Abstract
Introduction
Central sleep apnea due to Cheyne-Stokes breathing (CSA-CSB) commonly occurs in adult patients with chronic heart failure, but has rarely been described in children. We describe a case of CSA-CSB in a pediatric patient with dilated cardiomyopathy and acute heart failure.
Report of Case
A 12-year-old is admitted to the intensive care unit in the setting of new diagnosis of dilated cardiomyopathy leading to acute systolic and diastolic heart failure requiring inotropic infusions. After admission she is noted to have self-resolving desaturations on continuous pulse oximetry while asleep. Sleep medicine is consulted for further evaluation. She has desaturations during naps and night-time sleep that are not associated with any snoring, congestion, cough, choking, or gagging. She underwent adenotonsillectomy 7 years prior. Her father has dilated cardiomyopathy. Current medications are spironolactone, furosemide, ranitidine, loratadine, enoxaparin, milrinone and epinephrine infusion. Physical exam reveals an obese girl with absent tonsils, clear breath sounds, and tachycardia. Cardiac MRI showed severely dilated left ventricle with global hypokinesia and depressed function (EF 7%). Polysomnography reveals AHI 24.2/hr, with oAHI 0/hr and cAHI 24.2/hr. No snoring, flow limitation, or thoracoabdominal paradox is seen. Cheyne-Stokes respiration is present leading to diagnosis of CSA-CSB.
Supplemental oxygen is provided to blunt desaturations. While waiting for titration PSG she underwent placement of a left ventricular assist device and orthotopic heart transplantation. Following heart transplantation she had resolution of desaturations while asleep without supplemental oxygen; family declined repeat polysomnography.
Conclusion
Central sleep apnea with Cheyne-Stokes breathing is associated with increased mortality in adult patients with heart failure and provides important prognostic information if identified. The prevalence of central sleep apnea and its implications are unknown in pediatric patients and our case highlights the need to consider sleep disordered breathing as a cause of desaturations in patients with acute heart failure.
CON: Persistent Central Sleep Apnea/Hunter-Cheyne-Stokes Breathing, Despite Best Guideline-Based Therapy of Heart Failure With Reduced Ejection Fraction, Is Not a Compensatory Mechanism and Should Be Suppressed