Heart failure in infants and children — branching viva

Station opening

Examiner: "Define heart failure in a child and explain why the mechanism matters more than the label." [3]

Strong candidate (must-hit)

• Defines paediatric heart failure as a clinical syndrome in which the heart cannot deliver adequate cardiac output, or does so only at raised filling pressure; explains that it is not one diagnosis but the end result of many mechanisms, and that the whole skill is to name the mechanism — a volume-overload shunt that is cured by closure, a pressure-load obstruction that is cured by relief, or an intrinsic pump failure that needs neurohormonal therapy and escalation — because the mechanism decides the management and, in most cases, the cure. [3] [6]

Weak candidate

• "Heart failure is when the heart doesn't pump properly, and we give diuretics." [3]

Branch A — The six-week-old in overcirculation

Examiner: "A thriving six-week-old has developed tachypnoea, sweating with feeds and failure to thrive, with a pansystolic murmur and an apical flow rumble. What is the diagnosis, why now, and what do you do?" [3]

Strong

• Diagnoses heart failure from pulmonary overcirculation caused by a moderate-to-large left-to-right shunt, most likely a ventricular septal defect; explains the four-to-eight-week window as the postnatal fall in pulmonary vascular resistance exposing and enlarging the shunt; grades it modified Ross class III; identifies the apical flow rumble as the sign of a large shunt through increased mitral inflow; starts a medical bridge with a loop diuretic (furosemide 1 to 2 mg/kg/day), an ACE inhibitor and caloric supplementation, using oxygen cautiously because it is a pulmonary vasodilator; arranges urgent echocardiography to confirm and size the defect; and refers for closure within the first year. [3] [6]

Weak

• "Give high-flow oxygen and a fluid bolus and see if the baby improves." [3]

Branch B — The two-day-old with duct-dependent collapse

Examiner: "A two-day-old term infant, previously well, is brought in grey, mottled and poorly perfused with weak pulses and a lactate of 8. There is no murmur. What is happening, and what is your first action?" [3]

Strong

• Diagnoses a duct-dependent circulation that has collapsed as the ductus closed — a hypoplastic left heart, a critical aortic stenosis, an interrupted aortic arch or a severe coarctation; explains that the presentation is shock and poor perfusion rather than congestion because the systemic output depended on the duct; states that the first action is to start a prostaglandin E1 infusion immediately to reopen the duct, alongside resuscitation, and only then to obtain the echocardiogram; arranges urgent transfer to a tertiary paediatric cardiology centre. [3] [6]

Weak

• "Give a fluid bolus and antibiotics for sepsis and wait for the blood cultures." [3]

Branch C — The adolescent with acute myocarditis

Examiner: "A fourteen-year-old with a viral prodrome now has breathlessness, a gallop, a displaced apex and hepatomegaly. What is the diagnosis, how do you confirm it, and what is the escalation if he deteriorates?" [4]

Strong

• Diagnoses acute myocarditis presenting as pump failure; confirms with echocardiography (a globally impaired, often dilated left ventricle with a low ejection fraction), an elevated troponin and NT-proBNP, and selected cardiac MRI; manages with admission, oxygen, a diuretic and an ACE inhibitor, with prompt treatment of any arrhythmia; and, anticipating the rapid deterioration that myocarditis can show, escalates to intensive care with milrinone for low output, non-invasive or invasive ventilation, and mechanical circulatory support (VA-ECMO or a Berlin Heart EXCOR ventricular assist device) as a bridge to recovery or transplantation. [4] [10]

Weak

• "It's a viral illness; send him home with paracetamol and review in a week." [4]

Branch D — The child with dilated cardiomyopathy

Examiner: "A ten-year-old with a dilated cardiomyopathy and an ejection fraction of 20 percent is on maximal medical therapy but is still symptomatic. Discuss the prognosis markers, the beta-blocker evidence, and the escalation pathway." [7]

Strong

• Cites the Pediatric Cardiomyopathy Registry finding that elevated resting heart rate and progressive left ventricular remodelling independently predict mortality, which justifies listing for transplantation; summarises the Shaddy carvedilol randomised controlled trial as showing no overall benefit in children, explaining the selective use of beta-blockade; and outlines the escalation to mechanical circulatory support with the Berlin Heart EXCOR ventricular assist device (Almond cohort) as a bridge to heart transplantation, with a palliative pathway if transplantation is not an option. [7] [10]

Weak

• "Increase his carvedilol — it's proven to improve survival in children." [7]

Close

Examiner: "Summarise your approach to the child with heart failure in one sentence." [3] [6]

Strong

• "Heart failure in a child is the syndrome of inadequate output or raised filling pressure: I classify it by the modified Ross severity grades and by the mechanism — volume overload, pressure overload, or pump failure — and I find and treat the cause, because most childhood heart failure is surgically curable; for the pump failures I resuscitate, give a diuretic and an ACE inhibitor, use a beta-blocker selectively because the carvedilol trial was negative, and escalate to the Berlin Heart EXCOR and transplantation before irreversible end-organ injury." [3] [6]