Future pharmacologic agents for treatment of heart failure in children

Brazilian Guideline for Exercise Testing in Children and Adolescents - 2024

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Effectiveness of angiotensin-converting enzyme inhibitors in pediatric patients with mid to severe aortic valve regurgitation

The long-term benefit of angiotensin-converting enzyme inhibitors in pediatric patients with aortic valve regurgitation is under consideration. Eighteen patients with mid to severe aortic valve regurgitation were retrospectively evaluated. Echocardiographic parameters (left ventricular end-diastolic diameter, shortening fraction, left ventricular posterior wall thickness, and grade of aortic valve regurgitation) were analyzed before and during therapy with angiotensin-converting enzyme inhibitors. Data are given as standard deviation scores (Z-scores) derived from body surface-adjusted normal values. Median (interquartile range) age at start of therapy was 8.4 (5.4 to 10.0) years, and total follow-up 2.3 (0.9 to 5.4) years. Left ventricular end-diastolic diameter increased from 3.6 (2.3 to 4.5) to 3.7 (2.4 to 4.8), and left ventricular posterior wall diameter decreased from 1.9 (1.1 to 3.0) to 1.1 (0.5 to 2.3). Grade of aortic valve regurgitation increased from 3.5 (2.3 to 4.0) to 4.0 (2.0 to 4.0), and shortening fraction decreased from 39% (34% to 43%) to 37% (34% to 42%). No significant effect of angiotensin-converting enzyme inhibitors on left ventricular dimensions or function was found in our population of patients with mid to severe aortic valve regurgitation. Angiotensin-converting enzyme inhibitors may not alter left ventricular overload in pediatric patients with aortic valve regurgitation.

Contemporary management of pediatric heart failure

The spectrum of causes of pediatric heart failure is broad and differs significantly from that seen in most adult patients. Left-to-right shunts and outflow obstruction lesions are responsible for a large number of pediatric cases of heart failure. Most of these are now treated successfully with surgery or catheter intervention. Medical therapy is the mainstay of care for myocardial disorders with diuretics, angiotensin-converting enzyme inhibitors, beta-blockade and cardiac glycosides. There are few prospective trials of these agents in a pediatric population, but extrapolated data support their use in children. In addition to medical therapy, interventions such as automatic implantable cardioverter defibrillators and resynchronization therapy have become increasingly common in pediatric heart disease, as well as in adult patients with congenital heart disease.

Nesiritide for the treatment of pulmonary hypertension and cor pulmonale in an infant

Nesiritide is a synthetic form of B-type natriuretic peptide. It is approved for the treatment of acute exacerbations of congestive heart failure in hospitalized adult patients. It is currently under investigation for use in other settings and other patient populations. This article describes administration of nesiritide to an infant patient with severe pulmonary hypertension and cor pulmonale. No adverse reactions occurred during administration of the drug. Specifically, there was no hypertension, vomiting, arrhythmia, or changes in renal function. No changes in renal function occurred in the months subsequent to treatment. This case report illustrates that nesiritide can be safely administered to critically ill infants with pulmonary hypertension and cor pulmonale. Our patient experienced a decrease in pulmonary pressure and improved clinical condition during and after the infusion. However, further study is required to fully evaluate the safety and efficacy of nesiritide for these patients.