Effects of captopril on the distribution of left ventricular output with ventricular septal defect

Optimizing treatment for chronic congestive heart failure in children

Treatment strategies for chronic heart failure in children have generally been extrapolated from studies in adults with heart failure. This presentation reviews the existing knowledge and recommendations regarding the treatment of chronic heart failure in adults and the information that is available in children. Medications currently recommended for use in adults include diuretics, digoxin, angiotensin-converting enzyme inhibitors, and beta-blockers. These recommendations are based on results from large, randomized, multicenter trials. Anecdotal evidence suggests similar beneficial effects of these medications in children. The fact that the etiologies, pathophysiology, and physiologic consequences of heart failure in children often differ greatly from those in adults, however, justifies the development of prospective, randomized trials to evaluate these medications specifically in children. Findings from these types of studies will provide critical information for developing guidelines for the appropriate treatment of children with chronic heart failure.

Efficacy and dosage of enalapril in congenital and acquired heart disease

In a tertiary referral centre 63 patients underwent 67 treatment periods with enalapril. The median age was 5.4 months. All children had signs of heart failure: congestive cardiac failure with breathlessness at rest was present in 88%. Haemodynamic groups were left-to-right shunt (n = 15), impaired ventricular function (n = 14), after cardiac surgery (n = 23), valvar regurgitation (n = 12), and hypertension (n = 3). Serial clinical, radiological, and laboratory data were used to judge outcome. The mean (SD) maximal dose was 0.30 (0.21) mg/kg/day. Thirty nine (58%) patients improved, 20 (30%) showed no improvement, and eight (12%) had side effects requiring discontinuation of enalapril. Renal failure in eight patients was related to young age, low weight, and left-to-right shunt group. Three patients died in congestive heart failure with renal failure. Enalapril was clinically safe and effective for children with cardiac failure secondary to ventricular impairment, valvar regurgitation, or after cardiac surgery. Renal failure was a problem in young infants with left-to-right shunts.

Acute hemodynamic effects of converting enzyme inhibition in children with intracardiac shunts

The short-term hemodynamic effects of intravenous enalaprilat were assessed in 26 infants and children, aged 6 months to 15 years, with intracardiac shunts undergoing cardiac catheterization. Pulmonary and systemic pressure, flow, and resistance indices were measured by the direct Fick method before and 30 min after enalaprilat at 0.06 mg/kg. Aortic and pulmonary artery pressure decreased 15 and 20%, respectively, by 10 min, with little further change at 30 min. The heart rate did not change significantly and there was no reduction in systemic flow. In those with a large ventricular septal defect and normal or near-normal pulmonary resistance (less than 3.5 u.m2, n = 8), the mean pulmonary-systemic flow ratio decreased from 2.9 +/- 0.3 to 2.4 +/- 0.3 (p less than 0.05) and the mean left-to-right shunt from 7.4 +/- 0.8 to 5.9 +/- 0.7 L/min/m2 (p less than 0.02). Those with an elevated pulmonary vascular resistance (greater than 5 u.m2, n = 8) showed a varied response. Two children, both with Down's syndrome, an atrioventricular canal defect, and reversible pulmonary hypertension (as assessed by an infusion of isoproterenol), had no decrease in pulmonary vascular resistance with enalaprilat. There were no adverse effects. Converting enzyme inhibitors may benefit "heart failure" associated with large ventricular septal defects and normal or mildly elevated pulmonary resistance.