Skip to main content

The Ross Classification for Heart Failure in Children After 25 Years: A Review and an Age-Stratified Revision

Abstract

Accurate grading of the presence and severity of heart failure (HF) signs and symptoms in infants and children remains challenging. It has been 25 years since the Ross classification was first used for this purpose. Since then, several modifications of the system have been used and others proposed. New evidence has shown that in addition to signs and symptoms, data from echocardiography, exercise testing, and biomarkers such as N-terminal pro-brain natriuretic peptide (NT-proBNP) all are useful in stratifying outcomes for children with HF. It also is apparent that grading of signs and symptoms in children is dependent on age because infants manifest HF differently than toddlers and older children. This review culminates in a proposed new age-based Ross classification for HF in children that incorporates the most useful data from the last two decades. Testing of this new system will be important to determine whether an age-stratified scoring system can unify the way communication of HF severity and research on HF in children is performed in the future.

This is a preview of subscription content, access via your institution.

References

  1. Aurbach SR, Richmond ME, Lamour JM et al (2010) BNP levels predict outcome in pediatric heart failure patients: post hoc analysis of the pediatric carvedilol trial. Circ Heart Fail 3:606–611

    Article  Google Scholar 

  2. Butler J, Khadim G, Paul KM et al (2004) Selection of patients for heart transplantation in the current era of heart failure therapy. J Am Coll Cardiol 43:787–793

    PubMed  Article  Google Scholar 

  3. Cohn JN, Levine B, Olivari T et al (1984) Plasma norepinephrine as a guide to prognosis in patients with chronic congestive heart failure. N Engl J Med 311:819–823

    PubMed  Article  CAS  Google Scholar 

  4. Connelly D, Rutkowski M, Auslender M, Artman M (2001) The New York University pediatric heart failure index: a new method of quantifying chronic heart failure severity in children. J Pediatr 138:644–648

    Article  Google Scholar 

  5. Das BB, Taylor AL, Boucek MM, Wolfe RW, Yetman AT (2006) Exercise capacity in pediatric heart transplant candidates: Is there any role for the 14 ml/kg/min guideline? Pediatr Cardiol 27:226–229

    PubMed  Article  CAS  Google Scholar 

  6. Evim MS, Ucar B, Kilic Z, Colak O (2010) The value of serum N-terminal pro-brain natriuretic peptide levels in the differential diagnosis and follow-up of congestive cardiac failure and respiratory distress due to pulmonary aetiologies in infants and children. Cardiol Young 20:495–504

    Article  Google Scholar 

  7. Fernandes FP, Manlhiot C, McCrindle BW, Mertens L, Kantor PF, Friedberg MK (2011) Usefulness of mitral regurgitation as a marker of increased risk for death or cardiac transplantation in idiopathic dilated cardiomyopathy in children. Am J Cardiol 107:1517–1521

    PubMed  Article  Google Scholar 

  8. Giardini A, Fenton M, Andrews RE, Derrick G, Burch M (2011) Peak oxygen uptake correlates with survival without clinical deterioration in ambulatory children with dilated cardiomyopathy. Circulation 124:1713–1718

    PubMed  Article  CAS  Google Scholar 

  9. Guimaraes GV, d’Avila VM, Camargo PR, Moreira LFP, Luces JRL, Bocchi EA (2008) Prognostic value of cardiopulmonary exercise testing in children with heart failure secondary to idiopathic dilated cardiomyopathy in a non-B-blocker setting. Eur J Heart Fail 10:560–565

    PubMed  Article  CAS  Google Scholar 

  10. Laer S, Mir TS, Behn F et al (2002) Carvedilol therapy in pediatric patients with congestive heart failure: a study investigating clinical and pharmacokinetic parameters. Am Heart J 143:916–922

    PubMed  Article  Google Scholar 

  11. Lechner E, Gitter R, Mair R et al (2008) Aminoterminal brain natriuretic peptide levels in children and adolescents after Fontan operation correlate with congestive heart failure. Pediatr Cardiol 29:901–905

    PubMed  Article  Google Scholar 

  12. Patel MS, Berg AM, Vincent RN, Mahle WT (2010) Serum parameters and echocardiographic predictors of death or need for transplant in newborns, children, and young adults with heart failure. Am J Cardiol 105:1798–1801

    PubMed  Article  Google Scholar 

  13. Ratnasamy C, Kinnamon DD, Lipshultz SE, Rusconi P (2008) Associations between neurohormonal and inflammatory activation and heart failure in children. Am Heart J 155:527–533

    PubMed  Article  CAS  Google Scholar 

  14. Reithmann C, Reber D, Kozlik-Feldmann R et al (1997) A postreceptor defect of adenylyl cyclase in severely failing myocardium from children with congenital heart disease. Eur J Pharm 330:79–86

    Article  CAS  Google Scholar 

  15. Ross RD (2001) Grading the graders of congestive heart failure in children. J Pediatr 138:618–620

    PubMed  Article  CAS  Google Scholar 

  16. Ross RD, Daniels SR, Schwartz DC, Hannon DW, Shukla R, Kaplan S (1987) Plasma levels of norepinephrine in infants and children with congestive heart failure. Am J Cardiol 59:911–914

    PubMed  Article  CAS  Google Scholar 

  17. Ross RD, Bollinger RO, Pinsky WW (1992) Grading the severity of congestive heart failure in infants. Pediatr Cardiol 13:72–75

    PubMed  Article  CAS  Google Scholar 

  18. Rusconi PG, Ludwig DA, Ratnasamy C et al (2010) Serial measurements of serum NT-proBNP as markers of left ventricular function and remodeling in children with heart failure. Am Heart J 160:776–783

    PubMed  Article  CAS  Google Scholar 

  19. Saunders M, Gorelick MH (2011) Nelson textbook of pediatrics, 19th edn. Saunders Elsevier, Philadelphia, p 280

    Google Scholar 

  20. Shah A, Feraco AM, Harmon C, Tacy T, Fineman JR, Bernstein HS (2009) Usefulness of various plasma biomarkers for diagnosis of heart failure in children with single ventricle physiology. Am J Cardiol 104:1280–1284

    PubMed  Article  CAS  Google Scholar 

  21. Srisawasdi P, Vanavanan S, Charoenpanichkit C, Kroll MH (2010) The effect of renal dysfunction on BNP, NT-proBNP, and their ratio. Am J Clin Pathol 133:14–23

    PubMed  Article  CAS  Google Scholar 

  22. Sugimoto M, Manabe H, Nakau K et al (2010) The role of N-terminal pro-B type natriuretic peptide in the diagnosis of congestive heart failure in children. Circ J 74:998–1005

    PubMed  Article  CAS  Google Scholar 

  23. Tissieres P, Aggouon Y, Da Cruz E et al (2006) Comparison of heart failure classifications in children undergoing valvular surgery. J Pediatr 149:210–215

    PubMed  Article  Google Scholar 

  24. Wong DTH, George K, Wilson J et al (2011) Effectiveness of serial increases in amino-terminal pro-B-type natriuretic peptide levels to indicate the need for mechanical circulatory support in children with acute decompensated heart failure. Am J Cardiol 107:573–578

    PubMed  Article  CAS  Google Scholar 

  25. Wu JR, Chang HR, Huang TY, Chiang CH, Chen SS (1996) Reduction in lymphocyte B-adrenergic receptor density in infants and children with heart failure secondary to congenital heart disease. Am J Cardiol 77:170–174

    PubMed  Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Robert D. Ross.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Ross, R.D. The Ross Classification for Heart Failure in Children After 25 Years: A Review and an Age-Stratified Revision. Pediatr Cardiol 33, 1295–1300 (2012). https://doi.org/10.1007/s00246-012-0306-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00246-012-0306-8

Keywords

  • Age-based Ross classification
  • Heart failure
  • Ross classification