Current State of Pediatric Heart Failure

Bibhuti B Das, Bibhuti B Das

Abstract

Pediatric heart failure (HF) represents an important cause of morbidity and mortality in childhood. There is an overlapping relationship of HF, congenital heart disease, and cardiomyopathy. The goal of treatment of HF in children is to maintain stability, prevent progression, and provide a reasonable milieu to allow somatic growth and optimal development. Current management and therapy for HF in children are extrapolated from treatment approaches in adults. There are significant barriers in applying adult data to children because of developmental factors, age variation from birth to adolescence, and differences in the genetic expression profile and β-adrenergic signaling. At the same time, there are significant challenges in performing well-designed drug trials in children with HF because of heterogeneity of diagnoses identifying a clinically relevant outcome with a high event rate, and a difficulty in achieving sufficient enrollment. A judicious balance between extrapolation from adult HF guidelines and the development of child-specific data on treatment represent a wise approach to optimize pediatric HF management. This approach is helpful as reflected by the increasing role of ventricular assist devices in the management of advanced HF in children. This review discusses the causes, epidemiology, pathophysiology, clinical manifestations, conventional medical treatment, clinical trials, and the role of device therapy in pediatric HF.

Keywords: advanced heart failure; mechanical circulatory support; pediatric heart failure; ventricular assist device.

Conflict of interest statement

The author declares no conflict of interest.

Figures

Figure 1
Figure 1
Common causes of heart failure in children—the relationship of ventricular dysfunction to CHD and cardiomyopathy.
Figure 2
Figure 2
Pathophysiology of chronic heart failure. (AT1 = angiotensinogen 1, ↑ = increase, ↓ = decrease, NP = natriuretic peptide, ANP = atrial natriuretic peptide, BNP = B-type natriuretic peptide).
Figure 3
Figure 3
Perfusion and congestion model: patterns of presentation in heart failure in children [22]. (Presented with permission from the Publisher, Elsevier, originally published in Canadian Journal of Cardiology 2013; 29:1535-1552) (License Number 4335401450214).
Figure 4
Figure 4
Diagnosis and management of acute heart failure in children. (CHD = congenital heart disease, PGE = prostaglandin E, SCD = sudden cardiac death, CBC = complete blood count, CMP = comprehensive metabolic panel, ABG = arterial blood gas, CXR = chest-X-ray, ECG = electrocardiogram, ECHO= echocardiogram, ACLS = advanced cardiac life support, PALS = pediatric advanced life support, ICU = intensive care unit, ECMO = extra-corporeal membrane oxygenation, VAD = ventricular assist device, MRI = magnetic resonance imaging, CRP = C-reactive protein, ESR = erythrocyte sedimentation rate, R/O = rule out, LBBB = left bundle branch block, BNP = B-type natriuretic peptide).
Figure 5
Figure 5
Indication of mechanical circulatory support and device selection in children with heart failure. (BSA = body surface area, IV = intravenous).

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