Paeds SAQs · cardiology
Cardiogenic shock and mechanical circulatory support — formative SAQs
Two formative SAQs on cardiogenic shock and mechanical circulatory support in children: the school-age child who presents three days after a viral illness in compensated then decompensating cardiogenic shock from fulminant myocarditis, testing the bedside distinction from distributive shock, the cautious-fluid principle, the SCAI stages, and the escalation to venoarterial extracorporeal membrane oxygenation as a bridge to recovery; and the adolescent with decompensated dilated cardiomyopathy requiring a durable ventricular assist device, testing the device choice, the four goals of support, the anticoagulation complication burden, and the bridge-to-transplant framing.
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Target exams
SAQ 1 — Fulminant myocarditis in a school-age child (10 marks, 15 minutes)
A previously well six-year-old boy presents three days after a febrile respiratory illness. He is cold and mottled with weak pulses, a capillary refill of four seconds, oliguria and a gallop rhythm. His blood pressure is 95/60 mmHg (normal for age), his respiratory rate is 42, and his lactate is 5.2 mmol/L. The electrocardiogram shows widespread ST and T-wave changes. The echocardiogram shows a globally hypokinetic left ventricle with a moderate pericardial effusion but no tamponade physiology. A diagnosis of cardiogenic shock from fulminant myocarditis is made. [2]
a) Explain why the normal blood pressure does not exclude shock, and state the bedside feature that confirms the shock is cardiogenic rather than distributive. (2 marks) [2] [13]
b) Outline your initial resuscitation, naming the fluid strategy and contrasting it with septic shock, the inotrope agents you would use, and the immediate disposition. (4 marks) [12] [11]
c) Using the SCAI classification, assign this child's stage on arrival and state the feature that marks progression to the stage requiring mechanical circulatory support. (2 marks) [2]
d) Six hours later his blood pressure falls to 60/40, the lactate rises to 8 mmol/L, and he remains oliguric on milrinone, dobutamine and adrenaline. What has happened, what is the definitive next intervention, and what is the expected goal and prognosis of that intervention in fulminant myocarditis? (2 marks) [10] [15]
SAQ 2 — Decompensated dilated cardiomyopathy in an adolescent (10 marks, 15 minutes)
A fourteen-year-old boy with known dilated cardiomyopathy presents with progressive breathlessness, a gallop rhythm, hepatomegaly and cool peripheries over three days. He is hypotensive with a lactate of 3.5 mmol/L. The echocardiogram shows a severely impaired, dilated left ventricle with moderate mitral regurgitation. He is stabilised on inotropes and a cautious fluid trial, but fails to improve. The cardiac team proceeds to durable mechanical circulatory support. [13]
a) Name the durable ventricular assist device most appropriate for an adolescent of his size, and state the device used for smaller children and infants, citing the relevant trial. (3 marks) [3] [5]
b) Define the four goals of mechanical circulatory support and state which goal applies to this boy and why. (3 marks) [6] [4]
c) Anticoagulation is mandatory. State the dominant complications the team must monitor for daily, and name two further device-related complications. (2 marks) [7] [8]
d) Outline the disposition and follow-up considerations for an adolescent on a durable device awaiting transplant, including the role of adherence and transition. (2 marks) [3] [13]
References
- [1]Amdani S; Rossano JW; Wilmot I; et al Evaluation and Management of Chronic Heart Failure in Children and Adolescents With Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circulation, 2024.PMID 38808502
- [2]Baran DA; Grines CL; Bailey S; et al SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society for Cardiovascular Angiography and Interventions (SCAI), and the Society of Thoracic Surgeons (STS). Catheter Cardiovasc Interv, 2019.PMID 31104355
- [3]Fraser CD Jr; Jaquiss RD; Rosenthal DN; et al Prospective trial of a pediatric ventricular assist device. N Engl J Med, 2012.PMID 22873533
- [4]Fraser CD Jr; Jaquiss RD The Berlin Heart EXCOR Pediatric ventricular assist device: history, North American experience, and future directions. Ann N Y Acad Sci, 2013.PMID 23750961
- [5]Almond CS; Morales DL; Blackstone MH; et al Berlin Heart EXCOR Pediatric ventricular assist device Investigational Device Exemption study: study design and rationale. Am Heart J, 2011.PMID 21884857
- [6]Rihal CS; Naidu SS; Givertz MM; et al 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care. J Card Fail, 2015.PMID 26036425
- [7]Assmann A; Boekstegers P; Brcic I; et al Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure -A clinical practice guideline. ESC Heart Fail, 2022.PMID 34811959
- [8]Bembea MM; Agus M; Akcan-Arikan A; et al Extracorporeal Membrane Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs. Pediatr Crit Care Med, 2023.PMID 36995097
- [9]Bhaskar P; Dhar R; Stephenson AL; et al Use of ECMO for Cardiogenic Shock in Pediatric Population. J Clin Med, 2021.PMID 33917910
- [10]Sachdev A; Chauhan S; Gupta D; et al Refractory pediatric cardiogenic shock: A case for mechanical support. Indian J Crit Care Med, 2016.PMID 27994387
- [11]Schranz D Pharmacological Heart Failure Therapy in Children: Focus on Inotropic Support. Handb Exp Pharmacol, 2020.PMID 31707469
- [12]Burkhardt BEA; Rucker G; Stiller B Inotropes for the prevention of low cardiac output syndrome and mortality for paediatric cardiac surgery patients. Cochrane Database Syst Rev, 2024.PMID 39588800
- [13]Rossano JW; Cherng An V; Lin KY; et al Heart failure in children: etiology and treatment. J Pediatr, 2014.PMID 24928699
- [14]Esangbedo ID; Biagas KV; Ma X; et al Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review. Pediatr Crit Care Med, 2020.PMID 32345933
- [15]Feng T; Zhao Y; Li L; et al Clinical outcomes of VA-ECMO in children with fulminant myocarditis: a single-centre case series. BMC Pediatr, 2026.PMID 42056983
- [16]Levin A Levosimendan. J Pediatr Intensive Care, 2013.PMID 31214430