International Journal of Cardiology 60 (1997) 139–142

Preoperative management of congestive heart failure in neonates: the

closed hood

Christian Kreutzer*, Eduardo Alberto Kreutzer, Roald Fernando Varon, Maria Ines Roman,
Ana Maria De Dios, Andres Jorge Schlichter, Guillermo O.A. Kreutzer
Children’ s Hospital of Buenos Aires, Gallo 1320 (1425) Buenos Aires, Argentina

Received 27 February 1997; revised 9 April 1997; accepted 9 April 1997

Abstract

In this study we report the results of the use of a closed hood with no external administration of CO 2 to increase pulmonary vascular
resistance by lowering the inspired fraction of oxygen (FiO 2 ) and raising the inspired fraction of carbon dioxide (FiCO 2 ) in patients with
congenital heart disease and increased pulmonary blood flow. Between December 1995 and May 1996, 9 neonates (F:5, M:4) were
admitted. Each study patient was assigned to clinical classes using a 1 to 4 classification. Ages ranged between 2 and 30 days (mean 18),
weight between 2.25 and 3.65 kg (mean 2.89). A plastic hood, closed on the top with a plastic membrane and with the gas entrance open
to room air was placed over the head of the patients. Patients increase pCO 2 by rebreathing their own expired CO 2 . After 24 h of the
onset of the treatment the media of points of congestive heart failure 1 to 4 classification decrease from a mean of 4 to a mean of
2.2860.44 ( p50.001). A statistically significant improvement in symptoms and lowering of pO 2 and pH while raising pCO 2 has been
demonstrated in this study.  1997 Elsevier Science Ireland Ltd.

Keywords: Congestive Heart Failure; Congenital heart disease; Pulmonary vascular resistance; Hypoplastic left heart syndrome

1. Introduction resistance by modifying pH, pCO 2 and pO 2 has

been well described [1,2]. Recently Jacobs et al. [3]
Congenital heart disease with increased pulmon- described the use of hoods and tents with adminis-
ary blood flow is the most common cause of tration of CO 2 at 3% in pre-operative and post-
congestive heart failure in the neonate and young operative stages of the Norwood procedure, and in
infant and proper management is a significant deter- congenital heart disease with congestive heart fail-
minant of surgical outcome. The decrease of pul- ure due to increased pulmonary blood flow. In this
monary vascular resistance during the first weeks of study we report the results of the use of a closed
life produces a dramatic increase of pulmonary hood with no external administration of CO 2 to
blood flow and consequently a volume overload of increase pulmonary vascular resistance until the
the systemic ventricle. The manipulation of pul- patient is operated by lowering the FiO 2 and rais-
monary vascular resistance and systemic vascular ing the FiCO 2 during simultaneous administration
of enalapril to decrease systemic vascular resist-
*Corresponding author. Tel.: 154 1 9629065. Fax: 154 1 8118185. ance. The strategy consists in keeping pCO 2 be-

0167-5273 / 97 / $17.00  1997 Elsevier Science Ireland Ltd. All rights reserved
PII S0167-5273( 97 )00091-0
140 C. Kreutzer et al. / International Journal of Cardiology 60 (1997) 139 – 142

tween 48 and 58 mm of Hg, pH between 7.27 and tricular septal defect unbalanced with total anomalous
7.35 and pO 2 between 50 and 60 mm of Hg. pulmonary venous return: 1 pt. (Table 1.)
Ages ranged between 2 and 30 days (median 21,
mean 18), weight between 2.25 and 3.65 kg (mean
2.89). All patients were medicated before admission
2. Materials and methods with high doses of diuretics (furosemide), 33% with
digoxin and enalapril at a dose of 0.2 mg / kg / day
Between December 1995 and May 1996, 9 neo- was started. All three medications were continued
nates (F:5, M:4) with congestive heart failure due to until the patients were operated. Chest X- Rays,
increased pulmonary blood flow and without assisted Arterial blood gases, were taken at admission and 24
ventilation were admitted in the cardiovascular ward h after the starting of the treatment. Saturation
of the Children’s Hospital of Buenos Aires. Patients (measured using a Nonin pulse oximeter, Model
with respiratory failure with hypercapnia above 45 8600), heart and respiratory rate (with a Mennen
mm of Hg, oxygen saturation below 85% in single horizon 2000) and FiO 2 (with a air oximeter Medix
ventricle physiology and 90% in biventricular hearts model OX 1) were continuosly monitored and regis-
were excluded from this study. tered every 10 min. A plastic hood, closed on the top
Each study patient was assigned to clinical classes with a plastic membrane and with the gas entrance
using a 1 to 4 classification described by Kimball et open to room air was placed over the head of the
al. [4]: patients. Patients increase pCO 2 by rebreathing their
Class 1: No symptoms. own expired CO 2 . The only source of gas interchange
Class 2: Tachypnea and diaphoresis with feeding was the gas entrance and the base perimeter of the
and no growth delay. hood in contact with the bed and neck of the patient.
Class 3: Tachypnea and diaphoresis with feeding Patients were feed when possible through a nasogas-
without weight gain. tric tube and enteral night supplement was used.
Class 4: Symptomatic at rest with tachypnea, Sedation with meperidine at 1 mg / kg every 8 h was
retractions, grunting and diaphoresis, without weight used only in hypoplastic left heart syndrome cases.
gain. The preoperative diagnosis were: Truncus ar- Results were processed with a t-test (raw) and a
teriosus: 2 pts., Truncus with Interrupted aortic arch 1 p,0.05 was considered significant. Parental consent
pt., Hypoplastic left heart syndrome(HLHS): 2 pts., was obtained in all cases and the study protocol
Ventricular septal defect: 2pts., Ventricular septal conforms to the ethical guidelines of the 1975
defect plus Coartation of Aorta: 1 pt, and Atrioven- Declaration of Helsinki and approved by the Bioetical

Table 1
Demographic and clinical data
Name Age Weight (kg) Diagnosis Sat. O 2 Heart rate Resp. rate Length Comments
(days)
Initial Final Pre Post Pre Post Pre Post
HM 21 days 2.58 2.95 Truncus II 92% 88% 160 149 65 42 35 Salmonella gastroent.
SD 30 days 3.05 3.50 Truncus I 93% 87% 179 154 74 61 30 Salmonella gastroent.
FC 25 days 2.50 2.60 Truncus I1IAA 93% 88% 180 165 85 70 2
OR 2 days 3.10 3.10 HLHS 90% 86% 165 154 78 63 2
LO 3 days 2.50 2.50 HLHS 91% 89% 165 155 75 64 1
VF 29 days 3.25 3.50 VSD1CoA 95% 90% 181 161 72 56 14
GM 7 days 2.24 2.54 VSD1ASD1Ductus 95% 91% 162 140 58 51 13
LI 28 days 3.25 3.40 VSD 94% 89% 164 149 71 60 21
TY 21 days 3.63 3.75 CAVC1TAPRV 93% 88% 170 153 75 63 16 Pneumonia?
Mean 92.89 88.44 169.56 152.33 72.56 58.89
p 0.000 0.000 0.002
Truncus: Persistent Truncus Arteriousus. HLHS: Hypoplastic Left Heart Syndrome. IAA: Interrupted Aortic Arch. VSD: Ventricular Septal Defect. CoA:
Coarctation of the Aorta. ASD: Atrial Septal Defect.
 C. Kreutzer et al. / International Journal of Cardiology 60 (1997) 139 – 142 141

Committee of the Children’s Hospital of Buenos ventricle. This particular group of patients must be
Aires. operated on, generally in the first month of life and a
critical preoperative condition is a significant risk
factor for hospital mortality [5]. Low weight, respira-
3. Results tory disfunction, pulmonary edema, atelectasis, respi-
ratory muscles dystrophy, and renal failure form a
All of the patients were very symptomatic at life threatening group of disorders that severely
admission and all of them were in class 4 of compromise early results. The successful model of
congestive heart failure. FiO 2 decreased from a mean decreasing pulmonary blood flow to increase sys-
of 21% to a mean of 17.8%60.7 ( p50.001) after one temic flow can be adapted to other anomalies pre-
h of treatment. After 24 h of the onset of the operative and postoperative. With this in mind, we
treatment FiO 2 decreased from a mean of 21% to a started the use of the closed hood preoperatively and
mean of 17.6%60.9 ( p50.001) respiratory rates postoperatively with the rationale of lowering the
from a mean of 72.5667.67 to a mean of 58.8968.25 FiO 2 and possibly raising the FiCO 2 , which would
breaths per min ( p50.002), saturation from a mean increase the pulmonary vascular resistance, decrease
of 92.8961.69 to a mean of 88.4461.51% ( p5 the pulmonary blood flow and increase the systemic
0.001), heart rates from a mean 169.5668.29 to a blood flow.
mean of 152.3368.40 beats per min ( p50.001), pH Statistical significance in improving symptoms and
from a mean of 7.4260.03 to mean of 7.3560.03 in lowering FiO 2 , pO 2 and pH while raising pCO 2
( p50.001), pO 2 from a mean of 6865.43 to a mean has been demonstrated after 24 h of treatment.
of 5663.37 ( p50.001) mm of Hg, and pCO 2 in- However, adequate clinical management and medica-
crease from a mean of 35.5661.51 to a mean of tion may have played a role ˆ in the final result.
4762.71 ( p50.001) mm of Hg. (Table 2). The mean A weight gain was observed in this study group
of points for congestive heart failure 1 to 4 classifica- and many factors are associated with this: better
tion decreased from a mean of 4 to a mean of cardiac function, less respiratory distress, less con-
2.2860.44 ( p50.001). The patients remained stable sumption of caloric energy, more caloric intake by
until they were operated. It was possible to feed all nutrition through a nasogastric tube and enteral night
patients except those with hypoplastic left heart supplement, appropriate medication and expert man-
syndrome and a weight gain was observed (mean agement. In this series four patients had to wait long
13.4 g / day). (Table 1) for surgery because of infectious complications such
as Salmonella Infanti gastroenteritis (that needed four
weeks of antibiotic treatment to eliminate the
4. Discussion patogenus bacteria from intestinal tract) and because
unfortunately our surgical waiting list was too long;
The raising of pulmonary vascular resistance is one all the time, that they spent in their recovery was in
the most new strategies in the management of new- the cardiology ward with the hood in place. (Our unit
borns with congestive heart failure due to increase is a 20 bed facility with only 7 ICU beds, and we
pulmonary blood flow with overload of the systemic only can perform one to two cases a day, depending
on their complexity).
Table 2 The limitations of this study are that there are no
Results after 24 h of treatment direct measurements of the pulmonary flow / systemic
Pre Post p value flow Q p /Q s ratio and FiCO 2 but indirectly. Q p /Q s
pH 7.4260.03 7.3560.03 0.001 can be evaluated in the absence of lung disease by the
pO 2 (mm of Hg) 68.3365.43 56.1163.37 0.001 systemic oxygen saturation in patients with single
pCO 2 (mm of Hg) 35.5661.51 47.1162.71 0.001
at O 2 (%) 92.8961.69 88.4461.51 0.001 ventricle physiology by the tables described by the
Heart rate (beats per min) 169.5668.29 152.3368.4 0.001 Boston Group [6]. Also it is possible to evaluate
Resp. rate (breaths per min) 72.5667.67 58.8968.25 0.002 FiCO 2 by knowing FiO 2 at the hood with an air
All values given as means6S.D. oximeter. In this study, FiO 2 decrease from a mean of
142 C. Kreutzer et al. / International Journal of Cardiology 60 (1997) 139 – 142

21% decreased to a mean 17.860.7 and remain stable [2] Wessel DL, Hickey PR, Hansen DD. Prostaglandin metabolism and
pulmonary vascular responses to changes in pCO 2 in infants.
after 24 h; that difference would be explained by a Pediatric Res 1987;214 A:1.
3 / 4% FiCO 2 . Unfortunately it was impossible for our [3] Jacobs ML, Rychick J, Murphy JD, Nicholson SD, Stevin JM,
unit to measure FiCO 2 at the hood because of lack of Norwood WI. Results of the Norwood’s operation for lesions other
than Hypoplastic left heart syndrome. J Thorac Cardiovasc Surg
accurate equipment. 1995;110:1555–62.
This procedure should be reserved for those pa- [4] Kimball TR, Daniels SR, Meyer RA, Hannon D, Tian J, Shukla R,
tients without severe respiratory failure: Patients with Schwartz D. Effect of Digoxin on contractility and symptoms in
infants with a large ventricular septal defect. Am J Cardiol
pCO 2 above 45, oxygen saturation below 85% in
1991;68:1377–82.
single ventricle pysiology and below 90% in biven- [5] Jonas R, Hansen DD, Cook N, Wessel DL. Anatomic subtype and
tricular hearts were excluded from this study. survival after reconstructive operation for hypoplastic left heart
The possibility of placing a hood on this patients syndrome. J Thorac Cardiovasc Surg 1994;107:1121–8.
[6] Castaneda AR, Jonas RA, Meyer JE and Hanley FL. Cardiac
with a FiO 2 of 17–18% represents a fast, reliable, Surgery of the neonate and infant. Philadelphia: W.B. Saunders,
and economic way to stabilize this patients preopera- 1994:81.
tively and perhaps it would be use for transports with
expert management to tertiary centers in patients with
hypoplastic left heart syndrome and other anomalies.

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