Heart failure in children: clinical aspect and management

Matrix metalloproteinase-9 in pediatric rheumatic heart disease with and without heart failure

In cardiovascular disorders, the myocardium may be subjected to the breakdown and remodeling of collagen by metalloproteinase-9 (MMP-9). We hypothesized that the serum MMP-9 concentration may be elevated in pediatric patients with rheumatic heart disease (RHD) and heart failure (HF), and its level can be correlated with the HF severity. Thus, in the present study, we aimed to evaluate the sensitivity and accuracy of MMP-9 to predict HF in children with RHD and to determine its effectiveness as an indicator of the degree of HF. This study included 98 consecutive children admitted to the Department of Pediatrics, Zagazig University Hospital, Al Sharqia Governorate, Egypt with newly diagnosed RHD. Their ages ranged from 8.5 to 16 years. Fifty-eight children had RHD without HF while 40 children were complicated with HF which was diagnosed clinically and by echocardiography. A total of 44 healthy children were enrolled as a control group. MMP-9 serum levels were estimated by enzyme-linked immunosorbent assay. The serum MMP-9 concentration was higher in the RHD without HF and RHD with HF groups than this level noted in the control (P<0.001). MMP-9 was a significant predictor of HF; area under the curve (AUC)=0.85 [95% confidence interval (CI), 0.76-0.94]. At the level of 386.9 ng/ml, MMP-9 detected HF with a sensitivity 95% (95% CI, 83.08-99.39), specificity 74.14% (95% CI, 60.96-84.74), positive predictive value 71.70% (95% CI, 61.96-79.75), negative predictive value 95.56% (95% CI, 84.67-98.82) and accuracy 82.65% (95% CI, 73.69-89.56). In addition, MMP-9 showed a significant negative correlation with ejection fraction and fractional shortening (P=0.01 and P=0.02, respectively). In conclusion; MMP-9 may be an independent sensitive marker with which to detect HF in children with RHD and it can predict the prognoses of these patients as it correlates with the severity of HF. Further studies considering MMP-9 in the detection of 'silent' RHD in school aged children and asymptomatic HF in children with known RHD especially in rural areas, are highly recommended.

Systematic literature review on the economic, humanistic, and societal burden of heart failure in children and adolescents

INTRODUCTION

Unlike the adult heart failure (HF) patient population, there is scarce information on the overall burden of HF in the pediatric population across geographies and within different age groups.

AREAS COVERED

A systematic review aims to describe and quantify the economic, humanistic, and societal burden of pediatric (age <18 years) HF on patients and caregivers. Eighteen published studies over a period of 10 years (1 January 2006-20 May 2016) were identified through Embase, Medline, Cochrane Library and selected congresses. Studies from the US reported higher HF-related hospitalization-rates in infants aged <1 year (49.3%-63.9%) versus children aged 1-12 years (18.7%-30.9%) in HF diagnosed patients. Across the studies, the average length of hospital stay was 15 days, increasing to 26 days for infants. Average annual hospital charges were higher for infants (US$176,000) versus children aged 1-10 years (US$132,000) in the US. In Germany, diagnosis-related group (DRG)-based hospital-allowances per HF-case increased from €3,498 in 1995 to €4,250 in 2009.

EXPERT OPINION

To our knowledge, this is the first systematic review, which provides valuable insights into the burden of HF in children and adolescents, and strengthens current knowledge of pediatric HF. However, there is a need for larger population-based studies with wider geographical coverage.

Systematic Literature Review on the Incidence and Prevalence of Heart Failure in Children and Adolescents

While the epidemiology of adult heart failure has been extensively researched, this systematic review addresses the less well characterized incidence and prevalence of pediatric HF. The search strategy used Cochrane methodology and identified 83 unique studies for inclusion. Studies were categorized according to whether the HF diagnosis was reported as primary (n = 10); associated with other cardiovascular diseases (CVDs) (n = 49); or associated with non-CVDs (n = 24). A narrative synthesis of the evidence is presented. For primary HF, the incidence ranged from 0.87/100,000 (UK and Ireland) to 7.4/100,000 (Taiwan). A prevalence of 83.3/100,000 was reported in one large population-based study from Spain. HF etiology varied across regions with lower respiratory tract infections and severe anemia predominating in lower income countries, and cardiomyopathies and congenital heart disease major causes in higher income countries. Key findings for the other categories included a prevalence of HF associated with cardiomyopathies ranging from 36.1% (Japan) to 79% (US); associated with congenital heart disease from 8% (Norway) to 82.2% (Nigeria); associated with rheumatic heart diseases from 1.5% (Turkey) to 74% (Zimbabwe); associated with renal disorders from 3.8% (India) to 24.1% (Nigeria); and associated with HIV from 1% (US) to 29.3% (Brazil). To our knowledge, this is the first systematic review of the topic and strengthens current knowledge of pediatric HF epidemiology. Although a large body of research was identified, heterogeneity in study design and diagnostic criteria limited the ability to compare regional data. Standardized definitions of pediatric HF are required to facilitate cross-regional comparisons of epidemiological data.

Pediatric Heart Failure, Lagging, and Sagging of Care in Low Income Settings: A Hospital Based Review of Cases in Ethiopia

Introduction. Causes of acute heart failure in children range from simple myocarditis complicating chest infection to complex structural heart diseases. Objective. To describe patterns, predictors of mortality, and management outcomes of acute heart failure in children. Methods. In retrospective review, between February 2012 and October 2015 at a tertiary center, 106 admitted cases were selected consecutively from discharge records. Data were extracted from patients chart and analyzed using SPSS software package. t-test and statistical significance at P value < 0.05 with 95% CI were used. Result. Acute heart failure accounted for 2.9% of the total pediatric admissions. The age ranged from 2 months up to 14 years with mean age of 8 years. Male to female ratio is 1 : 2.1. Rheumatic heart disease accounted for 53.7%; pneumonia, anemia, infective endocarditis, and recurrence of acute rheumatic fever were the main precipitating causes. Death occurred in 19% of cases. Younger age at presentation, low hemoglobin concentration, and undernutrition were associated with death with P value of 0.00, 0.01, and 0.02, respectively. Conclusions and Recommendation. Pediatric heart failure in our settings is diagnosed mainly in older age groups and mostly precipitated due to preventable causes. Significant mortality is observed in relation to factors that can be preventable in children with underlying structural heart disease. Early suspicion and diagnosis of cases may reduce the observed high mortality.

Experts' recommendations for the management of cardiogenic shock in children

Cardiogenic shock which corresponds to an acute state of circulatory failure due to impairment of myocardial contractility is a very rare disease in children, even more than in adults. To date, no international recommendations regarding its management in critically ill children are available. An experts’ recommendations in adult population have recently been made (Levy et al. Ann Intensive Care 5(1):52, 2015; Levy et al. Ann Intensive Care 5(1):26, 2015). We present herein recommendations for the management of cardiogenic shock in children, developed with the grading of recommendations’ assessment, development, and evaluation system by an expert group of the Groupe Francophone de Réanimation et Urgences Pédiatriques (French Group for Pediatric Intensive Care and Emergencies). The recommendations cover four major fields of application such as: recognition of early signs of shock and the patient pathway, management principles and therapeutic goals, monitoring hemodynamic and biological variables, and circulatory support (indications, techniques, organization, and transfer criteria). Major principle care for children with cardiogenic shock is primarily based on clinical and echocardiographic assessment. There are few drugs reported as effective in childhood in the medical literature. The use of circulatory support should be facilitated in terms of organization and reflected in the centers that support these children. Children with cardiogenic shock are vulnerable and should be followed regularly by intensivist cardiologists and pediatricians. The experts emphasize the multidisciplinary nature of management of children with cardiogenic shock and the importance of effective communication between emergency medical assistance teams (SAMU), mobile pediatric emergency units (SMUR), pediatric emergency departments, pediatric cardiology and cardiac surgery departments, and pediatric intensive care units.

Heart Failure in Children

Heart failure (HF) in children differs from that in adults in many respects. The causes and clinical presentations may differ considerably among children of different age groups and between children and adults. The time of onset of HF holds the key to the etiological diagnosis. Clinical presentation of HF in younger children can be nonspecific requiring heightened degree of suspicion. The overall outcome with HF is better in children than in adults as HF in children is commonly due to structural heart disease and reversible conditions which are amenable to therapy. The principles of management include treatment of the cause, correction of any precipitating event, and treatment of systemic or pulmonary congestion. Though HF in adults has been the subject of extensive research and generation of evidence-based guidelines, there is a scarcity of evidence base in pediatric HF.

Pleural effusions in children undergoing cardiac surgery

Persistent pleural effusions are a source of significant morbidity and mortality following surgery in congenital heart disease. In this review, we discuss the etiology, pathophysiology, and management of this common complication.

The changing epidemiology of congenital heart disease

Congenital heart disease is the most common congenital disorder in newborns. Advances in cardiovascular medicine and surgery have enabled most patients to reach adulthood. Unfortunately, prolonged survival has been achieved at a cost, as many patients suffer late complications, of which heart failure and arrhythmias are the most prominent. Accordingly, these patients need frequent follow-up by physicians with specific knowledge in the field of congenital heart disease. However, planning of care for this population is difficult, because the number of patients currently living with congenital heart disease is difficult to measure. Birth prevalence estimates vary widely according to different studies, and survival rates have not been well recorded. Consequently, the prevalence of congenital heart disease is unclear, with estimates exceeding the number of patients currently seen in cardiology clinics. New developments continue to influence the size of the population of patients with congenital heart disease. Prenatal screening has led to increased rates of termination of pregnancy. Improved management of complications has changed the time and mode of death caused by congenital heart disease. Several genetic and environmental factors have been shown to be involved in the etiology of congenital heart disease, although this knowledge has not yet led to the implementation of preventative measures. In this Review, we give an overview of the etiology, birth prevalence, current prevalence, mortality, and complications of congenital heart disease.