Acute decompensated heart failure (ADHF) in children is characterized by high burdens of comorbidities, mortality, and frequent readmission, especially among patients with underlying congenital heart disease (CHD) according to a study published the Circulation: Heart Failure.

Children with ADHF represent a minority of admissions to pediatric cardiac intensive care units (CICUs). Children with CHD have ADHF as a final common pathway. There is limited understanding of the demographics, treatment strategies, complications, and outcomes for children with a broad array of etiologies for ADHF. This was an analysis of pediatric CICU admissions identified from a multicenter North American clinical registry for pediatric ADHF, conducted to define the epidemiology of critical ADHF and to identify risk factors for mortality.

The data of 26,294 patients ≤18 years admitted to a CICU at of 1 of 23 participating Pediatric Cardiac Critical Care Consortium (PC) centers between August 2014 and April 2017 were examined. ADHF was defined as the presence of documented systolic and/ or diastolic ventricular dysfunction and receipt of at least one of the following critical care therapies:  continuous vasoactive or diuretic infusion, respiratory support, or mechanical circulatory support. Demographics, diagnosis, therapies, complications, and mortality are described for the cohort, as well as in patients with ADHF and with or without CHD. Logistic regression analysis was performed to identify predictors of CICU mortality.

In this cohort, there were 1494 unique ADHF admissions (55% boys; 60% white; 57% with underlying CHD). The median age at presentation for ADHF was 0.93 years (interquartile range, 0.1–9.3 years). Admitted patients were treated with: vasoactive infusions (88%), central venous catheters (86%), mechanical ventilation (59%), and high flow nasal cannula (46%). Common complications among the ADHF admissions included arrhythmias (19%), cardiac arrest (10%), ventricular tachycardia (8%), sepsis (7%), and stroke (5%).

The median length of CICU stay was 7.9 days (interquartile range, 3–18 days), and the CICU readmission rate was 22%. CICU mortality (15%) was found to be higher for patients with vs without CHD (19% vs 11%, respectively; P <.001). CICU mortality was associated with the following independent risk factors: age <30 days, CHD, vasoactive infusions, ventricular tachycardia, mechanical ventilation, sepsis, pulmonary hypertension, extracorporeal membrane oxygenation, and cardiac arrest.

CHD was associated with an increased mortality for all age groups, with the strongest effect observed in neonates for whom this risk was 16-fold greater compared with that of the reference group (ie, children >1 year old without CHD; adjusted OR 16.2; 95% CI, 7.2–36.4; P <.001).

Limitations of the study include the lack of a consensus definition of pediatric ADHF, and the possible impact of unmeasured confounders not captured by this data set.

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“[W]e expect these results will inform the heart failure, transplant, and critical care communities while also fueling targeted research and quality improvement initiatives that reduce CICU-related morbidity and mortality in the ADHF population, especially among those patients with underlying CHD,” concluded the study authors.

Reference

Lasa JJ, Gaies M, Bush L, Zhang W, Banerjee M, Alten JA, et al. Epidemiology and outcomes of acute decompensated heart failure in children (published online April 9, 2020). Circ Heart Fail. doi:10.1161/CIRCHEARTFAILURE.119.006101