兒科學教學課件：Congenital Heart Disease And Heart Failure

CongenitalHeartDiseaseAndHeartFailureObjectivePartone:CaseDiscussionParttwo:HeartFailurediagnosticcriteriaprinciplesofmanagementPartone:CaseDiscussionGeneralinformation:male,1Y11M,Chiefcomplaints:heartmurmurformorethanone-year,coughforsixdays,feverfortwodays.Pasthistory:susceptibletocolds,twicepneumonia,feedingdifficulties,excessivesweating,laboredrespirationwhileeating.

Physicalexamination:

bodyweight:10Kg,nocyanosis;chestabdominalbreathing,threedepressionssign,cracklesinthelungs;protrusionofprecordium,Ⅳ/6gradepansystolicmurmurinthethirdandfourthleftintercostalspaces,palpablethrill,accentuationofP2;liverenlargedwithitsloweredge2cmbelowtherightcostalmargin.Case

DiscussionAssistantexamination:

ChestX-ray:increasedlungmarkings,cardiacenlargement,C/T(cardiothoracicratio):0.56Electrocardiogram(ECG):highleftventricularvoltage（leftventricularhypertrophy）UltrasonicCardiogram(UCG):ventricularseptaldefect,pulmonaryhypertensionCaseDiscussionCluesofDiagnosis1.Involvedorgans?Lungs；heart2.EtiologicalFactor?

Infection；congenital3.Functionoforgans?Heartfailure

Diagnosis1.acutepneumonia

2.congenitalheartdisease:

ventricularseptaldefect

pulmonaryhypertension

chroniccardiacinsufficiency(heartfailure)PrinciplesofTreatment1.symptomatictreatment:

oxygen,nutritionalsupport,physicalormedicalcooling,nebulization,sucksputum,etc.2.treatmentforpneumonia:anti-infectiveagents(antibiotics),acordingtothepathogensPrinciplesofTreatment3.treatmentforheartfailure:cardiotonicagents(digoxin);diuretics(hydrochlorothiazide,Antisterone);ACEinhibitor(Capoten)4.

treatmentforVSD

surgeryParttwo:HeartFailureHowtorecognize?1、ininfants2、inchildrenCLINICALMANIFESTATIONSInInfantsoftenatypical,biventricularfailureChronic:feedingdifficulties,excessiveperspiration，poorweightgain，irritability，tachypneawhilesucking,dyspnea,

hepatomegalyAcute:suddendyspnea,dysphoria,palenessorcyanosis,tachycardiaandgalloprhythm,wheezesandcracklesinlungs,hepatomegalyCLINICALMANIFESTATIONSInChildrenSilmilartoadultsFatigue,effortintolerance,anorexia,abdominalpainandcough,increasedheartrate(atrest)，tachypneabutshallowbreathLeftheartfailure(haemostasisinpulmonarycirculation):cough,tachypnea,dyspnea,wheezesandcracklesinlungs,galloprhythmRightheartfailure(haemostasisinsystemiccirculation):anorexia,abdominalpain,jugulardistension,positivehepatojugularreflux,hepatomegalywithtenderness,edema,decreaseinurineoutputChestX-raycardiomegaly,diminutionofcardiacimpulseincreasedlungmarkings,pulmonaryplethora,haemostasisinPulmonaryvein,acutepulmonaryedemaElectrocardiogram(ECG)Helpfulinmakingaetiologicaldiagnosis

supervisingtheuseofdigitalis

Echocardiogram

Helpfulinidentifyingtheprimaryheartdisease(congenitalheartdefects)detectingcardiacfunctionandcardiachemodynamicparameters(enddiastolicvolume(EDV),ejectionfraction(EF),fractionalshortening(FS),cardiacoutput(CO),etc)Treatment1、Rest：bedrest,inasemi-uprightpositionkeepquiet,avoidcryingandirritatingusesedativeswhennecessary2、Diet：

eatmorefrequentlybutsmallermealslightdietbutnutritiousfoodnasogastricfeedingwhennesessaryTreatment3、Fluidrestriction：totleintravenousfluidvolume:75ml/kg/daymaintainwater,electrolyteandacid-basebalanceTreatmentTreatment4、oxygen:tachypneaandcyanosis:giveoxygen,keepairwayunobstructedSeverepulmonaryedema:positivepressureventilation

Treatment5、Digitalis：mechanism：enhancemyocardialcontractilityandsystolicvelocity，increaseCO,excitevagusnerve,slowheartrateandatrioventricularconduction，diminishmyocardialoxygenconsumption,inhibitvasoconstrictioncausedbysympatheticnervesystem,improvesystemicandpulmonarycirculationsTreatmentInstructions：Criticallyill

patient:

cedilanid,iv,digitalization(?initially,followedby?q4-6h×2)Ordinarypatient:

digoxin,po,digitalization(?initially,followedby?q12h×2)Maintenance:digoxin,po,q12h,(started≈12hafterfulldigitalization)TreatmentAttention：1、Notetheuseofdigitalisrecently,avoidoverdose2、Reduce1/3dosageinpatientswithmyocarditis,inprematureinfantsorneonates(lessthan2weeksold)3、avoidgivingcalcium4、measureserumelectrolytelevels,avoidhypokalemiaTreatmentclinicalmanifestationsofdigitalistoxicity

1、arrhythmiaandconductiondisturbance2、nauseaandvomiting3、somnolence,dizziness,chromatopsiaTreatment6、Diuretics：inconjunctionwithdigitalisinsevereheartfailure

interferewithreabsorptionofwaterandsodiumbythekidneys,reducecirculatingbloodvolume，reducepulmonaryfluidoverloadandventricularfillingpressureAcuteheartfailure:Lasix,ivChronicheartfailure:dihydrochlorothiazide(DHCT)andPotassium-sparingdiuretics,po

Treatment7、ACEInhibitors:blockingtheproductionofangiotensinII,producearterialdilatation,decreaseperipheralvascularresistance,reduceventricularafterloadhavebeneficialeffectsoncardiacremodelingdecreasesystemicvenoustone,reducepreloadinterferewithaldosteroneproduction,controlsaltandwaterretentionCaptopril(Capoten):

0.5~1.0mg/kg/time,bidortid,

poEnalapril(Vasotec):0.08~0.1mg/kg/day,qd,

poBenazapril:0.1mg/kg/day,qd,po,aweeklater,increasedto0.3~0.4mg/kg/daygraduallyTreatmentACEIshouldbeusedwithcautionin:（1）bilateralrenalarterystenosis（2）significantlyhighserumcreatinine(>225.2μmol/L)（3）hyperkalemia(>5mmol/L)（4）hypotensionTreatmentTreatment8、PhosphodiesteraseInhibitors

InhibitPhosphodiesterase,preventthedegradationofintracellularcyclicadenosinemonophosphate,intracellular

CAMP↑,positiveinotropiceffectsonthe