Pediatric Cardiology

Association Between Serial B-Type Natriuretic Peptide Levels, Vasoactive Drug Weaning, and Adverse Cardiovascular Outcomes in Pediatric Heart Failure. Loss KL, Su J, Menteer J, Weisert MA, Shaddy RE, Kantor PF.J Am Heart Assoc. 2024 Aug 20;13(16):e031132. doi: 10.1161/JAHA.123.031132. Epub 2024 Aug 9.PMID: 39119990 Take Home Points: More than 50% reduction in proBNP levels by six day was a valuable data piece helping in assisting the prognosis and adding a predictive value in management. Qualitatively RV systolic dysfunction baseline at admission, and persistent RV dysfunction is an independent factor in multivariate analysis for adverse cardiovascular outcomes. The severity of LV systolic dysfunction, LV dilation, presence of moderate or more mitral regurgitation, presence of qualitative RV systolic dysfunction, and a higher baseline BNP, BUN, and creatinine level are associated with higher intravenous vasoactive drugs support. Commentary from Dr. Vimal Jayswal (Indiana, USA), editor of Pediatric & Fetal Cardiology Journal Watch.                                                                                                                                                               Introduction: Pediatric heart failure is a complex pathophysiological disease with inherent challenges during inpatient management, this is due to limited cardiovascular reserve and severely ill patient population that makes it more difficult to predict its prognosis in a timely fashion before acute cardiovascular events such as death or listing for heart transplant occurred. Non-invasive biomarkers such as pro-B-type natriuretic peptide have been an active area of interest for researchers. This study provides a good insight into inpatient management by monitoring trend of pro BNP, percentage decrease from initial admission level, > 50 % drop in proBNP by 6th day of hospitalization could be a valuable tool for an eventual clinical composite score model for prognosis and prediction of ACV event outcomes.  Pro BNP levels are routinely monitored during inpatient hospitalization for pediatric heart failure patients; it is produced by ventricular myocytes in response to pressure and volume overload and wall tension. Daphne Hsu et al showed in children with moderately symptomatic HF, BNP ≥140 pg/mL and age >2 years identified subjects at higher risk for worse outcome. Price et al reported a positive association of a BNP level of 300 pg/mL with a 90-day composite outcome of HF-related hospitalization, HF-related death, or listing for transplantation.  Data collection and its clinical relevance: It’s a comprehensive retrospective chart review study from January, 2005 to July, 2021 with acute decompensated heart failure and with biventricular physiology with systemic left ventricular dysfunction. It's a robust study with emphasis on linear mixed-effects modeling to analyze BNP trends.   Results: Results were assessed either in the form of acute cardiovascular events, such as heart transplantation, death, or mechanical circulation. The secondary outcome such as successful weaning of inotropic support. Figure 1 The most commonly used drug for IV Vasoactive support during all hospitalizations was milrinone (N=81, 83.6%),  followed by dopamine (N=70, 72.2%), epinephrine (N=51, 52.6%), nicardipine (N=23, 23.7%), dobutamine (N=11, 11.3%), vasopressin (N=7, 7.2%), esmolol (N=6, 6.5%), and norepinephrine (N=4, 4.1%). Diuretics were used in 122 hospitalizations (93.1%), with IV intermittent or continuous furosemide being used in 92 (70.2%). 47% (N=62) of hospitalization reached ACV outcomes: 11 (8.4%) died, 11 8.4%) underwent HT, and 40 (30.5%) needed MCS. Of those patients who needed MCS, 10 (25%) received exclusively extracorporeal membrane oxygenation, 25 (62.5%) received exclusively VAD, and 5 (12.5%) received both extracorporeal membrane oxygenation and VAD during the hospitalization. Individuals who received IVV support (74/94) had a higher initial BNP level (1030 [542–1920] versus 572 [206–1630] pg/mL, P=0.038). None of the others baseline demographic, clinical, laboratory, or echocardiographic characteristics differentiated patients who failed weaning from those who weaned successfully from IVV support. Risk Factors for ACV Outcomes: The risk of ACV increased with a reduced baseline LVSF, LVEF, and the presence of qualitative RV systolic dysfunction. Limitation of study: It’s a single center retrospective study focusing on a biventricular pediatric heart failure patient with LV systolic dysfunction and results cannot be generalized on many single ventricle patients or other unrepaired complex congenital heart defects patients. Similarly, improvement in new modality for pediatric heart failure management, response to diuretics, improvement in ICU care, nursing care would also bring complexity in interpreting the data and extrapolating to current management.  Conclusion: In pediatric patients admitted with acute decompensated heart failure, baseline RV systolic dysfunction was independently associated with adverse CV outcomes. We identified a high prevalence of IV Vasoactive support that was associated with the severity of LV systolic dysfunction, LV dilation, presence of moderate or more mitral regurgitation, presence of qualitative RV systolic dysfunction, and a higher baseline BNP, BUN, and creatinine level. A serial decline in BNP levels reliably indicated patients unlikely to experience adverse CV outcome and likely to have successful weaning from IV vasoactive support.