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

Cardiovascular Disease in the Young Council's Science and Clinical Education Lifelong Learning Committee: Year in Review.

2018

e010617

2018 Nov 06

2047-9980

10.1161/JAHA.118.010617

J Am Heart Assoc

30571390

Cardiac transplantation in children with Down syndrome, Turner syndrome, and other chromosomal anomalies: A multi-institutional outcomes analysis.

2018

749-754

2018 Jun

1557-3117

<p><strong>BACKGROUND: </strong>The purpose of this study was to describe the prevalence, characteristics, and outcomes in pediatric patients with chromosomal anomalies (CA) undergoing orthotopic heart transplantation (OHT).</p>

<p><strong>METHODS: </strong>A query of the database of the Pediatric Health Information System, a large administrative and billing database of 43 tertiary children's hospitals, was performed for the Years 2004 to 2016. Pediatric patients who received OHT were analyzed based on presence and type of CA. CA analyzed included: Down syndrome (DS); Turner syndrome (TS)/gonadal dysgenesis; conditions due to anomaly of unspecified chromosome; autosomal deletion; microdeletion; and autosomal anomaly. Healthcare-associated charge analysis during hospitalization for OHT and survival after OHT were assessed.</p>

<p><strong>RESULTS: </strong>A total of 3,080 hospitalizations were identified in which OHTs were performed. Of these OHTs, 64 (2.1%) were performed in patients with a concomitant diagnosis of CA. The presence of CA did not confer a higher risk of in-hospital mortality after OHT (odds ratio 1.2 [0.5 to 3.2], p = 0.651). Differences in in-hospital mortality between different types of CA, including DS and TS, did not reach statistical significance. Survival at 1-year post-OHT was similar in patients with CA compared to those without CA (p = 0.248). Length of stay after OHT was longer in patients with CA: 76 (interquartile range [IQR] 76 to 142 days vs 49 [IQR 21 to 98] days) (p &lt; 0.001), respectively. Overall adjusted hospital charges were significantly higher in the CA group: $1.2 million (IQR $740,000 to $2.2 million) vs $792,000 (IQR $425,000 to $1.5 million] (p &lt; 0.001), respectively.</p>

<p><strong>CONCLUSIONS: </strong>CA is present in ~2% of pediatric patients undergoing OHT. The presence of CA was not associated with increased mortality in pediatric patients undergoing OHT. Limitations of this study include the small number of patients available for analysis and a likely highly selective cohort of patients with CA.</p>

10.1016/j.healun.2018.01.1296

29449075

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

Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Chronic Heart Failure.

2016

S20-34

2016 Mar

1529-7535

<p><strong>OBJECTIVE: </strong>Heart failure is a serious complication that can occur in patients with a variety of congenital and acquired disorders including congenital heart disease, cardiomyopathy, and myocarditis. Furthermore, heart failure patients comprise an increasing number of ICU admissions. Thus, it is important for those caring for patients with critical cardiovascular disease to have a thorough understanding of the medications used for the treatment of heart failure. The aim of this review is to provide an overview, rationale, indications, and adverse effects of medications used in the treatment of chronic heart failure.</p>

<p><strong>DATA SOURCES: </strong>PubMed, Medline, Cochrane Database of Systemic Reviews.</p>

<p><strong>STUDY SELECTION: </strong>Studies were selected on their relevance for pediatric heart failure. When limited data on pediatric heart failure were available, studies in adult patients were selected.</p>

<p><strong>DATA EXTRACTION: </strong>Relevant findings from studies were selected by the authors.</p>

<p><strong>DATA SYNTHESIS: </strong>The rationale for the efficacy of most heart failure medications used in pediatric patients is extrapolated from studies in adult heart failure. Commonly used medications for chronic heart failure include β-receptor antagonists (e.g., carvedilol and metoprolol), and medications aimed at blocking the renin-angiotensin-aldosterone system (e.g., angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone receptor antagonists). In addition, diuretics are useful for symptoms of fluid overload. For patients with impaired perfusion, inotropic agents are useful acutely, but may be associated with worse outcomes when used chronically. Newer medications that have been recently approved in adults (e.g., serelaxin, ivabradine, and neprilysin inhibitor [angiotensin receptor blocker]) may prove to be important in pediatric heart failure.</p>

<p><strong>CONCLUSIONS: </strong>Heart failure patients are in an important population of critically ill children. The pharmacologic approach to these patients is aimed at treating symptoms of congestion and/or poor perfusion and improving long-term outcomes.</p>

10.1097/PCC.0000000000000624

Pediatr Crit Care Med

26945326

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

Heart Transplantation-The Pediatric Cardiac Critical Care Perspective.

2016

S171-S177

2016 Aug

1529-7535

<p><strong>OBJECTIVES: </strong>Although there have been tremendous advancements in the care of severe pediatric cardiovascular disease, heart transplantation remains the standard therapy for end-stage heart disease in children. As such, these patients comprise an important and often complex subset of patients in the ICU. The purpose of this article is to review the causes and management of allograft dysfunction and the medications used in the transplant population.</p>

<p><strong>DATA SOURCES: </strong>MEDLINE, PubMed, and Cochrane Database of systemic reviews.</p>

<p><strong>CONCLUSIONS: </strong>Pediatric heart transplant recipients represent a complex group of patients that frequently require critical care. Their immunosuppressive medications, while being vital to maintenance of allograft function, are associated with significant short- and long-term complications. Graft dysfunction can occur from a variety of etiologies at different times following transplantation and remains a major limitation to long-term posttransplant survival.</p>

10.1097/PCC.0000000000000813

Pediatr Crit Care Med

27490596

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