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Published on: April 18, 2025
Haemodynamic profiles of children with end-stage heart failure
Sharon Chen1, John C Dykes1, Doff B McElhinney1
1Stanford University, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA.
Insights
Congestion is more prevalent than low cardiac output in pediatric heart transplant candidates and links to symptoms and organ dysfunction. Combined congestion and low output significantly increase the risk of adverse outcomes.
Area of Science:
- Pediatric Cardiology
- Transplantation Medicine
- Hemodynamics
Background:
- End-stage heart failure in children often requires heart transplantation.
- Understanding hemodynamic profiles is crucial for managing these complex patients.
- Associations between specific hemodynamic parameters and clinical outcomes require further elucidation.
Purpose of the Study:
- To investigate the relationship between hemodynamic profiles (pulmonary capillary wedge pressure, right atrial pressure, cardiac index) and clinical status in children awaiting heart transplantation.
- To determine how these hemodynamic profiles correlate with symptoms, end-organ dysfunction (renal, hepatic), and waitlist outcomes.
Main Methods:
- Retrospective analysis of 1059 children listed for heart transplant between 1993 and 2013.
- Inclusion of cardiac catheterization data including pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), and cardiac index (CI).
- Outcomes assessed included New York Heart Association (NYHA)/Ross classification, renal and hepatic dysfunction, and death or clinical deterioration on the waitlist.
Main Results:
- Congestion (PCWP > 15 mmHg) was observed in 58% of children, with 28% having severe congestion (PCWP > 22 mmHg).
- Low cardiac output (CI < 2.2 L/min/m²) was present in 22% of patients.
- Worse NYHA/Ross classification correlated with increased PCWP; renal dysfunction with increased RAP; and hepatic dysfunction with both increased PCWP and RAP.
- Severe congestion was associated with an increased risk of death or clinical deterioration (OR 1.6), and the highest risk was observed in children with both low output and severe congestion (OR 1.9).
Conclusions:
- Congestion is a more frequent hemodynamic abnormality than low cardiac output in pediatric patients with end-stage heart failure awaiting transplantation.
- Hemodynamic parameters like PCWP and RAP are significantly associated with symptom severity and end-organ dysfunction.
- The combination of severe congestion and low cardiac output identifies a high-risk group for adverse events during the waitlist period.
Aims:
To evaluate associations between haemodynamic profiles and symptoms, end-organ function and outcome in children listed for heart transplantation.
Methods And Results:
Children <18 years listed for heart transplant between 1993 and 2013 with cardiac catheterization data [pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), and cardiac index (CI)] in the Pediatric Heart Transplant Study database were included. Outcomes were New York Heart Association (NYHA)/Ross classification, renal and hepatic dysfunction, and death or clinical deterioration while on waitlist. Among 1059 children analysed, median age was 6.9 years and 46% had dilated cardiomyopathy. Overall, 58% had congestion (PCWP >15 mmHg), 28% had severe congestion (PCWP >22 mmHg), and 22% low cardiac output (CI < 2.2 L/min/m2). Twenty-one per cent met the primary outcome of death (9%) or clinical deterioration (12%). In multivariable analysis, worse NYHA/Ross classification was associated with increased PCWP [odds ratio (OR) 1.03, 95% confidence interval (95% CI) 1.01-1.07, P = 0.01], renal dysfunction with increased RAP (OR 1.04, 95% CI 1.01-1.08, P = 0.007), and hepatic dysfunction with both increased PCWP (OR 1.03, 95% CI 1.01-1.06, P < 0.001) and increased RAP (OR 1.09, 95% CI 1.06-1.12, P < 0.001). There were no associations with low output. Death or clinical deterioration was associated with severe congestion (OR 1.6, 95% CI 1.2-2.2, P = 0.002), but not with CI alone. However, children with both low output and severe congestion were at highest risk (OR 1.9, 95% CI 1.1-3.5, P = 0.03).
Conclusion:
Congestion is more common than low cardiac output in children with end-stage heart failure and correlates with NYHA/Ross classification and end-organ dysfunction. Children with both congestion and low output have the highest risk of death or clinical deterioration.
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