Pediatric Heart Failure 2025 – Day-2 Expert Reflections
Pediatric Heart Failure 2025 – Day-2 Expert Reflections
Source: Jordan Cardiac Society Conference –Key insights and follow-up commentary from the second-day pediatric sessions and national roundtable discussions on heart failure in children.
1. Etiologic Insights – Pediatric vs Adult HF
• Ischemia is rare in children: Pediatric HF is overwhelmingly non-ischemic, caused mainly by congenital or structural defects.
Adult HF, in contrast, is dominated by ischemic heart disease (≈ 70%) and hypertension.
• Most common pediatric causes:
Congenital heart disease (60–70%), cardiomyopathies (20–25%), myocarditis (10–15%), rheumatic and Kawasaki disease, and chemotherapy-related (anthracycline) cardiomyopathy.
Less frequent: arrhythmia-induced, endocrine/metabolic, or infiltrative disorders.
• Clarification:
• Rheumatic heart disease does not refer to autoimmune “rheumatism” but rather to post-streptococcal valvular inflammation following Group A Streptococcus throat infection — leading to chronic mitral and aortic valve damage and later HF.
• SLE (Systemic Lupus Erythematosus), on the other hand, is a true autoimmune disorder that may cause myocarditis or pericarditis; it is much rarer but often treatable with immunosuppressive therapy.
• Distinctive pattern: Pediatric HF often results from volume/pressure overload or myocardial inflammation, not coronary atherosclerosis.
Many cases are potentially reversible with timely intervention — unlike the chronic degenerative course typical in adults.
2. Clinical Staging Adapted to Pediatrics
• Ross Classification (Infants & Young Children): focuses on feeding intolerance, tachypnea, diaphoresis, and growth failure.
• Modified NYHA (for Older Children): evaluates limitation during school or play activities rather than occupational effort.
• Difference from Adult AHA/ACC Staging (A–D):
• Pediatric systems are symptom-based, emphasizing growth and developmental parameters.
• Adult staging is disease-progression-based, following risk → structural change → symptomatic → refractory HF.
• Pediatric staging guides daily care and growth monitoring, while adult staging defines long-term prognosis and therapy planning.
3. Diagnostic Refinements
• Echocardiography: the cornerstone for assessing chamber size, systolic/diastolic function, and valves.
• Traditional EF: measures the percentage of blood pumped out of the ventricle. EF may remain normal even when the myocardium is already weakening.
• GLS (Global Longitudinal Strain): detects this early decline before EF falls, serving as an early-warning sign for subtle LV dysfunction.
It measures how strongly the heart muscle contracts along its length—from base to apex.
When the heart beats, fibers shorten and twist lengthwise—like a sponge squeezed from both ends.
GLS tracks this motion by following tiny “speckles” on the heart wall using speckle-tracking echocardiography.
• This technique became practical with the spread of 3-D / 4-D echocardiography, allowing quantitative detection of early dysfunction.
• Cardiac MRI (CMR): identifies fibrosis or edema and differentiates myocarditis vs cardiomyopathy, guiding prognosis and transplant timing.
• Biomarkers: BNP and NT-proBNP correlate with severity and should be trended serially.
4. Pharmacologic & Device Updates
• ARNI (Sacubitril/Valsartan): FDA-approved ≥ 1 year; cornerstone therapy for pediatric HFrEF when tolerated.
• β-Blockers & MRAs: remain mainstays; dosing individualized by weight and target HR.
• Ivabradine: FDA-approved ≥ 6 months; for symptomatic children in sinus rhythm with HR > 100 bpm despite β-blocker—reflecting the higher physiologic pediatric HR compared with adult targets (≈ 60–70 bpm).
• SGLT2 Inhibitors: still investigational in pediatrics; not yet part of the “four-pillar” therapy. Consider only after standard triple therapy (ARNI/ACEI + β-blocker + MRA) in expert centers.
• ECMO / VAD: ECMO for acute decompensation or cardiogenic shock before multi-organ failure; VADs (e.g., Berlin Heart EXCOR, HeartMate III) as long-term bridges to recovery or transplant.
5. Supportive and Preventive Care
• Psychosocial and transition-of-care programs are vital, especially for adolescents moving to adult clinics.
• Vaccination bundle: influenza, pneumococcus, RSV (where eligible).
• Nutrition: address both caloric needs and micronutrient deficiencies (iron, vitamin D).
• Home monitoring:
• Home scale: daily weight tracking; > 1–2 kg gain in 48 h signals fluid retention.
• Tele-HF tools: remote SpO₂ and ECG upload for early detection of decompensation.
6. National Recommendations and Future Priorities
• Establish a Jordan Pediatric HF Registry linked with adult registries for longitudinal data.
• Launch district HF clinics with certified HF nurses and coordinators.
• Create standardized transfer pathways (door-to-VAD / door-to-transplant) to ensure timely access to advanced care.
• Strengthen public awareness campaigns for early recognition of pediatric cardiac symptoms.
• Integrate tele-HF monitoring into national quality-improvement initiatives.
7. Key Takeaway
Pediatric heart failure differs fundamentally from adult HF in etiology, physiology, and reversibility.
The use of GLS and 3-D / 4-D echocardiography, alongside pediatric-specific staging and unified national pathways, represents a transformative step in modern cardiac care.
The Jordan Cardiac Society’s Pediatric HF Program establishes a regional model for standardized, multidisciplinary management—ensuring that every child receives timely, evidence-based, and compassionate treatment.
