Pediatric heart failure and pediatric cardiomyopathies

Heart failure in children occurs with a heterogenous group of congenital and acquired diseases. Systolic ventricular dysfunction is the most common cause of pediatric heart failure; however, primary diastolic dysfunction can occur, particularly in patients with restrictive cardiomyopathy or complex congenital heart disease. Residual lesions, cyanosis, pulmonary hypertension, arrhythmias, and Fontan physiology are important contributors to heart failure severity. Heart failure in children ranges from acute decompensation with venous congestion and/or low cardiac output to more indolent manifestations such as growth failure or fatigue. Children with heart failure due to congenital heart disease may have a gradual decline in functional status that can be difficult to ascertain without close follow-up. Hepatic, renal, and infectious complications are important comorbidities that exacerbate heart failure. The approach to the child with heart failure includes instituting treatments to relieve acute symptoms and improve cardiac output, identifying underlying causes and comorbidities amenable to intervention, and risk stratifying patients to guide long-term management. Children with dilated cardiomyopathy are particularly challenging because they have dichotomous outcomes ranging from death or heart transplantation to normalization of function. Medical therapies in children with heart failure are largely based on data from adults with heart failure, despite significant differences in underlying cause and comorbidities. Advanced heart failure therapies such as ventricular assist devices and transplantation have transformed long-term outcomes in this population. Achieving optimal outcomes in children with heart failure requires a multidisciplinary patient-centered team with expertise in medical and surgical therapies, pharmacology, arrhythmias, and critical and palliative care.