Grading the severity of congestive heart failure in infants

Pattern and determinants of health-related quality of life of adolescents with congenital heart disease in Cameroon: A single-center cross-sectional study

Background

Health-related quality of life (HRQoL) assessment is necessary for the management of patients with congenital heart diseases (CHD). No study has yet been reported on Cameroonian adolescents. The aim of this study was to evaluate the profile of and look for determinants of HRQoL in adolescents with CHD in Cameroon.

Methods

This was a cross-sectional study with prospective recruitment carried out on 71 adolescents diagnosed with CHD aged 12 to 18 years and recruited at the Douala General Hospital. Sociodemographic and clinical data were collected using a structured questionnaire. HRQoL was assessed using the pediatric quality of life inventory (PedsQL4.0) for child and parent reports. Multivariate linear regression was used to assess the determinants of HRQoL. Differences were considered significant for p < 0.05.

Results

Mean age of participants was 15 ± 2 years with 54.9% women. Mean physical and psychosocial functioning scores were 50.7 ± 13.9 and 60.5 ± 9.6 for parent report and 49.5 ± 13.4 and 59.1 ± 9.1 for child report respectively; with no significant difference according to gender. Distribution of functioning scores according to anatomical complexity showed no significant difference while it was lower in patients with a greater physiological severity and to those with no surgical intervention compared to the others. After multivariate adjustments, physiological stage 3 or 4 was negatively associated while cardiac intervention was positively associated with HRQoL.

Conclusion

CHD adolescents exhibit a low level of quality of life. Cardiac intervention positively affects HRQoL and should be targeted in the reduction of HRQoL burden from CHD in Cameroon.

Pulmonary hemodynamics before and after pediatric heart transplantation

BACKGROUND

Pulmonary hypertension (PH) may limit the outcome of pediatric heart transplantation (pHTx). We evaluated pulmonary hemodynamics in children undergoing pHTx.

METHODS

Cross-sectional, single-center, observational study analyzing pulmonary hemodynamics in children undergoing pHTx.

RESULTS

Twenty-three children (female 15) underwent pHTx at median (IQR) age of 3.9 (.9-8.2) years with a time interval between first clinical signs and pHTx of 1.1 (.4-3.2) years. Indications for pHTx included cardiomyopathy (CMP) (n = 17, 74%), congenital heart disease (CHD) (n = 5, 22%), and intracardiac tumor (n = 1, 4%). Before pHTx, pulmonary hemodynamics included elevated pulmonary artery pressure (PAP) 26 (18.5-30) mmHg, pulmonary capillary wedge pressure (PCWP) 19 (14-21) mmHg, left ventricular enddiastolic pressure (LVEDP) 17 (13-22) mmHg. Transpulmonary pressure gradient (TPG) was 6.5 (3.5-10) mmHg and pulmonary vascular resistance (Rp) 2.65 WU*m2 (1.87-3.19). After pHTx, at immediate evaluation 2 weeks after pHTx PAP decreased to 20.5 (17-24) mmHg, PCWP 14.5 (10.5-18) mmHg (p < .05), LVEDP 16 (12.5-18) mmHg, TPG 6.5 (4-12) mmHg, Rp 1.49 (1.08-2.74) WU*m2 resp.at last invasive follow up 4.0 (1.4-6) years after pHTx, to PAP 19.5 (17-21) mmHg (p < .05), PCWP 13 (10.5-14.5) mmHg (p < .05), LVEDP 13 (10.5-14) mmHg, TPG 7 (5-9.5) mmHg, Rp 1.58 (1.38-2.19) WU*m2 (p < .05). In CHD patients PAP increased (p < .05) after pHTx at immediate evaluation and decreased until last follow-up (p < .05), while in CMP patients there was a continuous decline of mean PAP values immediately after HTx (p < .05).

CONCLUSIONS

While PH before pHTx is frequent, after pHTx the normalization of PH starts immediately in CMP patients but is delayed in CHD patients.

NT-proBNP levels as a predictor of higher left ventricular end-diastolic pressure in children with small perimembranous ventricular septal defect

INTRODUCTION

The decision to close small ventricular septal defect is still controversial. Previous study showed that ventricular dysfunction in adulthood is correlated with small perimembranous ventricular septal defect. N terminal pro B-type natriuretic peptide (NT-proBNP) is a neurohormone secreted primarily from the ventricles in response to increased left and right ventricular pressure and volume load. The left ventricular end-diastolic pressure will reflect ventricular performance. This study aimed to evaluate the correlation between left ventricular end-diastolic pressure and the NT-proBNP in children with small perimembranous ventricular septal defect.

MATERIALS AND METHODS

Level of NT-proBNP in 41 patients with small perimembranous ventricular septal defect was measured before transcatheter closure procedure. We also measured the left ventricular end-diastolic pressure in each patients during catheterisation. We investigated the value of NT-proBNP in patients with small perimembranous ventricular septal defect and its correlation with the level of left ventricular end-diastolic pressure.

RESULT

We found positive correlation between NT-proBNP and left ventricular end-diastolic pressure (r = 0.278, p = 0.046). The median of NT-proBNP at left ventricular end-diastolic pressure < 10 was lower than at left ventricular end-diastolic pressure ≥ 10 (0.87 ng/ml versus 1.83 ng/ml, p = 0.023). The results of the NT-proBNP diagnostic test for predicting left ventricular end-diastolic pressure ≥ 10 using Receiver Operating Characteristic (ROC) analysis showed the area under the curve value of 0.715 (95% CI: 0.546-0.849). The cut-off value >0.99 ng/ml of NT-proBNP has 75.0% sensitivity and 72.2% specifity.

CONCLUSION

Level of NT-proBNP higher than 0.99 ng/ml was correlated significantly with left ventricular end-diastolic pressure ≥10 in children with small perimembranous ventricular septal defect.

Diagnosis and Management of Pediatric Heart Failure

Heart failure is a highly morbid syndrome, recognized as a major cause of adult mortality. Heart failure in pediatric patients, whether in the setting of congenital or acquired heart disease, is similarly associated with high mortality and resource utilization. Understanding the clinical presentation, diagnosis, and initial stabilization of pediatric heart failure is paramount for any acute care clinician as it may mimic common childhood ailments like viral respiratory or gastrointestinal illnesses. Pediatric heart failure occurs in patients with palliated or unpalliated congenital heart disease, familial or acquired cardiomyopathy, acquired valve disease, and myocarditis. This review will focus on heart failure in pediatric patients with structurally normal hearts and will summarize what is known about patterns of presentation, etiologies, diagnostic evaluation, and the acute and chronic management of this highly morbid syndrome.

Renal Outcomes in Neonates and Infants with Transposition Physiology Undergoing Arterial Switch Procedure

Acute kidney injury (AKI) in children with Transposition of Great arteries (TGA) undergoing Arterial Switch operation (ASO) is an important complication in the post-operative period associated with worse outcomes. AKI in children post open cardiac surgery has been well studied, with lesser data in literature pertaining to TGA and its sub-types specifically. This was a prospective, observational study enrolling infants with TGA undergoing ASO at a single center over a span of a decade from January 2010 to December 2020. The infants were followed during the duration of ICU and hospital stay, with documentation of baseline and intraoperative parameters as well as post-operative course. Out of 145 infants enrolled in the study, 83.1% developed AKI with majority (83.9%) having stage 1 AKI. Higher odds of AKI were seen in infants requiring Norepinephrine [odds ratio - 16.76 (95% CI 2.19-128.2), p < 0.001] and those who developed gram-negative infections [2.81 (1.04-7.56), p - 0.036]. Infants with AKI had significantly higher vasoactive-inotropic support at day 1 than those without AKI [16 (12.5-21.50 vs 13 (10.25-15.75), p - 0.014]. Seventeen infants in the AKI group (14%) died as opposed to none in the non-AKI group (p = 0.076). Median hours of ventilator support required were significantly higher in those with AKI than those who did not develop AKI (48 vs 45.5 p = 0.015). The infants with ASO + ASD + PDA (53% of neonates who died) were younger, had less weight at admission, more gram-negative sepsis and need for dopamine, as compared to ASO + VSD + ASD (23.5% of mortality) and ASO + ASD + VSD + aortic arch repair (23.5% of mortality). AKI in infants with TGA undergoing ASO is common and associated with poorer outcomes. In this subpopulation, AKI development is associated most commonly with hemodynamic instability and infections. This is the first study, looking at outcomes of TGA depending on the sub-types of ASO surgeries done in the infants [ASO with ASD + PDA or ASD + VSD or ASD + VSD + Arch Repair].

Outcomes of repair of anomalous origin of pulmonary artery branch from aorta ascendens with autologous tissue: a rare condition revisited

BACKGROUND

Anomalous origin of pulmonary artery branch from ascending aorta (APA) in the presence of two separate semilunar valves is an uncommon entity necessitating early diagnosis and surgery to prevent development of irreversible pulmonary vascular disease. We evaluated our experience with the technique and outcome of 11 patients with this condition.

METHODS

Between January 2000 and December 2019, 11 patients were diagnosed with APA. Echocardiographic data were collected from the records, including the site of origin of the anomalous pulmonary artery, additional defects, pulmonary artery pressures, and biventricular function. Intraoperative charts were reviewed for the details of the surgical procedure and cardiopulmonary bypass. Post-operative data included survival, ventilatory support, and duration of hospital stay. After discharge, children were reviewed at 1 month, 3 months, 6 months, and then at yearly intervals.

RESULTS

Of the 11 patients, females were more than males (7:4) with a median age of 6 months (15 days-28 years) and median weight of 5.7 kg (1.8-40 kg). Nine patients underwent direct re-implantation of anomalous pulmonary artery branch to main pulmonary artery. The survival rate was 88.8% in our series. On follow-up, no re-operations or re-interventions were required and all surgically corrected patients were in stable clinical condition.

CONCLUSION

Early- and midterm outcomes of children who underwent surgery for APA is convincing. Early direct re-implantation of the anomalous branch pulmonary artery to main pulmonary artery without any graft material is the optimal surgical strategy for these patients.

The value of cardiac magnetic resonance imaging in endocardial fibroelastosis

INTRODUCTION

Endocardial fibroelastosis (EFE), an uncommon congenital heart disorder often occurring in infants, has a poor prognosis. It is of great significance to perform early diagnosis and accurately analyze cardiac function to enable further clinical treatment and prognosis decisions. This study aimed to explore the findings of cardiac magnetic resonance (CMR) in patients with EFE, including morphological changes and cardiac function analyses. Additionally, we compared the difference in the evaluation of the cardiac function between CMR and echocardiography (Echo).

METHODS

Eleven patients with EFE (nine females and two males, aged between 0.3 and 1.9 years), treated in our hospital, were analyzed retrospectively. Left ventricular posterior wall thickness (LVPW), anterior wall thickness (LVAW), fractional shortening (FS), ejection fraction (EF), end-systolic diameter (ESD), end-diastolic diameter (EDD), end-systolic volume (ESV), and end-diastolic volume (EDV) were assessed using both Echo and CMR. The Original Ross classification and the New York Heart Association functional classification were used to grade the patients' cardiac function. The correlations between clinical cardiac function classification and MRI- and Echo-derived imaging data were determined.

RESULTS

All patients showed a thickened endocardium and left ventricle globular dilatation on CMR. We observed significant systolic dysfunction and whole or segmental abnormal ventricular movement. Compared with those measured by Echo, the EF, FS, and EDV values were significantly lower when measured using CMR. Compared with Echo measurements, the ESV, ESD, LVAW, and LVPW values were significantly higher when measured using CMR. CMR-measured EF and FS correlated better with the clinical cardiac functional score than those derived from Echo (EF, r = 0.646 > 0.224; FS, r = 0.627 > 0.245, respectively).

CONCLUSION

In patients with EFE, the characteristic morphological changes of the heart could be displayed accurately using CMR. The parameters measured by CMR were more accurate than those of Echo and correlated well with clinical cardiac function scores, mainly because it does not make invalid geometrical assumptions.

Clinical Profile and Risk Factors for Cardiac Death in Pediatric Patients With Primary Dilated Cardiomyopathy at a Tertiary Medical Center in China

AIM

We sought to identify the clinical characteristics and risk factors for cardiac mortality in pediatric patients with primary dilated cardiomyopathy (DCM) in China.

METHODS

A total of 138 pediatric patients who were consecutively diagnosed with primary DCM from January 2011 to December 2020 were included. We assessed patients' clinical symptoms and performed laboratory examinations, electrocardiography, and echocardiography.

RESULTS

Of these patients, 79 (57%) had severe systolic dysfunction (left ventricular ejection fraction of < 30%), 79 (57.2%) developed DCM before 12 months of age, 62 (45%) were male, 121 (87.7%) presented with advanced heart failure (cardiac functional class III/IV), and 54 (39.1%) presented with arrhythmia. At a median follow-up of 12 months, the overall cardiac mortality rate was 33%, and 40 of 46 deaths occurred within 6 months following DCM diagnosis. A multivariate Cox regression analysis identified several independent cardiac death predictors, including an age of 12 months to 5 years [hazard ratio (HR) 2.799; 95% confidence interval (CI) 1.160-6.758; P = 0.022] or 10-15 years (HR 3.617; 95% CI 1.336-9.788; P = 0.011) at diagnosis, an elevated serum alanine aminotransferase (ALT) concentration (≥ 51.5 U/L) (HR 2.219; 95% CI 1.06-4.574; P = 0.031), and use of mechanical ventilation (HR 4.223; 95% CI 1.763-10.114; P = 0.001).

CONCLUSION

The mortality rate of primary DCM without transplantation is high. Age, an elevated serum ALT concentration, and the need for mechanical ventilation predict mortality in patients with primary DCM, providing new insights into DCM risk stratification.

NT pro- B-type Natriuretic Peptide in the Small Ventricular Septal Defect in Children

Background: Brain natriuretic peptide is a cardiac hormone secreted from the left ventricular myocardium due to ventricular expansion and volume overload. A recent study shows that small VSD will have risk of ventricular dysfunction in adulthood. Another complications such as endocarditis, congestive heart failure, aortic regurgitation, arrhythmia also we should be aware. Evaluations of the plasma B-type natriuretic peptide level (NT pro BNP) are currently being considered as methods to identify the possible presence of ventricular dilation in small VSD. Objective: To evaluate the change in plasma B-type natriuretic peptide after transcatheter closure of VSD. Methods: A pretest-posttest design was conducted on VSD patients before and after transcatheter closure. Plasma B-type natriuretic peptide level were measured before and 30 days after the transcatheter closure of VSD. Result: A total of 32 peri membranous VSD patients were included in this study with 62.5 % female patients (n=20) and 37.5 % male patients (n=12). A significant decrease was observed in the median NT pro BNP level when the level before closure of 1.08 (0.74 – 3.47) ng/ml was compared to the level after closure of 0.91 (0.68 – 2.07) ng/ml (p<0.05). Conclusion: Significant decreases in NT pro BNP level are seen in small VSD patients 30 days after transcatheter closure. Patients with small peri membranous VSD are generally considered to need occlusion for their childhood defect.  

Risk factors and outcomes of deep tissue Candida invasion in neonates with invasive candidiasis

BACKGROUND

Deep tissue Candida invasion represents a special entity among neonates with invasive candidiasis. We aimed to explore the risk factors and clinical outcomes for deep tissue Candida invasion among neonates with invasive candidiasis.

METHODS

A retrospective data review of neonates admitted to NICU of Madinah maternity and children hospital, KSA from January 2012 to December 2019 was done. Data were analysed between infants with or without deep tissue candidiasis among infants with invasive candidiasis. Invasive candidiasis was defined as positive blood or catheter collected urine culture for Candida. Deep tissue Candida invasion was defined as an infection of the central nervous system, eyes, heart, skeletal system, lungs, liver or kidneys.

RESULT

A total of 14 (11%) out of 130 neonates with invasive candidiasis had deep tissue Candida invasion. Persistent positive blood culture for Candida [OR 15.2, 95% CI (2.0-114), p = .01], prematurity [OR 7.6, 95% CI (1.04-56.4), p = .04] and prolonged antibiotic duration [OR 1.3, 95% CI (1.02-1.6), p = .03] are independent risk factors for deep tissue Candida invasion. Deep tissue Candida invasion was associated with significantly higher rates of cerebral palsy, hydrocephalus, heart failure and longer length of hospital stay compared to infants without deep tissue invasion.

CONCLUSION

Persistent Candida growth in blood cultures, prematurity and long-term antibiotic use are significant risk factors for deep tissue Candida invasion. Deep tissue Candida invasion is associated with prolonged hospital stay and higher neonatal morbidity.

Anesthetic Considerations in Pediatric Patients With Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) in pediatrics is a significant cause for morbidity and mortality in children. Congenital heart disease and cardiomyopathy are the leading etiologies of ADHF. It is common for these children to undergo diagnostic, therapeutic, or surgical procedure under anesthesia, which may be associated with significant morbidity and mortality. The importance of preanesthetic multidisciplinary planning with all involved teams, including anesthesia, cardiology, intensive care, perfusion, and cardiac surgery, cannot be emphasized enough. In order to safely manage these patients, it is imperative for the anesthesiologist to understand the complex pathophysiological interactions between cardiopulmonary systems and anesthesia during these procedures. This review discusses the etiology, pathophysiology, clinical manifestations, and perioperative management of these patients.

Advanced Heart Failure in Special Population-Pediatric Age

Heart failure (HF) is an important health care issue in children because of its considerable morbidity and mortality. Advanced HF encompasses patients who remained symptomatic despite optimal medical treatment and includes patients who require special management, such as continuous inotropic therapy, mechanical circulatory support, or heart transplantation (HT). HT is the gold standard for children with advanced HF; nonetheless, the number of suitable donors has not increased for decades, leading to prolonged waitlist times and increased mortality rates. Therefore, the role of pediatric mechanic circulatory support has been assessed as an alternative treatment in patients in whom heart transplant could not be performed. The authors discuss the epidemiology, causes, pathophysiology, clinical manifestation, medical treatment, device therapy, and HT in pediatric HF, and a particular emphasis was posed on patients with advanced HF.

Epidemiology of Pediatric Heart Failure in the USA-a 15-Year Multi-Institutional Study

The epidemiology of pediatric heart failure (HF) has been characterized for congenital heart disease (CHD) and cardiomyopathies (CM), but the impact of CM associated with CHD has not been studied. This study aims to describe the characteristics and outcomes of inpatient pediatric HF patients with CHD, CM, and CHD with CM (CHD + CM) across the USA. We included all HF patients with CM diagnoses with and without CHD using ICD 9/10 codes ≤ 19 years old from January 2004 to September 2019 using the Pediatric Health Information System database. We identified 67,349 unique patients ≤ 19 years old with HF, of which 87% had CHD, 7% had CHD + CM, and 6% had CM. Pediatric HF admissions increased significantly from 2004 to 2018 with an associated increase in extracorporeal circulatory support (ECLS) use. Heart transplantation (HTX) increased only in the CHD and CHD + CM groups. CHD patients required less ECLS with and without HTX; however, they had significantly higher inpatient mortality after those procedures than the other groups (p < 0.001). CM patients were older (median 115 months) and had the lowest inpatient mortality after HTX with and without ECLS (p < 0.05). CHD + CM showed the highest overall inpatient mortality (15%), and cumulative hospital billed charges (median US$ 541,374), all p < 0.001. Pediatric HF admissions have increased from 2004 to 2018. ECLS use and HTX have expanded in this population, with an associated decrease in inpatient mortality in the CHD and CM groups. CHD + CM patients are a growing population with the highest inpatient mortality.

Pulmonary arterial hypertension associated with congenital heart disease: lessons learnt from the large Turkish Nationwide Registry (THALES)

Pulmonary hypertension is a group of diseases, including pulmonary arterial hypertension associated with congenital heart disease (APAH-CHD), characterized by progressive deterioration in pulmonary hemodynamics associated with substantial morbidity and mortality risk. THALES is a national multicenter, prospective observational registry, providing data on patients with APAH-CHD. The study comprised APAH-CHD patients (>3 months of age) with confirmed diagnosis of right heart catheterization or echocardiographic findings. Initial and follow-up data were collected via regular hospital visits. Descriptive statistics are used for definitive purposes. Overall, 1034 patients aged 3 months–79 years (median 11.2 [Q1–Q3: 2.2–24.3] years) with APAH-CHD were enrolled at 61 centers, 50.3% being retrospectively enrolled. Most had either Eisenmenger's syndrome (49.2%) or systemic-to-pulmonary shunts (42.7%). Patients were mostly in functional class I–II at the time of diagnosis (46.6%). Mean 6-min walk distance (6MWD) was 369 ± 120 m. Mean pulmonary arterial pressure was 54.7 ± 22.2 mmHg for the whole group, and was highest in patients with Eisenmenger's syndrome. Targeted therapies were noted in 398 (38.5%) patients (monotherapy in 80.4%). Follow-up data were available in 506 patients. Survival at 140 months was 79% and was associated with baseline 6MWD >440 m (p = 0.009), brain natriuretic peptide level < 300 ng/L (p < 0.001). Follow-up 6MWD >165 m (p < 0.0001), brain natriuretic peptide level <300 ng/L (p = 0.031), and targeted therapies (p = 0.004) were also predictive of survival. THALES is the largest registry dedicated to APAH-CHD to date and provides important contributions on demographics, clinical characteristics, and gaps in disease management.

Perspective: A Framework to Screen Pediatric and Adolescent Hematopoietic Cellular Therapy Patients for Organ Dysfunction: Time for a Multi-Disciplinary and Longitudinal Approach

Hematopoietic Cell Transplantation (HCT) is a potentially curative therapy for children and adolescent/young adults (AYA) with high-risk malignancies as well as some non-malignant genetic diseases. However, HCT may be associated with endotheliopathies and/or organ dysfunction that may progress to pediatric multi-organ dysfunction syndrome (pMODS) and require critical care intervention. Discipline specific scoring systems may be used to characterize individual organ dysfunction, but the extent to which they are used to prospectively monitor HCT patients with mild dysfunction is unknown. Further, separate scoring systems may be used to define risk of mortality and inform prognostication among those who require critical care support. Our understanding of the epidemiology, risk factors, morbidity, mortality, required monitoring, optimal prevention strategies and appropriate management of children undergoing HCT who develop organ dysfunction, endotheliopathies and/or progress to pMODS is poor. Discipline-specific registries and clinical studies have described improving outcomes for children undergoing HCT, including those who require critical care support; however, longitudinal studies/prospective registries that capture common data elements among HCT patients with and without organ dysfunction, endotheliopathies and pMODS are needed to facilitate inter-disciplinary collaboration and optimally characterize the risk profiles, define screening and prophylaxis regimens and mitigate toxicity.

Paediatric dilated cardiomyopathy in Khartoum state, Sudan: a prospective study

BACKGROUND

Dilated cardiomyopathy (DCM) is a disease of the heart muscle that affects ventricular function; it is a debilitating disease that can lead to heart failure and death in children. There is a lack of good epidemiological data about paediatric DCM in Sudan or in sub-Saharan Africa.

OBJECTIVE

To study the incidence, causes and outcome of DCM among children in Sudan.

METHODS

A prospective cross-sectional study that was conducted in three paediatric hospitals in Khartoum state, Sudan over the period of 6 months.

RESULTS

During the study period, 55 children were seen with the diagnosis of DCM; The female: male ratio was 1.9:1. The incidence of DCM in Khartoum state was found to be 1.4 cases per 100 000 children per year, 10 children (18 %) were diagnosed in the first year of their life. Twenty-seven children (49 %) showed evidence of failure to thrive, being below the fifth percentile for weight. The most common cause of DCM was found to be postviral in 27 children (49%), followed by Idiopathic in 25 children (45%). The most common presentation was the shortness of breath in 53 children (97%), on echocardiography 26 children (47 %) showed evidence of severe left ventricular impairment and 23 children (42%) showed moderate ventricular impairment. Regarding the outcome, 8 children (15%) recovered, the condition of 11 children (20%) remained static and there were 36 deaths (65%).

CONCLUSION

The incidence of DCM in Sudanese children was found to high with a higher mortality compared with middle-income and high-income countries; Improvement in the entire health system is needed to tackle this condition.

Risk Factors for Cardiac Adverse Events in Infants and Children with Complex Heart Disease Scheduled for Bi-ventricular Repair: Prognostic Value of Pre-operative B-Type Natriuretic Peptide and High-Sensitivity Troponin T

Few reports have described the prognostic value of measuring both B-type natriuretic peptides (BNP) and high-sensitivity troponin T (hs-TnT) in pediatric patients with complex congenital heart disease (CHD) undergoing surgery. We assessed demographic, hemodynamic, and laboratory data, including BNP and hs-TnT levels, for the prediction of cardiac adverse events in 85 patients. Cardiac adverse events were defined as death, cardiac arrest, worsening heart failure requiring inotropic agents and/or respiratory support, and unscheduled surgery/intervention either within or after 12 months of surgery. There were 17 cardiac adverse events. Of the demographic variables, low birth weight (< 2500 g: Odds ratio [OR], 5.97; 95% confidential interval [CI] 1.48-24.0; p = 0.001) and Ross/New York Heart Association [NYHA] class (≥ 2.0) (OR 12.7; 95% CI 3.08-52.7; p = 0.0004) were strongly association with cardiac adverse events. Among hemodynamic and laboratory variables, preoperative BNP (OR 14.04; 95% CI 2.15-91.7; p = 0.001) and hs-TnT levels (OR 16.66; 95% CI 2.27-122; p = 0.002) were found to be independent risk factors. Receiver operating characteristic analysis determined BNP and hs-TnT levels of 60.9 pg/mL and 0.025 ng/mL, respectively, to be markers of high risk. Kaplan-Meier analysis demonstrated significant differences in the freedom from cardiac adverse events between Group A (BNP or hs-TnT elevated, n = 26) and Group B (both biomarkers elevated, n = 19; log-rank, p < 0.001). In conclusion, low birth weight (< 2500 g) and Ross/NYHA class ≥ 2.0 are strongly associated with cardiac adverse events. Preoperative BNP and hs-TnT also provide prognostic information in patients with complex CHD scheduled for surgery. Using both markers in combination predicts cardiac adverse events better than using either separately.

Health-related quality of life in children with congenital heart disease aged 5 to 7 years: a multicentre controlled cross-sectional study

Background

In the context of tremendous progress in congenital cardiology, more attention has been given to patient-related outcomes, especially in assessing health-related quality of life (HRQoL) of patients with congenital heart diseases (CHD). However, most studies have mainly focused on teenagers or adults and currently, few HRQoL controlled data is available in young children. This study aimed to evaluate HRQoL of children with CHD aged 5 to 7 y.o., in comparison with contemporary peers recruited in school, as well as the factors associated with HRQoL in this population.

Methods

This multicentre controlled prospective cross-sectional study included 124 children with a CHD (mean age = 6.0 ± 0.8 y, 45% female) during their outpatient visit and 125 controls (mean age = 6.2 ± 0.8 y, 54% female) recruited at school. A generic paediatric HRQoL instrument was used (PedsQL 4.0).

Results

Self-reported HRQoL in children with CHD was similar to controls, overall (73.5 ± 1.2 vs. 72.8 ± 1.2, P = 0.7, respectively), and for each dimension. Parents-reported HRQoL was significantly lower in the CHD group than in controls. HRQoL was predicted by the disease severity and by repeated invasive cardiac procedures (surgery or catheterization).

Conclusion

HRQoL in young children with CHD aged 5 to 7 years old was good and similar to controls. This study contributed to the growing body of knowledge on HRQoL in congenital cardiology and emphasized the need for child and family support in the most complex CHD.

Trial registration This study was approved by the institutional review board of Montpellier University Hospital (2019_IRB-MTP_02-19) on 22 February 2019 and was registered on ClinicalTrials.gov (NCT03931096) on 30 April 2019, https://clinicaltrials.gov/ct2/show/NCT03931096.

An Unusual Case of Neonatal High-Output Heart Failure: Infantile Hepatic Hemangioma

BACKGROUND

Infantile hepatic hemangioma (IHH) is a rare but life-threatening disorder that must be considered in the newborn presenting with high-output heart failure (HF). IHH is a tumor comprised of large vascular beds, which require a significant increase in blood flow as the lesion grows. This, in turn, creates an undue burden on the cardiovascular system, leading to high-output HF and potentially, respiratory distress. Recent changes have been made in the classification of certain hepatic hemangiomas and their treatments.

CASE REPORT

A 10-day-old girl presented to the Emergency Department with increased respiratory effort and an episode of apnea and cyanosis. A chest x-ray study was obtained and showed cardiomegaly and pulmonary edema concerning for HF. The patient was promptly admitted to the pediatric intensive care unit, where advanced imaging was obtained revealing findings consistent with IHH. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: HF in an infant is a critical condition often requiring prompt intervention and rapid diagnosis of the correct etiology to save a life. IHH is an example of an extrathoracic etiology of pediatric HF that has undergone recent changes in terminology and diagnosis. Increased awareness among emergency physicians of this disease process and its treatments can lead to expeditious diagnosis and treatment of this potentially life-threatening illness.

Neonatal Rabbit Model for Pressure-Overloaded Heart Failure and Preliminary Exploration of Mechanism

BACKGROUND

This study aimed to establish a model of pediatric heart failure (PHF) with concomitant left ventricle pressure overload by transverse aortic constriction (TAC) and study the PHF mechanism primarily at the gene transcription level.

METHODS

Twenty-four neonatal rabbits within 7 days after birth were randomly divided into sham (n = 8), moderate TAC (50% constriction, n = 8) and severe TAC (sTAC; 75% constriction, n = 8) groups. After the procedure transthoracic echocardiography was performed at 2, 4, and 6 weeks to measure left ventricle structure and function. Histologic staining and gene sequencing of left ventricle myocardial tissue were performed at 6 weeks.

RESULTS

Six weeks after procedure transthoracic echocardiography showed that the pressure at the ligation of the aorta was 12.13 ± 0.95 mm Hg in the sTAC group, which was 26 times more than that of the sham group (P < .05), and left ventricular dilatation began to appear in the sTAC group. Gene sequencing showed significantly different microRNA expression between the sTAC and sham groups. Bioinformatics analysis among the 3 groups showed that the expression of ocu-miR-411-5p, ocu-miR-214-3p, and ocu-miR-432-5p was decreased in the sTAC group compared with the sham group (P < .05) and that the focal adhesion, insulin, and PI3K-Akt signaling pathways were also affected.

CONCLUSIONS

Aortic constriction of 75% was optimal for the establishment of the PHF model. The expression of ocu-miR-411-5p, ocu-miR-214-3p, and ocu-miR-432-5p was significantly decreased, and the focal adhesion, insulin, and PI3K/AKT pathways may play significant roles in PHF progression.

Beta-blockers for congestive heart failure in children

BACKGROUND

Beta-blockers are an essential part of standard therapy in adult congestive heart failure and therefore, are expected to be beneficial in children. However, congestive heart failure in children differs from that in adults in terms of characteristics, aetiology, and drug clearance. Therefore, paediatric needs must be specifically investigated. This is an update of a Cochrane review previously published in 2009.

OBJECTIVES

To assess the effect of beta-adrenoceptor-blockers (beta-blockers) in children with congestive heart failure.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and LILACS up to November 2015. Bibliographies of identified studies were checked. No language restrictions were applied.

SELECTION CRITERIA

Randomised, controlled, clinical trials investigating the effect of beta-blocker therapy on paediatric congestive heart failure.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and assessed data from the included trials.

MAIN RESULTS

We identified four new studies for the review update; the review now includes seven studies with 420 participants. Four small studies with 20 to 30 children each, and two larger studies of 80 children each, showed an improvement of congestive heart failure with beta-blocker therapy. A larger study with 161 participants showed no evidence of benefit over placebo in a composite measure of heart failure outcomes. The included studies showed no significant difference in mortality or heart transplantation rates between the beta-blocker and control groups. No significant adverse events were reported with beta-blockers, apart from one episode of complete heart block. A meta-analysis of left ventricular ejection fraction (LVEF) and fractional shortening (LVFS) data showed a very small improvement with beta-blockers. However, there were vast differences in the age, age range, and health of the participants (aetiology and severity of heart failure; heterogeneity of diagnoses and co-morbidities); there was a range of treatments across studies (choice of beta-blocker, dosing, duration of treatment); and a lack of standardised methods and outcome measures. Therefore, the primary outcomes could not be pooled in meta-analyses.

AUTHORS' CONCLUSIONS

There is not enough evidence to support or discourage the use of beta-blockers in children with congestive heart failure, or to propose a paediatric dosing scheme. However, the sparse data available suggested that children with congestive heart failure might benefit from beta-blocker treatment. Further investigations in clearly defined populations with standardised methodology are required to establish guidelines for therapy. Pharmacokinetic investigations of beta-blockers in children are also required to provide effective dosing in future trials.

Value of Exercise Stress Echocardiography in Children with Hypertrophic Cardiomyopathy

BACKGROUND

Exercise stress echocardiography (ESE) is a valuable diagnostic and prognostic tool in adults with hypertrophic cardiomyopathy (HCM). Inducible and resting left ventricular outflow tract gradients are important predictors of heart failure. However, there are minimal data on the utility of this modality in children.

METHODS

Retrospective review of all pediatric HCM patients who underwent ESE at Boston Children's Hospital (January 2007-June 2018) was carried out. Patients were assigned to one of three categories based on left ventricular outflow tract gradients: group 1: <30 mm Hg at rest and exercise; group 2: <30 mm Hg at rest and ≥30 mm Hg with exercise; and group 3: ≥ 30 mm Hg at rest and exercise. Records were reviewed for earliest occurrence of composite endpoint of any one of the following: cardiac syncope, chest pain, nonsustained and sustained ventricular tachycardia, aborted cardiac arrest, heart failure class ≥ II, or HCM-related death/transplantation.

RESULTS

A total of 91 children (67% males) with median age 12 years (6-24 years) at first ESE and median left ventricle wall thickness of 20 mm formed the cohort. Median follow-up duration was 3 years. During ESE, only one child experienced an event and was resuscitated. Of the 91 children, 25 were classified as group 1, 40 as group 2, and 26 as group 3. Twenty-six patients met the composite endpoint, including two heart transplant, one aborted cardiac arrest, and one sudden cardiac death. Group 3 patients had a 5 times higher risk of developing symptoms and/or serious clinical outcome at any age (hazard ratio = 5.18; 95% CI, [1.39-19.2]; P = .014). During our short follow-up time, group 2 patients had a higher risk of outcome, but this did not achieve statistical significance (hazard ratio = 1.95; 95% CI, [0.5-7.6]; P = .33).

CONCLUSIONS

In this large series of pediatric patients with HCM, ESE can be performed safely and served as an effective tool to identify the lowest risk patients for cardiac outcome.

Variation in clinical usefulness of biomarkers of acute kidney injury in young children undergoing cardiac surgery

BACKGROUND

Acute kidney injury (AKI) is one of the most significant postoperative complications of pediatric cardiac surgery. Because serum creatinine has limitations as a diagnostic marker of AKI, new biomarkers including neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and interleukin-18 (IL-18) are being evaluated to overcome these limitations and detect AKI at an early stage after cardiac surgery.

PURPOSE

This study aimed to investigate the clinical usefulness of these biomarkers in young children.

METHODS

Thirty patients with congenital heart diseases who underwent cardiac surgery using cardiopulmonary bypass (CPB) were selected, and their urine and blood samples were collected at baseline and 6, 24, and 48 hours after surgery. Serum creatinine and blood urea nitrogen levels as well as NGAL, KIM-1, and IL-18 levels in urine samples were measured, and clinical parameters were evaluated.

RESULTS

Of the 30 patients, 12 developed AKI within 48 hours after cardiac surgery. In the AKI group, 8 of 12 (66.6%) met AKI criteria after 24 hours, and urine KIM-1/creatinine (Cr) level (with adjustment of urine creatinine) peaked at 24 hours with significant difference from baseline level. Additionally, urine KIM-1/Cr level in the AKI group was significantly higher than in the non-AKI group at 6 hours. However, urine NGAL/Cr and IL-18/Cr levels showed no specific trend with time for 48 hours after cardiac surgery.

CONCLUSION

It is suggested that urine KIM-1/Cr concentration could be considered a good biomarker for early AKI prediction after open cardiac surgery using CPB in young children with congenital heart diseases.

Approach to a Child with Congestive Heart Failure

Pediatric heart failure (PHF) is an important cause of mortality and morbidity. Whereas ischemic heart disease is the most important cause of heart failure in adults, congenital heart diseases (CHD) and cardiomyopathies are important etiologies of PHF. Management of PHF also differs from that of adults. Here authors have reviewed the literature on PHF with respect to etiology, symptoms, investigations and treatment strategies.

Mitral Valve Surgery in Neonates, Infants, and Children: Surgical Approach, Outcomes, and Predictors

The surgical treatment of mitral disease in pediatrics is challenging. Managing diversity in patient anatomy, growth, and the need for long-term anticoagulation requires trade-offs between imperfect solutions. We sought to assess our approach to pediatric mitral valve surgery and identify predictors associated with mortality and recurrent mitral disease. The medical records, echocardiograms, and operative reports of all patients who underwent surgical intervention on the mitral valve from January 2000 to April 2016 were reviewed. A total of 143 patients underwent mitral valve surgery, 64 of which were neonates or infants (ages 10-355 days) and 79 of which were children (ages 1-17.8 years). Neonates and infants had a higher preoperative New York Heart Association heart failure classification in comparison to children (P < 0.001) with a less severe degree of mitral valve insufficiency (P = 0.007). Postoperative outcomes for primary repair patients (n = 133) demonstrated significant differences in recurrence of mitral valve disease, with 38% of neonates/infants and 21% of children affected (P = 0.028). Five-year rates of mortality or transplant were 22% (8%, 33%) in neonates and infants compared to 4% (0%, 10%) in children, P = 0.013. Mitral valve surgery in neonates and infants is particularly high risk and is associated with higher rate of recurrence and reintervention early. However, if successful early, mitral valve repair in neonates and infants can result in a durable freedom from reintervention that parallels freedom from reintervention in older children undergoing repair. Further understanding of mechanisms of failure and better matching of anatomic substrate to strategy is needed.

Derivation and Validation of a Nomogram to Predict In-Hospital Complications in Children with Tetralogy of Fallot Repaired at an Older Age

Background

We aimed to develop and validate a prediction model for in‐hospital complications in children with tetralogy of Fallot repaired at an older age.

Methods and Results

A total of 513 pediatric patients from the Tianjin data set formed a derivation cohort, and 158 pediatric patients from the Hefei and Xiamen data sets formed validation cohorts. We applied least absolute shrinkage and selection operator analysis for variable selection and logistic regression coefficients for risk scoring. We classified patients into different risk categorizations by threshold analysis and investigated the association with in‐hospital complications using logistic regression. In‐hospital complications were defined as death, need for extensive pharmacologic support (vasoactive‐inotrope score of ≥20), and need for mechanical circulatory support. We developed a nomogram based on risk classifier and independent baseline variables using a multivariable logistic model. Based on risk scores weighted by 11 preoperative and 4 intraoperative selected variables, we classified patients as low, intermediate, and high risk in the derivation cohort. With reference to the low‐risk group, the intermediate‐ and high‐risk groups conferred significantly higher in‐hospital complication risks (adjusted odds ratio: 2.721 [95% CI, 1.267–5.841], P=0.0102; 9.297 [95% CI, 4.601–18.786], P<0.0001). A nomogram integrating the ARIAR‐Risk classifier (absolute and relative low risk, intermediate risk, and aggressive and refractory high risk) with age and mean blood pressure showed good discrimination and goodness‐of‐fit for derivation (area under the receiver operating characteristic curve: 0.785 [95% CI, 0.731–0.839]; Hosmer‐Lemeshow test, P=0.544) and external validation (area under the receiver operating characteristic curve: 0.759 [95% CI, 0.636–0.881]; Hosmer‐Lemeshow test, P=0.508).

Conclusions

A risk‐classifier–oriented nomogram is a reliable prediction model for in‐hospital complications in children with tetralogy of Fallot repaired at an older age, and strengthens risk/benefit–based decision‐making.

Impact of Breast Milk, Respiratory Insufficiency, and Gastroesophageal Reflux Disease on Enteral Feeding in Infants With Omphalocele

OBJECTIVES

The aim of this study was to document the process of achieving full enteral feeding in infants with omphalocele and to identify factors that affect feeding success.

METHODS

After institutional review board approval (study no. 5100169), 123 infants with omphalocele, born between 1993 and 2011 were reviewed. Mortalities were excluded. All survivors had complete follow-up. Variables suspected to impact enteral feeding in infants with non-giant versus giant omphalocele were compared. Independent t test, Mann-Whitney, and χ test were used. Regression evaluated for variable independence.

RESULTS

Of 123 infants with omphalocele, 97 (79%) survived, 62/97 (64%) had non-giant, and 35/97 (36%) giant omphalocele. For survivors, the mean gestational age was 37 ± 4 weeks with median follow-up of 4.4 years (range: 1.4-7.4 years). The median time to full feeds was 4 days (range: 0-85 days) for non-giant versus 8 days (range: 1-96 days) for giant, a significant difference (P < 0.01). Breast milk significantly decreased time to full feeds independent of omphalocele size. Giant omphalocele infants had a significantly higher incidence of respiratory insufficiency at birth (P < 0.01) and sac rupture (P = 0.02), but fewer chromosomal anomalies (P = 0.04). Respiratory insufficiency at birth (P < 0.01) and gastroesophageal reflux disease (P < 0.01) independently delayed feeding in omphalocele infants.

CONCLUSIONS

Infants with non-giant omphalocele can achieve full enteral feeds within the first week of life, but giant omphalocele infants require significantly more time. Breast milk independently promotes feeding success whereas gastroesophageal reflux disease and respiratory insufficiency at birth independently delay feeding in infants with omphalocele.

Heart Failure in Ethiopian Children: Mirroring the Unmet Cardiac Services

Background

HeartFailure (HF) is a progressive clinical and pathophysiological syndrome caused by cardiovascular and noncardiovascular abnormalities. Childhood HF has not been well studied in Sub-Sharan Africa, particularly in Ethiopia. Hence, this study aimed at describing the pattern and outcome of pediatrics HF at a referral-teaching hospital.

Methods

Medical records of 216 HF children aged 2 months to 14 years, and admitted between January 2014 and January 2016 were reviewed. Clinical information was collected, analyzed and presented in tables and pie charts.

Results

A total of 2000 children were admitted to Hawassa University Hospital during the study period. HF accounted for 10.8% (216) of pediatrics admissions, 51.9% males. The median age of the study subjects was 6 years. Functionally, NYHA/Ross class III and IV consisted 65(30.1%) and 139(64.4%) of HF. Structural heart disease was the commonest cause of HF, 144(66.7%): Rheumatic heart disease (RHD),75(52%), and congenital heart disease (CHD),64(44.5%). Anemia and renal cases contributed to 50(23.1) and 12(5.6%) of HF.CHD was predominantly documented in <5 years. Pneumonia 66(42.9%), and infective endocarditis 29(18.8%) were the common precipitating/comorbid conditions with HF. The case fatality rate of HF was 13.9 %(30).

Conclusion

In this study, HF accounted for a tenth of pediatrics admissions. Structural heart disease was the commonest cause of heart failure. CHD and RHD affected predominantly children of <5 years of age and >5 years of age. Echocardiographic screening of HF cases for structural heart disease and optimal care for patients with underlying structural heart disease are recommended.

Pediatric heart failure therapy: why β1-receptor blocker, tissue ACE-I and mineralocorticoid-receptor-blocker?

Pediatric heart failure (HF) treatment lagged behind the knowledge of pharmacological research and evidence-based clinical experience in adults. Considering the lack of prospective, double blind randomized studies in children, the review is focused on the preferred indication of specific β1-adrenoreceptor blockers (ARB), mineralocorticoid antagonists and tissue angiotensin-converting enzyme inhibitors (ACE-I). Our recommendations are based on the specificity in children, the effectiveness and the side-effect profile of HF-drugs, the receptor-physiological knowledge and the negative results of the few pediatric HF studies with an "evidence study label". In the interest of our pediatric patients, effective HF treatment has not longer to be postponed by balancing between evidence-based versus pathophysiology-based approach. At our institution, bisoprolol, lisinopril and spironolactone (BLS) are used treating HF in patients with left-right shunt lesions, reduced ejection fraction as well as during the inter-stage after HLHS-Hybrid approach. Chronic use of diuretics and fluid restriction is avoided, if always possible; intravascular volume deficiency stimulates further the neurohumoral axis. Pediatric HF needs to be treated with a strategy respecting the variable pathophysiology and the differences of receptor physiology between children and adult patients. The personalized treatment can be easily proofed by the surrogate parameters as heart rate, breath pattern, weight gain and image-derived parameters as well as biomarkers. Effective HF-therapy is also the basis for novel regenerative strategies in particular for young children with "end-stage" HF avoiding cardiac transplant or death.

Correlation Between Cardiopulmonary Exercise Test, Spirometry, and Congenital Heart Disease Severity in Pediatric Population

Congenital heart disease (CHD) is a common chronic disease. This study aimed to verify the relationship between spirometry and exercise capacity in children, considering the CHD severity. All cardiopulmonary exercise testing (CPET) and Spirometry from CHD children (5-18 years) were retrospectively reviewed during three years. CPET and Spirometry were analyzed and correlated based on the CHD severity[modified Ross classification (mR)]. Patients (n = 321) were analyzed and subdivided for CHD severity (n = 49, n = 149, n = 80, n = 43, from mR1 to mR4, respectively). The maximal workload (Wmax) in mR1 and mR2 was higher than in patients from mR3 and mR4. Peak oxygen uptake (peak VO2) was reduced in mR3 and mR4 compared to mR1 and mR2. Carbon dioxide output was only significantly lower in mR4. Although spirometric parameters were globally in the normal range, forced expiratory volume and forced vital capacity were different between subgroups (p < 0.001 and p = 0.002, respectively). Wmax and peakVO2 were weakly or moderately but significantly correlated with spirometry. Respiratory exchange ratio and final blood oxygen saturation were only significantly and weakly correlated to obstruction in small airways. The most severe CHD patients had lower exercise capacity and lung function parameters. A weak to moderate correlation between CPET and spirometry was found. However, the lung function reported in our study was normal, but with a negative correlation with the age. It reinforces the benefits of precocious and regularly spirometry and CPET assessment in CHD children.

Paediatric Ebstein's anomaly: how clinical presentation predicts mortality

BACKGROUND

Forecasting the prognosis of a child when diagnosed with Ebstein's anomaly is difficult. We, therefore, studied which factors at the time of diagnosis are associated with death during childhood.

METHODS

All consecutive patients (0-18 years) diagnosed with Ebstein's anomaly in the Netherlands between 1980 and 2014 were included. Survival curves were obtained using the Kaplan-Meier method. By using the Cox proportional hazard model, we analysed the factors (at diagnosis) that were associated with death.

RESULTS

We included 176 patients. Thirty-one patients (18%) died before the age of 18 years. The 1-year survival was 84% and remained stable at 82% from 35 months after diagnosis and onwards. Modified Ross Heart Failure Class 4 at the time of diagnosis was the most important risk factor for death during childhood (HR 12.5, 95% CI 4.4 to 35.9). Furthermore, diagnosis in the neonatal period (HR 4.2, 95% CI 1.5 to 12.0), severe tricuspid valve regurgitation (HR 2.4, 95% CI 1.2 to 5.0), severe right ventricular outflow tract obstruction (HR 3.7, 95% CI 1.8 to 7.7) and a patent ductus arteriosus (HR 2.8, 95% CI 1.3 to 6.0) at the time of diagnosis were univariately associated with death. Multivariable analysis showed that presentation with Heart Failure Class 4 and a ventricular septal defect is the strongest predictor of death in childhood and adolescence.

CONCLUSION

Patients with Ebstein's anomaly presenting with Heart Failure Class 4 and a ventricular septal defect have a high risk of death during childhood.

Prognostic value of homocysteine and highly sensitive cardiac troponin T in children with acute heart failure

OBJECTIVE

Heart failure (HF) is a progressive disorder in children. Many HF biomarkers have been identified to assess its severity and predict its course. The aim of this study was to evaluate the prognostic value of plasma levels of homocysteine (HCY) and highly sensitive cardiac troponin T (hs-cTnT) in children with HF.

MATERIALS AND METHODS

Eighty children with acute HF were enrolled in this study as the patient group and 80 healthy children of matched age and sex served as the control group. HCY and hs-cTnT serum levels were measured before and after HF treatment; additionally, echocardiographic examinations were performed before and after therapy. All patients were followed up for 3 months.

RESULTS

Plasma levels of HCY and hs-cTnT were significantly higher in children with HF before treatment, compared with their levels in children with HF after treatment and with the control group. This increase in serum levels of both biomarkers was associated with increased severity of HF according to the Ross classification of HF. HCY had higher specificity, positive predictive value, and accuracy than hs-cTnT. Serum levels of both biomarkers had a significant positive correlation with cardiomegaly and a significant negative correlation with left ventricular ejection fraction and fraction shortening. Marked elevation of both serum biomarkers was significantly associated with poor outcome with mortality rate of 10%.

CONCLUSION

Plasma HCY and serum hs-cTnT levels have a good prognostic value in children with congestive heart failure (CHF) and their levels significantly correlated with clinical and echocardiographic data, severity of HF, and adverse outcome in children with CHF.

Haemodynamic profiles of children with end-stage heart failure

Aims

To evaluate associations between haemodynamic profiles and symptoms, end-organ function and outcome in children listed for heart transplantation.

Methods and results

Children <18 years listed for heart transplant between 1993 and 2013 with cardiac catheterization data [pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), and cardiac index (CI)] in the Pediatric Heart Transplant Study database were included. Outcomes were New York Heart Association (NYHA)/Ross classification, renal and hepatic dysfunction, and death or clinical deterioration while on waitlist. Among 1059 children analysed, median age was 6.9 years and 46% had dilated cardiomyopathy. Overall, 58% had congestion (PCWP >15 mmHg), 28% had severe congestion (PCWP >22 mmHg), and 22% low cardiac output (CI < 2.2 L/min/m2). Twenty-one per cent met the primary outcome of death (9%) or clinical deterioration (12%). In multivariable analysis, worse NYHA/Ross classification was associated with increased PCWP [odds ratio (OR) 1.03, 95% confidence interval (95% CI) 1.01-1.07, P = 0.01], renal dysfunction with increased RAP (OR 1.04, 95% CI 1.01-1.08, P = 0.007), and hepatic dysfunction with both increased PCWP (OR 1.03, 95% CI 1.01-1.06, P < 0.001) and increased RAP (OR 1.09, 95% CI 1.06-1.12, P < 0.001). There were no associations with low output. Death or clinical deterioration was associated with severe congestion (OR 1.6, 95% CI 1.2-2.2, P = 0.002), but not with CI alone. However, children with both low output and severe congestion were at highest risk (OR 1.9, 95% CI 1.1-3.5, P = 0.03).

Conclusion

Congestion is more common than low cardiac output in children with end-stage heart failure and correlates with NYHA/Ross classification and end-organ dysfunction. Children with both congestion and low output have the highest risk of death or clinical deterioration.

Application of Neonatologist Performed Echocardiography in the Assessment and Management of Neonatal Heart Failure unrelated to Congenital Heart Disease

Neonatal heart failure (HF) is a progressive disease caused by cardiovascular and non-cardiovascular abnormalities. The most common cause of neonatal HF is structural congenital heart disease, while neonatal cardiomyopathy represents the most common cause of HF in infants with a structurally normal heart. Neonatal cardiomyopathy is a group of diseases manifesting with various morphological and functional phenotypes that affect the heart muscle and alter cardiac performance at, or soon after birth. The clinical presentation of neonates with cardiomyopathy is varied, as are the possible causes of the condition and the severity of disease presentation. Echocardiography is the selected method of choice for diagnostic evaluation, follow-up and analysis of treatment results for cardiomyopathies in neonates. Advances in neonatal echocardiography now permit a more comprehensive assessment of cardiac performance that could not be previously achieved with conventional imaging. In this review, we discuss the current and emerging echocardiographic techniques that aid in the correct diagnostic and pathophysiological assessment of some of the most common etiologies of HF that occur in neonates with a structurally normal heart and acquired cardiomyopathy and we provide recommendations for using these techniques to optimize the management of neonate with HF.

Design for the sacubitril/valsartan (LCZ696) compared with enalapril study of pediatric patients with heart failure due to systemic left ventricle systolic dysfunction (PANORAMA-HF study)

BACKGROUND

Sacubitril/valsartan (LCZ696) is an angiotensin receptor neprilysin inhibitor approved for the treatment of adult heart failure (HF); however, the benefit of sacubitril/valsartan in pediatric HF patients is unknown.

STUDY DESIGN

This global multi-center study will use an adaptive, seamless two-part design. Part 1 will assess the pharmacokinetics/pharmacodynamics of single ascending doses of sacubitril/valsartan in pediatric (1 month to <18 years) HF patients with systemic left ventricle and reduced left ventricular systolic function stratified into 3 age groups (Group 1: 6 to <18 years; Group 2: 1 to <6 years; Group 3: 1 month to <1 year). Part 2 is a 52-week, efficacy and safety study where 360 eligible patients will be randomized to sacubitril/valsartan or enalapril. A novel global rank primary endpoint derived by ranking patients (worst-to-best outcome) based on clinical events such as death, initiation of mechanical life support, listing for urgent heart transplant, worsening HF, measures of functional capacity (NYHA/Ross scores), and patient-reported HF symptoms will be used to assess efficacy.

CONCLUSION

The PANORAMA-HF study, which will be the largest prospective pediatric HF trial conducted to date and the first to use a global rank primary endpoint, will determine whether sacubitril/valsartan is superior to enalapril for treatment of pediatric HF patients with reduced systemic left ventricular systolic function.

Ivabradine in Children With Dilated Cardiomyopathy and Symptomatic Chronic Heart Failure

BACKGROUND

Heart rate reduction as a therapeutic target has been investigated in adults with heart failure (HF). Ivabradine has shown promising efficacy, but has not been evaluated in children. Currently, treatment recommendations for chronic pediatric HF are based mainly on chronic HF guidelines for adults.

OBJECTIVES

The authors explored the dose-response relationship of ivabradine in children with dilated cardiomyopathy and symptomatic chronic HF. The primary endpoint was ≥20% reduction in heart rate from baseline without inducing bradycardia or symptoms.

METHODS

This was a randomized, double-blind, placebo-controlled, phase II/III study with 12 months of follow-up. Children (n = 116) receiving stable HF therapy were randomized to either ivabradine or placebo. After an initial titration period, the dose was adjusted to attain the primary endpoint. Left ventricular function (echocardiography), clinical status (New York Heart Association functional class or Ross class), N-terminal pro-B-type natriuretic peptide, and quality of life (QOL) were assessed.

RESULTS

The primary endpoint was reached by 51 of 73 children taking ivabradine (70%) versus 5 of 41 taking placebo (12%) at varying doses (odds ratio: 17.24; p < 0.0001). Between baseline and 12 months, there was a greater increase in left ventricular ejection fraction in patients taking ivabradine than placebo (13.5% vs. 6.9%; p = 0.024). New York Heart Association functional class or Ross class improved more with ivabradine at 12 months than placebo (38% vs. 25%; p = 0.24). There was a trend toward improvement in QOL for ivabradine versus placebo (p = 0.053). N-terminal pro-B-type natriuretic peptide levels decreased similarly in both groups. Adverse events were reported at similar frequencies for ivabradine and placebo.

CONCLUSIONS

Ivabradine safely reduced the resting heart rate of children with chronic HF and dilated cardiomyopathy. Ivabradine's effect on heart rate was variable, highlighting the importance of dose titration. Ivabradine treatment improved left ventricular ejection fraction, and clinical status and QOL showed favorable trends. (Determination of the efficacious and safe dose of ivabradine in paediatric patients with dilated cardiomyopathy and symptomatic chronic heart failure from ages 6 months to 18 years; ISRCTN60567801).

Evaluation of NT-proBNP in children with heart failure younger than 3 years old

INTRODUCTION

Heart failure (HF) is characterized by neuroendocrine activation. The cardiac natriuretic hormones, including atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), together with their related pro-peptides (proANP and proBNP) represent a group of peptide hormones produced by the heart. A normal NT-proBNP level has a high negative predictive value for heart failure. The use of NT-proBNP testing is helpful in diagnosing acute HF in the emergency care setting, allowing an early and optimal treatment. The purpose of this study is to assess the prognostic value of NT-proBNP in heart failure in children younger than 3 years old and to establish whether it correlates with the NYHA/Ross functional class and left ventricle systolic function.

METHODS

We enrolled 24 consecutive children with HF due to congenital heart diseases and dilated cardiomyopathy. The serum levels of NT-proBNP were measured, all patients underwent echocardiography and left ventricle ejection fraction was calculated.

RESULTS

The highest median value of NT-proBNP was recorded in patients with cyanotic heart diseases (248.0 fmol/mL), p = 0.610. NT-proBNP had a negative correlation with the ejection fraction of the left ventricle: Spearman's rank correlation coefficient was -0.165.

CONCLUSIONS

NT-proBNP levels correlate with the severity of HF in infants and small children younger than 3 years old with heart failure due to congenital heart diseases and dilated cardiomyopathy.

Plasma microvesicle analysis identifies microRNA 129-5p as a biomarker of heart failure in univentricular heart disease

Biomarkers of heart failure in adults have been extensively studied. However, biomarkers to monitor the progression of heart failure in children with univentricular physiology are less well understood. We proposed that as mediators of diverse pathophysiology, miRNAs contained within circulating microvesicles could serve as biomarkers for the presence and progression of heart failure in univentricular patients. To test this, we studied the association of heart failure with elevations in specific miRNAs isolated from circulating microvesicles in a cohort of children with univentricular heart disease and heart failure. We conducted a single site cross-sectional observational study of 71 children aged 1 month-7 years with univentricular heart disease and heart failure. We demonstrated that levels of miR129-5p isolated from plasma microvesicles were inversely related to the degree of clinical heart failure as assessed by Ross score. We then showed that miR129-5p levels are downregulated in HL1 cells and human embryonic stem cell-derived cardiomyocytes exposed to oxidative stress. We demonstrated that bone morphogenetic protein receptor 2, which has been implicated in the development of pulmonary vascular disease, is a target of miR129-5p, and conversely regulated in response to oxidative stress in cell culture. Levels of miR129-5p were inversely related to the degree of clinical heart failure in patients with univentricular heart disease. This study demonstrates that miR129-5p is a sensitive and specific biomarker for heart failure in univentricular heart disease independent of ventricular morphology or stage of palliation. Further study is warranted to understand the targets affected by miR129-5p with the development of heart failure in patients with univentricular physiology.

Pediatric Heart Failure: A Practical Guide to Diagnosis and Management

Pediatric heart failure represents an important cause of morbidity and mortality in childhood. Currently, there are well-established guidelines for the management of heart failure in the adult population, but an equivalent consensus in children is lacking. In the clinical setting, ensuring an accurate diagnosis and defining etiology is essential to optimal treatment. Diuretics and angiotensin-converting enzyme inhibition are the first-line therapies, whereas beta-blockers and devices for electric therapy are less used in children than in adults. In the end-stage disease, heart transplantation is the best choice of treatment, while a left ventricular assist device can be used as a bridge to transplantation (due to the difficulties in finding organ donors), recovery (in the case of myocarditis), or destination therapy (for patients with systemic disease).

Wasting, underweight and stunting among children with congenital heart disease presenting at Mulago hospital, Uganda

BACKGROUND

Children with congenital heart disease are at increased risk of malnutrition. The aim of this study was to describe the prevalence of wasting, underweight and stunting among children with congenital heart disease attending Mulago National Referral Hospital, Uganda.

METHODS

A cross-sectional study among 194 children aged 0-15 years was conducted between August 2013 and March 2014. Anthropometric measurements and clinical assessments were carried out on all children. Anthropometric z-scores based on WHO 2007 reference ranges were generated for each child. Weight-for-height z-scores were generated for children 0-5 years, weight-for-age z-scores for children 0-10 years, and height-for-age and BMI-for-age z-scores for all children. Risk factors associated with malnutrition were determined by Poisson regression.

RESULTS

One hundred and forty five (74.7%) children were aged 0-5 years; and 111 of 194 (57.2%) were female. Forty five of 145 (31.5%) children aged 0-5 years were wasted; 77 of 181 (42.5%) children aged 0-10 years were underweight; 88 of 194 (45.4%) children were stunted; and 53 of 194 (27.3%) children were thin (BMI for age z score < -2). Moderate to severe anaemia (RR 1.11, 95% CI: 1.01-1.22) and moderate to severe heart failure (RR 1.24, 95% CI: 1.13-1.36) were associated with wasting and underweight respectively. Stunting was associated with moderate to severe heart failure (RR 1.11, 95% CI: 1.01-1.21) while thinness was associated with moderate to severe heart failure (RR 1.12, 95% CI: 1.04-1.21) and moderate to severe anaemia (RR 1.15, 95% CI: 1.06-1.25).

CONCLUSION

Malnutrition is common in children with congenital heart disease, and is associated with anaemia and heart failure. There is need to integrate strategies to identify and manage malnutrition during the care of children with congenital heart disease.