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Clinical and Echocardiographic Determinants of Moderate Heart Failure in Children with Acyanotic Congenital Heart
I Ketut Alit Utamayasa1,2, Prima Hari Nastiti1,2, Ayurveda Zaynabila Heriqbaldi3
1Department of Child Health, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia.
Insights
Left ventricular remodeling and elevated mean pulmonary arterial pressure are key indicators of moderate heart failure in children with acyanotic congenital heart disease. These findings aid in developing predictive models for pediatric heart failure management.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease
- Heart Failure Research
Background:
- Heart failure (HF) is a significant complication in pediatric acyanotic congenital heart disease (CHD).
- Limited evidence exists for integrating clinical and echocardiographic data to stratify HF severity in this population.
- This study addresses the need for better HF assessment tools in children with acyanotic CHD.
Purpose of the Study:
- To identify factors associated with moderate heart failure in pediatric acyanotic CHD.
- To develop and internally validate an exploratory prediction model for moderate HF.
- To improve the understanding and management of HF in children with CHD.
Main Methods:
- Retrospective analysis of 219 children (0-16 years) with acyanotic CHD.
- Defined moderate HF using Ross score or NYHA class.
- Employed Firth's penalized logistic regression and internal validation techniques (bootstrap, LOOCV).
Main Results:
- Moderate HF identified in 59.8% of patients.
- Left ventricular (LV) remodeling (LVIDD z-score > +2) and elevated mean pulmonary arterial pressure (MPAP) were independently associated with moderate HF.
- An MPAP threshold of ≥26.4 mmHg showed 78.6% sensitivity for identifying moderate HF.
Conclusions:
- LV remodeling and elevated MPAP are significant independent predictors of moderate HF in pediatric acyanotic CHD.
- The exploratory prediction model showed acceptable discrimination using routine variables.
- Further prospective, multicenter external validation is necessary before clinical application.
Abstract:
Background: Heart failure (HF) remains a major complication of acyanotic congenital heart disease (CHD) in children. Evidence integrating clinical and echocardiographic variables for HF severity stratification in pediatric acyanotic CHD remains limited. This study aimed to identify factors associated with moderate HF and develop an exploratory internally validated prediction model. Methods: This retrospective single-center outpatient study included 219 children aged 0-16 years with acyanotic CHD, identified from medical records spanning January 2023 to December 2025. Moderate HF was defined as Ross score 7-9 (≤5 years) or NYHA class III (>5 years). Multivariable analysis was performed using Firth's penalized logistic regression. Internal validation used bootstrap optimism correction and leave-one-out cross-validation (LOOCV). Model discrimination was assessed using area under the receiver operating characteristic curve (AUC). Results: Moderate HF was identified in 131 patients (59.8%). LV remodelling defined by LVIDD z-score > +2 (adjusted OR 3.70, 95% CI 1.22-11.24; p = 0.021) and higher mean pulmonary arterial pressure (MPAP) (adjusted OR 1.03 per mmHg, 95% CI 1.00-1.06; p = 0.049) were independently associated with moderate HF. Premature birth showed an inverse association with moderate HF (adjusted OR 0.25, 95% CI 0.13-0.48; p < 0.001). The exploratory five-variable model demonstrated acceptable discrimination (apparent AUC 0.780, 95% CI 0.728-0.849; bootstrap-corrected AUC 0.760; LOOCV AUC 0.749, 95% CI 0.681-0.811), with adequate calibration. An MPAP threshold of ≥26.4 mmHg yielded 78.6% sensitivity for moderate HF identification. Conclusions: LV remodelling and elevated MPAP were independently associated with moderate HF in children with acyanotic CHD. The exploratory internally validated model demonstrated acceptable discrimination using routinely available variables. This model is exploratory and not yet ready for clinical use; prospective multicenter external validation is required before any clinical implementation.
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An X-ray, or radiograph, is a non-invasive method that uses ionizing radiation to take images of internal structures. It is mainly used in cardiac imaging to examine the heart, lungs, and major blood vessels, aiming to identify abnormalities in the heart's size, shape, and position, such as heart failure, congenital defects, and vascular...