Comparison of the epidemiology and co-morbidities of heart failure in the pediatric and adult populations: a retrospective, cross-sectional study

Prevalence, Etiology, and Fatality Rates of Childhood Heart Failure in Nigeria: A Systematic Review and Meta-analysis

Objectives

The objectives of the study were to describe the burden, etiology, and fatality rates of heart failure in Nigerian children.

Methods

We searched PubMed database, Google scholar, TRIP database, EMBASE, African Index Medicus, and reference lists of selected articles for studies on burden, etiology, and fatality rates of heart failure in children in Nigeria published from 1977 to 2016. Two researchers reviewed the papers independently. Ten studies were selected that included 14,921 children and 1353 with heart failure.

Results

The overall prevalence of heart failure using all the studies reviewed was 8.3% (95% CI: 4.9-12.6). The prevalence was 13.4% (95% CI: 10.9-16.3) in studies that excluded neonates and 4.5% (95% CI: 2.8-6.5) in studies that included neonates. The most common causes of heart failure were severe anemia (38.9%, 95% CI: 30.0-49.4), respiratory tract infections (32.4%, 95% CI: 25.5-39.7), congenital heart disease (8.4%, 95% CI: 6.8-10.2), and sepsis (7.6%, 95% CI: 3.0-14.0). The overall fatality rate was 16.0% (95% CI: 9.0 - 24.6) and was higher in studies that include neonates.

Conclusion

Heart failure is common in children hospitalized in Nigeria. Its etiology is largely from non-cardiac conditions associated with severe hypoxia and mortality rates are high in children in Nigeria.

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.

The role of regenerative therapy in the treatment of right ventricular failure: a literature review

Right ventricular (RV) failure is a commonly encountered problem in patients with congenital heart disease but can also be a consequence of left ventricular disease, primary pulmonary hypertension, or RV-specific cardiomyopathies. Improved survival of the aforementioned pathologies has led to increasing numbers of patients suffering from RV dysfunction, making it a key contributor to morbidity and mortality in this population. Currently available therapies for heart failure were developed for the left ventricle (LV), and there is clear evidence that LV-specific strategies are insufficient or inadequate for the RV. New therapeutic strategies are needed to address this growing clinical problem, and stem cells show significant promise. However, to properly evaluate the prospects of a potential stem cell-based therapy for RV failure, one needs to understand the unique pathophysiology of RV dysfunction and carefully consider available data from animal models and human clinical trials. In this review, we provide a comprehensive overview of the molecular mechanisms involved in RV failure such as hypertrophy, fibrosis, inflammation, changes in energy metabolism, calcium handling, decreasing RV contractility, and apoptosis. We also summarize the available preclinical and clinical experience with RV-specific stem cell therapies, covering the broad spectrum of stem cell sources used to date. We describe two different scientific rationales for stem cell transplantation, one of which seeks to add contractile units to the failing myocardium, while the other aims to augment endogenous repair mechanisms and/or attenuate harmful remodeling. We emphasize the limitations and challenges of regenerative strategies, but also highlight the characteristics of the failing RV myocardium that make it a promising target for stem cell therapy.

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.

Epidemiology and Outcomes of Acute Decompensated Heart Failure in Children

BACKGROUND

Acute decompensated heart failure (ADHF) is a highly morbid condition among adults. Little is known about outcomes in children with ADHF. We analyzed the Pediatric Cardiac Critical Care Consortium registry to determine the epidemiology, contemporary treatments, and predictors of mortality in critically ill children with ADHF.

METHODS

Cardiac intensive care unit (CICU) patients ≤18 years of age meeting Pediatric Cardiac Critical Care Consortium criteria for ADHF were included. ADHF was defined as systolic or diastolic dysfunction requiring continuous vasoactive or diuretic infusion, respiratory support, or mechanical circulatory support. Demographics, diagnosis, therapies, complications, and mortality are described for the cohort. Predictors of CICU mortality were identified using logistic regression.

RESULTS

Among 26 294 consecutive admissions (23 centers), 1494 (6%) met criteria for analysis. Median age was 0.93 years (interquartile range, 0.1-9.3 years). Patients with congenital heart disease (CHD) comprised 57% of the cohort. Common therapies included the following: vasoactive infusions (88%), central venous catheters (86%), mechanical ventilation (59%), and high flow nasal cannula (46%). Common complications were arrhythmias (19%), cardiac arrest (10%), sepsis (7%), and acute renal failure requiring dialysis (3%). Median length of CICU stay was 7.9 days (interquartile range, 3-18 days) and the CICU readmission rate was 22%. Overall, CICU mortality was 15% although higher for patients with CHD versus non-CHD (19% versus 11%; P<0.001). Independent risk factors associated with CICU mortality included age <30 days, CHD, vasoactive infusions, ventricular tachycardia, mechanical ventilation, sepsis, pulmonary hypertension, extracorporeal membrane oxygenation, and cardiac arrest.

CONCLUSIONS

ADHF in children is characterized by comorbidities, high mortality rates, and frequent readmission, especially among patients with CHD. Opportunities exist to determine best practices around appropriate use of mechanical support, cardiac arrest prevention, and optimal heart transplantation candidacy to improve outcomes for these patients.

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.

Stem Cell Therapy for Hypoplastic Left Heart Syndrome: Mechanism, Clinical Application, and Future Directions

Hypoplastic left heart syndrome is a type of congenital heart disease characterized by underdevelopment of the left ventricle, outflow tract, and aorta. The condition is fatal if aggressive palliative operations are not undertaken, but even after the complete 3-staged surgical palliation, there is significant morbidity because of progressive and ultimately intractable right ventricular failure. For this reason, there is interest in developing novel therapies for the management of right ventricular dysfunction in patients with hypoplastic left heart syndrome. Stem cell therapy may represent one such innovative approach. The field has identified numerous stem cell populations from different tissues (cardiac or bone marrow or umbilical cord blood), different age groups (adult versus neonate-derived), and different donors (autologous versus allogeneic), with preclinical and clinical experience demonstrating the potential utility of each cell type. Preclinical trials in small and large animal models have elucidated several mechanisms by which stem cells affect the injured myocardium. Our current understanding of stem cell activity is undergoing a shift from a paradigm based on cellular engraftment and differentiation to one recognizing a primarily paracrine effect. Recent studies have comprehensively evaluated the individual components of the stem cells' secretomes, shedding new light on the intracellular and extracellular pathways at the center of their therapeutic effects. This research has laid the groundwork for clinical application, and there are now several trials of stem cell therapies in pediatric populations that will provide important insights into the value of this therapeutic strategy in the management of hypoplastic left heart syndrome and other forms of congenital heart disease. This article reviews the many stem cell types applied to congenital heart disease, their preclinical investigation and the mechanisms by which they might affect right ventricular dysfunction in patients with hypoplastic left heart syndrome, and finally, the completed and ongoing clinical trials of stem cell therapy in patients with congenital heart disease.

Genetics of heart rate in heart failure patients (GenHRate)

BACKGROUND

Elevated resting heart rate (HR) is a risk factor and therapeutic target in patients with heart failure (HF) and reduced ejection fraction (HFrEF). Previous studies indicate a genetic contribution to HR in population samples but there is little data in patients with HFrEF.

METHODS

Patients who met Framingham criteria for HF and had an ejection fraction < 50% were prospectively enrolled in a genetic HF registry (2007-2015, n = 1060). All participants donated blood for DNA and underwent genome-wide genotyping with additional variants called via imputation. We performed testing of previously identified variant "hits" (43 loci) as well as a genome-wide association (GWAS) of HR, adjusted for race, using Efficient Mixed-Model Association Expedited (EMMAX).

RESULTS

The cohort was 35% female, 51% African American, and averaged 68 years of age. There was a 2 beats per minute (bpm) difference in HR by race, AA being slightly higher. Among 43 candidate variants, 4 single nucleotide polymorphisms (SNPs) in one gene (GJA1) were significantly associated with HR. In genome-wide testing, one statistically significant association peak was identified on chromosome 22q13, with strongest SNP rs535263906 (p = 3.3 × 10^-8). The peak is located within the gene Cadherin EGF LAG Seven-Pass G-Type Receptor 1 (CELSR1), encoding a cadherin super-family cell surface protein identified in GWAS of other phenotypes (e.g., stroke). The highest associated SNP was specific to the African American population.

CONCLUSIONS

These data confirm GJA1 association with HR in the setting of HFrEF and identify novel candidate genes for HR in HFrEF patients, particularly CELSR1. These associations should be tested in additional cohorts.

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.

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.

Outcome of pediatric heart transplantation in blood culture positive donors in the United States

Active donor infection at the time of organ procurement poses a potential infection risk and may increase post-transplant morbidity and mortality in recipients. Our hypothesis was that pediatric heart transplant recipients from blood culture positive donors (BCPD) would have increased morbidity and mortality compared to non-blood culture positive donors (NBCPD). A retrospective analysis of pediatric heart transplant recipients using the organ procurement and transplant network (OPTN) between 1987 and 2015 was conducted. Recipient as well as donor data were analyzed. Propensity score matching with 1:2 ratios was performed for recipient variables. Post-transplant morbidity and mortality were compared for recipients of BCPD and NBCPD. Among 9618 heart transplant recipients, 450 (4.7%) were from culture positive donors. Recipients of BCPD had longer duration of listing as Status 1; diagnosis of congenital heart disease or restrictive cardiomyopathy and required support (IV inotropes, Inhaled NO and LVAD) prior to transplant. Post-transplant survival between the 2 groups was not different. Propensity-matched recipients had similar length of stay; stroke rate; need for dialysis; pacemaker implantation and treated rejection episodes in the first year post-transplant. Careful acceptance of BCPD may have the potential to increase availability of donor hearts in the pediatric population.

Epidemiology of heart failure in pediatric populations in low- and middle-income countries: a protocol for a systematic review

BACKGROUND

Heart failure (HF) in pediatric populations is a major public health concern. It is associated with high rates of hospital admissions, disability, and mortality in high-income countries (HIC), but its burden is poorly documented in low- and middle-income countries (LMICs). We present a protocol for a systematic review and meta-analysis to summarize available data on the prevalence, incidence, etiologies, treatment, and outcomes including hospital admission and mortality and economic burden of HF in neonates, infants, children, and adolescents in LMICs.

METHODS

A comprehensive search of articles published between January 01, 2000, and December 31, 2017, will be performed in PubMed/MEDLINE, EMBASE, Global Index Medicus, and Web of Science. All cross-sectional, cohort studies and case-control studies reporting on the prevalence, incidence, etiologies, treatment, prognosis, admission rates, mortality, and economic burden of HF in pediatric populations in LMICs will be included in the review. The methodological quality of included studies will be appraised accordingly. For prognosis data, the Quality in Prognosis Studies (QUIPS) tool will be used. The symmetry of funnel plot and Egger's test will be used to identify publication bias. An overall summary estimate of prevalence/incidence of pediatric HF across studies will be obtained from study-specific estimates pooled through a random-effect model. Heterogeneity of studies will be assessed by the χ 2 test on Cochrane's Q statistic. A p value less than 0.05 will be considered significant for factors that predict mortality. This systematic review and meta-analysis will be reported following the PRISMA guidelines.

DISCUSSION

This study will report and summarize epidemiology data, as well as the economic burden of HF in neonates, infants, children, and adolescents of LMICs. Limitations will mainly arise from the heterogeneity in the diagnostic of HF.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017070189.

The Pediatric Heart Failure Workforce: An International, Multicenter Survey

Our objective was to understand the scope of pediatric heart failure (HF) and the current staffing environment of HF programs. An online survey was distributed to members of the Pediatric Heart Transplant Study and the Pediatric Council of the International Society for Heart and Lung Transplantation. All participants received the primary 23-question survey. Additionally, HF program directors received a 32-question supplemental survey. Of 235 invitations sent, there were 69 (29%) primary surveys and 34 program director surveys completed (24 U.S. programs, 9 outside non-U.S., and one non-specified location). A formal HF program was reported by 88% of directors. There were 150 [IQR 50-200] outpatients/institution and 40% [25-50] of patients had congenital heart disease. Inpatient HF census was 3 [2-4] patients. Most programs (70%) used a consulting service model to provide HF specialty care, while only 10 (30%) utilized an inpatient HF service. Inpatient HF service programs had a higher daily inpatient census versus consult service model programs (4 [3-7] vs. 2 [1-4], respectively; p = 0.022) and had a higher number of full-time equivalents dedicated to HF (5.5 [2-7] vs. 2.5 [1-4], respectively; p = 0.024). Only 47% of programs report a general fellowship rotation devoted to HF. Advanced practice providers (APP) were utilized in 15 programs, nurse coordinators in 2, and both in 3. Most HF programs are formalized, utilize APP, and have inadequate HF staffing to utilize a separate inpatient HF service. Exposure of general pediatric cardiology fellows to HF care is variable between institutions.

Heart Failure in Pediatric Patients With Congenital Heart Disease

Heart failure (HF) is a complex clinical syndrome resulting from diverse primary and secondary causes and shared pathways of disease progression, correlating with substantial mortality, morbidity, and cost. HF in children is most commonly attributable to coexistent congenital heart disease, with different risks depending on the specific type of malformation. Current management and therapy for HF in children are extrapolated from treatment approaches in adults. This review discusses the causes, epidemiology, and manifestations of HF in children with congenital heart disease and presents the clinical, genetic, and molecular characteristics that are similar or distinct from adult HF. The objective of this review is to provide a framework for understanding rapidly increasing genetic and molecular information in the challenging context of detailed phenotyping. We review clinical and translational research studies of HF in congenital heart disease including at the genome, transcriptome, and epigenetic levels. Unresolved issues and directions for future study are presented.

Other Risks/Possible Benefits of Obesity

Obesity is not a cosmetic or social issue; it is an animal health issue. The metabolic effects of obesity on insulin resistance and development of hyperlipidemia and the mechanical stress excess weight places on the musculoskeletal system are well established in the literature. Additional health risks from obesity, such as fatty accumulation in the liver, intestinal bacterial dysbiosis, and changes to renal architecture, are less well understood, but have been demonstrated to occur clinically in obese animals and may lead to deleterious long-term health effects. Keeping dogs and cats lean lowers their risk for development of certain diseases and leads to a longer and better quality of life.

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.

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.

Mechanical circulatory support in pediatrics

There is no reliable published data on the overall prevalence or incidence of heart failure (HF) in children. However, the success of mechanical circulatory support (MCS) in management of HF has raised the prospect of a previously unavailable treatment modality. Orthotopic heart transplant (OHTx) remains the gold standard treatment, but the number of patients requiring this treatment far outweighs the donor availability. It is therefore not surprising to see the popularity of various MCS modalities, with different devices ranging from veno-arterial extra corporeal membrane oxygenation (VA-ECMO) to ventricular assist devices (VADs), which are either para-corporeal or intra-corporeal, with pulsatile or continuous flow. Indication, timing and the choice of the type of mechanical support are crucial so in order to avoid potential lethal complications such as hemorrhage, thrombo-embolism and infections. In the pediatric population, MCS is used mainly as bridge to transplantation but can be used as bridge to recovery in patients with acute myocarditis or following open-heart surgery. Active research is currently underway to develop newer and more durable devices that will assist the pediatric population across all age groups. This research will support different pathologies that have lower incidences of major morbidities, particularly as greater durations of MCS are expected due to a paucity of donors for OHTx. The combined experience developed through the usage of different devices in pediatric and adult populations has led to the to the application of MCS in some subgroups of grown-up congenital heart diseases (CHDs) patients, particularly those with systemic right ventricular failure.

Characteristics and outcomes of heart failure-related intensive care unit admissions in children with cardiomyopathy

OBJECTIVE

The purpose of this study was to describe patient characteristics and outcomes of heart failure (HF)-related intensive care unit (ICU) hospitalizations in children with cardiomyopathy (CM).

METHODS AND RESULTS

A query of the Pediatric Health Information System database, a large administrative and billing database of 43 tertiary children's hospitals, was performed. A total of 17,309 HF-related ICU hospitalizations from 2005 to 2010 of 14,985 children ≤18 years old were analyzed. Of those, 2,058 (12%) hospitalizations for CM-HF in 1,599 (11%) children were identified. Classification into CM subtypes was not possible owing to database limitations. The number of yearly CM-HF hospitalizations significantly increased during the study period (P = .036). Overall mortality was 11%, and cardiac transplantation occurred in 20% of hospitalizations. Mechanical circulatory support (MCS) was used in 261 (13%) of hospitalizations. Renal failure, MCS, respiratory failure, sepsis, and vasoactive medications were associated with mortality on multivariable analysis. Significant comorbidities associated with these hospitalizations included arrhythmias in 42%, renal failure in 13%, cerebrovascular disease in 6%, and hepatic impairment in 5%.

CONCLUSIONS

HF-related ICU hospitalizations in children with cardiomyopathy are increasing. These children are at high risk for poor outcomes with an in-hospital mortality of 11%.

Exploration of ICD-9-CM coding of chronic disease within the Elixhauser Comorbidity Measure in patients with chronic heart failure

INTRODUCTION

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes capture comorbidities that can be used to risk adjust nonrandom patient groups. We explored the accuracy of capturing comorbidities associated with one risk adjustment method, the Elixhauser Comorbidity Measure (ECM), in patients with chronic heart failure (CHF) at one Veterans Affairs (VA) medical center. We explored potential reasons for the differences found between the original codes assigned and conditions found through retrospective review.

METHODS

This descriptive, retrospective study used a cohort of patients discharged with a principal diagnosis coded as CHF from one VA medical center in 2003. One admission per patient was used in the study; with multiple admissions, only the first admission was analyzed. We compared the assignment of original codes assigned to conditions found in a retrospective, manual review of the medical record conducted by an investigator with coding expertise as well as by physicians. Members of the team experienced with assigning ICD-9-CM codes and VA coding processes developed themes related to systemic reasons why chronic conditions were not coded in VA records using applied thematic techniques.

RESULTS

In the 181-patient cohort, 388 comorbid conditions were identified; 305 of these were chronic conditions, originally coded at the time of discharge with an average of 1.7 comorbidities related to the ECM per patient. The review by an investigator with coding expertise revealed a total of 937 comorbidities resulting in 618 chronic comorbid conditions with an average of 3.4 per patient; physician review found 872 total comorbidities with 562 chronic conditions (average 3.1 per patient). The agreement between the original and the retrospective coding review was 88 percent. The kappa statistic for the original and the retrospective coding review was 0.375 with a 95 percent confidence interval (CI) of 0.352 to 0.398. The kappa statistic for the retrospective coding review and physician review was 0.849 (CI, 0.823-0.875). The kappa statistic for the original coding and the physician review was 0.340 (CI, 0.316-0.364). Several systemic factors were identified, including familiarity with inpatient VA and non-VA guidelines, the quality of documentation, and operational requirements to complete the coding process within short time frames and to identify the reasons for movement within a given facility.

CONCLUSION

Comorbidities within the ECM representing chronic conditions were significantly underrepresented in the original code assignment. Contributing factors potentially include prioritization of codes related to acute conditions over chronic conditions; coders' professional training, educational level, and experience; and the limited number of codes allowed in initial coding software. This study highlights the need to evaluate systemic causes of underrepresentation of chronic conditions to improve the accuracy of risk adjustment used for health services research, resource allocation, and performance measurement.

The Use of the Medical Dictionary for Regulatory Activities in the Identification of Mitochondrial Dysfunction in HIV-Infected Children

OBJECTIVE

To demonstrate the utility of a medical terminology-based method for identifying cases of possible mitochondrial dysfunction (MD) in a large cohort of youths with perinatal HIV infection and to describe the scoring algorithms.

METHODS

Medical Dictionary for Regulatory Activities (MedDRA)^® version 6 terminology was used to query clinical criteria for mitochondrial dysfunction by two published classifications, the Enquête Périnatale Française (EPF) and the Mitochondrial Disease Classification (MDC). Data from 2,931 participants with perinatal HIV infection on PACTG 219/219C were analyzed. Data were qualified for severity and persistence, after which clinical reviews of MedDRA-coded and other study data were performed.

RESULTS

Of 14,000 data records captured by the EPF MedDRA query, there were 3,331 singular events. Of 18,000 captured by the MDC query, there were 3,841 events. Ten clinicians blindly reviewed non MedDRA-coded supporting data for 15 separate clinical conditions. We used the Statistical Analysis System (SAS) language to code scoring algorithms. 768 participants (26%) met the EPF case definition of possible MD; 694 (24%) met the MDC case definition, and 480 (16%) met both definitions.

LIMITATIONS

Subjective application of codes could have affected our results. MedDRA terminology does not include indicators of severity or persistence. Version 6.0 of MedDRA did not include Standard MedDRA Queries, which would have reduced the time needed to map MedDRA terms to EPF and MDC criteria.

CONCLUSION

Together with a computer-coded scoring algorithm, MedDRA terminology enabled identification of potential MD based on clinical data from almost 3000 children with substantially less effort than a case by case review. The article is accessible to readers with a background in statistical hypothesis testing. An exposure to public health issues is useful but not strictly necessary.

Prevalence, morbidity, and mortality of heart failure-related hospitalizations in children in the United States: a population-based study

BACKGROUND

Few data exist on prevalence, morbidity, and mortality of pediatric heart failure hospitalizations. We tested the hypotheses that pediatric heart failure-related hospitalizations increased over time but that mortality decreased. Factors associated with mortality and length of stay were also assessed.

METHODS AND RESULTS

A retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database was performed for pediatric (age ≤18 years) heart failure-related hospitalizations for the years 1997, 2000, 2003, and 2006. Hospitalizations did not significantly increase over time, ranging from 11,153 (95% confidence interval [CI] 8,898-13,409) in 2003 to 13,892 (95% CI 11,528-16,256) in 2006. Hospital length of stay increased from 1997 (mean 13.8 days, 95% CI 12.5-15.2) to 2006 (mean 19.4 days, 95% CI 18.2 to 20.6). Hospital mortality was 7.3% (95% CI 6.9-8.0) and did not vary significantly between years; however, risk-adjusted mortality was less in 2006 (odds ratio 0.70, 95% CI 0.61 to 0.80). The greatest risk of mortality occurred with extracorporeal membrane oxygenation, acute renal failure, and sepsis.

CONCLUSIONS

Heart failure-related hospitalizations occur in 11,000-14,000 children annually in the United States, with an overall mortality of 7%. Many comorbid conditions influenced hospital mortality.

Clinical features of heart failure hospitalization in younger and elderly patients in Taiwan

BACKGROUND

  This study compared the comorbidities, drugs, expenses and in-hospital mortality between younger and elderly patients hospitalized with heart failure.

METHODS

A random sample of 1,000.000 insurants of the National Health Insurance program of Taiwan in 2005 was used. Comparisons were made between younger (20-64years) and elderly (≥65years) patients.

RESULTS

Heart failure hospitalization was identified in 2692 patients. Ageing, female sex, diabetes, hypertension, chronic obstructive pulmonary disease, nephropathy, infection and ischaemic heart disease were significantly associated with heart failure hospitalization. The incidence was 88 and 2181 per 100,000 population, in younger and elderly people, respectively. The most common comorbidity in the elderly was hypertension (38·3%), followed by infection (32·0%) and ischaemic heart disease (31·9%). In younger patients, hypertension (41·3%), diabetes (35·5%) and ischaemic heart disease (29·8%) were the most common comorbidity. Diuretics were the most common drugs for both the younger (74·4%) and the elderly (76·9%) patients, followed by angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers and aspirin. The length of stay was longer (17·1 vs. 11·0days, P<0·0001), total expense higher (105,290·5 vs. 85,473·6 New Taiwan Dollars, P<0·05) and in-hospital mortality higher (4·2% vs. 2·7%, P=0·0823) in the elderly. Length of stay, nephropathy, infection, ischaemic heart disease and peripheral arterial disease were associated with expenses. In-hospital mortality was associated with age, length of stay, cancer, infection and peripheral arterial disease.

CONCLUSIONS

The elderly have a 25-fold higher risk of heart failure hospitalization, longer length of in-hospital stay, higher total medical expense and higher in-hospital mortality.

Heart failure in children: clinical aspect and management

Heart failure (HF) is a complex syndrome, with several definitions, the commonest being "an abnormality of cardiac function whereby heart in unable to pump at a rate commensurate with the requirement of the metabolizing tissues, or does so only at elevated filling pressures". In case of children, this requirement includes growth and development. Unlike as seen in adults, HF in children is commonly due to structural heart disease and reversible conditions. Thus the treatment for HF is commonly required for short term only. The overall outcome with HF is better in children than in adults. While the general principles on management are similar to those in adults, the evidence for the use of drugs in children is less convincing. It requires a judicious balance of extrapolation from adult medicine, keeping in mind that children are not small adults.

Beta-blockers for congestive heart failure in children

BACKGROUND

Beta-blockers are an essential part of standard therapy in adult congestive heart failure and are therefore also expected to be beneficial in children. However, congestive heart failure in children differs strongly from that in adults in terms of characteristics and aetiology; also, an increased drug clearance has been reported. Paediatric needs have therefore to be specifically investigated.

OBJECTIVES

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

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 4 2007), MEDLINE (1966 to January 2008), EMBASE (1980 to January 2008), and LILACS (1980 to January 2008). 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 authors independently extracted and assessed data from the included trials.

MAIN RESULTS

Three studies with an overall number of 203 participants were identified. Two small studies, with 20 and 22 children respectively, showed an improvement of congestive heart failure, while a larger study with 161 participants showed no evidence of benefit over placebo in the composite measure of heart failure outcomes which was the main outcome measure of the trial (56% improvement in both the placebo and the treatment group, p=0.74). However, study populations showed vast differences with regard to treatment (choice of beta-blocker, dosing, duration of treatment), age and age range of the participants and in particular with regard to condition (aetiology and severity of heart failure; homogeneity of condition in the study population). In addition methods and outcome measures differed strongly and were not standardised. The results can therefore not be compared against each other.

AUTHORS' CONCLUSIONS

There are not enough data to recommend or discourage the use of beta-blockers in children with congestive heart failure. Further investigations in clearly defined populations with standardised methodology are required to establish guidelines for therapy. Pharmacokinetic investigations of beta-blockers in children are required to provide effective dosing in future trials.

Epidemiology of heart failure in a tertiary pediatric center

BACKGROUND

In contrast to the adult age group, epidemiologic studies on heart failure (HF) in the pediatric population are lacking. The aim of this prospective study was to analyze the epidemiology of HF during infancy and childhood.

METHODS

Of the 1,196 children with congenital and acquired heart diseases, primarily diagnosed during a 10-y period in one hospital, we identified those patients who developed HF.

RESULTS

Within 10 y, 1,196 children with heart disease were indexed. Heart failure occurred in 124 of these patients (10.4%): 64 out of 1,031 children with congenital heart diseases (6.2%), 13 out of 96 children with rhythm or conduction disturbances (13.5%), 23 out of 39 children with acquired heart diseases (59.0%), and 24 out of 30 children with cardiomyopathies (80.0%). Heart failure occurred in 72 cases (58.1%) during the first year of life. The incidence in infancy was much more pronounced for congenital heart diseases than for other cardiac conditions. The mortality associated with HF and its cause was also lower for children with congenital heart disease (4.7%) than for the other cardiac conditions (8.7%, 23.0%, and 25.0%, for acquired heart diseases, rhythm disturbances, and cardiomyopathies, respectively).

CONCLUSION

Clear differences exist between HF in infants and HF in children. Our study supports the observation that congenital heart disease is the most common causative factor of HF during infancy. Older children with HF are more likely to have acquired heart diseases, cardiomyopathies, and arrhythmias, and these conditions have a considerable mortality.

Children with chronic organ failure possibly ending in organ transplantation: a survey in an Italian region of 5,000,000 inhabitants

AIM

The Italian Piedmont region sponsored in 2005 a population-based registry to assess the epidemiology of childhood chronic organ failure involving kidneys, liver, heart or lungs.

METHODS

Patients in chronic organ failure who were younger than 18 years were selected, and entered the registry when accomplishing the standard failure criteria for each organ. The cases were reported by the general paediatricians of the region and integrated with the data gathered by the Children University Hospital, a tertiary care centre.

RESULTS

In Piedmont (647,727 inhabitants < 18 years), a total of 146 children (217 cases per million of paediatric population) were found to be affected by chronic organ failure (mean age 10 years; range 0-17). The organ failure involved kidneys in 68 subjects (48%), liver in 24 (17%), heart in 21 (15%) and lungs in 28 (20%), and was severe in 32 subjects (6 on transplantation waiting list). The most represented disease leading to chronic renal failure was renal hypodysplasia (79%). Chronic liver failure was mostly caused by biliary atresia (30%), autoimmune hepatitis (25%) and Wilson's disease (21%). Dilated cardiomyopathy (62%) and surgically treated congenital cardiopathy were the two leading causes of chronic heart failure. The most represented disease leading to chronic lung failure was cystic fibrosis (89%).

CONCLUSION

This is the first report of the literature focusing on the epidemiology of chronic organ failure in children encompassing a region of 4,000,000 inhabitants. This clinical condition is rare, but medically and socially very demanding not only in childhood but the life along, as most of these patients will need solid organ transplantation decades later.

Noncardiac comorbidities of congenital heart disease in children

BACKGROUND

Noncardiac conditions may complicate heart disease care, contribute to the progression of the disease and alter the response to treatment. The aim of this prospective study was to evaluate the proportion of cardiac children with such significant conditions.

METHODS

Of the 1058 children with congenital heart disease primarily diagnosed during a 10-year-period in one hospital, we identified those patients who had significant congenital and acquired comorbidities.

RESULTS

Associated problems were diagnosed in 224 children (21.2%). Among them, 118 children (11.2%) had genetic or syndromic conditions, of which 38 had Trisomy 21. Six subspecialty areas accounted for the vast majority of the cases: neurology (n = 140), pulmonology (n = 36), orthopaedics (n = 26), nephro-urology (n = 19), gastroenterology (n = 14) and endocrinology (n = 13). The most frequent associated conditions were mental retardation, asthma, epilepsy and scoliosis. During the study period, death occurred in 46 of the children (4.3%) and was not related to the cardiac disease in 20 cases (1.9%).

CONCLUSION

A substantial proportion of children with congenital heart disease have significant noncardiac comorbidities. Close collaboration between paediatric cardiologists and paediatricians of other subspecialties is imperative to optimize care for these children.