HEART FAILURE IN CHILDREN

Presented by :

Dena Karina F
Luhur Pribadi
Muammar Riyandi

Departement of Child Health RSCM

Faculty of Medicine University of Indonesia

Pendahulua
n

Gagal jantung pada pediatrik

etiologi yang beragam berbagai
macam presentasi klinis
Mempunyai patofisiologi yang sama
tidak terobati mempercepat
kematian
Penyakit jantung pada anak gagal
jantung penyumbang 50 %
transplantasi jantung

Boucek MM, et al .Registry for the International Society for Heart and Lung Transplantation: seventh official pediatric report2004. J Heart Lung
Transplant. 2004

Definisi

Prevalensi

Gagal jantung di USA 900.000

masuk rumah sakit selama setahun
250.000 meninggal pertahunnya
Sebagian besar gagal jantung terjadi
pada saat dewasa
Pada anak Pediatric
Cardiomyopathy Registry annual
incidence 1.13 kasus cardiomyopathy
pada setiap 100.000 anak

Lipshultz SE, Sleeper LA, Towbin JA, et al. The incidence of pediatric cardiomyopathy in two regions of the United
States. N Engl J Med 2003

ETIOLOGI
Infant

Child n
Adolescent

Unoperat
Post
Acquire
Congeni
Dys
ed
operated
d Non
Aritmia
tal
ventrikel
cardiac
Rheumatic

NonSepsi
Cardiac

Marfan
Mitral
Residual heart
syndrom
Cardiomyopat
regurgitasi
Shunt
disease
VSD
Renal
hy
Aortic
Mitral
Infective
failure
ASD
myocarditis
regurgitasi
regurgitasi
endocarditi
Pulmonary
PDA
Aortic
Ebstein
s
Hypertensi
Myocarditi
anomaly
regurgitasi
Renal Failure on (primary
Truncu
Eisenmeng Residual
sHypotyroidism
or

er
s Syndrom obstruction Cardyomy secondary)
opathy
Moss and Adams Heart Disease in Infant, Children,
and Adolescent-including the fetus and young adults , 7
th

Patofisiologi

Physical findings and

cardiomegaly on a chest
film is nearly a prerequisite
sign of CHF
Echocardiographic confirm
the diagnosis of heart
failure and estimate the
No single test
severity of heart failure,
is specific for
help identify the cause of
CHF
heart failure.
ECG the least important
test for the diagnosis of CHF
BNP levels can distinguish
between cardiac and
pulmonary causes of
respiratory distress in
Park M. Congestive Heart Failure. In: Pediatric Cardiology for Practitioners. 5th ed. Chapter 27.

Principles of
Diagnosis

Clinical
manifestatio
n
Because HF has
multiple causes, it
has a variety of agedependent clinical
presentations.1

Hsu DT, Pearson GD. Heart failure in children part II: Diagnosis, treatment, and future directions. Circ Hear Fail. 2009;2(5):490-498.
2
Madriago E, Silberbach M. Heart failure in infants and children. Pediatr Rev. 2010;31(1):4-12.
3
Park M. Congestive Heart Failure. In: Pediatric Cardiology for Practitioners. 5th ed. Chapter 27. Mosby; 2008 .

Compensatory
Mechanism

Physical
Examination

Tachycardia, gallop rhythm,

and weak and thready pulses
Signs of increased
sympathetic discharges (e.g.,
growth failure, perspiration,
cold and wet skin)

Left sided failure

(Pulmonary Venous
Congestion)
Infants
Children
Tachypnea Dyspnea
Respirator
on
y distress
exertion
(retraction Orthopnea
Wheezing
s),
grunting
and
pulmonary
crackles

Park M. Congestive Heart Failure. In: Pediatric Cardiology for Practitioners. 5th ed. Chapter 27.

Right sided failure

(systemic Venous
Congestion)
Infants
Children
Hepatome Decreased
exercise
galy
capacity
Puffy
Hepatomegal
eyelids

y
Distended
neck veins
ankle edema
ascites,
and/or pleural
effusions.

Clinical
Classification
The Ross Heart
Failure
Classification was
developed to provide
a global assessment
of heart failure
severity in infants,
and has subsequently
been modified to
apply to all pediatric
ages.
Hsu DT, Pearson GD. Heart failure in children part I: History, etiology, and pathophysiology. Circ Hear Fail. 2009;2(1):63-70

ACC/AHA for
HF staging
The ACC/AHA
staging identifies
patients at risk for
HF who require early
intervention to
prolong the
symptom-free state;
It also delineates
patients who require
aggressive
management of
symptoms once
Rosenthal D, Chrisant MRK, Edens E, et al. International Society for Heart and Lung Transplantation: Practice guidelines for management of heart
they
become
failure in children. J Heart Lung Transplant. 2004;23(12):1313-1333.

CHEST X-RAY

www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.html

CHD and
Pulmonary
Function

Healy, F., Hanna, B. D., & Zinman, R. (2012). Pulmonary Complications of Congenital Heart Disease. Paediatric Respiratory
Reviews, 13(1), 1015.

 Anak PJB seringkali mengalami infeksi saluran napas dan

bila terkena lebih lama sembuh dibanding anak yang
normal, gagal jantung memperburuk keadaan tersebut.
Faktor yang dianggap menyebabkan lamanya infeksi
tersebut adalah :

CHF & RRTI

adanya kompresi bronkus besar oleh atrium kiri atau

arteri pulmonalis yang membesar akibat hipertensi
pulmonal defek pada bersihan jalan nafas

Terjadinya edema paru menjadi nidus infeksi untuk

saluran nafas bawah

Terjadinya atelektasis (akibat kompresi ekstrinsik

oleh malformasi vascular atau defek restriktif dari
edema paru), hipoksemia pulmonal dan hypoplasia
jalan napas

Wilar, R., & Wantania, J. M. (2006). Beberapa Faktor yang Berhubungan dengan Episode Infeksi Saluran Pernapasan Akut pada Anak dengan Penyakit Jantung
Bawaan. Sari Pediatri, 8, 154158
Healy, F., Hanna, B. D., & Zinman, R. (2012). Pulmonary Complications of Congenital Heart Disease. Paediatric Respiratory Reviews, 13(1), 1015.

ECHOCARDI
OGRAPHY
congestive heart failure
itself is not an

echocardiographi
c diagnosis;

Echocardiography, the primary imaging modality in

pediatric cardiology, provides excellent structural
and functional detail in children.
Although not useful for the evaluation of HF,
which is a clinical diagnosis,
echocardiography is essential for identifying :

therefore, the
Causes of HF such as structural heart disease,
underlying etiology is
ventricular dysfunction (both systolic and
best identified by
diastolic)
means of detailed
history taking and
Confirm enlargement of ventricular chambers
physical examination
Serial evaluation of the efficacy of therapy
and often by means of
chest
radiography.
Madriago, E., & Silberbach, M. (2010). Heart failure in infants and children. Pediatrics in Review / American Academy of Pediatrics,
31(1), 412.
Hsu DT, Pearson GD. Heart failure in children part II: Diagnosis, treatment, and future directions. Circ Hear Fail. 2009;2(5):490-498

Laboratory
BNP and NTpro BNP

A BNP level > 300 pg/mL has been shown to

predict death, transplantation, or heart failure
hospitalization and was more strongly
correlated with poor outcome than symptoms
or echocardiographic findings.1

Guidelines for the use of

Auerbach, S.et al : In children with moderately
brain natriuretic peptide
symptomatic HF, BNP > 140 pg/mL at higher
(BNP) and N-terminal prorisk for worse outcome
BNP levels in adult
patients are not
Chun-wang Lin. Et.al : Optimal cutoff values of
generalizable to children,
plasma NT-proBNP for the diagnosis of HF
because the type of
were 502 ng/L (0-1 year), 456 ng/L (1-3
ventricular impairment,
years), 445 ng/L (4-7 years), and.355
underlying cardiac
ng/L (8-14 years).
morphology, age, gender,
and assay method may
affect the reference
values for theseHsu DT, Pearson GD. Heart failure in children part II: Diagnosis, treatment, and future directions. Circ Hear Fail. 2009;2(5):490-498
erbach SR, Richmond ME, Lamour JM, et al. BNP levels predict outcome in pediatric heart failure patients post hoc analysis of the Pediatric Carvedilol Trial. Circ
markers.1
Fail.failure
2010;3(5):606-611
Lin C-W, Zeng X-L, Zhang J-F, Meng X-H. Determining the optimal cutoff values of plasma NT-proBNP levels for the diagnosis Hear
of heart
in children of
1

age up to 14 years. J Card Fail. 2014;20(3):168-173.

 HFpEF does exist in children.

Heart
Failure with
Preserved
Ejection
Fraction in
Children
(HFpEF)

Prevalence is rare (only 0.5% of all cohorts with

possible and diagnosed cardiovascular diseases
compared to prevalence: 1.15.5% in adult)
the underlying pathophysiology of HFpEF in children
represented by concentric hypertrophy, diastolic
dysfunction and possibly ventricular systolic and
arterial stiffening
The diagnosis of HFpEF requires :
(1) signs or symptoms of HF
(2) normal or mildly abnormal systolic left ventricular
(LV) function
(3) evidence of diastolic LV dysfunction.

Nakagawa, M. (2013). Clinical Characteristics of Heart Failure With Preserved Ejection Fraction in Children. Circulation Journal, 77(9), 2249225

Management

McMurray JJ et al. European Heart Journal (2012) 33,

Park MK, Pediatric Cardiology for Practitioners, Elsevier 2008

Treatment
Of
Underlying
Causes Or
Contributing
Factors

Surgery if feasible
Treat the contributing factor (hypertension,
infection fever, anemia, etc)
Antiarrhythmic agents or cardiac pacemaker
therapy if indicated.
If hyperthyroidism is the cause of heart
failure, this condition should be treated.

Park MK, Pediatric Cardiology for Practitioners,

Control of
the heart
failure state

Diuretics are usually used with inotropic

agents.
Afterload-reducing agents, such as ACE
inhibitors, have gained popularity because
they can increase cardiac output without
increasing myocardial oxygen consumption.
Rapid-acting inotropic agents (dopamine,
dobutamine) are used in critically or acutely
ill infants and children.
Recently, lowdose -adrenergic blockade has
been added to the treatment of dilated
cardiomyopathy with encouraging results.
Park MK, Pediatric Cardiology for Practitioners, Elsevier 2008

-Adrenergic
blockers

Carvedilol, The initial dose was 0.09mg/kg

twice daily and the dose was increased
gradually to 0.36 and 0.75 mg/kg as
tolerated, up to the maximum adult dose of
50 mg/day.
Metoprolol. The starting dose was 0.1 to 0.2
mg/kg per dose twice a day and was slowly
increased over a period of weeks to 1.1
mg/kg/day (range 0.5 to 2.3 mg/kg/day).

Park MK, Pediatric Cardiology for Practitioners, Elsevier 2008

Device
Therapy For
Heart Failure

One study in seven children with congenital

heart disease and a right bundle branch
block pattern found that resynchronizaton
therapy resulted in small but statistically
significant acute improvement in cardiac
output and right ventricular.
Although still controversial there are
guidelines for the use of ICD in children
some of which has been extrapolated from
adult trials.
Dubin AM feinstein JA, Reddy VM, et al. Circulation
2003;107:2287-89
Walsh EP. Pacing Clin Electrophysiology
2008;31(suppl1):S38-S40
Sia MJ Bar Cohen Y. Circ Arrhythm Electrophysol
3008;1:298-306

Nutrition and
Exercise in
Pediatric
Heart Failure

Significant nutritional cost to infants who

are trying to both grow and cope with the
increased metabolic demands of heart
failure symptoms.
Sodium restriction is not recommended in
infants and young children
Regular physical activity can result in
sustained improvements in physical
functioning even in children with complex
congenital heart disease.

Hsu, DT. Pearson DG. Circ Heart Fail.

References

Boucek MM, et al .Registry for the International Society for Heart and Lung
Transplantation: seventh official pediatric report2004. J Heart Lung
Transplant. 2004
Moss and Adams Heart Disease in Infant, Children, and Adolescentincluding the fetus and young adults , 7th ed, LWW, 2008
Madriago, E., & Silberbach, M. (2010). Heart failure in infants and children.
Pediatrics in Review / American Academy of Pediatrics, 31(1), 412.
Park M. Congestive Heart Failure. In: Pediatric Cardiology for Practitioners.
5th ed. Chapter 27. Mosby; 2008.
Hsu DT, Pearson GD. Heart failure in children part I: History, etiology, and
pathophysiology. Circ Hear Fail. 2009;2(1):63-70
Hsu DT, Pearson GD. Heart failure in children part II: Diagnosis, treatment,
and future directions. Circ Hear Fail. 2009;2(5):490-498
www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.htm
l
Rosenthal D, Chrisant MRK, 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):1313-1333.
Wilar, R., & Wantania, J. M. (2006). Beberapa Faktor yang Berhubungan
dengan Episode Infeksi Saluran Pernapasan Akut pada Anak dengan
Penyakit Jantung Bawaan. Sari Pediatri, 8, 154158
Healy, F., Hanna, B. D., & Zinman, R. (2012). Pulmonary Complications of
Congenital Heart Disease. Paediatric Respiratory Reviews, 13(1), 1015.
Sadoh, W. E., & Osarogiagbon, W. O. (2013). Underlying congenital heart
disease in Nigerian children with pneumonia. African Health Sciences,
13(3), 607612.
McMurray JJ et al. European Heart Journal (2012) 33, 17871847

THANK YOU
HAPPY EID MUBARAK