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Congestive Heart Failure

Congestive heart failure is not common in children, but can occur due to certain congenital heart defects, some acquired heart diseases such as rheumatic fever or Kawasaki disease, or a cardiomyopathy.

Poor pumping of the left ventricle raises the blood pressure in the ventricle during the short rest period between heart contractions. This causes increased blood pressure in the lungs. Small amounts of blood plasma are forced out of the lungs’ blood vessels into the lung tissue (the lungs become “wet” or “congested” with blood similar to a dry sponge becoming wet). Over time, the increased pressure in the lungs affects the pumping ability of the right ventricle. Eventually, the diseased or damaged left ventricle is unable to pump enough blood to the rest of the body. Other organs in the body, particularly the kidneys, sense this decrease in blood flow and attempt to make up for it by increasing the volume of blood. The combination of poor pumping by the heart and the extra fluid in the blood vessels leads to more leakage of plasma fluid through the vessel walls into the body tissues.

Diagnosis

Your child's doctor will ask about symptoms of shortness of breath with physical effort, waking from sleep short of breath and swelling in the legs and ankles. If your child has suddenly gained weight, it may be due to the sudden accumulation of fluid (edema) associated with congestive heart failure.

The doctor will use a stethoscope to listen for faint sounds of abnormal heart function. He or she will also listen to lungs for "crackles," which hint at escaped fluid and “wet” lungs. Your child's doctor will press on the abdomen to feel the size of your child's liver. Your child's neck veins will be examined for swelling, and legs will be checked for edema.

Laboratory tests help confirm the diagnosis. A chest x-ray may show enlargement of your heart or signs of fluid in your lungs. An echocardiogram may show how the heart is working and whether there is any obstruction to blood flow or leakiness of the valves.

Symptoms

In mild cases, the only symptom may be shortness of breath with exertion. In severe cases, the fluid fills the lung's air sacs and causes severe shortness of breath and cough, even when you are resting or lying down to sleep.

If the right ventricle fails because of the elevated pressure in the lungs, swelling of the legs and ankles, called edema, may result. Edema may also affect other organs, such as the liver and intestinal tract, and hinder their function. If the right ventricle fails because of a cause other than left ventricular failure, swelling of the legs may be the first symptom. If the liver becomes congested, it may be enlarged and painful. Shortness of breath may also occur with right sided failure as the right ventricle also affects the function of the left ventricle and may cause it to work less well.

Treatment

Treatment is aimed at reducing the workload of the heart and getting the heart muscle to squeeze more effectively. The best way to reduce the heart's workload is to rest it. The only time the heart can rest is between beats. Your child's doctor may recommend bed rest or reduced physical activity. The limits on activity will vary depending on how severe the heart failure is, but most people benefit from a gentle exercise program. The specialists in our Heart Center help treat congestive heart failure. Learn more.

A simple but important way to ease the heart's work and decrease edema is to reduce salt in your child's diet. Salt causes the body to retain water, adding to the volume of blood. The increased blood volume causes the ventricle to work harder and contributes to edema.

Medications are used to reduce the workload of the heart. Blood pressure drugs (anti-hypertensives) can be used to reduce the pressure against which the heart has to pump. Diuretics (water pills) force the kidneys to excrete the extra water the body has built up. A special class of drugs called ACE inhibitors act on the kidneys to both affect blood pressure and reduce the retention of fluids. Lower blood pressure and lower blood volume ease the workload of the heart.

A major effort in treating congestive heart failure is to improve the heart muscle’s ability to squeeze. Your child's body attempts to do this by enlarging each heart muscle cell. This strengthens the heart muscle. Like all muscles, there is a limit to the heart's strength. By itself this may not be enough to do the job.

Long-term Effects

Despite treatment, congestive heart failure remains a common and serious disease. A proper mix of medicines, reduced salt and reduced physical activity can greatly improve symptoms and can usually allow your child to return to a relatively normal lifestyle. The underlying disease that caused congestive heart failure will continue to need close medical supervision.

Resources

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