Management of Pediatric Heart Failure

Abstract

Heart failure in children is complex with multiple diverse etiologies, severities of presentation, and fluctuating clinical courses over time. Morbidity and mortality are high. Treatment approaches are based predominantly on expert consensus guidelines extrapolated from adult evidence-based literature. The goal is to encourage reverse remodeling of the myocardium that is failing due to maladaptive changes related to the underlying heart failure pathophysiology. Establishing guideline directed medical therapy is key concurrent with addressing other key factors contributing to ventricular dysfunction and heart failure. The purpose of this review is to summarize the current state of the art management of systolic heart failure in children. ABSTRACT Heart failure (HF) in children is a complex syndrome with multiple diverse etiologies and both acute and chronic presentations. Chronic presentations can persist throughout childhood and adolescence, and require diligent management with ongoing reassessment to maximize survival and quality of life. Stages of HF are key to recognize as they guide both management and inform prognosis. In more severe cases, children can present with signs of low cardiac output and circulatory collapse with potential to transition either to a chronic HF stage or progress to a need for advanced HF therapies. Morbidity and mortality are high. Managing HF requires a multidisciplinary approach that can adapt to the needs of the different phases of childhood and adolescence. Treatment can include medications, nutritional support, activity modifications, and potentially surgical intervention, pacemaker, respiratory or mechanical support, or even heart transplantation. Limited evidence exists for almost all medical therapies used in the management of HF in children and approaches are predominantly extrapolated from extensive adult experience. There are multiple maladaptive pathways in the failing heart; medications that modify these maladaptive pathways promote "reverse remodelling" of the myocardium and are key to the management, forming the basis for "guideline directed medical therapy". The purpose of this review is to summarize the current state of the art management of systolic HF in children.