Chronic Heart Failure In Children Research Articles

A Review of Contemporary and Future Pharmacotherapy for Chronic Heart Failure in Children.

This review delves into the most recent therapeutic approaches for pediatric chronic heart failure (HF) as proposed by the International Society for Heart and Lung Transplantation (ISHLT), which are not yet publicly available. The guideline proposes an exhaustive overview of the evolving pharmacological strategies that are transforming the management of HF in the pediatric population. The ISHLT guidelines recognize the scarcity of randomized clinical trials in children, leading to a predominance of consensus-based recommendations, designated as Level C evidence. This review article aims to shed light on the significant paradigm shifts in the proposed 2024 ISHLT guidelines for pediatric HF and their clinical ramifications for pediatric cardiology practitioners. Noteworthy advancements in the updated proposed guidelines include the endorsement of angiotensin receptor-neprilysin inhibitors (ARNIs), sodium-glucose cotransporter 2 inhibitors (SGLT2is), and soluble guanylate cyclase (sGC) stimulators for treating chronic HF with reduced ejection fraction (HFrEF) in children. These cutting-edge treatments show potential for enhancing outcomes in pediatric HFrEF. Nonetheless, the challenge persists in validating the efficacy of therapies proven in adult HFrEF for the pediatric cohort. Furthermore, the proposed ISHLT guidelines address the pharmacological management of chronic HF with preserved ejection fraction (HFpEF) in children, marking a significant step forward in pediatric HF care. This review also discusses the future HF drugs in the pipeline, their mechanism of actions, potential uses, and side effects.

Evaluation and Management of Chronic Heart Failure in Children and Adolescents With Congenital Heart Disease: A Scientific Statement From the American Heart Association.

With continued medical and surgical advancements, most children and adolescents with congenital heart disease are expected to survive to adulthood. Chronic heart failure is increasingly being recognized as a major contributor to ongoing morbidity and mortality in this population as it ages, and treatment strategies to prevent and treat heart failure in the pediatric population are needed. In addition to primary myocardial dysfunction, anatomical and pathophysiological abnormalities specific to various congenital heart disease lesions contribute to the development of heart failure and affect potential strategies commonly used to treat adult patients with heart failure. This scientific statement highlights the significant knowledge gaps in understanding the epidemiology, pathophysiology, staging, and outcomes of chronic heart failure in children and adolescents with congenital heart disease not amenable to catheter-based or surgical interventions. Efforts to harmonize the definitions, staging, follow-up, and approach to heart failure in children with congenital heart disease are critical to enable the conduct of rigorous scientific studies to advance our understanding of the actual burden of heart failure in this population and to allow the development of evidence-based heart failure therapies that can improve outcomes for this high-risk cohort.

Chronic Heart Failure in Children: State of the Art and New Perspectives.

Pediatric heart failure (HF) is an important clinical condition with high morbidity and mortality. Compared to adults, pediatric HF shows different etiologies characterized by different physiology, a different clinical course, and deeply different therapeutic approaches. In the last few years, new drugs have been developed and new therapeutic strategies have been proposed with the goal of identifying an individualized treatment regimen. The aim of this article is to review the new potential drugs and non-pharmacological therapies for pediatric heart failure in children.

Original Methods of Memorizing Information as a Way of Practical of Practical Teaching for Interns

The article presents the experience of using original methods of memorizing information for teaching interns of all specialties. A number of pedagogical principles have been revised and updated to optimize learning. During training in the profession of a doctor, one of the most difficult elements of cognition is memorizing the doses of drugs, the ability to apply them in practice. During training in the profession of a doctor, one of the most difficult cognition elements is memorizing the doses of drugs, the ability to apply them in practice. The human brain has hard time memorizing numerical information until it is converted into visual images that the brain can understand. The authors have used the way of presenting difficult to memorize material in an interesting poetic form and the method of figurative nomination using the figurative-logical thinking of interns through the development of emotionally colored associative connections. 64 interns of various specialties who took part in the practical lesson “Acute and chronic heart failure in children” were randomly divided into two groups. In the main group (32 people, 50,0 %) the authors used the method of figurative nomination and mnemonic techniques, in the control group (32 people, 50,0 %) there was a standard methodological presentation of the material. The use of these methods in training interns improved the efficiency of memorizing information for a long time by 31,8 %. Keywords: methods of teaching, mnemonics, memory, figurative nomination technique, education

The role of hemodynamic parameters in chronic heart failure diagnosis in children

Despite the achievements in this field in recent years, concerning the chronic myocardial dysfunctions, pathogenesis, diagnosis and treatment management, the chronic heart failure continues to hold preeminence in the structure of cardiovascular complications and remains now one of the leading causes of invalidity of young contingent and infant mortality, presenting one of the most pressing public health problems. This requires looking for new methods of noninvasive early diagnosis with application of modern laboratory and investigational tests facilitating the identification in preclinical stages of chronic myocardial dysfunctions (CMD) by assessment of new biomarkers of myocardial injury. Objectives of the study. Hemodynamic parameters changes estimation in the evolution of chronic heart failure in children. Material and methods. The study included 233 patients with chronic heart failure, of which 78 were children and adolescents aged 10-17 years with CMD secondary to arterial hypertension. The diagnosis of arterial hypertension was established according to the ESA (European Society of Cardiology, 2009) recommendations, but the assessment of clinical manifestations of chronic heart failure was evaluated according to NYHA (New York Heart Association classification). The estimation of hemodynamic parameters was performed using echocardiography method using “Ultramark-8” (US device A) under Mand Doppler. Obtained results. In patients with arterial hypertension the types of concentric hypertrophy of left ventricular myocardial index mass (IMMVS) -59.2±14.2 and relative LV wall thickness (GRPVS) -0.46±0.22 cm were assessed. It is important to note that the study assessed the type of eccentric hypertrophy with IMMVS 66.4±7.6 and 0.44±0.25 cm GRPVS. Concentric geometric remodeling variant noted IMMVS average value of 48.4±4.2 and GRPVS- 0.44±0.21 cm. Identification of LV hypertrophy, increased GRPVS, IMMVS increase, the MMV based on echocardiographic examination of the heart reveals the geometric performance called “pathological remodeling” which actually confirms the occurrence of chronic myocardial dysfunction in patients with CHF secondary hypertension. Conclusions. Early identification of changes of cardiac performance parameters (MMV, IMMVS, GRPVS, HVS) under the conditions of the persistent tensional over estimation, reveals the early development of types of early myocardial pathological left ventricular remodeling and facilitates the options and diagnostic criteria of the heart remodeling in children with CMD secondary arterial hypertension in order to choose a selected pathogenetic treatment.

Cut-off values of amino-terminal pro-B-type natriuretic peptide for the diagnosis of chronic heart failure in children of age stratification with congenital heart disease prior to heart surgery

Objective To detect the plasma amino-terminal pro-B-type natriuretic peptide (NT-ProBNP) of children with congenital heart disease(CHD) prior to heart surgery,to analysize its sensitivity,specificity and Youden index by receiver operating characteristic(ROC) curve,to explore the cut-off values of plasma NTProBNP for the diagnosis of congestive heart failure(CHF) in children under 5 years old before and after age stratification.Method The plasma NT-proBNP was detected for 100 children with CHD prior to heart surgery (experimental group) and 100 normal children(control group) between January 2011 to January 2013.Age stratification(0 ～ 1 year group,～3 years group and ～ 5 year group) was conducted in children with CHF younger than 5 years old to explore the cut-off values of plasma NT-ProBNP for the diagnosis of CHF.Results The NT-proBNP of 34 patients with CHF(n =100) was in accordance to Ross criteria The cut-off values were 502 ng/ L before age stratification,and they were 552 ng/L,449 ng/L,349 ng/L after age stratification for 0 ～ 1 year group,～ 3 years group and ～ 5 group.Conclusion The cut-off values of plasma NT-ProBNP for CHF were 552 ng/L、449 ng/L、349 ng/L for 0 ～ 1 year group,～ 3 years group and ～ 5 year group. Key words: Congenital heart disease; Congestive heart failure; Amino-terminal pro-B-type natriuretic peptide ; Cut-off value; Children

The impact of the carvedilol therapy on the chronic heart failure in children. Does it depend on the morphological deference of systemic ventricle?

Background: There have been a few reports about the use of carvedilol in children with congenital heart disease (CHD) to treat chronic heart failure. Purpose: To examine the effectiveness of carvedilol for children with chronic heart failure including congenital heart disease.[Subjects]32 patients admitted for heart failure were initiated carvedilol from January 1999 to December 2012. They consisted of 16 males and 16 females, with ages ranging from 1.8 years to 21.6 years (mediam age:5.3±6.0 years). Fourteen patients had congenital heart disease (hypoplastic heart syndrome in 7 and other CHDs in 7). Heart failure occurred due to myocardial infarction in 6, cardiomyopathy in 7 and myocarditis in 5. The mean age when they were initiated carvedilol administration was 1.1±3.7 years (range:1 months to 13 years).The mean follow-up period was 3.3±3.6 years (range:1.1 years to 13.5 years). Methods: To evaluate the efficacy of carvedilol therapy quantitatively, we use these parameters: cardiothoracic ratio (CTR), b-type natriuretic peptide (BNP), fractional area change (FAC), Tei index,of systolic ventricle, and the early diastolic velocity at the mitral annulus (e'). We devided the patients into two groups. In group A, The patients have systemic ventricule, while in group B, the patients have systemic ventricle. We compared the parameters between two groups before initiation of carvedilol and at the end of the flollow-up period. Moreover, we compared the difference of the change of these parameters in each group.[Results]In both groups,CTR,BNP and Tei index were decreased significantly (CTR:A 55±5% vs. 50±5%,p<0.01, B 59±6% vs. 51±6%,p<0.001; mean BNP:A 251±335pg/ml vs. 26±24pg/ml p<0.01,B 286±781pg/ml vs. 26±153pg/ml p<0.01, Tei:A 0.65±0.13 vs. 0.44±0.11 p<0.01,B 0.59±0.15 vs. 0.31±0.10 p<0.001). FAC is also improved significantly in both groups (A 0.27±0.07 vs. 0.34±0.05, p<0.01,B 0.21±0.08 vs. 0.36±0.07, p<0.001). But e' is not changed significantly during this period (A 6.0±4.2cm/s vs. 7.2±2.3cm/s, B 5.9±2.9cm/s vs. 11.0±3.9cm/s). Then, there was no significant difference in the change of each parameters between two groups. Conclusions: Carvedilol therapy for chronic heart failure in children is effective in the patients with CHD. The efficacy does not depend on the morphological difference of the systemic ventricule, right or left

The cost of out-patient management of chronic heart failure in children with congenital heart disease

To evaluated the economic burden to families of managing chronic heart failure in children with congenital heart disease. This longitudinal study was conducted over a year. The families of children with congenital heart disease who were being managed for chronic heart failure in the clinic were recruited for the study. With the aid of a structured questionnaire, data were collected on a monthly basis for three consecutive months, on the family's monthly income, cost of anti-failure medicines, transportation and the number of man-hours spent on clinic visitation. The percentage of the mean monthly income spent on medicines, transportation and the total cost of care were also computed. Thirty two families were recruited for the study. The children were 16(50%) each of males and females with a mean age of 2.2 ± 1.7 years. The mean monthly income was $314.93 ± 271.36 while the mean cost of total care was $17.61 ± 10.58. The mean percentage of income spent on total care was 16.3 ± 26.2 % with a range of 0.7 - 122%. Families from low socioeconomic class spent significantly higher percentage of income on medicines and total care compared to those in middle or high socioeconomic classes, P = 0.0095 and 0.041 respectively. Only three (0.09%) patients had surgery for their condition. The mean percentage of income spent on care was significant and amounted to catastrophic health expenditure for a third of the families. Government input in strengthening the existing cardiac centres, establish new ones and subsidising the cost of surgery to meet the needs for open heart surgery for children with CHDs is recommended.

Outpatient Continuous Parenteral Inotropic Therapy as Bridge to Transplantation in Children With Advanced Heart Failure

Background Advanced heart failure in children is associated with high morbidity and mortality and is often refractory to standard medical therapy. The purpose of this study was to review our institutional experience with the use of outpatient parenteral inotropic therapy (PIT) for advanced chronic heart failure in children. Methods and Results We reviewed the medical records of all patients treated with PIT as outpatients. Seven patients received outpatient PIT from 2/99 to 1/05 (mean age was 14.6 years ± 3.7). Median duration of therapy was 10 weeks (range 4–84 weeks). The mean number of emergency department visits per patient was greater before starting PIT than after starting PIT (2.3 ± 1.8 versus 1.1 ± 2.2, P < .05). The mean number of hospital admissions from exacerbation of heart failure symptoms decreased after starting PIT (2.1 ± 1.3 versus 0.6 ± 0.8, P < .05). Mean EF% in patients with systolic dysfunction improved while on therapy (30 ± 14% before versus 39 ± 16% after, P < .05). There was 1 death and 5 complications in 2 patients. Six patients were successfully bridged to transplantation. Conclusion Outpatient continuous parenteral inotropic therapy may serve as a successful bridge to cardiac transplantation in selected pediatric outpatients.

ACE Inhibitors in Pediatric Patients with Heart Failure

This article reviews reports of ACE inhibitor use in pediatric heart failure and summarizes the present implications for clinical practice. Captopril, enalapril, and cilazapril are orally active ACE inhibitors, and widely used in pediatric cardiology, although more than ten other ACE inhibitors have been applied clinically in adults. Effects of ACE inhibitors on the renin-angiotensin-aldosterone system in pediatric patients are similar to those in adults. ACE inhibitors lower aortic pressure and systemic vascular resistance, do not affect pulmonary vascular resistance significantly, and lower left atrial and right atrial pressures in pediatric patients with heart failure. In infants with a large ventricular septal defect and pulmonary hypertension, ACE inhibitors decrease left-to-right shunt in those infants with elevated systemic vascular resistance. ACE inhibitors induce a small increase in left ventricular ejection fraction, left ventricular fractional shortening, and systemic blood flow in children with left ventricular dysfunction, mitral regurgitation, and aortic regurgitation. These beneficial effects usually persist long term without the development of tolerance. Therapeutic trials of ACE inhibitors have been reported in children with heart failure and divergent hemodynamics, including myocardial dysfunction, left-to-right shunt, such as large ventricular septal defect and pulmonary hypertension, aortic or mitral regurgitation, and Fontan circulation. Hypotension and renal failure usually occur within 5 days after starting ACE inhibition or increasing the dose and, in most cases, recovery is seen after reduction or cessation of the drug. With all ACE inhibitors, smaller doses are administered initially to prevent excessive hypotension, and doses are increased gradually to the target dose. Captopril is administered orally, usually every 8 hours. Daily doses range from 0.3 to 1.5 mg/kg in children. Enalapril is administered orally, once or twice a day, and daily doses range from 0.1 to 0.5 mg/kg. Enalaprilat is administered intravenously, one to three times a day, in doses ranging from 0.01 to 0.05 mg/kg/dose. For the treatment of chronic heart failure in children, ACE inhibitors are essential along with other medications including diuretics, digoxin, and beta-blockers (beta-adrenoceptor antagonists).

Optimizing treatment for chronic congestive heart failure in children.

Treatment strategies for chronic heart failure in children have generally been extrapolated from studies in adults with heart failure. This presentation reviews the existing knowledge and recommendations regarding the treatment of chronic heart failure in adults and the information that is available in children. Medications currently recommended for use in adults include diuretics, digoxin, angiotensin-converting enzyme inhibitors, and beta-blockers. These recommendations are based on results from large, randomized, multicenter trials. Anecdotal evidence suggests similar beneficial effects of these medications in children. The fact that the etiologies, pathophysiology, and physiologic consequences of heart failure in children often differ greatly from those in adults, however, justifies the development of prospective, randomized trials to evaluate these medications specifically in children. Findings from these types of studies will provide critical information for developing guidelines for the appropriate treatment of children with chronic heart failure.

Medical management of chronic heart failure in children.

Chronic heart failure (CHF) in children occurs mostly as a result of systolic dysfunction of the systemic ventricle or of congenital defects leading to large left-to-right shunts and pulmonary overcirculation. The ensuing symptoms and signs are similar in both cases, and include respiratory distress, poor feeding and growth, and hepatic congestion. Grading the severity of the symptoms accurately and reproducibly is important for studying CHF and the response to therapy. The Ross classification for young children and the New York Heart Association classification for older children are frequently utilized for such grading. The standard therapy for CHF in children consists of diuretics, to reduce cardiac preload and improve symptoms, and the maximization of nutritional support. The role of digoxin in treating CHF in children is controversial, especially regarding those children with pulmonary overcirculation where the function of the systemic ventricle is usually well preserved. As the importance of neurohormonal changes in the pathogenesis of worsening CHF is elucidated, newer medications aimed at counteracting such changes are becoming more important in the medical therapy of CHF in children. ACE inhibitors improve function and survival in adults with CHF, and they probably do the same in children with systemic ventricular dysfunction. It is less clear how effective they are in pulmonary overcirculation, but patients with high flow and low pulmonary resistance are most likely to benefit. In infants receiving treatment with ACE inhibitors, it is necessary to monitor for renal insufficiency or renal failure. beta-Adrenoceptor blockade has also been established as an effective therapy for adults with CHF with beneficial effects on survival and left ventricular function. While data for the pediatric population are limited, early studies suggest that beta-adrenoceptor antagonists (beta-blockers) may work well in infants and children with CHF. Caution must be used by starting treatment with very low dosages of beta-blockers and gradually increasing to the desired goals with close monitoring of blood pressure and heart rate. It is clear that larger multicenter trials are crucial to our ability to provide the most appropriate treatment for children with CHF. The demand for effective medical treatment will increase as more patients with palliated single ventricles survive surgery and then develop CHF from dysfunction of a hypertrophic and dilated single ventricle.