Cardiogenic Shock in Children: Clinical Presentation and Outcomes

Abstract

<h3>Purpose</h3> Descriptive and outcomes data for cardiogenic shock (CS) are lacking in children. We present our findings of CS in a large cohort of children hospitalized with acute heart failure (AHF). <h3>Methods</h3> We performed a retrospective single-center cohort study of children aged 0-18y hospitalized with AHF from 01/2004 to 12/2018. CS was defined as the presence of ventricular dysfunction on echocardiogram plus ≥ 2 of the following: lactate > 2mmol/L, cool extremities, systemic hypotension, use of mechanical circulatory support (MCS), or cardiopulmonary resuscitation (CPR) ≤ 24 hrs since admission (excluding sepsis or hypovolemia). The primary outcome was hospital mortality. <h3>Results</h3> There were 797 AHF hospitalizations in 577 patients, with median age 7y (1 - 15y). Etiologies of AHF included cardiomyopathy (CMP, 53%), any cause HTx graft failure (15%), congenital heart disease (CHD, 15%), myocarditis (11%), and others (6%). Overall 51% of patients had prior history of HF. CS was identified in 207 hospitalizations (26%). Patients with CS were younger than those without CS (median age 4y vs 8y, p <0.001), with no difference in sex or race/ethnicity distribution. Patients with prior history of HF were less likely to present in CS compared to new-onset HF (14% vs 38%, p <0.001). Overall, 25% of CMP, 53% of myocarditis, 20% of HTx graft failure, and 17% of CHD presented in CS (p <0.001). Patients in CS were more likely to have tachycardia (63% vs 41%, p <0.001), dyspnea (74% vs 64%, p = 0.016), and loss of appetite (49% vs 38%, p = 0.011) at presentation. Patients presenting in CS had a higher BNP at admission (median 3268 pg/mL vs 1648 pg/mL, p <0.001). During the hospitalization, the CS cohort were more likely to receive mechanical ventilation (88% vs 26%, p <0.001), renal replacement therapy (16% vs 5%, p <0.001), and CPR (37% vs 8%, p <0.001). MCS was deployed more commonly in patients presenting in CS (45% vs 15%, p <0.001), however the proportion undergoing HTx during the hospitalization was similar to the non-CS group (16% vs 13%, p = 0.419). Patients presenting in CS had higher mortality (24% vs 8%, p<0.001) and longer hospital length of stay (median 30 days vs 17 days, p <0.001). <h3>Conclusion</h3> Over one-fourth of children hospitalized with AHF develop CS, with associated high rates of morbidity and mortality. Risk stratification of pediatric CS should be considered to optimize early use of rescue therapies and improve survival to recovery or HTx.