Predictive factors of cardiogenic shock in children with supraventricular tachycardia

PCJ6-23 - Predictive factors of cardiogenic shock in children with supraventricular tachycardia

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.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0111-2) contains supplementary material, which is available to authorized users.

Supraventricular tachycardia (SVT) is the most common symptomatic arrhythmias in children. Re-entry tachycardias are the most common form, on the contrary automatic tachycardias are relatively rare. There are four types or re-entry: along anomalous pathway with bi-directional (Wolff-Parkinson-White) or unidirectional conduction, intranodal re-entry, intra-atrial re-entry that is common after surgical procedure, and finally the uncommon sinus node re-entry. Automatic tachycardias may be atrial or junctional. The different types of tachycardia have a different incidence according to the age: in the first year of age re-entry along anomalous pathway is the dominant form, while intranodal reentry becomes common during adolescence. The age at the beginning of tachycardia is important for long term prognosis. When SVT starts in the first months of life it disappears in 80% of cases within the first year of life; on the contrary, if tachycardia starts later spontaneous remission is detected in only 15%-20% of patients. In infancy heart failure is the more common presenting symptom, thereafter palpitations become the principal cause of recognition of SVT. Syncope is reported in about 8% of cases and in another 15% usually neonates and infants, the SVT has an occasional detection. Electrocardiogram (ecg) usually allows the precise diagnosis of various types of SVT, and every effort should be made to record ecg during tachycardia. The parameters that should be evaluated are: heart rate, P wave axis, PR and RP interval, and finally presence or absence of AV block. Short lasting episodes should be difficult to be recorded; in these cases cardio-call and trans-telephonic transmission represent useful techniques to obtain SVT demonstration. Patients with SVT require a complete evaluation with others diagnostic techniques: echocardiogram, Holter monitoring, stress test, that should be chosen according the type of tachycardia. Electrophysiologic evaluation is now rarely performed for diagnostic purpose; trans-esophageal atrial stimulation being less invasive than intracardiac evaluation is more extensively employed when diagnosis of SVT is uncertain. Transesophageal stimulation is useful in the following situations: 1) evaluation of patients with symptoms suggestive of paroxistic tachycardia but without ecg documentation, 2) to assess the mechanism responsible for re-entry tachycardia: macro re-entry versus intranodal re-entry 3) to evaluate characteristics of anomalous pathway with bi-directional conduction, and 4)to terminate re-entrant SVT.

We report a case of an infant who presented in profound cardiovascular collapse with a normal sinus rhythm initially. A diagnosis of supraventricular tachycardia (SVT) was established only after hemodynamic stabilization. The possibility of SVT being masked because of severe metabolic derangements and/or painful therapeutic procedures should be kept in mind when managing cardiogenic shock in children. Such a consideration is of practical significance in planning therapy, such as the avoidance of digitalis in a patient with Wolf-Parkinson-White syndrome.

Cardiogenic shock is caused by dysfunction of the cardiac pump, resulting in multiple organ failure and metabolic disturbances.Because of its rapid onset, various manifestations, rapid progress and high mortality rate, it becomes one of the critical diseases in pediatrics.Early diagnosis and active treatment is the key to improve prognosis.The application of hemodynamic monitoring and mechanical circulatory assist devices play an increasingly important role in the treatment of cardiogenic shock in children. Key words: Cardiogenic shock; Diagnosis; Treatment; Mechanical circulatory assist; Children,

Cardiogenic Shock in Children: Clinical Presentation and Outcomes

Supraventricular tachycardia (SVT) in children is a common disturbance of cardiac rhythm that is usually managed without difficulty by using a methodical approach. Technically, the term SVT refers to any rapid rhythm originating in or involving the atria or atrioventricular (AV) node. The most common type of SVT treated in the pediatric clinic is a reentrant rhythm involving the AV node or a bypass tract (paroxysmal SVT [PSVT]). This type of SVT is characterized by sudden onset and cessation, very little beat-to-beat variability, and rates usually well beyond 220 beats/minute. Reentrant rhythms are susceptible to vagal maneuvers, pharmacologic intervention, and electrical cardioversion. Other types of SVT include atrial flutter (rare in children) and automatic tachycardias, which tend to vary in rate over time and start and stop more gradually. It is important to distinguish automatic tachycardias from PSVT because they do not resolve with vagal maneuvers or electrical cardioversion and because they are notoriously difficult to manage with medications. The automatic tachycardia most frequently confused with PSVT is sinus tachycardia, which usually requires no treatment. The first step in evaluation is to check the hemodynamic status. A small proportion of children who have PSVT may present with shock. If the child is hypotensive or has poor capillary refill, one must start immediate measures to restore effective perfusion, including securing reliable intravenous (IV) access and supine positioning.

Supraventricular tachycardia (SVT) in children is a common disturbance of cardiac rhythm that is usually managed without difficulty by using a methodical approach. Technically, the term SVT refers to any rapid rhythm originating in or involving the atria or atrioventricular (AV) node. The most common type of SVT treated in the pediatric clinic is a reentrant rhythm involving the AV node or a bypass tract (paroxysmal SVT [PSVT]). This type of SVT is characterized by sudden onset and cessation, very little beat-to-beat variability, and rates usually well beyond 220 beats/minute. Reentrant rhythms are susceptible to vagal maneuvers, pharmacologic intervention, and electrical cardioversion. Other types of SVT include atrial flutter (rare in children) and automatic tachycardias, which tend to vary in rate over time and start and stop more gradually. It is important to distinguish automatic tachycardias from PSVT because they do not resolve with vagal maneuvers or electrical cardioversion and because they are notoriously difficult to manage with medications. The automatic tachycardia most frequently confused with PSVT is sinus tachycardia, which usually requires no treatment. The first step in evaluation is to check the hemodynamic status. A small proportion of children who have PSVT may present with shock. If the child is hypotensive or has poor capillary refill, one must start immediate measures to restore effective perfusion, including securing reliable intravenous (IV) access and supine positioning.

Pediatric shock in school-aged children and adolescents presents distinct clinical challenges compared to younger age groups, with different etiological patterns and compensatory mechanisms. Understanding age-specific characteristics is crucial for optimizing management strategies and improving outcomes. To evaluate the clinico-etiological profile, laboratory correlations, and clinical outcomes of shock in children aged 5-15 years admitted to a tertiary care hospital. A prospective observational study was conducted over 24 months (March 2023-February 2025) involving 49 children aged 5-15 years presenting with shock. Shock was identified by the presence of tachycardia and/or hypotension with signs of systemic hypoperfusion. Comprehensive clinical assessment, laboratory investigations including inflammatory markers and sequential organ failure assessment (SOFA) scoring, and outcome monitoring were performed. Shock was classified using standardized operational definitions: Septic shock (distributive shock with confirmed or suspected infection), cardiogenic shock (primary cardiac dysfunction), and distributive shock (non-infectious causes, including anaphylaxis). The cohort comprised 49 children with a mean age of 9.2 ± 2.8 years and a slight male predominance (51%). Septic shock predominated (63.3%), followed by cardiogenic (20.4%) and distributive shock (16.3%). Fever was the most common presentation (40.8%), followed by seizures (10.2%). Preexisting medical conditions were present in 44.9% of cases, with neurological disorders being the most common (12.2%). All patients demonstrated tachycardia and delayed capillary refill, while hypotension was present in 28.6%. Laboratory evaluation revealed elevated inflammatory markers (mean C-reactive protein 91.8 mg/L, procalcitonin 16.2 ng/mL, lactate 2.2 mmol/L). Respiratory infections remained the leading cause of septic shock (29%), followed by central nervous system infections (19.4%). Dengue virus was isolated in 16.3% of all cases. Mechanical ventilation was required in 48% of patients, with 59.2% requiring multiple inotropes. The overall mortality rate was 18.4%, significantly associated with multiple inotrope use (P < 0.001) and altered sensorium on admission (P = 0.001). Mean pediatric intensive care unit and hospital stays were 8.2 ± 7.1 and 14.7 ± 9.8 days, respectively. Higher SOFA scores correlated with prolonged intensive care stays (P = 0.002). School-aged children and adolescents with shock demonstrate a high prevalence of septic shock with substantial mortality. Neurological involvement and requirement for multiple inotropes predict poor outcomes. Early recognition, appropriate antimicrobial therapy, and judicious hemodynamic support remain crucial for improving survival in this age group.

Mechanical support options for children and small adolescents in low cardiac output syndrome or cardiogenic shock are often still limited to veno arterial extracorporeal life support and subsequent left or biventricular assist device implantation. We aim to transfer mechanical support options with microaxial flow pump devices from the adult to the paediatric population and therefore aim to identify patient selection criteria and evaluate possible support duration and bridging modalities in a paediatric Impella registry. This is a single-centre retrospective observational study including every patient <18 years presenting with cardiogenic shock and treated with an Impella device only from 2022 to 2024. The study cohort included 6 patients with a median age of 12 (3-17 years), median weight of 35.6 kg (12-115 kg) and a median body surface area (BSA) of 1.2 m2 (0.57-2.4 m2). Intermacs levels were 2 (4 patients) and 3 (2 patients). Heart failure aetiologies were dilative cardiomyopathy (3 patients), myocarditis (1 patient), acute rejection after cardiac transplantation (1 patient) and low cardiac output syndrome after complex endocarditis surgery (1 patient). The implanted devices were an Impella 2.5 [1], Impella CP [2] and Impella 5.5 [3]. Median support duration was 7 (4-45) days. Two patients could be bridged to recovery. Three patients were bridged to an left ventricular assist device, and 1 patient was bridged to cardiac transplantation. We observed no mortality and no neurological complications. Left ventricular unloading in cardiogenic shock in children and adolescents using an Impella is feasible and safe. In older patients allowing for implantation of larger devices, a longer support duration is possible.

Cardiogenic shock is a pathophysiologic state where an abnormality of cardiac function is responsible for the failure of the cardiovascular system to meet the metabolic needs of the body tissues.Though it is less common than hypovolemia as the primary etiology in paediatric shock, eventually myocardial function is affected because of reduced perfusion in all forms of shock. Myocardial malfunction, in other forms of shock, is secondary to ischemia, acidosis, drugs, toxins or inflammation. Cardiogenic shock is a low output state characterized by elevated filling pressures, neurohormonal activation with the evidence of end-organ hypoperfusion. The management is challenging and consists of a combination of conventional cardio-respiratory support, vasoactive medications with correction of the anatomic cardiac defects. Treatment options like Extracorporeal membrane oxygenation and Ventricular assist devices provide a bridge to recovery, surgery or transplant. As cardiogenic shock in children carries a high risk of morbidity and mortality, emphasis should be placed on expedient management to arrest the pathophysiological cascade and avoid hypotension.This article aims to review the aetio-pathophysiological basis of pediatric cardiogenic shock, diagnostic options, recent advances in management modalities and outcome.

Introduction: The objective of this study was to evaluate the epidemiological, diagnostic and therapeutic aspects of cardiogenic shock in children at the Albert Royer Children’s Hospital in Dakar. Methods: This was a retrospective, descriptive and analytical study from January 2020 to February 2021, including all children aged 2 months to 16 years hospitalised for cardiogenic shock diagnosed on the basis of clinical and ultrasound criteria. Results: During the study, 38 patients were hospitalised for cardiogenic shock. The hospital prevalence was 4.2%. The mean age of onset of shock was 64 months, and there was a predominance of females with a sex ratio of 1.92. Consanguinity was found in 42% of the patients. Consanguinity was found in 42% of patients. Infection was identified as a trigger for cardiogenic shock in 18 (52.9%) of our patients. The most common type of heart disease was rheumatic heart disease in 12 (32%) of the patients. The mortality rate was 65.8%. Conclusion: Cardiogenic shock is a diagnostic and therapeutic emergency. Its prevalence and mortality are still high in developing countries.

Scarce data exist on the relationship of C-reactive protein (CRP) or plasminogen activator inhibitor-1 (PAI-1) to the occurrence of heart failure (HF) or cardiogenic shock (CS) after acute myocardial infarction (AMI) and on the relationship between these biomarkers and mortality in CS patients. Thus, we compared high-sensitivity CRP and PAI-1 antigen plasma levels on admission among 3 age- and gender-matched AMI patients groups (consisting of 60 patients with CS, 60 with HF, and 60 without HF on admission), after determining that PAI-1 levels did not vary significantly diurnally in these groups by comparing the data among subgroups which were divided according to admission time within the groups. For CS patients, we also conducted regression analyses to examine the relations of these biomarkers to mortality. CRP levels both in CS (P < 0.001) and HF (P < 0.05) patients were significantly higher compared to those without HF, PAI-1 levels in CS patients were significantly higher compared to both those with (P < 0.05) and without HF (P > 0.01), and CRP and PAI-1 were independent predictors of in-hospital (Odds ratio [OR] = 6.12, 95% confidence intervals [95%CI] = 1.47-25.54 and OR = 5.92, 95%CI = 1.31-26.77, respectively) and 1-year mortality (OR = 5.53, 95%CI = 1.21-25.17 and OR = 5.48, 95%CI = 1.09-27.52, respectively) in CS patients. In conclusion, at admission, CRP is associated with the occurrence of CS and HF and PAI-1 is associated with the occurrence of CS after AMI, and they are of prognostic value in CS complicating AMI.

BackgroundIn multisystem inflammatory syndrome in children (MIS-C), diagnostic delay could be associated with severity. This study aims to measure the time to diagnosis in MIS-C, assess its impact on the occurrence of cardiogenic shock, and specify its determinants.MethodsA single-center prospective cohort observational study was conducted between May 2020 and July 2022 at a tertiary care hospital. Children meeting the World Health Organization MIS-C criteria were included. A long time to diagnosis was defined as six days or more. Data on time to diagnosis were collected by two independent physicians. The primary outcome was the occurrence of cardiogenic shock. Logistic regression and receiver operating characteristic curve analysis were used for outcomes, and a Cox proportional hazards model was used for determinants.ResultsTotally 60 children were assessed for inclusion, and 31 were finally analyzed [52% males, median age 8.8 (5.7–10.7) years]. The median time to diagnosis was 5.3 (4.2–6.2) days. In univariable analysis, age above the median, time to diagnosis, high C-reactive protein, and high N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with cardiogenic shock [odds ratio (OR) 6.13 (1.02–36.9), 2.79 (1.15–6.74), 2.08 (1.05–4.12), and 1.70 (1.04–2.78), respectively]. In multivariable analysis, time to diagnosis ≥ 6 days was associated with cardiogenic shock [adjusted OR (aOR) 21.2 (1.98–227)]. Time to diagnosis ≥ 6 days had a sensitivity of 89% and a specificity of 77% in predicting cardiogenic shock; the addition of age > 8 years and NT-proBNP at diagnosis ≥ 11,254 ng/L increased the specificity to 91%. Independent determinants of short time to diagnosis were age < 8.8 years [aHR 0.34 (0.13–0.88)], short distance to tertiary care hospital [aHR 0.27 (0.08–0.92)], and the late period of the COVID-19 pandemic [aHR 2.48 (1.05–5.85)].ConclusionsTime to diagnosis ≥ 6 days was independently associated with cardiogenic shock in MIS-C. Early diagnosis and treatment are crucial to avoid the use of inotropes and limit morbidity, especially in older children.

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