PEDIATRICS

Acquired heart disease

MARIVIC MOTILLA-ESGUERRA, MD
Objectives
1. To know the different acquired heart diseases
2. To know the etiology of acquired heart diseases
3. To know the pathophysiology of acquired heart diseases
4. To know the management acquired heart diseases

Bacterial Agents in Pediatric Infective Endocarditis

COMMON: NATIVE VALVE OR OTHER CARDIAC LESIONS
Viridans group streptococci (S.mutans, S. sanguis, S. mitis)
Staphylococcus aureus
Group D streptococcus (enterococcus) (S.bovis, S. faecalis)

CHD vs. normal heart

Infective Endocarditis
a microbial infection of the endocardial (endothelial) surface of
the heart.
Native or prosthetic heart valves
Endocarditis also can involve septal defects
The mural endocardium
Intravascular foreign devices

intracardiac patches

surgically constructed shunts

intravenous catheters.

UNCOMMON: NATIVE VALVE OR OTHER CARDIAC LESIONS

Streptococcus pneumoniae
Haemophilus influenzae
Coagulase-negative staphylococci
Coxiella burnetii (Q fever)
Neisseria gonorrhoeae
Brucella
Chlamydia psittacli
Chlamydia trachomatis
Chlamydia pneumoniae
Legipnella
Bartonella
HACEK group
Streptobacillus moniliformis
Pasteurella multocida
Campylobacter fetus

Culture negative (6% of cases)

PROSTHETIC VALVE

Microorganisms

Staphylococcus epidermidis
Staphylococcus aureus
Viridans group streptococcus
Pseudomonas aeruginosa
Serratia marcescens
Diphtheroids
Legionella species[*]
HACEK group[]
Fungi[]

Pre-existing congenital/acquired heart disease

Pressure gradient turbulence

tissue damage

fibrin / platelet adherence

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PEDIATRICS

Acquired heart disease

lysosomal granules release

hydrolytic enzymes

Laboratory Diagnosis

Clinical and Laboratory Findings in Patients with IE

Clinical
Finding

Frequency
++++
+++

Fever
Non-specific symptoms (myalgia,
arthralgia, headache, malaise)
Heart murmur (new or changing)

++

Heart Failure
Petechiae
Embolic phenomena
Splenomegaly
Neurologic Findings
Osler nodes, Janeway lesions,
Roth spots, splinter hemorrhages
Legend:

++
++
++
++
++
+

++++

very common

++ infrequent

+++

in most cases

+ rare

Finding

Frequency

Positive blood culture (off antibiotics)

++++

Elevated acute phase reactants

++++

Anemia

+++

Hematuria

+++

Presence of rheumatoid factor

++

Leukocytosis

++

Legend:
++++

very commom

+++

in most cases

++

Infrequent

rare

Clinical Features

Laboratory

New or changing murmurs are usually heard

- Frequent auscultation is essential
Patients with suspected embolic events are candidates for
serial echo to localize vegetations and to define changes that
may occur with time
Splenomegaly may be present in a majority of instances
when the disease has been present for weeks or months
Neurologic findings are present in 20% of children and may
simulate the picture of an abscess, infarct or aseptic
meningitis

Blood Culture most valuable tool

Collection of 2 or 3 samples over a 24 hr period is adequate
in most cases
Acute phase reactants are elevated
ESR only minimally elevated (as the disease progresses ,
the ESR will increase)
- remain elevated for some time even after documented
bacteriologic cure
Immune complexes or Rheumatoid factor
Anemia common, particularly in long standing infection
May be hemolytic or may represent anemia of chronic
disease
Microscopic or macroscopic hematuria represents renal
embolization or nephritis
Leukocytosis is not a consistent finding but is more
common in acute IE
Antibodies against techoic acid and cell wall peptidoglycan in
severe staphylococcal infection may be present

2D-Echocardiography

A negative echocardiogram does not rule out endocarditis

More helpful in children with normal cardiac anatomy or
with isolated valvar abnormalities in children with more
complex congenital anomalies
Duke Major Criteria : oscillating intracardiac mass or
vegetation, an annular abscess, prosthetic valve partial
dehiscence, and new valvular regurgitation

DIAGNOSIS: Duke criteria

Major:
(+) blood culture
Evidence of endocarditis on echocardiography
A. Positive echocardiogram for IE defined as:
i. Oscillating intracardiac mass on valve or supporting
structures, in the path of regurgitant jets, or an implanted
material in the absence of an alternative anatomic explanation or
ii.Abscess, or
iii.New partial dehiscence of prosthetic valve or
B. New valvular regurgitation (worsening or changing of preexisting
murmur)
Minor criteria
Predisposition: predisposing heart condition or intravenous drug use
Fever: temperature > 38.0 C (100.4 F)
Vascular phenomena: major arterial emboli, septic pulmonary
infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival
hemorrhages, and Janeway lesions. Immunologic phenomena:
glomerulonephritis, Osler's nodes, Roths spots and rheumatoid

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PEDIATRICS

Acquired heart disease

MARIVIC MOTILLA-ESGUERRA, MD

factor. Microbiological evidence: positive blood culture but does not

meet a major criterion as noted above or serological evidence of
active infection with organism consistent with IE. Echocardiographic
findings: consistent with IE but do not meet a major criterion as
noted above Excludes single positive cultures for coagulasenegative staphylococci, diphtheroids, and organisms that do not
commonly cause endocarditis.
2 major criteria or 1 major and 3 minor criteria or 5 minor criteria

PROGNOSIS AND COMPLICATIONS

Heart failure-mitral and aortic valve

Myocardial abscess and toxic myocarditisArrhythmias

Systemic emboli

2 Major
1 Major + 2 Minor

Diseases of the myocardium

Cardiomyopathies

Diseases of the myocardium

primary vs. secondary

Classification:
Dilated
Hypertrophic
Restrictive

Pulmonary embolism VSD TOF

mycotic aneurysms
rupture of a sinus of Valsalva, obstruction of a valve
secondary to large vegetations, acquired VSD, and heart
block as a result of involvement (abscess) of the conduction
system.
meningitis, osteomyelitis, arthritis, renal abscess, and
immune complexmediated glomerulonephritis.

TREATMENT(Back page)
Rheumatic Fever and Rheumatic Heart Disease
Rheumatic Fever:

An auto immune disease preceded by GABS

Generalized disease affecting all the connective tissues of

the body

Characterized by periods of exacerbation

Commonly affects 6-15 years old

Diagnostic Criteria
Major Criteria
1. Arthritis
2. Carditis
3. Erythema Marginatum
4. Subcutaneous nodules
5. Chorea

Minor Criteria
Clinical
Fever

Arthralgia (joint pains w/o objective findings)

Pericarditis
Constrictive pericarditis

Accumulation of fluid in the pericardial space

Tamponade

Diagnosis

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Acquired heart disease

Clinical Manifestations

Precordial pain- sharp, stabbing pain radiating to the Left

shoulder and back

Friction rub

Pulsus paradoxus - caused by the normal slight decrease in

systolic arterial pressure during inspiration. With cardiac
tamponade, this normal phenomenon is exaggerated,
probably because of decreased filling of the left side of the
heart with the inspiratory phase of respiration.

Diagnosis

Echocardiogram

ECG
o Low voltage QRS
o T wave inversion
o Electrical alterna

AHA Guideline 2008

Prophylactic regiments for dental, oral, or respiratory tract , procedures
Agents
Standard oral prophylaxis
Unable to take oral medications

Amoxycillin

Regimen (single dose 30-60min before

procedure)
50 mg/kg p.o. (max 2 g)

Ampicillin or
Cefazolin or ceftriaxone

50 mg/kg IM/IV(max2g)
50 mg/kg IM/IV (max1g)

Clindamycin or
Cephalexin a or
Azithromycin or clarithromycin

20 mg/kg (max 600 mg)

50 mg/kg (max 2 g)
15 mg/kg (max 500 mg)

Penicillin allergic-oral regimen

Penicillin allergic and unable to take oral

medication

Clindamycin
or
20 mg/kg IV (max 600 mg)
Cefazolin a
50 mg/kg IM/IV(max 1g)
a Cephalosporins should not be used in individuals with immediate-type hypertensivity reaction (urticaria, angioedema, or anaphylaxis) to
penicillins.

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PEDIATRICS

Acquired heart disease

MARIVIC MOTILLA-ESGUERRA, MD

Recitation:
Acquired Heart Disease
1. Kawasaki
2. Mitral Valve Prolapse
3. Rheumatic Heart Disease
4. Pericarditis
5. Cardiac tamponade

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