Care of the Child with a Care of the Child with a Cardiovascular DisorderCardiovascular Disorder

Becca MaddoxBecca Maddox

NURS 1102NURS 1102

Spring 2002Spring 2002

Health Promotion and Risk ManagementHealth Promotion and Risk Management

Congenital - Women of child-bearing age should Congenital - Women of child-bearing age should be immunized against rubella and varicella. be immunized against rubella and varicella. Parents with family history of congenital defects Parents with family history of congenital defects need to have children screenedneed to have children screened

Acquired - Children with hypertension, Acquired - Children with hypertension, hyperlipidemia and rheumatic fever are at hyperlipidemia and rheumatic fever are at increased risk.increased risk. Rheumatic fever follows a group A beta-Rheumatic fever follows a group A beta-

hemolytic streptococcus infection (otitis hemolytic streptococcus infection (otitis media, streptococcal pharyngitis and impetigo media, streptococcal pharyngitis and impetigo should have antibiotic therapy)should have antibiotic therapy)

Avoid excessive salt, lack of exercise, obesity, Avoid excessive salt, lack of exercise, obesity, diets high in saturated fats (reduce to 30% of diets high in saturated fats (reduce to 30% of calories by school age)calories by school age)

Cardiovascular Disorders and the Nursing Cardiovascular Disorders and the Nursing ProcessProcess

Careful history taking and physical examination are Careful history taking and physical examination are most importantmost important

Common procedures for diagnosis are Common procedures for diagnosis are echocardiogram and cardiac catheterizationechocardiogram and cardiac catheterization

Common nursing diagnoses:Common nursing diagnoses: Decreased cardiac output related to congenital Decreased cardiac output related to congenital

structural defectstructural defect Altered tissue perfusion related to inadequate Altered tissue perfusion related to inadequate

cardiac outputcardiac output

Knowledge deficit related to care of the child Knowledge deficit related to care of the child pre- and postoperativelypre- and postoperatively

Fear related to lack of knowledge about child’s Fear related to lack of knowledge about child’s diseasedisease

Altered family processes related to stresses of Altered family processes related to stresses of the diagnosis and care responsibilitiesthe diagnosis and care responsibilities

Ineffective individual or family coping related Ineffective individual or family coping related to lack of adequate supportto lack of adequate support

Altered parenting related to inability to bond Altered parenting related to inability to bond with critically ill newbornwith critically ill newborn

Important interventions include teaching, Important interventions include teaching, providing opportunities to express fears, providing opportunities to express fears, providing psychological supportproviding psychological support

Other interventions include comfort measures, Other interventions include comfort measures, oxygen administration, managing cardiac failure, oxygen administration, managing cardiac failure, pre-and postop carepre-and postop care

Important TermsImportant Terms

Acyanotic heart diseaseAcyanotic heart disease Innocent heart murmurInnocent heart murmurAfterloadAfterload Left-to-right shuntLeft-to-right shuntBalloon angioplastyBalloon angioplasty Organic heart murmurOrganic heart murmurCardiac catheterizationCardiac catheterization PhonocardiogramPhonocardiogramContractilityContractility PolycythemiaPolycythemiaCyanosisCyanosis Postcardiac surgery syndromePostcardiac surgery syndromeCyanotic heart diseaseCyanotic heart disease Postperfusion syndromePostperfusion syndromeDiastoleDiastole PreloadPreloadEchocardiographyEchocardiography Right-to-left shuntRight-to-left shuntElectrocardiographyElectrocardiography SystoleSystoleFluoroscopyFluoroscopy VasculitisVasculitisHeart failureHeart failure

ReviewReview

A&P of the HeartA&P of the Heart Circulation of blood Circulation of blood CO = SV x HRCO = SV x HR CO is affected by CO is affected by preloadpreload, , afterloadafterload and and contractilitycontractility Frank-Starling law - SV can be increased by Frank-Starling law - SV can be increased by

increasing the stretch of the fibers. However, increasing the stretch of the fibers. However, excessive stretch results in a decrease in COexcessive stretch results in a decrease in CO

History TakingHistory Taking

Must be careful. Some of the symptoms are very Must be careful. Some of the symptoms are very subtle.subtle.

Some symptoms do not show up right after birthSome symptoms do not show up right after birth Typical presentations of infants are tachycardia, Typical presentations of infants are tachycardia,

tachypnea, and poor feedingtachypnea, and poor feeding Older children may present with fatigue and Older children may present with fatigue and

frequent lower respiratory infections. Some frequent lower respiratory infections. Some children may perspire excessivelychildren may perspire excessively

Edema is a late sign and usually presents first as Edema is a late sign and usually presents first as periorbital edema.periorbital edema.

May complain of decreased UOPMay complain of decreased UOP May have headaches, nose bleeds, high blood May have headaches, nose bleeds, high blood

pressure in upper extremitiespressure in upper extremities

History ContinuedHistory Continued

Obtain a detailed prenatal history including Obtain a detailed prenatal history including exposure to infections (cytomegalovirus, exposure to infections (cytomegalovirus, toxoplamosis, rubella or varicella), medication toxoplamosis, rubella or varicella), medication usage, drug and alcohol use, nutrition, exposure to usage, drug and alcohol use, nutrition, exposure to radiationradiation

Determine if there is any family history of Determine if there is any family history of congenital heart defects or heart disease, cognitive congenital heart defects or heart disease, cognitive impairments, renal diseaseimpairments, renal disease

Physical AssessmentPhysical Assessment Compare height and weight to standard growth chartCompare height and weight to standard growth chart Assess: Assess:

capillary refillcapillary refill presence of clubbingpresence of clubbing

cyanosis (pulmonary source vs. cardiac source)cyanosis (pulmonary source vs. cardiac source)

ruddy complexionruddy complexion lethargylethargy

rapid respirationsrapid respirations tachycardiatachycardia

abnormal body postureabnormal body posture presence of a murmurpresence of a murmur

Innocent murmurs vs. Organic murmursInnocent murmurs vs. Organic murmurs With all murmurs, document position in cardiac cycle, duration, With all murmurs, document position in cardiac cycle, duration,

quality, pitch, intensity, location, whether there is a thrill and whether quality, pitch, intensity, location, whether there is a thrill and whether the murmur changes with position changethe murmur changes with position change

Organic murmurs are either systolic or diastolic, long, harsh or Organic murmurs are either systolic or diastolic, long, harsh or blowing, loud, constant and heard not matter what position the child blowing, loud, constant and heard not matter what position the child is inis in

Diagnostic TestsDiagnostic Tests

ECG - indicates HR, rhythm, presence or absence ECG - indicates HR, rhythm, presence or absence of hypertrophy, ischemia or necrosis, of hypertrophy, ischemia or necrosis, abnormalities in the conduction system, abnormalities in the conduction system, presence of electrolyte imbalancespresence of electrolyte imbalances

Chest x-ray - shows heart size and shape, Chest x-ray - shows heart size and shape, presence of CHF, prominence of pulmonary blood presence of CHF, prominence of pulmonary blood flowflow

Fluoroscopy can be used to visualize the Fluoroscopy can be used to visualize the chambers of the heart, the great vessels, lungs, chambers of the heart, the great vessels, lungs, thoracic cage and diaphragm. Sometimes thoracic cage and diaphragm. Sometimes radioactive dye in injected. Sometimes contrast radioactive dye in injected. Sometimes contrast dye in used in conjunction with a cardiac cathdye in used in conjunction with a cardiac cath

Diagnostic Tests Cont’dDiagnostic Tests Cont’d

Echocardiogram - primary diagnostic test. Looks Echocardiogram - primary diagnostic test. Looks at the movement and dimensions of the cardiac at the movement and dimensions of the cardiac structures using high-frequency sound wavesstructures using high-frequency sound waves

Phonocardiogram - heart sounds are recorded Phonocardiogram - heart sounds are recorded and displayed as a diagramand displayed as a diagram

MRI - used to evaluate heart structure, size or MRI - used to evaluate heart structure, size or blood flowblood flow

Treadmill - studies response to exerciseTreadmill - studies response to exercise Lab tests - Hgb and Hct (polycythemia), ESR Lab tests - Hgb and Hct (polycythemia), ESR

(rheumatic fever, Kawasaki disease, myocarditis), (rheumatic fever, Kawasaki disease, myocarditis), ABG (presence of a right to left shunt), O2 Sat, ABG (presence of a right to left shunt), O2 Sat, clotting times (PT, PTT) and platelet count, Na, K, clotting times (PT, PTT) and platelet count, Na, K, dig leveldig level

Cardiac CatheterizationCardiac Catheterization

Can be either diagnostic or interventionalCan be either diagnostic or interventional Pressures in the heart can be measuredPressures in the heart can be measured CO can be evaluatedCO can be evaluated Blood samples can be obtained and tested (O2 sat)Blood samples can be obtained and tested (O2 sat) Electrical activity can be studiedElectrical activity can be studied Contrast can be injected to study blood flow, vessels and Contrast can be injected to study blood flow, vessels and

chamberschambers Balloon angioplasty can be performed to stretch stenosed Balloon angioplasty can be performed to stretch stenosed

areas or blockages in vesselsareas or blockages in vessels

Pre-procedure - Patient teachingPre-procedure - Patient teaching How the test will be done, what to expect during the test, that How the test will be done, what to expect during the test, that

afterward the child will have to lie flat and will have a bulky afterward the child will have to lie flat and will have a bulky dressing over the catheter insertion sitedressing over the catheter insertion site

Cardiac Catheterization Cont’dCardiac Catheterization Cont’d

Post-ProcedurePost-Procedure Will have to lie flat 3-4 hoursWill have to lie flat 3-4 hours VS every 15 minutes for the first several hoursVS every 15 minutes for the first several hours Check site every 15 minutes for integrity of dressing, Check site every 15 minutes for integrity of dressing,

hematoma, redness, swellinghematoma, redness, swelling Check pulses distal to site. Also check extremity for Check pulses distal to site. Also check extremity for

capillary refill and warmthcapillary refill and warmth Avoid dehydrationAvoid dehydration Avoid hypothermiaAvoid hypothermia Check site daily for signs of infectionCheck site daily for signs of infection Avoid tub baths and strenuous exercise for 2-3 daysAvoid tub baths and strenuous exercise for 2-3 days

Important Points about Care of the Child Important Points about Care of the Child with a Heart Defectwith a Heart Defect

Parents taking a child with a heart defect home should have Parents taking a child with a heart defect home should have discharge planning which includes name/number of a primary discharge planning which includes name/number of a primary care provider, emergency numbers, home health visits, care provider, emergency numbers, home health visits, instruction in what to do if child becomes cyanotic, CPR instruction in what to do if child becomes cyanotic, CPR training, training,

Should not allow a child with a cyanotic heart defect or severe Should not allow a child with a cyanotic heart defect or severe aortic stenosis to cry for extended periods of timeaortic stenosis to cry for extended periods of time

Don’t usually have to restrict sodium intake (regulates water Don’t usually have to restrict sodium intake (regulates water balance)balance)

Need vitamin supplements and maybe an iron supplementNeed vitamin supplements and maybe an iron supplement May need small feedings every 3-4 hours. May require feeding May need small feedings every 3-4 hours. May require feeding

tubes or high calorie formulas/supplementstubes or high calorie formulas/supplements

Important Points about Care Cont’dImportant Points about Care Cont’d

Children usually limit their own activities, but parents should Children usually limit their own activities, but parents should watch for respiratory distress when new activities are watch for respiratory distress when new activities are introducedintroduced

Children should receive their immunizations timelyChildren should receive their immunizations timely Even minor illnesses should be treated promptlyEven minor illnesses should be treated promptly Avoid dehydrationAvoid dehydration Receive prophylactic antibiotics prior to dental visits or oral Receive prophylactic antibiotics prior to dental visits or oral

surgery (Penicillin or Erythromycin)surgery (Penicillin or Erythromycin)

Congenital Heart DiseaseCongenital Heart Disease

Occurs in about 8% of term newborns. Higher in Occurs in about 8% of term newborns. Higher in pre-term infants. Can be as high as 10-15% in pre-term infants. Can be as high as 10-15% in infants who have a parent with aortic stenosis, infants who have a parent with aortic stenosis, ASD, VSD, or pulmonic stenosisASD, VSD, or pulmonic stenosis

Females - more prone to have PDA and ASDFemales - more prone to have PDA and ASD Males - more prone to have valvular aortic Males - more prone to have valvular aortic

stenosis, coarctation of the aorta, TOF and stenosis, coarctation of the aorta, TOF and transposition of the great vesselstransposition of the great vessels

The usual cause is failure of the heart to develop The usual cause is failure of the heart to develop beyond an early stage of embryonic developmentbeyond an early stage of embryonic development

Maternal rubella is associated with PDA, Maternal rubella is associated with PDA, stenosis, ASD, VSDstenosis, ASD, VSD

Congenital Heart DiseaseCongenital Heart Disease

Classification Classification Acyanotic vs. CyanoticAcyanotic vs. Cyanotic

Left-to-right shunt - oxygenated to unoxygenated bloodLeft-to-right shunt - oxygenated to unoxygenated blood Right-to-left shunt - deoxygenated blood to oxygenated Right-to-left shunt - deoxygenated blood to oxygenated

bloodblood

Hemodynamic and Blood Flow Patterns - allows Hemodynamic and Blood Flow Patterns - allows more predictable signs and symptomsmore predictable signs and symptoms

Increased pulmonary flowIncreased pulmonary flow Obstruction to blood flow (out of the heart)Obstruction to blood flow (out of the heart) Mixed blood flow (oxygenated and deoxygenated blood Mixed blood flow (oxygenated and deoxygenated blood

mixing in the heart or great vessels)mixing in the heart or great vessels) Decreased pulmonary flowDecreased pulmonary flow

Defects with IncreasedDefects with IncreasedPulmonary Blood FlowPulmonary Blood Flow

Blood flows from the left side of the heart to the Blood flows from the left side of the heart to the right side of the heart through an abnormal right side of the heart through an abnormal opening or connection between the system or opening or connection between the system or great arteriesgreat arteries Ventricular Septal Defect (VSD)Ventricular Septal Defect (VSD) Atrial Septal Defect (ASD)Atrial Septal Defect (ASD) Atrioventricular canal defect (AVC)Atrioventricular canal defect (AVC) Patent Ductus Arteriosis (PDA)Patent Ductus Arteriosis (PDA)

VSD - most common, 25% of all defects, 2 in VSD - most common, 25% of all defects, 2 in every 1000 live birthsevery 1000 live births opening in the septum between the two ventriclesopening in the septum between the two ventricles results in right ventricular hypertrophy and increased results in right ventricular hypertrophy and increased

pressure on the pulmonary arterypressure on the pulmonary artery

VSD Cont’dVSD Cont’d

May not be evident at birth because high pulmonary May not be evident at birth because high pulmonary resistance from incomplete opening of alveoli keeps the resistance from incomplete opening of alveoli keeps the blood from coming across to the right ventricleblood from coming across to the right ventricle

S&S (by age 4 to 8 weeks) - develops a loud, harsh, systolic S&S (by age 4 to 8 weeks) - develops a loud, harsh, systolic murmur along the left sternal border 3rd or 4th ICS, widely murmur along the left sternal border 3rd or 4th ICS, widely transmitted, usually with a thrilltransmitted, usually with a thrill

Diagnosed with echocardiography or MRIDiagnosed with echocardiography or MRI RV hypertrophy may also be seen on ECGRV hypertrophy may also be seen on ECG 60% close spontaneously - otherwise at risk of infectious 60% close spontaneously - otherwise at risk of infectious

endocarditis and cardiac failureendocarditis and cardiac failure May require a Silastic or Dacron patch to close opening if May require a Silastic or Dacron patch to close opening if

edges can’t be approximated and suturededges can’t be approximated and sutured Arrhythmias can be a complication post-opArrhythmias can be a complication post-op

Atrial Septal Defect (ASD)Atrial Septal Defect (ASD) Abnormal opening between the two atriaAbnormal opening between the two atria

ASD1 (ostium primum) - defect is at the lower end of the septumASD1 (ostium primum) - defect is at the lower end of the septum ASD2 (ostium secondum) - defect is near the center of the septum ASD2 (ostium secondum) - defect is near the center of the septum

and may be asymptomaticand may be asymptomatic More frequent in girls than boysMore frequent in girls than boys Harsh systolic murmur over 2nd or 3rd ICS, fixed splitting of S2Harsh systolic murmur over 2nd or 3rd ICS, fixed splitting of S2 Echo will show enlarged right side and increased pulmonary Echo will show enlarged right side and increased pulmonary

circulationcirculation Cath will reveal separation in atrial septum and increased O2 sat in RACath will reveal separation in atrial septum and increased O2 sat in RA At risk for infectious endocarditis and heart failureAt risk for infectious endocarditis and heart failure Can cause emboli in pregnant females if not correctedCan cause emboli in pregnant females if not corrected May require a patch if defect not able to be closedMay require a patch if defect not able to be closed May have arrhythmias post-opMay have arrhythmias post-op

Atrioventricular Canal (AVC) DefectAtrioventricular Canal (AVC) Defect

An incomplete fusion of the endocardial cushion. May be An incomplete fusion of the endocardial cushion. May be seen as a low ASD continuous with a high VSD. Mitral seen as a low ASD continuous with a high VSD. Mitral and tricuspid valves are usually distorted. Seen in 1 out and tricuspid valves are usually distorted. Seen in 1 out of 9 children with Down syndromeof 9 children with Down syndrome

Blood flow is usually left to right, but may flow between Blood flow is usually left to right, but may flow between all four chambersall four chambers

Same symptoms of heart failure as ASD and VSDSame symptoms of heart failure as ASD and VSD Requires surgical repair and possible double valve Requires surgical repair and possible double valve

replacementreplacement Must be monitored post-op for jaundice from RBC Must be monitored post-op for jaundice from RBC

destructiondestruction

Patent Ductus Arteriosus (PDA)Patent Ductus Arteriosus (PDA)

The ductus arteriosus between the pulmonary artery and The ductus arteriosus between the pulmonary artery and the aorta fails to close at birththe aorta fails to close at birth

May not close until 3 months causing blood to be May not close until 3 months causing blood to be shunted from the aorta to the pulmonary arteryshunted from the aorta to the pulmonary artery

Child will usually have a wide pulse pressure because Child will usually have a wide pulse pressure because diastolic is low related to decreased peripheral diastolic is low related to decreased peripheral resistance caused by the shunting of the bloodresistance caused by the shunting of the blood

Usually hear a continuous (systolic and diastolic) Usually hear a continuous (systolic and diastolic) murmur at the upper left sternal border or under the murmur at the upper left sternal border or under the clavicle of older childrenclavicle of older children

ECG is usually normal, may show ventricular ECG is usually normal, may show ventricular enlargement if the shunt is largeenlargement if the shunt is large

Cath is not usually needed unless to rule out other Cath is not usually needed unless to rule out other defectsdefects

PDA Cont’dPDA Cont’d

May be given indomethacin or a prostaglandin inhibitor to May be given indomethacin or a prostaglandin inhibitor to lower PGE1 levels and stimulate closure. Drug may be lower PGE1 levels and stimulate closure. Drug may be repeated as many as three times 12 to 24 hours apartrepeated as many as three times 12 to 24 hours apart

If medical management fails - If medical management fails - ligation of defectligation of defect visual assisted thoracoscopy (VAT) - a clip is placed on visual assisted thoracoscopy (VAT) - a clip is placed on

the ductusthe ductus If not surgery, child is a risk for heart failure related to the If not surgery, child is a risk for heart failure related to the

increased shunting, infectious endocarditis from recirculating increased shunting, infectious endocarditis from recirculating blood and potential stasis in the PAblood and potential stasis in the PA

Obstructive DefectsObstructive Defects

Narrowing of a vessel or valve. Results in high pressure Narrowing of a vessel or valve. Results in high pressure before the obstruction and lower after the obstruction. before the obstruction and lower after the obstruction. Prevents sufficient blood supply from reaching its Prevents sufficient blood supply from reaching its intended siteintended site Pulmonic stenosisPulmonic stenosis Aortic stenosisAortic stenosis Coarctation of the aortaCoarctation of the aorta

Pulmonic Stenosis - 25% to 35% of anomaliesPulmonic Stenosis - 25% to 35% of anomalies May be asymptomatic or have mild heart failureMay be asymptomatic or have mild heart failure Usually a grade IV or V systolic murmur with a thrill. Heard Usually a grade IV or V systolic murmur with a thrill. Heard

loudest at the upper left sternal border. May have a split S2loudest at the upper left sternal border. May have a split S2 ECG may show right ventricular hypertrophy. Cath can ECG may show right ventricular hypertrophy. Cath can

demonstrate degree of stenosis.demonstrate degree of stenosis.

Pulmonary Stenosis Cont’dPulmonary Stenosis Cont’d

Treatment depends on severity of stenosis and Treatment depends on severity of stenosis and the child’s agethe child’s age

If severe, the pressure may reopen the foramen ovale If severe, the pressure may reopen the foramen ovale allowing flow from left to right causing cyanosisallowing flow from left to right causing cyanosis

If severe, then given PGE1 to keep ductus arteriosus If severe, then given PGE1 to keep ductus arteriosus from closing so that the infant can get more blood from closing so that the infant can get more blood oxygenatedoxygenated

Balloon angioplasty may be tried to break valve Balloon angioplasty may be tried to break valve adhesions and relieve the stenosisadhesions and relieve the stenosis

If there is a lesser degree of stenosis, the child can If there is a lesser degree of stenosis, the child can be allowed to wait until they are 4 or 5 years old so be allowed to wait until they are 4 or 5 years old so that there is less surgical riskthat there is less surgical risk

Aortic StenosisAortic Stenosis

Prevents blood from flowing freely from the LV to the aortaPrevents blood from flowing freely from the LV to the aorta Can lead to hypertrophy of the left ventricle and heart failure and Can lead to hypertrophy of the left ventricle and heart failure and

pulmonary edemapulmonary edema Accounts for 5% of congenital abnormalitiesAccounts for 5% of congenital abnormalities The child is usually asymptomatic. Will usually hear a rough The child is usually asymptomatic. Will usually hear a rough

systolic murmur at 2nd ICS right sternal border which may radiate systolic murmur at 2nd ICS right sternal border which may radiate to right shoulder, clavicle or neck. May see signs of decreased CO to right shoulder, clavicle or neck. May see signs of decreased CO (faint pulses, hypotension, tachycardia, poor feeding). Child may (faint pulses, hypotension, tachycardia, poor feeding). Child may develop chest pain with activity. Sudden death can occur when O2 develop chest pain with activity. Sudden death can occur when O2 demand far exceeds supplydemand far exceeds supply

ECG may show left ventricular hypertrophy. Cath can show ECG may show left ventricular hypertrophy. Cath can show degree of stenosisdegree of stenosis

Treated with balloon angioplasty or surgical repair to divide the Treated with balloon angioplasty or surgical repair to divide the stenotic valve or dilate a contrictive aortic ringstenotic valve or dilate a contrictive aortic ring

Coarctation of the AortaCoarctation of the Aorta A constrictive band causes narrowing of the aorta either A constrictive band causes narrowing of the aorta either

between the subclavian vein and the ductus arteriosus between the subclavian vein and the ductus arteriosus (infantile or preductal) or distal to the ductus arteriosus (infantile or preductal) or distal to the ductus arteriosus (postductal)(postductal)

Since BP is greatest in the subclavian vein, you will see Since BP is greatest in the subclavian vein, you will see higher pressures in the upper extremities (at least 20 mmHg) higher pressures in the upper extremities (at least 20 mmHg) than in the lower extremities. The increased BP can cause than in the lower extremities. The increased BP can cause headaches or nosebleeds. Can even cause a CVAheadaches or nosebleeds. Can even cause a CVA

May only have a decreased femoral pulse. As child grows May only have a decreased femoral pulse. As child grows older, collateral circulation develops. Veins may become older, collateral circulation develops. Veins may become visible on the chest. Child may complain of leg pain on visible on the chest. Child may complain of leg pain on exertion. Child may or may not have a soft or moderately exertion. Child may or may not have a soft or moderately loud systolic murmur prominent at the base of the heartloud systolic murmur prominent at the base of the heart

Coarctation of the Aorta Cont’dCoarctation of the Aorta Cont’d

Repaired either with balloon angioplasty or Repaired either with balloon angioplasty or surgical removal of the narrowed portion. Try to surgical removal of the narrowed portion. Try to let the child grow for a while. Usually scheduled let the child grow for a while. Usually scheduled around age 2. Has to be done prior to around age 2. Has to be done prior to childbearing age in femaleschildbearing age in females

May have abdominal discomfort for a while post-May have abdominal discomfort for a while post-op related to increased blood flow to lower part of op related to increased blood flow to lower part of the body. the body.

Will usually still have an elevated BP for a while.Will usually still have an elevated BP for a while.

Mixed DefectsMixed Defects Transposition of the Great Arteries - The aorta comes off of the RV and Transposition of the Great Arteries - The aorta comes off of the RV and

the pulmonary artery comes off of the LV. (5% of anomalies)the pulmonary artery comes off of the LV. (5% of anomalies) Unless the infant also has an ASD and/or VSD this is incompatible Unless the infant also has an ASD and/or VSD this is incompatible

with life because you have two closed systemswith life because you have two closed systems RA - RV - Aorta - body - vena cavae to RARA - RV - Aorta - body - vena cavae to RA LA - LV - Pulmonary artery - lungs - pulmonary veins to LALA - LV - Pulmonary artery - lungs - pulmonary veins to LA

Usually cyanotic at birth, may have no murmur or various murmursUsually cyanotic at birth, may have no murmur or various murmurs Echo will show enlarged heart. Cath can show low O2 sat in the Echo will show enlarged heart. Cath can show low O2 sat in the

heart chambers. ECG may not show anythingheart chambers. ECG may not show anything Will be given PGE1 to try to keep the ductus open. Can also have Will be given PGE1 to try to keep the ductus open. Can also have

balloon passed through foramen ovale in order to enlarge the balloon passed through foramen ovale in order to enlarge the openingopening

Surgical intervention involves switching the aorta and the Surgical intervention involves switching the aorta and the pulmonary arterypulmonary artery

Mixed DefectsMixed Defects

Total Anamalous Pulmonary Venous ReturnTotal Anamalous Pulmonary Venous Return Pulmonary veins return to RA or superior vena cava Pulmonary veins return to RA or superior vena cava

instead of the LAinstead of the LA Systemic circulation depends on a patent foramen ovale Systemic circulation depends on a patent foramen ovale

and/or patent ductusand/or patent ductus Often these patients are also without a spleen as wellOften these patients are also without a spleen as well The infant is usually mildly cyanotic and tires easily The infant is usually mildly cyanotic and tires easily Will be kept on PGE1 until surgery to keep the ductus Will be kept on PGE1 until surgery to keep the ductus

arteriosus open. arteriosus open. The pulmonary veins are reimplanted into the LAThe pulmonary veins are reimplanted into the LA

Mixed DefectsMixed Defects Truncus Arteriosus - the infant has a single vessel coming off the RV Truncus Arteriosus - the infant has a single vessel coming off the RV

and LV instead of a separate pulmonary artery and aorta.and LV instead of a separate pulmonary artery and aorta. There is usually also a VSDThere is usually also a VSD Child is cyanotic and has a typical VSD murmurChild is cyanotic and has a typical VSD murmur The common trunk in restructured surgically to create an aorta The common trunk in restructured surgically to create an aorta

and a pulmonary arteryand a pulmonary artery Hypoplastic Left Heart Syndrome - the left ventricle doesn’t work. Hypoplastic Left Heart Syndrome - the left ventricle doesn’t work.

The RV hypertrophies as it tries to do all of the workThe RV hypertrophies as it tries to do all of the work Patient becomes increasingly cyanotic as more unoxygenated Patient becomes increasingly cyanotic as more unoxygenated

blood is shunted to the left sideblood is shunted to the left side Treatment is aimed to keep the ductus arteriosis open and Treatment is aimed to keep the ductus arteriosis open and

increase flow of blood to the aortaincrease flow of blood to the aorta No surgical repair at this timeNo surgical repair at this time Best hope is heart transplantBest hope is heart transplant

Defects with Decreased Pulmonary Defects with Decreased Pulmonary Blood FlowBlood Flow

Involve an obstruction of pulmonary blood flow which increases Involve an obstruction of pulmonary blood flow which increases pressure in the right side of the heart. pressure in the right side of the heart. If an ASD and or VSD also exists, then deoxygentated blood shunts If an ASD and or VSD also exists, then deoxygentated blood shunts

from the right side to the left sidefrom the right side to the left side Tricuspid Atresia - tricuspid valve is completely closed. Tricuspid Atresia - tricuspid valve is completely closed.

Blood can’t flow from RA to RV so goes through the patent foramen Blood can’t flow from RA to RV so goes through the patent foramen ovale to the LA.ovale to the LA.

Oxygenation occurs by blood being shunted through a patent ductus Oxygenation occurs by blood being shunted through a patent ductus to the lungsto the lungs

If the foramen ovale and ductus arteriosus close, the patient If the foramen ovale and ductus arteriosus close, the patient becomes profoundly cyanotic, tachycardic and dyspneic.becomes profoundly cyanotic, tachycardic and dyspneic.

Kept on PGE1 until surgeryKept on PGE1 until surgery Surgery consists of creating a subclavian-pulmonary artery shunt or Surgery consists of creating a subclavian-pulmonary artery shunt or

restructuring the right side of the heart with a baffle (Fontan restructuring the right side of the heart with a baffle (Fontan procedure)procedure)

Defects with Decreased Pulmonary Defects with Decreased Pulmonary Blood FlowBlood Flow

Tetralogy of Fallot (TOF) - 10% of congenital Tetralogy of Fallot (TOF) - 10% of congenital defects. defects. Consists of 4 anomaliesConsists of 4 anomalies

Pulmonary stenosisPulmonary stenosis VSD (usually large)VSD (usually large) Dextraposition (overriding) of the aorta Dextraposition (overriding) of the aorta Hypertrophy of the RV (acquired from the increased Hypertrophy of the RV (acquired from the increased

pressure in the RV from trying to push blood through pressure in the RV from trying to push blood through the stenosed pulmonary artery)the stenosed pulmonary artery)

““Blue baby” although may not be dramatically cyanotic Blue baby” although may not be dramatically cyanotic immediately after birthimmediately after birth

Exhibit poor physical growth, clubbing, systolic murmur, Exhibit poor physical growth, clubbing, systolic murmur, hypoxic spells, polycythemia, activity intolerance and hypoxic spells, polycythemia, activity intolerance and squattingsquatting

TOF cont’dTOF cont’d

X-ray shows cardiomegaly. Echo and ECG show X-ray shows cardiomegaly. Echo and ECG show the enlarged RV. Echo also shows decreased size the enlarged RV. Echo also shows decreased size of the PA and reduced flow through the lungs. of the PA and reduced flow through the lungs. Extent of the defect is determined through Extent of the defect is determined through cardiac cath. Lab values show increased RBC’s cardiac cath. Lab values show increased RBC’s and reduced O2 satand reduced O2 sat

Usually wait until child is 1 or 2 years old. Some Usually wait until child is 1 or 2 years old. Some institutions perform surgery earlier to prevent institutions perform surgery earlier to prevent hypoxic episodeshypoxic episodes

If having hypoxic episode, place infant in knee-to-If having hypoxic episode, place infant in knee-to-chest position. May require Morphine to dilate chest position. May require Morphine to dilate vessels or propanolol to reduce heart spasmvessels or propanolol to reduce heart spasm

TOF cont’dTOF cont’d

Can have a palliative repair in which the subclavian Can have a palliative repair in which the subclavian artery is used to create an artificial ductus artery is used to create an artificial ductus arteriosus (Blalock-Taussig procedure) to allow arteriosus (Blalock-Taussig procedure) to allow blood to flow from the aorta to the lungsblood to flow from the aorta to the lungs

After the Blalock-Taussig, the child will not have a After the Blalock-Taussig, the child will not have a palpable pulse in the right arm. The right arm palpable pulse in the right arm. The right arm should not be used for BP’s or blood sticksshould not be used for BP’s or blood sticks

Full repair includes relief of pulmonary stenosis, Full repair includes relief of pulmonary stenosis, VSD repair and correction of the overriding aortaVSD repair and correction of the overriding aorta

Cardiac SurgeryCardiac Surgery Pre-opPre-op

baseline vital signs at rest (count a full minute)baseline vital signs at rest (count a full minute) height and weightheight and weight hold dig for 24 hrshold dig for 24 hrs enemaenema patient and family teaching (surgery, equipment, what to expect patient and family teaching (surgery, equipment, what to expect

after surgery, tubes, the importance of deep breathing and after surgery, tubes, the importance of deep breathing and coughing)coughing)

Post-opPost-op VS every 15 minutes progressing to q 1 hr, ventilatory support, VS every 15 minutes progressing to q 1 hr, ventilatory support,

monitoring of heart rate and rhythm, BP, heart pressures, heart monitoring of heart rate and rhythm, BP, heart pressures, heart sounds, UOP, fluid status, ABG’s, PT, PTT, Plt, Hgb, Hct., K, Na, O2 sounds, UOP, fluid status, ABG’s, PT, PTT, Plt, Hgb, Hct., K, Na, O2 sat, lung sounds, bowel sounds, measurement of chest tube sat, lung sounds, bowel sounds, measurement of chest tube integrity and drainageintegrity and drainage

Cardiac Surgery Cont’dCardiac Surgery Cont’d

Incentive spirometry (deep breathing) and coughing after Incentive spirometry (deep breathing) and coughing after extubatedextubated

Pain managementPain management Explain procedures (extubation, chest tube removal, etc.)Explain procedures (extubation, chest tube removal, etc.) Administer antibioticsAdminister antibiotics Observe for signs and symptoms of infectionObserve for signs and symptoms of infection May need warming immediately post-op, but watch for May need warming immediately post-op, but watch for

temperature elevationtemperature elevation Assess for hypervolemiaAssess for hypervolemia Advance activities as toleratedAdvance activities as tolerated Avoid arm pulling and pulling with armsAvoid arm pulling and pulling with arms

Cardiac Surgery Cont’dCardiac Surgery Cont’d

Complications - bleeding, shock, heart block or Complications - bleeding, shock, heart block or arrhythmias, heart failure, neuro changes, arrhythmias, heart failure, neuro changes, postcardiac surgery syndrome (febrile illness postcardiac surgery syndrome (febrile illness with pericarditis and pleurisy - one week post-with pericarditis and pleurisy - one week post-op), postperfusion syndrome (3-12 weeks post-op op), postperfusion syndrome (3-12 weeks post-op - fever, splenomegaly, hepatomegaly, elevated - fever, splenomegaly, hepatomegaly, elevated WBC, malaise, maculopapular rash - CMV from WBC, malaise, maculopapular rash - CMV from donor blood) donor blood)

Cardiac Surgery Cont’dCardiac Surgery Cont’d

If valve replacement surgery - artificial valves are If valve replacement surgery - artificial valves are used more often, requires anticoagulation used more often, requires anticoagulation (Coumadin) or antiplatelet (aspirin, dipyridamole) (Coumadin) or antiplatelet (aspirin, dipyridamole) therapytherapy young girls should avoid accidental pregnancy, should young girls should avoid accidental pregnancy, should

not use an estrogen-based OCD nor an IUDnot use an estrogen-based OCD nor an IUD women desiring to become pregnant need to switch to women desiring to become pregnant need to switch to

Heparin therapyHeparin therapy prophylactic antibiotics need to be taken before dental prophylactic antibiotics need to be taken before dental

work or oral surgerywork or oral surgery may develop hemolytic anemia requiring blood may develop hemolytic anemia requiring blood

transfusionstransfusions

Cardiac Surgery Cont’dCardiac Surgery Cont’d

Heart Transplant - for hypoplastic left ventricle or Heart Transplant - for hypoplastic left ventricle or cardiomyopathycardiomyopathy ECG’s will show two P wavesECG’s will show two P waves Post-op care is the same as with other heart surgeriesPost-op care is the same as with other heart surgeries Patients will be placed on immunosuppresive therapyPatients will be placed on immunosuppresive therapy Rejection is the #1 cause of deathRejection is the #1 cause of death

Hyperacute rejection - immediately upon restoring Hyperacute rejection - immediately upon restoring circulationcirculation

Acute rejection - occurs in about 7 days, fever, Acute rejection - occurs in about 7 days, fever, tachycardia, ECG changestachycardia, ECG changes

Chronic rejection - may begin at about a yearChronic rejection - may begin at about a year

Cardiac Surgery Cont’dCardiac Surgery Cont’d

Pacemaker - if difficulty with conduction systemPacemaker - if difficulty with conduction system Consists of a battery pack and lead wiresConsists of a battery pack and lead wires Leads are usually epicardial as opposed to endocardial Leads are usually epicardial as opposed to endocardial

in childrenin children Parents and patient must be taught how to take the Parents and patient must be taught how to take the

patient’s pulsepatient’s pulse Batteries can last up to 15 years and they lose power Batteries can last up to 15 years and they lose power

slowly rather than stopping abruptlyslowly rather than stopping abruptly If patient has hiccuping, lead wire may need to be If patient has hiccuping, lead wire may need to be

repositionedrepositioned Magnets should be avoidedMagnets should be avoided

Acquired Heart DiseaseAcquired Heart Disease

Heart failure - most common. Heart failure - most common. Usually occurs as a result of a congenital heart disorder or a Usually occurs as a result of a congenital heart disorder or a

disease such as rheumatic fever, Kawasaki’s disease or disease such as rheumatic fever, Kawasaki’s disease or infectious endocarditis. infectious endocarditis.

The heart can’t pump enough blood to supply oxygen and The heart can’t pump enough blood to supply oxygen and nutrients to the bodynutrients to the body

The body compensates for a while. Remember CO = SV x HR The body compensates for a while. Remember CO = SV x HR and the Frank-Starling principle. For children less than 5 y.o., and the Frank-Starling principle. For children less than 5 y.o., increase in CO is mostly accomplished through increased HRincrease in CO is mostly accomplished through increased HR

As renal blood flow decreases, GFR slows allowing retention of As renal blood flow decreases, GFR slows allowing retention of sodium and fluid. When the body senses decreased supply of sodium and fluid. When the body senses decreased supply of oxygen, aldosterone is secreted which further promotes oxygen, aldosterone is secreted which further promotes retention of sodium in an attempt to increase blood flow to the retention of sodium in an attempt to increase blood flow to the kidneys. ADH secretion is also increased to help retain fluidkidneys. ADH secretion is also increased to help retain fluid

Heart Failure Cont’dHeart Failure Cont’d Symptoms depend on whether there is right- or left sided heart Symptoms depend on whether there is right- or left sided heart

failurefailure Right - back up of pressure into the portal system and venous Right - back up of pressure into the portal system and venous

system, hepatomegaly, abdominal pain, ascitiessystem, hepatomegaly, abdominal pain, ascities Left - back up of pressure in pulmonary system, dyspnea, rales, Left - back up of pressure in pulmonary system, dyspnea, rales,

bloody sputum on coughing, cyanosisbloody sputum on coughing, cyanosis Left sided failure ultimately leads to right sided failureLeft sided failure ultimately leads to right sided failure Edema is a late sign for children. If present, it shows up as periorbital Edema is a late sign for children. If present, it shows up as periorbital

edemaedema In infants, signs can be breathlessness from rapid respirations, In infants, signs can be breathlessness from rapid respirations,

tiring easily and poor feeding related to exhaustion and dyspnea, tiring easily and poor feeding related to exhaustion and dyspnea, may become diaphoretic when feeding, abrupt weight gain is the may become diaphoretic when feeding, abrupt weight gain is the most obvious indicationmost obvious indication

Apical heart beat may be displaced laterally and downward. May Apical heart beat may be displaced laterally and downward. May have a third heart sound.have a third heart sound.

Heart Failure Cont’dHeart Failure Cont’d Confirmed by echocardiogram, chest x-ray and ECGConfirmed by echocardiogram, chest x-ray and ECG Treatment is aimed at 1) improving cardiac function, 2) removing Treatment is aimed at 1) improving cardiac function, 2) removing

accumulated fluid and sodium, 3)decrease cardiac demands, 4) accumulated fluid and sodium, 3)decrease cardiac demands, 4) improve tissue O2improve tissue O2

Diuretics - Lasix, spironalactone, thiazides (may need K Diuretics - Lasix, spironalactone, thiazides (may need K replacement)replacement)

Improve contractility - Digoxin (given a loading dose and Improve contractility - Digoxin (given a loading dose and then a maintenance dose, dig level should be 0.8 to 2.0 u/L, then a maintenance dose, dig level should be 0.8 to 2.0 u/L, toxicity includes, nausea, vomiting, anorexia, slow heart rate, toxicity includes, nausea, vomiting, anorexia, slow heart rate, family teaching required, family teaching required, hold dose if HR < 100 for infants hold dose if HR < 100 for infants and toddlers, <80 for older children or <60 for adolescentsand toddlers, <80 for older children or <60 for adolescents))

Decrease afterload - hydralazine (vasodilator), nifedipine (Ca Decrease afterload - hydralazine (vasodilator), nifedipine (Ca channel blocker), nipride (vasodilator), or captopril (ACE channel blocker), nipride (vasodilator), or captopril (ACE inhibitor)inhibitor)

Heart Failure Cont’dHeart Failure Cont’d

Decrease oxygen demands - Provide rest periods Decrease oxygen demands - Provide rest periods and uninterrupted sleep, place in Semi-Fowler’s and uninterrupted sleep, place in Semi-Fowler’s position, space out activities/procedures, preserve position, space out activities/procedures, preserve body temperature, treat any infectionsbody temperature, treat any infections

Improve oxygenation - administer O2 as needed by Improve oxygenation - administer O2 as needed by hood, mask or nasal prongs. If prongs are used, hood, mask or nasal prongs. If prongs are used, check nostrils q 4hrscheck nostrils q 4hrs

Adequate nutrition is also important - may Adequate nutrition is also important - may need six to eight small meals daily rather than need six to eight small meals daily rather than 3 large meals, may need tube feedings3 large meals, may need tube feedings

Rheumatic FeverRheumatic Fever

An autoimmune disease that is a reaction to a An autoimmune disease that is a reaction to a group-A beta-hemolytic stretococcus infectiongroup-A beta-hemolytic stretococcus infection

Often follows an attack of pharyngitis, tonsillitis, Often follows an attack of pharyngitis, tonsillitis, scarlet fever, “strep” throat, or impetigoscarlet fever, “strep” throat, or impetigo

Children ages 6-15 are the most susceptibleChildren ages 6-15 are the most susceptible Very important that antibiotics are taken to treat the Very important that antibiotics are taken to treat the

initial infection to prevent rheumatic feverinitial infection to prevent rheumatic fever Systematic inflammatory disease that affects Systematic inflammatory disease that affects

primarily the heart, joints, brain and skin. Strep primarily the heart, joints, brain and skin. Strep loves heart valves. The mitral valve is the most loves heart valves. The mitral valve is the most commonly affected.commonly affected.

Rheumatic Fever Cont’dRheumatic Fever Cont’d Signs and SymptomsSigns and Symptoms

MinorMinor feverfever fatiguefatigue joint tendernessjoint tenderness elevated ESRelevated ESR

MajorMajor Aschoff bodies (hemorrhagic bullous lesions in the heart)Aschoff bodies (hemorrhagic bullous lesions in the heart) erythema marginatumerythema marginatum vegetation on valvesvegetation on valves pericarditispericarditis pericardial friction rubpericardial friction rub muffled heart soundsmuffled heart sounds accentuated third heart soundaccentuated third heart sound SC nodulesSC nodules chorea (sudden involuntary movements of limbs)chorea (sudden involuntary movements of limbs)

Rheumatic Fever Cont’dRheumatic Fever Cont’d Diagnosis - If have two major symptoms or one major and Diagnosis - If have two major symptoms or one major and

two minor symptoms, rising or elevated ASO titertwo minor symptoms, rising or elevated ASO titer TreatmentTreatment

Bedrest until ESR decreases (degree of bedrest is based on degree of Bedrest until ESR decreases (degree of bedrest is based on degree of carditis)carditis)

Antibiotics (penicillin, erythromycin) x 10 daysAntibiotics (penicillin, erythromycin) x 10 days Reduce inflammation (aspirin - watch for toxicity such as tinnitus, Reduce inflammation (aspirin - watch for toxicity such as tinnitus,

nausea, vomiting, headache, blurred vision)nausea, vomiting, headache, blurred vision) Corticosteroids (if not responding to aspirin alone)Corticosteroids (if not responding to aspirin alone) Phenobarbital for choreaPhenobarbital for chorea Treatment of heart failureTreatment of heart failure Prognosis depends on the amount of cardiac involvementPrognosis depends on the amount of cardiac involvement Kept on prophylactic antibiotics for 5 years or until 18 to prevent Kept on prophylactic antibiotics for 5 years or until 18 to prevent

recurrencerecurrence

Kawasaki DiseaseKawasaki Disease

Mucocutaneous Lymph Node Syndrome - an acute Mucocutaneous Lymph Node Syndrome - an acute systemic vasculitis which leads to the formation of systemic vasculitis which leads to the formation of aneurysms and myocardial infarctionaneurysms and myocardial infarction

Actual cause is still unknown. Altered immune Actual cause is still unknown. Altered immune function occurs after an infection. There is an function occurs after an infection. There is an increase in antibody production. Antibody-antigen increase in antibody production. Antibody-antigen complexes apparently bind to the vascular complexes apparently bind to the vascular endothelium and cause inflammation. The endothelium and cause inflammation. The inflammation leads to platelet aggregation and the inflammation leads to platelet aggregation and the formation of thrombi or obstruction of heart and formation of thrombi or obstruction of heart and blood vesselsblood vessels

Kawasaki DiseaseKawasaki Disease

Acute Phase (Stage I)Acute Phase (Stage I) High fever that doesn’t respond to antipyreticsHigh fever that doesn’t respond to antipyretics Lethargic and irritableLethargic and irritable May have red, swollen hands and feet, conjunctivitis, May have red, swollen hands and feet, conjunctivitis,

strawberry tongue and red, cracked lips, enlarged cervical strawberry tongue and red, cracked lips, enlarged cervical lymph nodes, variety of rashes, abdominal pain as internal lymph nodes, variety of rashes, abdominal pain as internal lymph nodes swell, anorexia, diarrhea, red and swollen joints lymph nodes swell, anorexia, diarrhea, red and swollen joints

Elevated WBC and ESRElevated WBC and ESR

Subacute Phase - about 10 days after onsetSubacute Phase - about 10 days after onset Peeling of skin on palms and soles of feetPeeling of skin on palms and soles of feet Platelet count rises (increases risk of clotting)Platelet count rises (increases risk of clotting) Aneurysms may form in coronary arteries - sudden death can Aneurysms may form in coronary arteries - sudden death can

occuroccur

Kawasaki DiseaseKawasaki Disease Convalescent Phase (Stage II) - begins at about the 25th day Convalescent Phase (Stage II) - begins at about the 25th day

and lasts until 40 daysand lasts until 40 days Stage III lasts from 40 days until the ESR returns to normalStage III lasts from 40 days until the ESR returns to normal Diagnosis is based on criteria (Table 40.3), blood studies and Diagnosis is based on criteria (Table 40.3), blood studies and

echocardiogramechocardiogram TreatmentTreatment

High dose aspirinHigh dose aspirin Dipyridamole - to increase coronary dilatation and prevent platelet Dipyridamole - to increase coronary dilatation and prevent platelet

accumulationaccumulation IV Gamma globulin - to reduce immune responseIV Gamma globulin - to reduce immune response

Observe child for signs of heart failureObserve child for signs of heart failure Inspect and palpate extremities for warmth and capillary refillInspect and palpate extremities for warmth and capillary refill

Kawasaki DiseaseKawasaki Disease

Provide comfort measuresProvide comfort measures Protect edematous areas from pressureProtect edematous areas from pressure May have dry, cracked lipsMay have dry, cracked lips Monitor for dehydration, encourage fluids, but Monitor for dehydration, encourage fluids, but

prevent fluid overloadprevent fluid overload Monitor nutritional statusMonitor nutritional status

EndocarditisEndocarditis

Inflammation and infection of the endocardium or Inflammation and infection of the endocardium or valves of the heartvalves of the heart

Generally caused by streptococcal viridans. Generally caused by streptococcal viridans. Sometimes can be staphylococcal or fungalSometimes can be staphylococcal or fungal

Strep enters the blood stream during oral Strep enters the blood stream during oral procedures, impetigo, UTI’sprocedures, impetigo, UTI’s

Vegetation of bacteria, fibrin, and blood appear Vegetation of bacteria, fibrin, and blood appear on the endocardium of the valves and heart on the endocardium of the valves and heart chambers - destroys the endothelial liningchambers - destroys the endothelial lining

Signs and Symptoms - abrupt, unexplained low-Signs and Symptoms - abrupt, unexplained low-grade intermittent fever, anorexia, malaise, grade intermittent fever, anorexia, malaise, weight loss, change in murmur, splenomegalyweight loss, change in murmur, splenomegaly

EndocarditisEndocarditis

Diagnosis - blood culture, ECG, elevated ESR and Diagnosis - blood culture, ECG, elevated ESR and C-reactive protein, anemias, leukocytosis, C-reactive protein, anemias, leukocytosis, microscopic hematuriamicroscopic hematuria

Treatment - antibiotics (PCN, Ampicillin, Treatment - antibiotics (PCN, Ampicillin, Gentamycin) for 2 to 8 weeks. Supportive therapy Gentamycin) for 2 to 8 weeks. Supportive therapy to prevent heart failure. Teach prevention with to prevent heart failure. Teach prevention with prophylactic antibiotics before procedures.prophylactic antibiotics before procedures.