Cardiac Catheterization: Uses and Care

Cardiac Catheterization Uses

• Diagnosis identifies structural heart defects
• Intervention corrects heart abnormalities
• Electrophysiologic Studies assesses electrical activity and heart rhythms

Pre-Cardiac Catheterization Care

• Baseline vital signs need assessment
• NPO status (nothing by mouth) must be ensured
• IV fluids are administered as prescribed
• Height and weight is measured and recorded
• Seafood or iodine allergies must be checked for (contrast dye precaution)
• Pedal pulses must be located and marked; dorsalis pedis and posterior tibialis
• Explain procedure to the child and parents to reduce anxiety

Post-Cardiac Catheterization Care

• Vital signs must be monitored frequently
• Diuretics should be administered if needed to reduce fluid overload
• Pedal pulses should be assessed to check for circulation
• Affected limb must be immobilized
• Femoral vein requires 4-6 hours of immobilization
• Femoral artery requires 6-8 hours of immobilization

Congenital Heart Defects: Atrial Septal Defect (ASD)

• Atrial Septal Defect is a hole between the atria
• ASD 1 (Ostium Primum) features a defect below the septum and is common in Down syndrome
• ASD 2 (Ostium Secundum) is the most common type, with a defect in the middle of the septum
• Sinus Venosus ASD involves a defect above the septum

Atrial Septal Defect Management

• Small defects - monitor for spontaneous closure, medications are antihypertensives, digoxin, and diuretics
• Large defects need open-heart surgery with a Dacron patch, median sternotomy with cardiopulmonary bypass

Congenital Heart Defects: Ventricular Septal Defect (VSD)

• Ventricular Septal Defect is an opening between ventricles
• VSD can lead to Eisenmenger Syndrome (right-to-left shunt due to increased right ventricular pressure)
• Small VSDs need monitoring, but may close spontaneously
• Large VSDs need open-heart surgery and a Dacron patch.

Congenital Heart Defects: Atrioventricular Canal Defect

• Atrioventricular Canal Defect involves failure of endocardial cushions to fuse
• Includes low ASD, high VSD, and cleft valves (tricuspid & mitral valves)
• Requires open-heart surgery, a Dacron patch, valve repair or replacement

Congenital Heart Defects: Patent Ductus Arteriosus (PDA)

• Persistent fetal ductus arteriosus
• Signs are continuous machinery-like murmur, bounding pulses, palpable thrill, and widened pulse pressure (S-D = >50mmHg)

Patent Ductus Arteriosus (PDA) Management

• Prostaglandin inhibitors (Indomethacin) close PDA
• Catheterization (coil or stent placement)
• Surgical ligation (via thoracotomy or VATS – Video-Assisted Thoracoscopic Surgery)

Congestive Heart Failure in Infants: Right-Sided CHF

• Right-Sided CHF - Blood backs up in systemic circulation
• Signs include jugular vein distension, peripheral edema (facial, abdominal ascites, pedal, anasarca), and hepatosplenomegaly (enlargement of liver and spleen)

Congestive Heart Failure in Infants: Left-Sided CHF

• Left-Sided CHF - Blood backs up in lungs
• Signs are tachycardia, tachypnea, diaphoresis, crackles in lungs, and pulmonary hypertension

Obstructive Heart Defects: Coarctation of the Aorta (COA)

• Coarctation of the Aorta is the narrowing near ductus arteriosus
• Upper body presents as high BP, warm skin, bounding pulses
• Lower body presents as low BP, cold/clammy skin, weak/absent femoral pulse

Coarctation of the Aorta (COA) Management

• Prostaglandin E1 reopens ductus arteriosus
• Balloon angioplasty
• Surgical repair (valvotomy)

Cyanotic Heart Disease

• Acyanotic means normal oxygen levels and increased pulmonary blood flow
• Includes ASD, VSD, Atrioventricular canal defect, and PDA
• Cyanotic means low oxygen levels, decreased pulmonary blood flow
• Includes Tetralogy of Fallot, Tricuspid atresia, Transposition of the great arteries (TGA), Truncus arteriosus, Hypoplastic left heart syndrome (HLHS), and Total anomalous pulmonary venous return (TAPVR)

Mixed Defects and Cyanotic Heart Diseases: Tetralogy of Fallot (TOF)

• Tetralogy of Fallot is the most common cyanotic defect
• Features include a large VSD, overriding aorta, and pulmonary stenosis
• Pulmonary stenosis is a condition where the pulmonary valve (between the heart's right ventricle and the pulmonary artery) is narrowed, restricting blood flow to the lungs
• There is right ventricular hypertrophy (a condition where the right ventricle, the heart chamber that pumps blood to the lungs, thickens due to chronic pressure overload, often caused by lung diseases or congenital heart conditions)
• Signs are cyanosis, clubbing, and squatting
• The heart is boot-shaped on X-ray

Tetralogy of Fallot (TOF) Management

• Blalock-Taussig Shunt connects the subclavian artery to the pulmonary artery
• Definitive repair (surgery) is required
• TET spells (hypoxic episodes) need management of knee-chest position, oxygen, IV fluids, Morphine, and propranolol

Tricuspid Atresia

• No tricuspid valve, it has no direct blood flow from RA to RV
• Fontan Procedure (connect RA to pulmonary artery)
• Glenn Shunt (SVC to pulmonary artery connection)

Transposition of the Great Arteries (TGA)

• Aorta and pulmonary artery are switched
• Arterial switch (Jatene procedure) corrects the defect
• Atrial switch (Mustard/Senning procedures) redirects blood flow

Truncus Arteriosus

• Single large artery instead of separate aorta and pulmonary artery
• Pulmonary artery banding (to control blood flow)
• Rastelli procedure (separates great arteries)

Hypoplastic Left Heart Syndrome (HLHS)

• HLHS is the underdeveloped left side of the heart
• Heart transplant (best option)
• Staged repair surgeries (Norwood, Glenn, Fontan)

Fetal Circulation Shunts

• Foramen ovale bypasses the lungs (RA → LA)
• Ductus arteriosus connects PA to the aorta
• Ductus venosus bypasses the liver
• There are two umbilical arteries and one vein

Rheumatic Fever (RF) Symptoms

• A systemic inflammatory disease that occurs as a complication of untreated Group A Beta-Hemolytic Streptococcus (Streptococcus pyogenes) pharyngitis
• Primarily affects the heart, joints, skin, and central nervous system

Jones Criteria for Diagnosis

• Diagnosis requires either 2 Major Criteria or 1 Major + 2 Minor Criteria

Major Jones Criteria (JONES)

• Joints (Polyarthritis) are migratory arthritis affecting large joints (knees, elbows, ankles, wrists)
• Carditis is pancarditis (affecting all heart layers: pericarditis, myocarditis, endocarditis)
• Nodules (Subcutaneous) are painless, firm nodules over extensor surfaces
• Erythema Marginatum are the painless, ring-like rash with clear center
• Sydenham’s Chorea (/St. Vitus’ Dance) involves involuntary, purposeless movements due to CNS involvement

Minor Jones Criteria

• Fever is often ≥ 38.5°C (101.3°F)
• Arthralgia is joint pain (without swelling, unlike polyarthritis)
• Laboratory Findings include ↑ Antistreptolysin O (ASO) titer (evidence of recent streptococcal infection) and ↑ C-reactive protein (CRP) & Erythrocyte Sedimentation Rate (ESR) indicating inflammation
• ECG Findings include a prolonged PR interval (indicating heart conduction abnormalities)

Rheumatic Fever (RF) Treatment

• With Bed rest, ESR normalizes (around 3-4 weeks)
• Aspirin/NSAIDs reduce inflammation and pain
• Penicillin Therapy prevents recurrence & progression to Rheumatic Heart Disease
• IM Benzathine Penicillin is given monthly for 5-10 years
• Oral Penicillin BID is an alternative for those unable to receive IM
• Dental Prophylaxis Prevents infective endocarditis before dental procedures

Rheumatic Fever (RF) Complications

• Rheumatic Heart Disease (RHD) – permanent heart valve damage result from Rheumatic Fever
• Infective Endocarditis can occur if dental prophylaxis is not followed

Kawasaki Disease (KD)

• A systemic vasculitis of unknown cause, primarily affecting children under 5 years old, with a higher incidence in Japan
• Leads to coronary artery complications

Signs & Symptoms of Kawasaki Disease (CRASH & Burn)

• Conjunctivitis is Bilateral, non-purulent
• Rash is Polymorphous, non-vesicular
• Adenopathy is Cervical, unilateral, >1.5 cm
• Strawberry tongue is red, with swollen lips & tongue
• Hand/foot changes include erythema, edema, and peeling
• Burn is a persistent fever (≥ 5 days)

Stages of Kawasaki Disease

• The Acute Phase (First 10 days) presents as fever and systemic inflammation.
• Treatment for Acute Phase is IV Immunoglobulin (IVIG) + High-dose Aspirin
• The Subacute Phase has risk of coronary artery aneurysms
• The Convalescence Phase sees gradual resolution of symptoms

Kawasaki Disease (KD) Treatment

• IVIG reduces risk of coronary artery complications
• High-dose Aspirin provides anti-inflammatory and antiplatelet effects
• Corticosteroids should be avoided as they may worsen coronary artery damage

Kawasaki Disease (KD) Complications

• Coronary Artery Aneurysms may lead to myocardial infarction

Pediatric Stages

• Neonate lasts from birth to 4 weeks
• Infant stage lasts from 0-12 months
• Toddler stage lasts from 1-3 years
• Preschooler stage lasts from 4-6 years
• School-age lasts from 7-12 years
• Adolescent lasts from 13-18 years

Neonatal Care

• Dry the Baby to prevent cold stress (risk: cyanosis, metabolic acidosis, hypoglycemia)
• Crede’s Prophylaxis prevents ophthalmia neonatorum (eye infection)
• Vitamin K Injection prevents hemorrhagic disease of the newborn
• Umbilical Cord Care Keeps the umbilical cord clean and dry
• Anthropometric Measurements consist of weight, length, and head circumference
• Initial Feeding needs breastfeeding encouragement
• Apgar Score assesses newborn’s physical condition
• Maturity Rating (Ballard/Dubowitz Scoring) notes physical maturity
• Skin in preterms is gelatinous, and is wrinkled, desquamation in terms
• Lanugo in preterms is abundant, and is sparse/absent in terms
• Ear Recoil in preterms is none, and has positive recoil in terms
• Breast Development in preterms is <3mm, and is >3mm/wrinkled in terms
• In terms, Genitalia has labia majora that covers minora. In preterms, labia minora is larger than majora
• Plantar Creases in preterms is 1/3 of the sole, and is 2/3/full sole in terms

High-Risk Newborns

• High-Risk Newborns are neonates with an increased risk of morbidity or mortality, particularly in the first 28 days of life
• Classification of high-risk newborns is done by size

Classifying High-Risk Newborns By Size

• Low Birth Weight (LBW): <2500g
• Very Low Birth Weight (VLBW): <1500g
• Extremely Low Birth Weight (ELBW): <1000g
• Appropriate for Gestational Age (AGA): Normal size for gestation