Cardiac Emergencies in Infants. Michael Luceri, DO

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1 Cardiac Emergencies in Infants Michael Luceri, DO October 7, 2017

2 I have no financial obligations or conflicts of interest to disclose.

3 Objectives Understand the scope of congenital heart disease Recognize the presentation of a critically ill neonate Categorize the disease to facilitate its treatment

4 Background Congenital heart defect (CHD) A gross structural abnormality of the heart or intrathoracic great vessels that is actually or potentially of functional significance Mitchell, et al (Circulation, 1971) 8-10/1000 live births, ~1% About half require an intervention Recent increased detection

5 Total CHD Birth Prevalence Over Time Time course of reported total congenital heart disease (CHD) birth prevalence from 1930 until The blue line shows the time trend, and the squares represent the calculated birth prevalence values for each time period. Birth Prevalence of Congenital Heart Disease Worldwide: A Systematic Review and Meta-Analysis J Am Coll Cardiol. 2011;58(21): doi: /j.jacc

6 Congenital Heart Defects Recent increased detection Improvements in echocardiography Doppler Fetal echocardiography Transesophageal echocardiography 3D echocardiography Advanced non-invasive imaging CT MRI No increase in disease severity!!!

7 Birth Prevalence of CHD Subtypes Over Time Time course of birth prevalence of the 8 most common CHD subtypes from 1945 until AoS = aortic stenosis; ASD = atrial septal defect; Coarc = coarctation; PDA = patent ductus arteriosus; PS = pulmonary stenosis; TGA = transposition of the great arteries; TOF = tetralogy of Fallot; VSD = ventricular septal defect. Birth Prevalence of Congenital Heart Disease Worldwide: A Systematic Review and Meta-Analysis J Am Coll Cardiol. 2011;58(21): doi: /j.jacc

8 Birth Prevalence of CHD Subtypes Reported birth prevalence of the 8 most common CHD subtypes per continent. Distribution of subtypes within total CHD is mentioned as percentages above bars. *Reported PS and TOF birth prevalence in Asia was significantly higher than in Europe (p < 0.001) and North America (p < 0.001). Reported Coarc birth prevalence in Asia was significantly lower than in Europe (p < 0.001). Reported TGA and AoS birth prevalence in Asia was significantly lower than in Europe (p < 0.001), North America (p < 0.001) and Oceania (p < 0.001). No data on TOF and AoS birth prevalence in Africa were available. Abbreviations as in Figure 4. Birth Prevalence of Congenital Heart Disease Worldwide: A Systematic Review and Meta-Analysis J Am Coll Cardiol. 2011;58(21): doi: /j.jacc

9 Circulation Fetal circulation Fetal lungs collapsed, alveoli filled with fluid High pulmonary vascular resistance (PVR), thus minimal pulmonary blood flow (Qp) Ohm s Law: V = I R (Voltage = Flow Resistance) In hemodynamics: Pressure (gradient) = Flow Resistance Flow = Pressure/Resistance Oxygenation from placenta via umbilical vein PFO & PDA shunt R L

10 Normal Heart

11 Normal Heart w/pda

12 Circulation Neonatal circulation Hormones of labor cease production of lung liquid i.e. Epinephrine, vasopressin, cortisol, etc. First breath and lung expansion Remaining liquid absorbed PVR decreases Qp increases Functional closure of PFO & PDA Now pulmonary & systemic circulation in series!

13 Circulation Certain lesions can interrupt serial blood flow: i.e. TOF, aortic stenosis, coarctation Transposition of the great arteries (TGA) Newborn then depends on the presence of a shunt Balloon atrial septostomy

14

15 Balloon Atrial Septostomy First interventional procedure: Rashkind Septostomy (1966) No animal studies Prone to material embolization

16 Circulation Certain lesions can interrupt serial blood flow: i.e. TOF, aortic stenosis, coarctation Transposition of the great arteries (TGA) Newborn then depends on the presence of a shunt Balloon atrial septostomy Prostagladins!!! Very forgiving, almost foolproof! When in doubt, try it out! Usually 0.01 mcg/kg/min works, can go up to 0.1 mcg/kg/min Watch for fever (14%), apnea (12%), and flushing (10%)

17 Presentation Varies dependent upon cardiac lesion, though can include: Cyanosis Peripheral/Acrocyanosis: common and benign Central: always pathologic Incomplete oxygenation in the lung Abnormal hemoglobin Intracardiac shunting Hyperoxia Test: Measure pre-ductal (RUE) P A O 2 in room air Measure again after 5-10 minutes of 100% FiO 2 Strongly consider cyanotic heart disease if P A O 2 is <150 mmhg Caveat #1: PPHN may also have P A O 2 <150 mmhg! Caveat #2: Hyperoxia can close a PDA that might be needed!

18 Presentation Varies dependent upon cardiac lesion, though can include: Murmur Tachycardia Respiratory distress Tachypnea, retractions Poor feeding and/or inadequate weight gain Irritability or sweating with feeds Shock Gallop, HSM, poor capillary refill, pallor, weak pulses

19 Classification Transposition of the great arteries Obstructed systemic perfusion Obstructed pulmonary blood flow Single ventricle lesions Heart failure

20 Transposition of the Great Arteries (TGA) 5-7% of all CHD Male/female ratio ~3:1 Blood must mix via ASD, VSD, or PDA

21 Transposition of the Great Arteries (TGA) Presentation 1 day old term male infant with poor feeding & severe cyanosis PE: tachypneic, symmetric pulses, single S2, no murmur, no HSM Reverse differential cyanosis ECG: RVH (normal) CXR: normal cardiac size, increased pulmonary vascularity Hyperoxia Test: P A O 2 = 42 mmhg on 100% FiO 2 Treatment Cath: Emergent balloon atrial septostomy Surgical repair: Atrial vs Arterial Switch

22 Transposition of the Great Arteries (TGA) Mustard ( Atrial Switch )

23 Transposition of the Great Arteries (TGA) Jatene Procedure ( Arterial Switch )

24 Classification Transposition of the great arteries Obstructed systemic perfusion Obstructed pulmonary blood flow Single ventricle lesions Heart failure

25 Obstructed systemic perfusion Examples include: Coarctation of the aorta

26 Obstructed systemic perfusion Examples include: Critical aortic stenosis

27 Obstructed systemic perfusion Examples include: Interrupted aortic arch

28 Obstructed systemic perfusion Systemic flow is critically compromised when PDA closes If untreated, will lead to shock and eventually death Ductal-dependent PDA will allow for right to left shunting

29 Obstructed systemic perfusion Presentation 3 day old term infant acutely develops feeding and breathing difficulties PE: tachypneic, tachycardic, murmur, gallop, HSM, poor capillary refill and pulses Dusky appearance ECG: RVH CXR: cardiomegaly, increased pulmonary vascularity Hyperoxia Test: P A O 2 = 180 mmhg on 100% FiO 2 Treatment Rx: PGE1 infusion; inotropic support; NO Afterload Reduction! Eventual catheter-based and/or surgical intervention

30 Classification Transposition of the great arteries Obstructed systemic perfusion Obstructed pulmonary blood flow Single ventricle lesions Heart failure

31 Obstructed pulmonary blood flow Examples include: Tetralogy of Fallot

32 Obstructed pulmonary blood flow Examples include: Critical pulmonic stenosis

33 Obstructed pulmonary blood flow Acute and marked cyanosis May have adequate perfusion initially (especially if atrial level communication) Severe cyanosis can induce shock due to limited systemic O2 delivery that alters myocardial function Ductal-dependent PDA will allow for left to right shunting

34 Obstructed pulmonary blood flow Presentation 1 day old term infant initially feeds well and appears healthy, then acutely becomes cyanotic PE: tachypneic, increased work of breathing, tachycardic, murmur Severely cyanotic ECG: RVH CXR: decreased pulmonary vascularity Hyperoxia Test: P A O 2 = 30 mmhg on 100% FiO 2 Treatment Rx: PGE1 infusion; sedation, preload, B-blockers, phenylephrine, Avoid inotropes! Eventual catheter-based and/or surgical intervention

35 Classification Transposition of the great arteries Obstructed systemic perfusion Obstructed pulmonary blood flow Single ventricle lesions Heart failure

36 Single ventricle lesions Examples include: Tricuspid atresia

37 Single ventricle lesions Examples include: Hypoplastic left heart syndrome

38 Single ventricle lesions Initial presentation as glorified ductal-dependent lesions Tricuspid Atresia*: Ductal-dependent pulmonary circulation HLHS: Ductal-dependent systemic circulation Small/underdeveloped ventricle cannot serve as a functional pumping chamber Must undergo staged repair culminating in a Fontan circulation * Assuming normally related great vessels

39 Single ventricle lesions Presentation Rapid onset with ductal closure Often no murmur! Ductal-dependent systemic circulation Reduced cardiac output Metabolic acidosis Profound shock Respiratory failure Ductal-dependent pulmonary circulation Profound cyanosis ECG & CXR: Variable Hyperoxia Test: P A O 2 < 150 mmhg on 100% FiO 2

40 Single ventricle lesions Treatment Rx: PGE1 infusion! Manipulate SVR with systemic vasodilators i.e. Milrinone and Nipride Manipulate PVR with ventilatory strategies Hypoxic gas admixture (FiO 2 18%) Controlled respiratory acidosis Optimize hematocrit Eventual catheter-based and/or surgical intervention

41 Stage 1: Norwood Procedure with Blalock- Taussig (BT) Shunt or Sano (RV-PA) Conduit

42 Stage 2: Glenn Procedure SVC connected to pulmonary arteries

43 Stage 3: Fontan Procedure IVC connected to pulmonary arteries

44 Classification Transposition of the great arteries Obstructed systemic perfusion Obstructed pulmonary blood flow Single ventricle lesions Heart failure Volume overload

45 Heart failure: volume overload Examples include: Ventricular septal defect

46 Heart failure: volume overload Examples include: Atrioventricular septal defect

47 Heart failure: volume overload Examples include: Patent ductus arteriosus

48 Heart failure: volume overload Left to right shunting results in pulmonary overcirculation Wasted of ineffective blood flow Degree of shunting depends on PVR/SVR ratio

49 Heart failure: volume overload Presentation 3 month old infant with chronic feeding difficulties, failure to thrive, history of respiratory difficulties/pneumonia PE: tachypneic, retractions, single loud S2, murmur, HSM, symmetric pulses ECG: Biventricular hypertrophy CXR: cardiomegaly, hyperinflation, congestion, increased pulmonary vascularity

50 Heart failure: volume overload

51 Heart failure: volume overload Treatment Diuretics Inotropic support Optimize O 2 carrying capacity Manipulate PVR/SVR ratio Systemic vasodilators (i.e. ACE-inhibitors) Optimize hemoglobin to balance circulation Ventilatory strategies to increase PVR Eventual catheter-based and/or surgical intervention

52 Ventilatory strategies to manipulate Qp/Qs ratio Treatment PVR SVR Qp/Qs Ratio Reduce FiO 2 Increase Decrease Decrease Increase CO 2 Increase Decrease Decrease Reduce ph Increase Decrease Decrease PEEP Increase Decrease Decrease

53 Summary Congenital heart disease is relatively common Cardiac emergencies are rare Recognize symptoms early and keep a high index of suspicion Attempt to categorize the suspected lesion according to presentation and testing results When in doubt, start PGE1 infusion!

54 Questions?

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