anthracycline with decreased LV
function, with no symptoms of HF, past or present. systolic function.
C Patients with underlying structural or functional heart Dilated cardiomyopathy with chronic HF
due to decreased LV
disease, and past or current symptoms of HF. systolic function.
D Patients with end-stage HF requiring continuous Acute decompensated HF due to viral

myocarditis.
infusion of inotropic agents, mechanical circulatory
support, cardiac transplant, or hospice care.
From Rosenthal D, Chrisant MR, Edens E, et al. International Society for Heart and Lung Transplantation: practice guidelines for
management of heart failure in children. J Heart Lung Transplant. 2004;23(12):1313.
DIAGNOSTICS
 Chest xray
 Electrocardiography (ECG)
 Echocardiography
 Magnetic Resonance Angiography
 Arterial blood gas
 Serum B-type (brain) natriuretic peptide (BNP)
DIAGNOSTICS
 CHEST RADIOGRAPHS
 Cardiomegaly
 Large left-to-right shunts have exaggeration of the pulmonary arterial
vessels to the periphery of the lung fields
 Fluffy perihilar pulmonary markings: venous congestion
DIAGNOSTICS
 ELECTROCARDIOGRAPHY (ECG)
 may help in assessing the cause of heart failure
 best tool for evaluating rhythm disorders
DIAGNOSTICS
 ECHOCARDIOGRAPHY
 standard for assessing ventricular function
 Fractional shortening (a single dimensional variable)
 determined as the difference between end-systolic and end-diastolic
diameter divided by end-diastolic diameter
 normal: 28 – 42%
DIAGNOSTICS
 ECHOCARDIOGRAPHY
 standard for assessing ventricular function
 Fractional shortening (a single dimensional variable)
 determined as the difference between end-systolic and end-diastolic
diameter divided by end-diastolic diameter
 normal: 28 – 42%
DIAGNOSTICS
 SERUM B-TYPE NATRIURETIC PEPTIDE
 cardiac neurohormone released in response to increased ventricular
wall tension
 In children, B-type natriuretic peptide may be elevated in other
conditions
Causes of Elevated Concentration of Natriuretic Peptides
CARDIAC NONCARDIAC
• Heart failure (HFpEF, HFrEF) • Ischemic stroke
• Acute coronary symptoms • Subarachnoid hemorrhage
• Pulmonary embolism • Renal dysfunction
• Myocarditis • Liver dysfunction (mainly liver cirrhosis with
• Left ventricular hypertrophy ascites)
• Hypertrophic or restrictive cardiomyopathy • Paraneoplastic syndrome
• Valvular heart disease • Chronic obstructive pulmonary disease
• Congenital heart disease • Severe infections (including pneumonia and
• Atrial and ventricular tachyarrhythmias sepsis)
• Heart contusion • Severe burns
• Cardioversion ICD shock • Anemia
• Surgical procedures involving the heart • Severe metabolic and hormone
• Pulmonary hypertension abnormalities (e.g. thyrotoxicosis, diabetic
ketosis)
TREATMENT
GENERAL MEASURES
 Strict bed rest only in extreme cases
Rest during the day
Sleep adequately at night
 Activity restriction modified based on patient’s
ability
Formal cardiopulmonary testing can be used
TREATMENT
DIET
 Increase number of calories per ounce of infant formula
 Nasogastric feeding (if poor suck) given as continuous
drip at night to decrease gastroesophageal reflux
 “No added salt” diets
 Abstinence from foods containing large amount of
sodium
TREATMENT
MEDICAL THERAPY
 Diuretics
 Afterload reducers
 Digitalis glycosides
 Alpha- and Beta-adrenergic agonists
 Phosphodiesterase inhibitors
 Beta-blockers
Alpha- and Beta-
Phosphodiesterase
adrenergic agonists
inhibitors
Preload Contractility Afterload
Diuretics Digitalis glycosides Afterload reducers
(ACEIs, ARBs)
Stroke Volume
Synergistic LV Contraction Beta-blockers
Wall Integrity Heart Rate
Valvular Competence
Cardiac Output
TREATMENT
TREATMENT
Kantor PF, Lougheed J, Dancea A, et al; Children’s Heart Failure Study Group. Presentation, diagnosis, and medical
management of heart failure in children: Canadian Cardiovascular Society guidelines. Can J Cardiol. 2013;29(12):1535–1552
TREATMENT
MEDICAL THERAPY (New Therapies*)
 Serelaxin
 Ivabradine
 ARB + neprilysin inhibitor
TREATMENT
ELECTROPHYSIOLOGIC APPROACHES
 Biventricular resynchronization pacing
 Implantable cardioverter-defibrillator
CARDIOGENIC SHOCK
CARDIOGENIC SHOCK
Low cardiac output  inadequate tissue perfusion
Causes:
1. Severe cardiac dysfunction before and after cardiac surgery
2. Septicemia
3. Severe burns
4. Anaphylaxis
5. Cardiomyopathy
6. Myocarditis
7. Myocardial infarction or stunning
8. Acute central nervous system disorders
TREATMENT
*The goal is to improve peripheral perfusion by increasing cardiac

output, where: cardiac output = heart rate x stroke volume.
TREATMENT
MECHANICAL CIRCULATORY SUPPORT
 Extracorporeal membrane oxygenation (ECMO)
 Ventricular assist device (VAD)
 Paracorporeal pneumatic pulsatile device – for children
 Berlin Heart EXCOR
Intracorporeal continuous flow devices
ECMO

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PEDIATRIC CARDIOLOGY Cybelle E. Caramba, M.D.

ROTATOR’S LECTURE Third Year Pediatric Resident

Vancomycin hydrochloride 30 mg/kg/24 hr IV in 2 equally divided 4 weeks

Pediatric dose : 40 mg/kg/24 hr IV in

1. Dental procedures requiring manipulation of the

• History taking is still important in diagnosis

D Patients with end-stage HF requiring continuous Acute decompensated HF due to viral

*The goal is to improve peripheral perfusion by increasing cardiac

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