Modified Ross score and echocardiographic score in children with heart failure: a subgroup analysis

  • I Made Karma Setiyawan pediatrician
  • Ni Putu Veny Kartika Yantie Pediatrician (Cardiologist)
  • Anak Agung Ngurah Ketut Putra Widnyana Department of Child Health, Medical Faculty of Universitas Udayana/Prof.Dr.I.G.N.G Ngoerah Hospital, Denpasar, Bali
  • I Gusti Lanang Sidiartha Department of Child Health, Medical Faculty of Universitas Udayana/Prof.Dr.I.G.N.G Ngoerah Hospital, Denpasar, Bali
  • Putu Gede Karyana Department of Child Health, Medical Faculty of Universitas Udayana/Prof.Dr.I.G.N.G Ngoerah Hospital, Denpasar, Bali
  • I Made Arimbawa Department of Child Health, Medical Faculty of Universitas Udayana/Prof.Dr.I.G.N.G Ngoerah Hospital, Denpasar, Bali
Keywords: children; heart failure; modified Ross score; echocardiographic score; remodelling


Background Over the past two decades, heart failure in children has increased in terms of symptom recognition and prevalence. The initial clinical manifestations of heart failure in children are non-specific. Therefore, diagnosis requires the support of echocardiography. The symptomatic severity of heart failure in children can be classified through a simple scoring system such as Ross score. The duration of heart disease, duration of therapy, and cardiac remodeling status may have clinical and anatomical effects on the disease.

Objective To analyze for a possible correlation between modified Ross score and echocardiographic score by subgroup analysis consisting of duration of heart disease, duration of therapy, and cardiac remodeling.

Methods This cross-sectional study included children aged 1 month - 18 years with heart failure who sought treatment at Prof.Dr. I.G.N.G Ngoerah Hospital, Denpasar from June 2019 to February 2020. Cardiac remodeling was defined as >20% increase in left ventricle internal end diastolic dimension (LVIDd) compared to normal values, ??based on body surface area. Spearman’s correlation test was used for statistical analysis.

Results A total of 30 subjects were analyzed in this study. The  median modified Ross score and echocardiography score were 3 points  (range 2-11) and 4 (range 2-6), respectively. The median durations of heart disease and preventive heart failure therapy were 2 years (range 7 days-15 years) and 1 year (range 7 days-15 years), respectively. The mean LVIDd was 4.3 (SD 1.4) cm. Twenty-one out of 30 subjects experienced a ? 20% increase of LVIDd from baseline. The modified Ross score and echocardiographic score had no significant correlation (r=0.18; P=0.33). However, the modified Ross score had significant correlations with duration of heart disease (r=-0.632; P<0.001) as well as duration of therapy (r=-0.584; P=0.001).  In addition, no correlation was found between echocardiographic score with heart disease and therapy duration (P>0.05). Echocardiography score and remodelling process was significantly correlated (r=0.64; P<0.001).

Conclusion There  is no correlation between modified Ross score and echocardiographic score. Duration of heart disease and duration of therapy are significantly negatively correlated with modified Ross scores. The remodelling process is positively correlated with echocardiographic score. Further research on acute symptomatic and validated echocardiographic scores are needed.

Author Biography

Ni Putu Veny Kartika Yantie, Pediatrician (Cardiologist)

Pediatric Cardiologist, Department of Child Health, Medical Faculty of Udayana University/Sanglah Hospital


1. Ross RD. The Ross classification for heart failure in children after 25 years : a review and age-stratified revision. Pediatr Cardiol. 2012;33:1295-300. DOI:
2. Nousi D, Christou A. Factors affecting the quality of life in children with congenital heart disease. Health Sci J. 2010;4:94-100.
3. Nandi D, Rossano JW. Epidemiology and cost of heart failure in children. Cardiol Young. 2015;25:1460-8. DOI :
4. Mahrani Y, Nova R, Saleh MI, Rahadianto KY. Correlation of heart failure severity and N-terminal pro-brain natriuretic peptide level in children. Paediatr Indones. 2016;56:315-9. DOI :
5. Rossano JW, Kim JJ, Decker JA, Price JF, Zafar F, Graves DE, et al. Prevalence, morbidity, and mortality of heart failure-related hospitalizations in children in the United States: a population-based study. J Card Fail. 2012;18:459-70. DOI:
6. Das RR, Panda SS, Panda M, Naik SS. Congestive cardiac failure in children : an update on patho-physiology and management. Cardiol Pharmacol. 2014;3:1-4. DOI:
7. Lin CW, Zeng XL, Jiang SH, Wu T, Wang JP, Zhang JF, et al. Role of the NT-proBNP level in the diagnosis of pediatric heart failure and investigation of novel combined diagnostic criteria. Exp Ther Med. 2013;6:995-9. DOI:
8. Jamaledeen M, Ali SKM. Correlation of clinical and echo-cardiographic scores with blood “brain natriuretic peptide” in paediatric patients with heart failure. East Afr Med J. 2012;89:359-62.
9. Hartupee J, Mann DL. Neurohormonal activation in heart failure with reduced ejection fraction. Nat Rev Cardiol. 2017;14:30–8. DOI:
10. 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;58:303-12. DOI:
11. Das BB. Current state of pediatric heart failure. Children (Basel). 2018;5:88. DOI:
12. Lipshultz SE, Easley KA, Orav EJ, Kaplan S, Starc TJ, Bricker JT, et al. Left ventricular structure and function in children infected with human immunodeficiency virus: the prospective P2C2 HIV Multicenter Study. Circulation. 1998;97(13):1246-56. DOI: 10.1161/01.cir.97.13.1246.
13. Kervancioglu P, Kervancioglu M, Tuncer MC, Hatipoglu ES. Left ventricular mass in normal children and its correlation with weight, height, and body surface area. Int J Morphol. 2011;29:982-7. DOI:
14. Reindl M, Reinstadler SJ, Tiller C, Feisritzer HJ, Kofler M, Brix A, et al. Prognosis-based definition of left ventricular remodeling after ST-elevation myocardial infarction. European Radiology. 2019;29:2330-9. DOI:
15. Marelli AJ, Mackie AS, Ionescu-Ittu R, Rahme E, Pilote L. Congenital heart disease in the general population changing prevalence and age distribution. Circulation. 2007;115:163-72. DOI:
16. Park MK. Pediatric cardiology for practitioners. 5th ed. Philadelphia2014 : Mosby; 2014.
17. Ohuchi H, Takasugi H, Ohashi H, Okada Y, Yamado O, Ono Y, et al. Stratification of pediatric heart failure on the basis of neurohormonal and cardiac autonomic nervous activities in patients with congenital heart disease. Circulation. 2003;108:2368-76. DOI :
18. Castaldi B, Cuppini E, Fumanelli J, Di Candia A, Sabatino J, Sirico D, et al. Chronic heart failure in children: state of the art and new perspectives. J Clin Med. 2023;12(7):2611. DOI:
19. Hsu DT, Pearson GD. Heart failure in children part I: history, etiology, and pathophysiology. Circ Heart Fail. 2009;2:63-70. DOI :
20. Glass L, Conway J. Innovation in pediatric clinical trials: the need to rethink the end-point. J Heart Lung Transplant. 2018;37:431–2. DOI :
21. Wong M, Staszewsky L, Latini R, Barlera S, Glazer R, Aknay N, et al. Severity of left ventricular remodeling defines outcomes and response to therapy heart failure. J Am Coll Cardiol. 2004;43:2022-7. DOI:
22. Eerola A, Jokinen EO, Savukoski TI, Pettersson KSI, Poutanen T, Pihkala JI. Cardiac troponin I in congenital heart defects with pressure or volume overload. Scand Cardiovasc J. 2013;47:154-9. DOI:
23. McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, et al. ESC committee for practice guidelines. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European Society of Cardiology. Eur Heart J. 2012;33(14):1787-847. DOI: 10.1093/eurheartj/ehs104
24. Stout KK, Broberg CS, Book WM, Cecchin F, Chen JM, Dimopoulos K, et al. Chronic heart failure in congenital heart disease. Circulation. 2016;133:770-801. DOI: 10.1161/CIR.0000000000000352
25. Aminullah M, Rima FA, Hoque A, Sazal MR, Biswas P, Hoque R. Echocardiographic evaluation of cardiac remodeling after surgical closure of ventricular septal defect in different age group. Journal of National Institute of Neurosciences Bangladesh. 2016;2:69-74. DOI:
How to Cite
Setiyawan IM, Kartika Yantie NP, Widnyana AAN, Sidiartha IG, Karyana P, Arimbawa IM. Modified Ross score and echocardiographic score in children with heart failure: a subgroup analysis. PI [Internet]. 28May2024 [cited 13Jul.2024];64(3):202-. Available from:
Pediatric Cardiology
Received 2023-01-31
Accepted 2024-05-28
Published 2024-05-28