Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Treatment of Acute Heart Failure

Diagnosis and Management of Pediatric Heart Failure

Heart failure is a highly morbid syndrome, recognized as a major cause of adult mortality. Heart failure in pediatric patients, whether in the setting of congenital or acquired heart disease, is similarly associated with high mortality and resource utilization. Understanding the clinical presentation, diagnosis, and initial stabilization of pediatric heart failure is paramount for any acute care clinician as it may mimic common childhood ailments like viral respiratory or gastrointestinal illnesses. Pediatric heart failure occurs in patients with palliated or unpalliated congenital heart disease, familial or acquired cardiomyopathy, acquired valve disease, and myocarditis. This review will focus on heart failure in pediatric patients with structurally normal hearts and will summarize what is known about patterns of presentation, etiologies, diagnostic evaluation, and the acute and chronic management of this highly morbid syndrome.

Anesthetic Considerations in Pediatric Patients With Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) in pediatrics is a significant cause for morbidity and mortality in children. Congenital heart disease and cardiomyopathy are the leading etiologies of ADHF. It is common for these children to undergo diagnostic, therapeutic, or surgical procedure under anesthesia, which may be associated with significant morbidity and mortality. The importance of preanesthetic multidisciplinary planning with all involved teams, including anesthesia, cardiology, intensive care, perfusion, and cardiac surgery, cannot be emphasized enough. In order to safely manage these patients, it is imperative for the anesthesiologist to understand the complex pathophysiological interactions between cardiopulmonary systems and anesthesia during these procedures. This review discusses the etiology, pathophysiology, clinical manifestations, and perioperative management of these patients.

Update on pediatric heart failure

PURPOSE OF REVIEW

This review highlights recent advances in the diagnosis and management of children with heart failure. We emphasize the clinical approach to patient care in the areas of acute decompensated heart failure, chronic heart failure, and failure of the patient with single ventricle physiology.

RECENT FINDINGS

Important guidelines regarding the recognition and management of heart failure in children have been proposed and adopted, providing guidance for early recognition and ongoing management. Early diuresis, and avoidance of excessive inotropic agent use, in favor of milrinone as an inotropic-vasodilator agent, are emphasized. Close monitoring of airway pressures to improve ventricular filling, and extubation to positive pressure or high-flow nasal cannula therapy are also important. Chronic heart failure therapy requires combination treatment with diuretics, and the three major classes of drugs. Management of the failing Fontan requires attention to the hepatic, pulmonary and lymphatic circulations.

SUMMARY

Improved outcomes in children with heart failure are possible. Inherent in this success is the engagement of an interdisciplinary team-based approach to care, with early recognition and escalation of care for specific patients who are not improving as predicted.

Congenital Cardiac Defects That Are Borderline Candidates for Biventricular Repair

This article discusses congenital heart defects that are marginal candidates for biventricular repair and highlights the anatomic considerations upon which the surgical decision is based. Specifically, the article reviews the importance of capacitance and compliance of the ventricles and their associated atrioventricular valves. For each of the defects discussed, the imaging modalities used to diagnose a marginal ventricle are reviewed and the surgical decision-making process is outlined. The article also reviews immediate postoperative treatment of these patients and when to consider biventricular repair of a marginal lesion to be a failure.

Initial presentation and management of pediatric heart failure

PURPOSE OF REVIEW

Heart failure is a rare but morbid diagnosis in the pediatric patient presenting to the emergency department (ED). Familiarity of the ED physician with the presentation, work-up, and management of pediatric heart failure is essential as accurate diagnosis is reliant on a high degree of suspicion.

RECENT FINDINGS

Studies evaluating pediatric heart failure are limited by its rarity and the heterogeneity of underlying conditions. However, recent reports have provided new data on the epidemiology, presentation, and outcomes of children with heart failure.

SUMMARY

The recent studies reviewed here highlight the significant diagnostic and management challenges that pediatric heart failure presents given the variety and lack of specificity of its presenting signs, symptoms, and diagnostic work-up. This review provides the ED physician with a framework for understanding of pediatric heart failure to allow for efficient diagnosis and management of these patients. The primary focus of this review is heart failure in structurally normal hearts.