Epidemiology and Outcomes of Acute Decompensated Heart Failure in Children.

2020

e006101

2020 Apr

1941-3297

<p><strong>BACKGROUND: </strong>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.</p>

<p><strong>METHODS: </strong>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.</p>

<p><strong>RESULTS: </strong>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%; &lt;0.001). Independent risk factors associated with CICU mortality included age &lt;30 days, CHD, vasoactive infusions, ventricular tachycardia, mechanical ventilation, sepsis, pulmonary hypertension, extracorporeal membrane oxygenation, and cardiac arrest.</p>

<p><strong>CONCLUSIONS: </strong>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.</p>

10.1161/CIRCHEARTFAILURE.119.006101

Circ Heart Fail

32301336

Pediatric Heart Failure: An Evolving Public Health Concern.

2019

2019 Nov 15

1097-6833

<p>The care of children suffering from heart failure presents unique challenges that are inadequately met at the present time. In the pediatric population, a wide variety of disease processes can result in heart failure, including primary cardiomyopathy as well as an expanding population of children with palliated complex congenital heart disease (CHD). Regardless of the underlying etiology of heart failure, pediatric heart failure outcomes remain poor despite growing resource utilization. In addition, given the overlap in symptomatology between heart failure and more common childhood illnesses, the diagnosis of new onset heart failure in children requires a heightened level of suspicion in combination with early pediatric cardiology consultation. Emerging molecular evidence suggests that pediatric heart failure is distinct from adult heart failure, which may contribute to the limited efficacy of adult heart failure therapies in the children. Significant improvement in pediatric heart failure outcomes will require a shift in the approach to clinical and translation research (including support for pediatric-specific heart failure therapies) as well as widespread implementation of multidisciplinary teams to care for pediatric heart failure in a chronic disease model. Increased awareness among pediatricians, funding agencies, and policymakers regarding the obstacles facing pediatric patients with heart failure is critical to meeting the needs of this complex patient population.</p>

10.1016/j.jpeds.2019.09.049

J. Pediatr.

31740144

Significant mortality, morbidity and resource utilization associated with advanced heart failure in congenital heart disease in children and young adults.

2018

9-19

2018 Dec 05

1097-6744

<p><strong>BACKGROUND: </strong>Children with congenital heart disease (CHD) are at risk for advanced heart failure (AHF). We sought to define the mortality and resource utilization in CHD-related AHF in children and young adults.</p>

<p><strong>METHODS: </strong>All hospitalizations in the Pediatric Health Information System database involving patients ≤21 years old with a CHD diagnosis and heart failure requiring at least 7 days of continuous inotropic support between 2004 and 2015 were included. Hospitalizations including CHD surgery were excluded.</p>

<p><strong>RESULTS: </strong>Of 465,482 CHD hospitalizations, AHF was present in 2,712 (0.6%) [58% infant, 55% male, 30% single ventricle]. AHF therapies frequently used included extracorporeal membrane oxygenation (ECMO) (15%) and cardiac transplant (16%). Ventricular assist device (VAD) support was rare (3%), although VAD use significantly increased from 2004 to 2015 (P &lt; .0010). Hospital mortality in CHD with AHF was 26%, with higher mortality associated with single ventricle heart disease (OR 1.64, 95% CI 1.23-2.19; P = .0009), infancy (OR 1.71, 95% CI 1.17-2.5; P = .0057), non-white race (OR 1.28, 95% CI 1.04-1.59; p=0.0234), and chronic complex comorbidities (OR 1.76, 95% CI 1.34-2.30; P &lt; .0001). Over the 11-year study period, despite the significant increase in CHD-related AHF hospitalizations (P &lt; .0001), hospital mortality improved (P = .0011). Median hospital costs were $252,000, a 6-fold increase above those without AHF, and was primarily driven by hospital length of stay (P &lt; .0001).</p>

<p><strong>CONCLUSION: </strong>AHF in children with CHD in uncommon but increasing and is associated with significant morbidity, mortality and resource utilization. Approximately 1 in 5 children do not survive to hospital discharge. Many risk factors for mortality may not be modifiable, and further study is needed to identify modifiable risk factors and improve care for this complex population.</p>

10.1016/j.ahj.2018.11.010

Am. Heart J.

30639612

Haemodynamic profiles of children with end-stage heart failure.

2017

2900-2909

2017 Oct 07

1522-9645

<p><strong>Aims: </strong>To evaluate associations between haemodynamic profiles and symptoms, end-organ function and outcome in children listed for heart transplantation.</p>

<p><strong>Methods and results: </strong>Children &lt;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 &gt;15 mmHg), 28% had severe congestion (PCWP &gt;22 mmHg), and 22% low cardiac output (CI &lt; 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 &lt; 0.001) and increased RAP (OR 1.09, 95% CI 1.06-1.12, P &lt; 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).</p>

<p><strong>Conclusion: </strong>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.</p>

10.1093/eurheartj/ehx456

Eur. Heart J.

29019615

Prevalence and Severity of Anemia in Children Hospitalized with Acute Heart Failure.

2016

622-629

2016 Dec

1747-0803

<p><strong>OBJECTIVE: </strong>Anemia is common among adult heart failure patients and is associated with adverse outcomes, but data are lacking in children with heart failure. The purpose of this study was to determine the prevalence of anemia in children hospitalized with acute heart failure and to evaluate the association between anemia and adverse outcomes.</p>

<p><strong>DESIGN: </strong>Review of the medical records of 172 hospitalizations for acute heart failure.</p>

<p><strong>SETTING: </strong>Single, tertiary children's hospital.</p>

<p><strong>PATIENTS: </strong>All acute heart failure admissions to our institution from 2007 to 2012.</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>OUTCOME MEASURES: </strong>Composite endpoint of death, mechanical circulatory support deployment, or cardiac transplantation.</p>

<p><strong>RESULTS: </strong>Patients ages ranged in age from 4 months to 23 years, with a median of 7.5 years, IQR 1.2, 15.9. Etiologies of heart failure included: dilated cardiomyopathy (n = 125), restrictive cardiomyopathy (n = 16), transplant coronary artery disease (n = 18), ischemic cardiomyopathy (n = 7), and heart failure after history of congenital heart disease (n = 6). Mean hemoglobin concentration at admission was 11.8 g/dL (±2.0 mg/dL). Mean lowest hemoglobin prior to outcome was 10.8 g/dL (±2.2 g/dL). Anemia (hemoglobin &lt;10 g/dL) was present in 18% of hospitalizations at admission and in 38% before outcome. Anemia was associated with increased risk of death, transplant, or mechanical circulatory support deployment (adjusted odds ratio 1.79, 95% confidence interval = 1.12-2.88, P = .011). For every 1 g/dL increase in the patients' lowest hemoglobin during admission, the odds of death, transplant, or mechanical circulatory support deployment decreased by 18% (adjusted odds ratio = 0.82, 95% confidence interval = 0.74-0.93, P = 0.002).</p>

<p><strong>CONCLUSIONS: </strong>Anemia occurs commonly in children hospitalized for acute heart failure and is associated with increased risk of transplant, mechanical circulatory support, and inhospital mortality.</p>

10.1111/chd.12355

Congenit Heart Dis

27060888

Hospital Charges for Pediatric Heart Failure-Related Hospitalizations from 2000 to 2009.

2016

512-8

2016 Mar

1432-1971

<p>Scarce data exist regarding costs of pediatric heart failure-related hospitalizations (HFRH) or how costs have changed over time. Pediatric HFRH costs, due to advances in management, will have increased significantly over time. A retrospective analysis of Healthcare Cost and Utilization Project Kids' Inpatient Database was performed on all pediatric HFRH. Inflation-adjusted charges are used as a proxy for cost. There were a total of 33,189 HFRH captured from 2000 to 2009. Median charges per HFRH rose from $35,079 in 2000 to $72,087 in 2009 (p &lt; 0.0001). The greatest median charges were incurred in patients on extracorporeal membrane oxygenation ($442,134 vs $53,998) or ventricular assist devices ($462,647 vs $55,151). Comorbidities, including sepsis ($207,511 vs $48,995), renal failure ($180,624 vs $52,812), stroke ($198,260 vs $54,974) and respiratory failure ($146,200 vs $48,797), were associated with greater charges (p &lt; 0.0001). Comorbidities and use of mechanical support increased over time. After adjusting for these factors, later year remained associated with greater median charges per HFRH (p &lt; 0.0001). From 2000 to 2009, there has been an almost twofold increase in pediatric HFRH charges, after adjustment for inflation. Although comorbidities and use of mechanical support account for some of this increase, later year remained independently associated with greater charges. Further study is needed to understand potential factors driving these higher costs over time and to identify more cost-effective therapies in this population.</p>

10.1007/s00246-015-1308-0

Pediatr Cardiol

26645995

Incidence, Severity, and Association With Adverse Outcome of Hyponatremia in Children Hospitalized With Heart Failure.

2016

1006-10

2016 Oct 1

1879-1913

<p>Hyponatremia is a common finding in adults hospitalized with heart failure (HF) and is associated with longer hospital stays and increased mortality. The significance of hyponatremia in children with HF is not known. We sought to determine the incidence of hyponatremia and association with clinical outcome in children hospitalized with HF. Admission and inpatient serum sodium concentrations were analyzed in 141 consecutive children hospitalized with acute decompensated HF. Inclusion criteria include patients (age, birth to 21&nbsp;years) with biventricular hearts who were hospitalized for HF from January 2007 to December 2012. The primary composite end point was death, cardiac transplantation, or the use of mechanical circulatory support (MCS) during hospitalization. Data for 141 patients were included in the analysis. The cohort included 48 patients (34%) with preexisting HF. Mean serum sodium at admission was 136 ± 4&nbsp;mmol/L (range 124 to 150&nbsp;mmol/L). Hyponatremia (serum sodium &lt;135&nbsp;mmol/L) was present in 45 patients (32%) at admission. Seventy-one patients (75%) with normal serum sodium concentrations at admission subsequently developed acquired hyponatremia during their hospitalization. Hyponatremia persisted at discharge in 17 of 66 patients (26%). Fifty-eight patients (41%) reached the composite end point during hospitalization (death, n&nbsp;= 15; cardiac transplantation, n&nbsp;= 27; MCS, n&nbsp;= 46). Hyponatremia at admission was independently associated with death, cardiac transplantation, or the use of MCS during hospitalization (odds ratio 3.1, p&nbsp;= 0.02). In conclusion, hyponatremia occurs commonly in children hospitalized with acute decompensated HF and is associated with increased risk of in-hospital mortality, cardiac transplantation, and need for MCS.</p>

10.1016/j.amjcard.2016.07.014

Am. J. Cardiol.

27530824

Readmissions for Heart Failure in Children.

2016

2016 Jun 29

1097-6833

<p><strong>OBJECTIVE: </strong>To assess the frequency of inpatient 30-day readmission for heart failure in children with cardiomyopathy discharged after an admission for heart failure and the impact of discharge pharmacotherapy on readmissions.</p>

<p><strong>STUDY DESIGN: </strong>The Pediatric Health Information System Database was queried for patients ≤18&nbsp;years of age with an International Classification of Diseases, Ninth Revision code for heart failure (428.xx) or cardiomyopathy (425.xx) discharged from 2004 to 2013. Patients were excluded if they had congenital heart disease, expired on the initial admission, or underwent cardiac surgery. Patient admission characteristics were documented and discharge medications were captured. Frequency of 30-day readmission for heart failure was identified, and mixed effects multivariable logistic regression analysis was performed to determine factors significant for readmission.</p>

<p><strong>RESULTS: </strong>A total of 2386 patients met study criteria (52.1% male, median age 8.1&nbsp;years [IQR 1.2-14.6&nbsp;years]). Vasoactive medications were used in 70.3% of patients on initial admission, the most common of which was milrinone (62.8%). Angiotensin converting enzyme inhibitors and beta-blockers were given at discharge to 67.4% and 35.9%, respectively. Frequency of 30-day readmission for heart failure was 12.9%. Duration of milrinone or beta-blocker use at discharge and institutional heart failure patient volume were associated with a greater odds of 30-day readmission, whereas mechanical ventilation on initial admission was associated with decreased odds of readmission.</p>

<p><strong>CONCLUSIONS: </strong>Pediatric patients with cardiomyopathy and heart failure have a high frequency of heart failure-related 30-day readmission. Outpatient pharmacotherapy at discharge does not appear to influence readmission.</p>

10.1016/j.jpeds.2016.06.003

J. Pediatr.

27372394