Challenges in managing pediatric heart failure, especially in resource-limited settings

Pediatric heart failure (HF) is a complex syndrome with high morbidity, characterized by distinct epidemiological profiles globally. While congenital heart disease and cardiomyopathies predominate in developed regions, rheumatic heart disease and delayed surgical interventions drive the burden in low- and middle-income countries. This review elucidates the unique pathophysiology of pediatric HF, which differs significantly from that of adult HF in terms of developmental cardiac physiology, molecular signaling, and maladaptive ventricular remodeling. Diagnosis remains challenging due to nonspecific symptoms and the limitations of adult-derived classification systems and biomarkers. Management strategies are evolving beyond traditional regimens, and clinicians are increasingly adopting the "four-pillar" therapies, including Angiotensin Receptor-Neprilysin Inhibitors and sodium-glucose cotransporter-2 inhibitors. However, pediatric-specific evidence remains limited compared to adult data. Notably, the recent PANORAMA-HF trial showed that sacubitril/valsartan was similarly effective to enalapril but did not achieve statistically superior outcomes in children. For end-stage HF, ventricular assist devices and heart transplantation are critical, though donor shortages persist. Furthermore, pulmonary artery banding has re-emerged as a surgical strategy to induce left ventricular recovery in young children with dilated cardiomyopathy. Given the disparity in outcomes and the reliance on extrapolated adult data, there is an urgent need for large-scale, pediatric-specific clinical trials to optimize global management strategies.