Turkiye Klinikleri Journal of Medical Sciences

.: ORIGINAL RESEARCH
Retrospective Evaluation of the Cases Presenting to the Pediatric Intensive Care Unit with Cardiogenic Shock in Terms of Etiology, Treatment and Long-Term Prognosis
Pediatrik Yoğun Bakım Ünitesine Kardiyojenik Şok Tablosunda Başvuran Olguların Etiyoloji, Tedavi ve Uzun Dönem Prognoz Açısından Retrospektif Değerlendirilmesi
Ebru AZAPAĞASIa, Selman KESİCİb, Bilge AKKAYAc, Tamer YOLDAŞd, Mutlu UYSAL YAZICIa, Zeynelabidin ÖZTÜRKe, Mehmet TAŞARf, Utku Arman ÖRÜNd
aDivision of Pediatric Intensive Care, Gazi University Faculty of Medicine, Ankara, Türkiye
bDivision of Pediatric Intensive Care, Hacettepe University Faculty of Medicine, Ankara, Türkiye
cDepartment of Pediatrics, University of Health Sciences Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Türkiye
dDivision of Pediatric Cardiology, University of Health Sciences Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Türkiye
eDivision of Pediatric Intensive Care, University of Health Sciences Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara Türkiye
fDivision of Cardiovascular Surgery, University of Health Sciences Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Türkiye
Turkiye Klinikleri J Med Sci. 2022;42(2):69-78
doi: 10.5336/medsci.2022-89203
Article Language: EN
Full Text
ABSTRACT
 Objective: Cardiogenic shock is acute circulation failure emerging with a linkage to disrupted myocardial contraction. The aim of this study is to identify the underlying etiology, assess the treatment methods, and the longterm prognoses of survivors among the patients admitted to intensive care with cardiogenic shock for the first time and without a previous heart disease history. Material and Methods: This study included patients admitted to the intensive care unit in our hospital for the first time with cardiogenic shock from March 2016 to March 2020. The age interval was 1 month to 18 years. The demographic, clinical, laboratory, and radiological findings for patients were recorded. All patients were evaluated with echocardiography at admission and 12 months after discharge. Results: Of the 24 patients included in this study, 50% were girls (n=12). Nineteen (79.1%) of the 24 patients had acute myocarditis as the underlying cause. Three (12.5%) patients had hypocalcaemia linked to vitamin D deficiency, 1 (4.2%) patient had anomalous left coronary artery from the pulmonary artery syndrome, and 1 (4.2%) patient had cardiac tamponade linked to purulent pericarditis. In echocardiographic examinations performed at a 12-month interval, left ventricle ejection fraction increased from 32.45±9.26% to 49.18±15.53%, and left ventricle end-diastolic diameter Z score decreased from 5.65 (4.4) to 2.02 (4.76). Conclusion: With appropriate fluids, diuretic treatment, inotrope management, and extracorporeal support, the prognosis for these patients has clearly improved in recent years.

Keywords: Pediatric intensive care; cardiogenic shock; myocarditis; dilated cardiomyopathy
ÖZET
 Amaç: Kardiyojenik şok, miyokardiyal kontraksiyonun bozulmasına bağlı akut dolaşım yetersizliğidir. Bu çalışmanın amacı, yoğun bakıma kardiyojenik şok kliniği ile ilk kez yatırılan ve bilinen kalp hastalığı olmayan hastalarda, altta yatan etiyolojiyi saptamak, uygulanan tedavi yöntemlerini ve yaşayan hastalarda uzun dönem prognozu değerlendirmektir. Gereç ve Yöntemler: Bu çalışmaya, Mart 2016-Mart 2020 tarihleri arasında kardiyojenik şok kliniği ile ilk kez hastanemiz yoğun bakım ünitesine yatırılan hastalar dâhil edildi. Yaş aralığı 1 ay-18 yaş idi. Hastaların demografik, klinik, laboratuvar ve radyolojik bulguları kaydedildi. Tüm hastalar, yatışta ve taburcu olduktan 12 ay sonra ekokardiyografi ile değerlendirildi. Bulgular: Çalışmaya 24 hasta dâhil edildi, %50'si kız (n=12) idi. Yirmi dört hastanın 19'unda (%79,1) altta yatan neden akut miyokardit, 3 (%12,5) hastada D vitamini eksikliğine bağlı hipokalsemi, 1 (%4,2) hastada sol koroner arterin pulmoner arterden çıkış anomalisi, 1 (4,2%) hastada pürülan perikardite bağlı kardiyak tamponad idi. On iki ay arayla yapılan ekokardiyografik incelemelerde sol ventrikül ejeksiyon fraksiyonunun %32,45±9,26'dan %49,18±15,53'e yükseldiği; sol ventrikül diyastol sonu çapı Z skorunun 5,65'ten (4,4) 2,02'ye (4,76) düştüğü bulundu. Sonuç: Uygun sıvı, uygun diüretik tedavi, doğru inotrop yönetimi ve uygun ekstrakorporeal destek tedavileri ile son yıllarda bu hastaların prognozlarında belirgin düzelme izlenmektedir.

Anahtar Kelimeler: Çocuk yoğun bakım; kardiyojenik şok; miyokardit; dilate kardiyomiyopati
REFERENCES:
  1. Brissaud O, Botte A, Cambonie G, Dauger S, de Saint Blanquat L, Durand P, et al. Experts' recommendations for the management of cardiogenic shock in children. Ann Intensive Care. 2016;6(1):14. [Crossref]  [PubMed]  [PMC] 
  2. Subramaniam S, Rutman M. Cardiogenic shock. Pediatr Rev. 2015;36(5):225-6. [Crossref]  [PubMed] 
  3. Massin MM, Astadicko I, Dessy H. Epidemiology of heart failure in a tertiary pediatric center. Clin Cardiol. 2008;31(8):388-91. [Crossref]  [PubMed]  [PMC] 
  4. Biarent D, Bingham R, Eich C, López-Herce J, Maconochie I, Rodríguez-Nú-ez A, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support. Resuscitation. 2010;81(10):1364-88. [Crossref]  [PubMed] 
  5. Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1):2-8. [Crossref]  [PubMed] 
  6. Tunuguntla H, Jeewa A, Denfield SW. Acute myocarditis and pericarditis in children. Pediatr Rev. 2019;40(1):14-25. [Crossref]  [PubMed] 
  7. Huang X, Sun Y, Su G, Li Y, Shuai X. Intravenous immunoglobulin therapy for acute myocarditis in children and adults. Int Heart J. 2019;60(2):359-65. [Crossref]  [PubMed] 
  8. Arola A, Pikkarainen E, Sipilä JO, Pykäri J, Rautava P, Kytö V. Occurrence and features of childhood myocarditis: a nationwide study in Finland. J Am Heart Assoc. 2017;6(11):e005306. [Crossref]  [PubMed]  [PMC] 
  9. Kim J, Cho MJ. Acute myocarditis in children: a 10-year nationwide study (2007-2016) based on the health insurance review and assessment service database in Korea. Korean Circ J. 2020;50(11):1013-22. [Crossref]  [PubMed]  [PMC] 
  10. Wu HP, Lin MJ, Yang WC, Wu KH, Chen CY. Predictors of extracorporeal membrane oxygenation support for children with acute myocarditis. Biomed Res Int. 2017;2017:2510695. [Crossref]  [PubMed]  [PMC] 
  11. Duncan BW, Bohn DJ, Atz AM, French JW, Laussen PC, Wessel DL. Mechanical circulatory support for the treatment of children with acute fulminant myocarditis. J Thorac Cardiovasc Surg. 2001;122(3):440-8. [Crossref]  [PubMed] 
  12. Kato S, Morimoto S, Hiramitsu S, Uemura A, Ohtsuki M, Kato Y, et al. Risk factors for patients developing a fulminant course with acute myocarditis. Circ J. 2004;68(8):734-9. [Crossref]  [PubMed] 
  13. Al-Biltagi M, Issa M, Hagar HA, Abdel-Hafez M, Aziz NA. Circulating cardiac troponins levels and cardiac dysfunction in children with acute and fulminant viral myocarditis. Acta Paediatr. 2010;99(10):1510-6. [Crossref]  [PubMed] 
  14. Lee EY, Lee HL, Kim HT, Lee HD, Park JA. Clinical features and short-term outcomes of pediatric acute fulminant myocarditis in a single center. Korean J Pediatr. 2014;57(11):489-95. [Crossref]  [PubMed]  [PMC] 
  15. Howard A, Hasan A, Brownlee J, Mehmood N, Ali M, Mehta S, et al. Pediatric myocarditis protocol: an algorithm for early identification and management with retrospective analysis for validation. Pediatr Cardiol. 2020;41(2):316-26. [Crossref]  [PubMed] 
  16. Chong SL, Bautista D, Ang AS. Diagnosing paediatric myocarditis: what really matters. Emerg Med J. 2015;32(2):138-43. [Crossref]  [PubMed] 
  17. Tschöpe C, Ammirati E, Bozkurt B, Caforio ALP, Cooper LT, Felix SB, et al. Myocarditis and inflammatory cardiomyopathy: current evidence and future directions. Nat Rev Cardiol. 2021;18(3):169-93. [Crossref]  [PubMed]  [PMC] 
  18. Ammirati E, Frigerio M, Adler ED, Basso C, Birnie DH, Brambatti M, et al. Management of acute myocarditis and chronic inflammatory cardiomyopathy: an expert consensus document. Circ Heart Fail. 2020;13(11):e007405. [PubMed]  [PMC] 
  19. Rodriguez-Gonzalez M, Sanchez-Codez MI, Lubian-Gutierrez M, Castellano-Martinez A. Clinical presentation and early predictors for poor outcomes in pediatric myocarditis: a retrospective study. World J Clin Cases. 2019;7(5):548-61. [Crossref]  [PubMed]  [PMC] 
  20. Feldman AM, McNamara D. Myocarditis. N Engl J Med. 2000;343(19):1388-98. [Crossref]  [PubMed] 
  21. Cooper LT Jr. Myocarditis. N Engl J Med. 2009;360(15):1526-38. [Crossref]  [PubMed]  [PMC] 
  22. Daubeney PE, Nugent AW, Chondros P, Carlin JB, Colan SD, Cheung M, et al; National Australian Childhood Cardiomyopathy Study. Clinical features and outcomes of childhood dilated cardiomyopathy: results from a national population-based study. Circulation. 2006;114(24):2671-8. [Crossref]  [PubMed] 
  23. Lipshultz SE, Sleeper LA, Towbin JA, Lowe AM, Orav EJ, Cox GF, et al. The incidence of pediatric cardiomyopathy in two regions of the United States. N Engl J Med. 2003;348(17):1647-55. [Crossref]  [PubMed] 
  24. Towbin JA, Lowe AM, Colan SD, Sleeper LA, Orav EJ, Clunie S, et al. Incidence, causes, and outcomes of dilated cardiomyopathy in children. JAMA. 2006;296(15):1867-76. [Crossref]  [PubMed] 
  25. Weintraub RG, Semsarian C, Macdonald P. Dilated cardiomyopathy. Lancet. 2017;390(10092):400-14. [Crossref]  [PubMed] 
  26. Sanyal D, Raychaudhuri M. Infants with dilated cardiomyopathy and hypocalcemia. Indian J Endocrinol Metab. 2013;17(Suppl 1):S221-3. [Crossref]  [PubMed]  [PMC] 
  27. Krishna MR. ALCAPA-A reversible cause of dilated cardiomyopathy in infants. Indian J Pediatr. 2022;89(2):197. [Crossref]  [PubMed] 
  28. Gupta P, Tomar M, Radhakrishnan S, Shrivastava S. Hypocalcemic cardiomyopathy presenting as cardiogenic shock. Ann Pediatr Cardiol. 2011;4(2):152-5. [Crossref]  [PubMed]  [PMC] 
  29. Calaghan SC, White E. The role of calcium in the response of cardiac muscle to stretch. Prog Biophys Mol Biol. 1999;71(1):59-90. [Crossref]  [PubMed] 
  30. Tomar M, Radhakrishnan S, Shrivastava S. Myocardial dysfunction due to hypocalcemia. Indian Pediatr. 2010;47(9):781-3. [Crossref]  [PubMed] 
  31. Dodge-Khatami A, Mavroudis C, Backer CL. Anomalous origin of the left coronary artery from the pulmonary artery: collective review of surgical therapy. Ann Thorac Surg. 2002;74(3):946-55. [Crossref]  [PubMed] 
  32. Pe-a E, Nguyen ET, Merchant N, Dennie C. ALCAPA syndrome: not just a pediatric disease. Radiographics. 2009;29(2):553-65. [Crossref]  [PubMed] 
  33. Bhaduri-McIntosh S, Prasad M, Moltedo J, Vázquez M. Purulent pericarditis caused by group a streptococcus. Tex Heart Inst J. 2006;33(4):519-22. [PubMed]  [PMC] 
  34. Cakir O, Gurkan F, Balci AE, Eren N, Dikici B. Purulent pericarditis in childhood: ten years of experience. J Pediatr Surg. 2002;37(10):1404-8. [Crossref]  [PubMed] 
  35. Majid AA, Omar A. Diagnosis and management of purulent pericarditis. Experience with pericardiectomy. J Thorac Cardiovasc Surg. 1991;102(3):413-7. [Crossref]  [PubMed] 

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