Хроническая сердечная недостаточность у детей: этиология, патогенез, клиника и диагностика

Хроническая сердечная недостаточность (ХСН) является грозным осложнением заболеваний сердечно-сосудистой системы или её поражений при других формах патологии и характеризуется значительным риском инвалидизации и смертности. В основе прогрессирования ХСН любой этиологии лежит ремоделирование сердечно-сосудистой системы, связанное с активацией нейрогормональных систем: симпатико-адреналовой (САС) и ренин-ангиотензин-альдостероновой (РААС). Цель обзора: представить современные концепции этиологии, патогенеза, диагностики и клинической картины ХСН у детей для оптимизации клинического ведения больных и расширения объёма знаний практикующих врачей. Современным фармакологическим методом лечения, влияющим на прогноз, предупреждающим прогрессирование поражения миокарда, является модулирование активности САС и РААС на циркуляторном, тканевом и клеточном уровнях. При определении тактики лечения детей следует установить этиологию ХСН, идентифицировать сопутствующие формы патологии, определить варианты и степень выраженности дисфункции миокарда, оценить тяжесть клинических проявлений.

обзор, дети, сердечная недостаточность, диагностика, клиника, прогноз

1. Mcdonagh T.A., Metra M., Adamo M., Gardner R.S., Baumbach A., Böhm M. и др. 2021 Рекомендации ESC по диагностике и лечению острой и хронической сердечной недостаточности. Российский кардиологический журнал. 2023; 28(1): 117–224. https://doi.org/10.15829/1560-4071-2023-5168 https://elibrary.ru/sjmikk

2. Frazier A., Hunt E.A., Holmes K. Pediatric cardiac emergencies: Children are not small adults. J. Emerg. Trauma Shock. 2011; 4(1): 89–96. https://doi.org/10.4103/0974-2700.76842

3. Penny D.J., Vick G.W. 3rd. Ventricular septal defect. Lancet. 2011; 377(9771): 1103–12. https://doi.org/10.1016/S0140-6736(10)61339-6

4. Басаргина Е.Н., Шарыкин А.С., Ковалев И.А., Котлукова Н.П., Леонтьева И.В. Диагностика и лечение хронической сердечной недостаточности у детей и подростков, методические рекомендации. М.; 2010. https://elibrary.ru/tlkkvx

5. Masarone D., Valente F., Rubino M., Vastarella R., Gravino R., Rea A., et al. Pediatric heart failure: a practical guide to diagnosis and management. Pediatr. Neonatol. 2017; 58(4): 303–12. https://doi.org/10.1016/j.pedneo.2017.01.001

6. Unger T., Li J. The role of the renin-angiotensin-aldosterone system in heart failure. J. Renin Angiotensin Aldosterone Syst. 2004; 5(Suppl. 1): S7–10. https://doi.org/10.3317/jraas.2004.024

7. Mille F., Burstein D. Diagnosis and management of pediatric heart failure. Indian J. Pediatr. 2023; 90(5): 492–500. https://doi.org/10.1007/s12098-022-04433-4

8. Riccardi M., Sammartino A.M., Piepoli M., Adamo M., Pagnesi M., Rosano G., et al. Heart failure: an update from the last years and a look at the near future. ESC Heart Fail. 2022; 9(6): 3667–93. https://doi.org/10.1002/ehf2.14257

9. Das B., Deshpande S., Akam-Venkata J., Shakti D., Moskowitz W., Lipshultz S.E. Heart failure with preserved ejection fraction in children. Pediatr. Cardiol. 2023; 44(3): 513–29. https://doi.org/10.1007/s00246-022-02960-7

10. Gevaert A.B., Kataria R., Zannad F., Sauer A.J., Damman K., Sharma K., et al. Heart failure with preserved ejection fraction: recent concepts in diagnosis, mechanisms and management. Heart. 2022; 108(17): 1342–50. https://doi.org/10.1136/heartjnl-2021-319605

11. Ross R.D., Bollinger R.O., Pinsky W.W. Grading the severity of congestive heart failure in infants. Pediatr. Cardiol. 1992; 13(2): 72–5. https://doi.org/10.1007/BF00798207

12. Läer S., Mir T.S., Behn F., Eiselt M., Scholz H., Venzke A., et al. Carvedilol therapy in pediatric patients with congestive heart failure: a study investigating clinical and pharmacokinetic parameters. Am. Heart J. 2002; 143(5): 916–22. https://doi.org/10.1067/mhj.2002.121265

13. Школьникова М.А., Алексеева Е.И., Дегтярева Е.А., Басаргина Е.Н., Березницкая В.В., Белозеров Ю.М. и др. Клинические рекомендации по детской кардиологии и ревматологии. М., 2011. https://elibrary.ru/tjeiil

14. Mir T.S., Marohn S., Läer S., Eiselt M., Grollmus O., Weil J. Plasma concentrations of N-terminal pro-brain natriuretic peptide in control children from the neonatal to adolescent period and in children with congestive heart failure. Pediatrics. 2002; 110(6): e76. https://doi.org/10.1542/peds.110.6.e76

15. Sugimoto M., Kuwata S., Kurishima C., Kim J.H., Iwamoto Y., Senzaki H. Cardiac biomarkers in children with congenital heart disease. World J. Pediatr. 2015; 11(4): 309–15. https://doi.org/10.1007/s12519-015-0039-x

16. Iacob D., Butnariu A., Leucuţa D.C., Samaşca G., Deleanu D., Lupan I. Evaluation of NT-proBNP in children with heart failure younger than 3 years old. Rom. J. Intern. Med. 2017; 55(2): 69–74. https://doi.org/10.1515/rjim-2017-0002

17. Nir A., Nasser N. Clinical value of NT-ProBNP and BNP in pediatric cardiology. J. Card. Fail. 2005; 11(5 Suppl.): S76–80. https://doi.org/10.1016/j.cardfail.2005.04.009

18. Kantor P.F., Lougheed J., Dancea A., McGillion M., Barbosa N., Chan C., et al. Presentation, diagnosis, and medical management of heart failure in children: Canadian Cardiovascular Society guidelines. Can. J. Cardiol. 2013; 29(12): 1535–52. https://doi.org/10.1016/j.cjca.2013.08.008

19. Klugman D., Berger J.T. Echocardiography and focused cardiac ultrasound. Pediatr. Crit. Care Med. 2016; 17(8 Suppl. 1): 222–4. https://doi.org/10.1097/PCC.0000000000000815

20. McMahon C.J., Nagueh S.F., Eapen R.S., Dreyer W.J., Finkelshtyn I., Cao X., et al. Echocardiographic predictors of adverse clinical events in children with dilated cardiomyopathy: a prospective clinical study. Heart. 2004; 90(8): 908–15. https://doi.org/10.1136/hrt.2003.020966

21. Thomas D.E., Wheeler R., Yousef Z.R., Masani N.D. The role of echocardiography in guiding management in dilated cardiomyopathy. Eur. J. Echocardiogr. 2009; 10(8): iii15–21. https://doi.org/10.1093/ejechocard/jep158

22. Pettersen M.D., Du W., Skeens M.E., Humes R.A. Regression equations for calculation of z scores of cardiac structures in a large cohort of healthy infants, children, and adolescents: an echocardiographic study. J. Am. Soc. Echocardiogr. 2008; 21(8): 922–34. https://doi.org/10.1016/j.echo.2008.02.006

23. Koestenberger M., Ravekes W., Everett A.D., Stueger H.P., Heinzl B., Gamillscheg A., et al. Right ventricular function in infants, children and adolescents: reference values of the tricuspid annular plane systolic excursion (TAPSE) in 640 healthy patients and calculation of z score values. J. Am. Soc. Echocardiogr. 2009; 22(6): 715–9. https://doi.org/10.1016/j.echo.2009.03.026

24. Bao S.F., Zhang Y.Q., Chen L.J., Zhong Y.M., Wang Q., Zhang Z.F. Assessment of right ventricular systolic function in children with repaired tetralogy of Fallot by multiple-view from single acoustic window with speckle tracking echocardiography. Echocardiography. 2019; 36(1): 133–41. https://doi.org/10.1111/echo.14200

25. Levy P.T., Machefsky A., Sanchez A.A., Patel M.D., Rogal S., Fowler S., et al. Reference ranges of left ventricular strain measures by two-dimensional speckle-tracking echocardiography in children: a systematic review and meta-analysis. J. Am. Soc. Echocardiogr. 2016; 29(3): 209–25.e6. https://doi.org/10.1016/j.echo.2015.11.016

26. Puchalski M.D., Lui G.K., Miller-Hance W.C., Brook M.M., Young L.T., Bhat A., et al. Guidelines for performing a comprehensive tran esophageal echocardiographic: examination in children and all patients with congenital heart disease: recommendations from the American Society of Echocardiography. J. Am. Soc. Echocardiogr. 2019; 32(2): 173–215. https://doi.org/10.1016/j.echo.2018.08.016

27. Lipshultz S.E., Law Y.M., Asante-Korang A., Austin E.D., Dipchand A.I., Everitt M.D., et al. Cardiomyopathy in children: classification and diagnosis: a scientific statement from the American Heart Association. Circulation. 2019; 140(1): e9–68. https://doi.org/10.1161/CIR.0000000000000682

28. Lakdawala N.K., Thune J.J., Colan S.D., Cirino A.L., Farrohi F., Rivero J., et al. Subtle abnormalities in contractile function are an early manifestation of sarcomere mutations in dilated cardiomyopathy. Circ. Cardiovasc. Genet. 2012; 5(5): 503–10. https://doi.org/10.1161/circgenetics.112.962761

29. Lopez L., Colan S., Stylianou M. Relationship of echocardiographic Z scores adjusted for body surface area to age, sex, race, and ethnicity: the pediatric heart network normal echocardiogram database. Circ. Cardiovasc. Imaging. 2017; 10(11): e006979. https://doi.org/10.1161/circimaging.117.006979

30. Cantinotti M., Scalese M., Giordano R., Franchi E., Marchese P., Vicava C., et al. Pediatric nomograms for left ventricle biplane 2D volumes in healthy Caucasian children. Echocardiography. 2020; 37(6): 971–5. https://doi.org/10.1111/echo.14701

31. Марцинкевич Г.И., Соколов А.А. Эхокардиография у детей, антропометрические и возрастные нормы, сравнительные возможности трехмерной эхокардиографии. Сибирский медицинский журнал. 2010; 25(4-1): 67–71. https://elibrary.ru/ndmgbj

32. Pees C., Glagau E., Hauser J., Michel-Behnke I. Reference values of aortic flow velocity integral in 1193 healthy infants, children, and adolescents to quickly estimate cardiac stroke volume. Pediatr. Cardiol. 2013; 34(5): 1194–200. https://doi.org/10.1007/s00246-012-0628-6

33. Lopez L., Saurers D.L., Barker P.C.A., Cohen M.S., Colan S.D., Dwyer J., et al. Guidelines for performing a comprehensive pediatric transthoracic echocardiogram: recommendations from the american society of echocardiography. J. Am. Soc. Echocardiogr. 2024; 37(2): 119–70. https://doi.org/10.1016/j.echo.2023.11.015

34. Lang R.M., Bierig M., Devereux R.B., Flachskampf F.A., Foster E., Pellikka P.A., et al. Recommendations for chamber quantification. Eur. J. Echocardiogr. 2006; 7(2): 79–108. https://doi.org/10.1016/j.euje.2005.12.014

35. Chinali M., Emma F., Esposito C., Rinelli G., Franceschini A., Doyon A., et al. Left ventricular mass indexing in infants, children, and adolescents: a simplified approach for the identification of left ventricular hypertrophy in clinical practice. J. Pediatr. 2016; 170: 193–8. https://doi.org/10.1016/j.jpeds.2015.10.085

36. Isa Tafreshi R., Radgoodarzi M., Arjmandi Rafsanjani K., Soheilipour F. Subclinical left ventricular dysfunction in children and adolescence with thalassemia intermedia. Front. Pediatr. 2022; 10: 774528. https://doi.org/10.3389/fped.2022.774528

37. Nagueh S.F., Smiseth O.A., Appleton C.P., Byrd B.F. 3rd, Dokainish H., Edvardsen T., et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American society of echocardiography and the European association of cardiovascular imaging. J. Am. Soc. Echocardiogr. 2016; 29(4): 277–314. https://doi.org/10.1016/j.echo.2016.01.011

38. Bhatla P., Nielsen J.C., Ko H.H., Doucette J., Lytrivi I.D., Srivastava S. Normal values of left atrial volume in pediatric age group using a validated allometric model. Circ. Cardiovasc. Imaging. 2012; 5(6): 791–6. https://doi.org/10.1161/CIRCIMAGING.112.974428

39. Koestenberger M., Nagel B., Ravekes W., Avian A., Burmas A., Grangl G., et al. Reference values and calculation of z-scores of echocardiographic measurements of the normal pediatric right ventricle. Am. J. Cardiol. 2014; 114(10): 1590–8. https://doi.org/10.1016/j.amjcard.2014.08.028

40. Wang S.S., Hong W.J., Zhang Y.Q., Chen S.B., Huang G.Y., Zhang H.Y., et al. Regression equations for calculation of z scores for echocardiographic measurements of left heart structures in healthy Han Chinese children. J. Clin. Ultrasound. 2018; 46(5): 328–33. https://doi.org/10.1002/jcu.22579

41. Lai W.W., Gauvreau K., Rivera E.S., Saleeb S., Powell A.J., Geva T. Accuracy of guideline recommendations for two-dimensional quantification of the right ventricle by echocardiography. Int. J. Cardiovasc. Imaging. 2008; 24(7): 691–8. https://doi.org/10.1007/s10554-008-9314-4

42. Roberson D.A., Cui W., Chen Z., Madronero L.F., Cuneo B.F. Annular and septal Doppler tissue imaging in children: normal z-score tables and effects of age, heart rate, and body surface area. J. Am. Soc. Echocardiogr. 2007; 20(11): 1276–84. https://doi.org/10.1016/j.echo.2007.02.023

43. Cui W., Roberson D.A., Chen Z., Madronero L.F., Cuneo B.F. Systolic and diastolic time intervals measured from Doppler tissue imaging: normal values and Z-score tables, and effects of age, heart rate, and body surface area. J. Am. Soc. Echocardiogr. 2008; 21(4): 361–70. https://doi.org/10.1016/j.echo.2007.05.034

44. Roberson D.A., Cui W. Right ventricular Tei index in children: effect of method, age, body surface area, and heart rate. J. Am. Soc. Echocardiogr. 2007; 20(6): 764–70. https://doi.org/10.1016/j.echo.2006.11.002

45. Koestenberger M., Ravekes W., Everett A.D., Stueger H.P., Heinzl B., Gamillscheg A., et al. Right ventricular function in infants, children and adolescents: reference values of the tricuspid annular plane systolic excursion (TAPSE) in 640 healthy patients and calculation of z score values. J. Am. Soc. Echocardiogr. 2009; 22(6): 715–9. https://doi.org/10.1016/j.echo.2009.03.026

46. Muraru D., Haugaa K., Donal E., Stankovic I., Voigt J.U., Petersen S.E., et al. Right ventricular longitudinal strain in the clinical routine: a state-of-the-art review. Eur. Heart J. Cardiovasc. Imaging. 2022; 23(7): 898–912. https://doi.org/10.1093/ehjci/jeac022

47. Eidem B.W., McMahon C.J., Cohen R.R., Wu J., Finkelshteyn I., Kovalchin J.P., et al. Impact of cardiac growth on Doppler tissue imaging velocities: a study in healthy children. J. Am. Soc. Echocardiogr. 2004; 17(3): 212–21. https://doi.org/10.1016/j.echo.2003.12.005

48. Mertens L.L. Right atrial contractile function in pediatric pulmonary hypertension: a novel marker for disease severity? Circ. Cardiovasc. Imaging. 2017; 10(12): e007264. https://doi.org/10.1161/circimaging.117.007264

49. Karamitsos T.D., Francis J.M., Myerson S., Selvanayagam J.B., Neubauer S. The role of cardiovascular magnetic resonance imaging in heart failure. J. Am. Coll. Cardiol. 2009; 54(15): 1407–24. https://doi.org/10.1016/j.jacc.2009.04.094

50. Hales-Kharazmi A., Hirsch N., Kelleman M., Slesnick T., Deshpande S.R. Utility of cardiac MRI in paediatric myocarditis. Cardiol. Young. 2018; 28(3): 377–85. https://doi.org/10.1017/S1047951117001093

51. Grothues F., Smith G.C., Moon J.C., Bellenger N.G., Collins P., Klein H.U., et al. Comparison of interstudy reproducibility of cardiovascular magnetic resonance with two-dimensional echocardiography in normal subjects and in patients with heart failure or left ventricular hypertrophy. Am. J. Cardiol. 2002; 90(1): 29–34. https://doi.org/10.1016/s0002-9149(02)02381-0

52. Mortensen K.H., Tann O. Computed tomography in paediatric heart disease. Br. J. Radiol. 2018; 91(1092): 20180201. https://doi.org/10.1259/bjr.20180201

53. Moustafa G.A., Kolokythas A., Charitakis K., Avgerinos D.V. Therapeutic utilities of pediatric cardiac catheterization. Curr. Cardiol. Rev. 2016; 12(4): 258–69. https://doi.org/10.2174/1573403x12666160301121253

54. Giardini A., Fenton M., Andrews R.E., Derrick G., Burch M. Peak oxygen uptake correlates with survival without clinical deterioration in ambulatory children with dilated cardiomyopathy. Circulation. 2011; 124(16): 1713–8. https://doi.org/10.1161/circulationaha.111.035956

55. Dubowy K.O., Baden W., Bernitzki S., Peters B. A practical and transferable new protocol for treadmill testing of children and adults. Cardiol. Young. 2008; 18(6): 615–23. https://doi.org/10.1017/S1047951108003181

56. Geiger R., Strasak A., Treml B., Gasser K., Kleinsasser A., Fischer V., et al. Six-minute walk test in children and adolescents. J. Pediatr. 2007; 150(4): 395–9, 399.e1-2. https://doi.org/10.1016/j.jpeds.2006.12.052