Emine AZAK, İbrahim İlker ÇETİN, Ayşe Esin KİBAR, Handan ÜNSAL

Çocuklarda Konjestif Kalp Yetersizliği

Konjestif kalp yetersizliği (KKY), kalbin dokuların metabolik gereksinimini karşılayacak miktarda kanı perifere pompalayamaması sonucunda oluşan klinik bir sendromdur. Kalp yetersizliğinin nedenleri ve mekanizmaları açısından yetişkinler ve çocuklar arasında belirgin farklılıklar vardır. Çocuklarda kalp yetersizliği genellikle, konjenital kalp hastalığı ve kardiyomiyopatiden kaynaklanır. Bu nedenler erişkinlerde kalp yetersizliğinden sorumlu olan koroner arter hastalığı ve hipertansiyon gibi nedenlerden önemli ölçüde farklıdır. Çocuklarda kalp yetersizliğinin diğer önemli nedenleri düşük debili kalp yetersizliği yapan kardiyomiyopati ve antrasiklin toksisitesidir. Konjestif kalp yetersizliğinin tanısı öykü, fizik muayene ve ekokardiyografik çalışmalar ile yapılır. Ekokardiyografi en yararlı noninvaziv çalışmadır. Natriüretik peptidlerin plazma düzeyleri, Atriyal Natriüretik Peptid (ANP) ve Beyin natriüretik peptit (BNP) kalp yetersizliği olan hastaların çoğunda artmıştır. Bu peptidlerin plazma seviyeleri yenidoğan ve hayatın ilk haftalarında yüksektir fakat zamanla normal yetişkin düzeylerine düştüğü gözlenir. Bu peptidlerin düzeyinin basınç ve volum yükü artmış kardiyak defektli çocuklarda normal çocuklarda görülen seviyeleri ile karşılaştırıldığında, BNP ve prohormon N-terminali düzeylerinin yüksek olduğu gösterilmiştir. Bununla birlikte çocuklarda kullanılabilecek uygun bir referans aralığı tanımlanmadığından bu peptidlerin kullanılırlığı sınırlıdır. Konjestif kalp yetersizliğinin tedavisi altta yatan ve katkıda bulunan nedenlerin ortadan kaldırılması ile kalp yetmezliğinin kontrolünden oluşur. Kalp yetersizliğine neden olan problemi ortadan kaldırmak mümkün olduğunca en çok arzu edilen bir yaklaşımdır. Klinisyenler olarak pediatrik kalp yetersizliği ile ilgili güncel bilgilere ihtiyacımız vardır. Bu derlemede kapsamlı olarak son yaklaşımlarında dahil olduğu pediatrik kalp yetersizliği tüm yönleriyle anlatılmaktadır.

Anahtar Kelimeler:

Çocuklar, Kalp yetersizliği

Congestive Heart Failure in Children

Cardiac failure is a clinical syndrome where the heart is unable to provide the output required to meet the metabolic demands of the body; however, the causes and mechanisms of cardiac failure are significantly different between adults and children. In children, cardiac failure is most often caused by congenital heart disease and cardiomyopathy. These causes are significantly different from those usually responsible for the conditions in adults, which include coronary artery disease and hypertension. Other significant causes of heart failure in children are cardiomyopathy and anthracycline toxicity, which lead to low‐output cardiac failure. The diagnosis of CHF relies on several sources of clinical findings, including history, physical examination and echocardiographic studies. Echocardiographic studies are the most helpful noninvasive studies. Plasma levels of natriuretic peptides, Atrial Natriuretic Peptide (ANP) and Brain Natriuretic Peptide (BNP), are increased in most patients with heart failure. The plasma levels of these peptides are elevated in the newborn and in the first weeks of life but decrease of the levels observed in normal adults. Increased levels of BNP and the N-terminal of its prohormone have been reported in most children with either pressure or volume overload cardiac lesions compared with the levels seen in normal children. However, the usefulness of the levels of these peptides appears limited because an appropriate reference range has not been established. The treatment of CHF consists of elimination of the underlying causes, treatment of the precipitating or contributing causes, and control of the heart failure state. Eliminating the underlying causes is the most desirable approach whenever possible. That is why clinicians need up-to-date knowledge about pediatric heart failure. The present review comprehensively describes all the aspects of pediatric heart failure including the recent approaches

Keywords:

Children, Heart failure,

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O’Laughlin MP. Congestive heart failure in children. Pediatr Clin North Am 1999;46:263.
Auslenderu M. Pathophysiology of pediatric heart failure. Progress in Pediatric Cardiology 2000;11:175-84.
Myung K. Park. Pediatric Cardiology for Practitioners. Mosby Elsevier, 2008:558-74.
Auslenderu M. Pathophysiology of pediatric heart failure. Progress in Pediatric Cardiology 2000;175-84.
Anthonio RL, van Veldhuisen DJ, Breekland A, Crijns HJ, van Gilst WH. Beta blocker titration failure is independent of severity of heartfailure. Am J Cardiol 2000;15:509-12.
Zile MR, Gaasch WH, Carroll JD, Feldman MD, Aurigemma GP, Schaer GL, et al. Heart failure with abnormal ejection fraction. Is measurement of diastolic function necessary to make the diagnosis of diastolic heart failure. Circulation 2001;104:779-82.
Talner NS. Heart Failure. Emmanuilides GC, Allen DH, Gutgesell HP, Riemenschneider TA (eds). Moss and Adams’ Heart Disease in Infants, Children, and Adolescents. Philadelphia: Lippincott Williams &Wilkin, 2008:1495-520.
Ross RD, Bollinger RO, Pinsky WW. Grading the severity of congestive heart failure in infants. Pediatric Cardiolog 1992;13:72- 5.
The Consessus Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (Consensus). N Engl J Med 1987;316:1429-35.
The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991;325:293-302.
Shaddy RE, Teitel DF, Brett C. Short term hemodynamic effects of captopril in children with congestive or restrictive cardiomyopathy. Circulation 1991;83:523-7.
Williams RV, Tani LY, Shaddy RE. Intermediate effects of treatment with metoprolol or carvedilol in children with left ventricular systolic dsyfunction. J Heart Lung Transplant 2002;21:906-9.
Azeka E, Franchini Ramires JA, Valler C, et al. Delisting of infants and children from the heart transplantation waiting list after carvedilol treatment. J Am Coll Cardiol 2002;40:2034-8.
Shaddy RE, Boucek MM, Hsu DT, Boucek RJ, Canter CE, Mahony L, et al. Carvedilol for children and adolescents with heart failure: A randomized controlled trial. JAMA 2007;298:1171-9.
Shaddy RE. Optimizing treatment for chronic congestive heart failure in children. Crit Care Med 2001;29:237.
Bonnet D. Treatment of chronic heart failure in the child. Arch Pediatr 2001;8:1379.
Ryerson LM, A PM. Rotating inotrope therapy in a pediatric population with decompensated heart failure. Pediatr Crit Care Med 2011;12:57- 60.
Namachivayam P, Crossland DS, Butt WW, Shekerdemian LS. Early experience with levosimendan in children with ventricular dysfunction. Pediatr Crit Care Med 2006;7:445-8.
Braun JP, Schneider M, Kastrup M, Liu J. Treatment of acute heart failure in an infant after cardiac surgery using levosimendan. Eur J Cardiothorac Surg 2004;26:228-30.
Jefferies JL, Price JF, Denfield SW, Chang AC, Dreyer WJ, McMahon CJ, et al. Safety and efficacy of nesiritide in pediatric heart failure. J Card Fail 2007;13:541-8.
Konstam MA, Kronenberg MW, Rousseau MF, Udelson JE, Melin J, Stewart D, et al. Effects of the angiotensin converting enzyme inhibitor enalapril on the long-term progression of left ventricular dilatation in patients with asymptomatic systolic dysfunction. Circulation 1993;88:2277-83.