Pediatric heart failure (PHF) is a life-threatening clinical syndrome and a leading cause of mortality in children, representing a final common pathway for diverse etiologies including congenital heart disease (CHD), cardiomyopathies, and myocarditis (1–4). Unlike adult heart failure, PHF pathophysiology is rooted in developmental and genetic aberrations, often leading to aggressive clinical courses (5, 6). The global incidence of PHF is estimated at 0.87–7.4 per 100,000 children. In China, with a CHD prevalence approaching 9 per 1,000 live births, the absolute disease burden is immense, creating a critical public health challenge (7–9).

The management of this high-risk population is contingent upon a centralized, specialized care model. Optimal outcomes require timely access to tertiary pediatric cardiac centers capable of providing advanced diagnostics, pharmacotherapy, and interventions, including mechanical circulatory support and transplantation (10, 11). However, China’s vast geography and uneven socioeconomic development have resulted in profound geospatial disparities in healthcare resource distribution. Robust evidence confirms that children in rural and less developed regions face significant barriers to care, including diagnostic delays, financial constraints, and limited access to specialized cardiac expertise, leading to inequitable health outcomes for a range of pediatric conditions (12–16).

While these systemic vulnerabilities are recognized, the magnitude and clinical consequences of these disparities specifically for pediatric heart failure across China have not been comprehensively quantified at a broader level. A detailed understanding of how geographic location influences patient characteristics, disease severity, treatment patterns, and ultimate survival is a critical first step toward addressing these inequities. Therefore, this study aims to conduct a national geospatial analysis of PHF care in China. By mapping the variations in clinical presentation, management, and outcomes across different regions, this investigation seeks to identify critical gaps in the care continuum and inform the development of a more equitable system for this vulnerable population.

This large-scale, national multicenter cohort study provides a stark and quantifiable account of the profound geospatial disparities characterizing PHF care in China. Our analysis revealed that a child’s geographic location—a proxy for a complex web of socioeconomic and healthcare system factors—was powerfully associated with their demographic profile, disease etiology, clinical severity at presentation, therapeutic management, and, most critically, their risk of in-hospital mortality. The findings paint a picture of a tiered healthcare landscape: an Eastern region with a profile resembling developed healthcare systems, a Western region burdened by late-presenting, severe congenital disease in younger infants, and a Central region exhibiting a paradoxical mix of characteristics with the highest adjusted mortality risk.

The most fundamental disparity observed is the stark contrast in the underlying causes of PHF. The Western region was dominated by CHD, particularly complex lesions like VSD and PDA, presenting in significantly younger infants. This pattern strongly suggests systemic delays in the diagnosis and referral of CHD in Western China, likely driven by a combination of factors including limited access to prenatal and postnatal echocardiography, lower healthcare literacy, and financial barriers that prevent families from seeking early care (8, 17, 18). The consequence is that children present later, with more advanced disease, as evidenced by the highest prevalence of ROSS Class III-IV failure, respiratory symptoms, and systemic venous congestion.

Conversely, the Eastern and Central regions had a higher burden of cardiomyopathy, a finding more aligned with PHF etiologies in high-income countries (19, 20). This shift suggests better early diagnosis and intervention for CHD in these regions, allowing other chronic myocardial diseases to constitute a larger proportion of advanced heart failure cases. The older age at presentation in the East further supports this, indicating a system where immediately life-threatening congenital defects are identified and corrected earlier, leaving a cohort of patients with progressive, chronic conditions.

The echocardiographic and biomarker data provide a pathophysiological underpinning to these clinical observations. The preserved LVEF and LVFS in Western patients, despite their severe clinical scores, are consistent with a predominantly volume-overloaded state from large left-to-right shunts (e.g., VSD, PDA) (3, 21). Their significantly elevated pulmonary artery pressure underscores the consequences of delayed intervention, leading to accelerated pulmonary vascular remodeling (22–24). In contrast, the Eastern cohort’s markedly lower LVEF aligns with the high prevalence of dilated cardiomyopathy, reflecting a primary systolic dysfunction phenotype (25, 26).

The biomarker profile further highlights regional differences in myocardial stress and injury. The Central region had the highest median BNP and CK-MB levels, indicating profound myocardial strain and injury, potentially exacerbated by a high burden of severe infection. Interestingly, the West had the lowest BNP levels, which, in the context of their severe clinical status, is a noteworthy finding. This apparent discrepancy can be explained by the unique pathophysiology of large, unrepaired left-to-right shunts that dominated this cohort. In chronic volume-overload states, the right ventricle and atria bear a significant portion of the hemodynamic burden, and BNP secretion may not rise in a linear fashion compared to pressure-overload or primary systolic dysfunction states (27–29). Furthermore, BNP interpretation in infancy is inherently complex. Baseline BNP levels are highly age-dependent, being physiologically higher in the first weeks of life and then declining (30, 31). Furthermore, the relative elevation of BNP is more significant than the absolute value. Therefore, the lower absolute BNP in the Western cohort, while the lowest in our study, may still represent a substantial elevation from the normal range for infants of a similar age (32). Therefore, the lower absolute BNP in the Western cohort likely reflects a combination of a different hemodynamic profile and the younger age of the patients, rather than a lesser degree of clinical severity. This pathophysiological variation challenges the use of BNP as a uniform severity adjustor in our model, potentially influencing the estimated geographic risk. The elevated liver enzymes (ALT, AST) in the West and Central regions are classic signs of systemic venous congestion and end-organ hypoperfusion, further corroborating the finding of more advanced, decompensated heart failure at presentation (33).

The pharmacological management patterns reveal a concerning gap in the application of GDMT, a challenge well-documented in pediatric heart failure due to a weaker evidence base and significant practice variation (34). The use of ACEIs and BBs was significantly lower in the West and Central regions compared to the East. This disparity may be attributed to several factors documented in the pediatric literature: a lack of specialized pediatric cardiology expertise and dedicated heart failure programs, which are unevenly distributed (35); justifiable concerns about extrapolating adult guidelines to infants with complex shunt physiology, where safety and efficacy are less certain (3, 36); or a systemic focus on acute surgical stabilization that can sometimes come at the expense of longitudinal medical optimization in the outpatient setting (37).

The extraordinarily high rate of antibiotic use in the West is particularly striking. This likely reflects a higher suspicion or prevalence of concurrent respiratory infections in a population with chronic pulmonary over-circulation, or potentially its use as a prophylactic measure in malnourished, vulnerable infants (38–40). The high utilization of hormones in the Central region is more difficult to interpret but may be linked to a higher incidence of myocarditis or a practice pattern favoring immunomodulation in severe, inflammatory presentations (41, 42). The concentrated use of advanced interventions like pacemakers and radiofrequency ablation almost exclusively in the East points to a critical centralization of complex electrophysiological care, creating a “postcode lottery” for children with arrhythmic complications of heart failure. The most critical finding of this study is that geographic region is an independent, powerful predictor of in-hospital mortality. Even after rigorous adjustment for age, etiology, disease severity (ROSS class, LVEF), and neurohormonal activation (BNP), children in the West faced a 2.58-fold higher odds of death, while those in the Central region faced a staggering 3.54-fold higher odds, compared to their counterparts in the East.

The elevated risk in the West can be reasonably attributed to the “double burden” of later presentation with more severe, advanced-stage disease and potentially less access to timely, specialized surgical intervention. The situation in the Central region is more complex and alarming. This is underscored by the finding that, despite a patient profile that was, in some aspects, intermediate between the East and West (e.g., age, CHD prevalence), it exhibited the highest adjusted mortality. This suggests that factors beyond what we measured—such as quality of intensive care, surgical outcomes, post-operative management, or unmeasured socioeconomic and nutritional factors—may be driving this excess mortality (43–45). The exceptionally high burden of severe infection, coupled with biomarker evidence of severe myocardial injury, points to a high-risk phenotype of ‘heart failure with multimorbidity,’ where systemic infection may trigger catastrophic decompensation. Unmeasured socioeconomic and nutritional factors likely contribute, but the data strongly suggest that the confluence of advanced heart failure and severe infection is a critical determinant of the heightened mortality observed in the Central region.

The protective association of cardiomyopathy with mortality (aOR: 0.24) is counterintuitive but may reflect the more chronic, manageable nature of many cardiomyopathies compared to critically ill, late-presenting infants with complex CHD, who dominated the high-mortality cohorts. This finding likely illustrates a disparity in acute risk profiles rather than an inherent biological advantage of cardiomyopathy, with the elevated mortality driven substantially by the high perioperative risk of late-presenting complex CHD. It may also indicate that centers with expertise in cardiomyopathy management (more prevalent in the East) achieve excellent outcomes, pulling down the overall risk for this group.

Several limitations inherent to this study’s design should be considered when interpreting its findings. First, the retrospective design inherently limits the availability of certain variables and is susceptible to unmeasured confounding, despite adjustments for key clinical factors in our analysis. Second, our cohort was drawn exclusively from major referral hospitals. While this reflects the centralized model for specialized pediatric cardiac care in China, it introduces referral bias by excluding children who died before referral or were managed locally. Importantly, children in remote and less developed regions face significant barriers to accessing tertiary centers and optimal care (12–14, 46, 47). Therefore, this bias likely leads to an underestimation of both the true mortality and the scale of the observed disparities, as both severely ill patients who die before referral and less severe cases treated locally are excluded from our tertiary-center cohort. Third, we lacked granular data on socioeconomic status, parental education, precise travel distances, and specific details on surgical timing and outcomes, all of which are critical mediators of the disparities we observed. Consequently, while our analysis confirms that geographic region is a strong independent predictor of mortality after accounting for clinical factors, it cannot distinguish the extent to which this effect is mediated by pre-hospital barriers (e.g., income, distance, education) versus differences in hospital-level care quality. The variable ‘region’ encapsulates all these unmeasured systemic determinants. Fourth, the use of in-hospital mortality as the primary outcome does not capture post-discharge deaths, which may be substantial, particularly in regions with poor follow-up care. Fifth, the observed regional variations should be interpreted with the understanding that some heterogeneity exists within each region, an inherent feature of real-world, national cohort data that enhances the generalizability of our findings. Furthermore, the exclusion of individual records with >20% missing data may introduce selection bias. A meaningful comparison of characteristics (e.g., outcomes, region) between excluded and included patients was not feasible, as the defining feature of the excluded group was the critical absence of this data. These limitations directly inform critical avenues for future research. Prospective, population-based studies that include primary and secondary healthcare centers are essential to capture the true burden of disease and avoid referral bias. Furthermore, subsequent investigations must integrate detailed socioeconomic metrics, travel data, and treatment process measures to fully elucidate the mechanisms behind the observed disparities. Finally, establishing national registries with long-term follow-up is paramount to understanding the full impact of PHF beyond the initial hospitalization and to evaluating the effectiveness of future interventions aimed at achieving healthcare equity.

In conclusion, this study provides robust evidence that a child’s geographic location in China is a powerful independent predictor of survival and care quality for pediatric heart failure. The profound disparities in patient characteristics, management, and outcomes between the East, West, and Central regions are not merely variations in practice but reflect deep-seated inequities in the healthcare ecosystem. Addressing these disparities requires moving beyond a one-size-fits-all approach and implementing targeted, region-specific strategies to build capacity, improve access, and standardize care. Ensuring that every child with heart failure in China, regardless of their birthplace, has an equal chance at survival is an urgent moral and public health imperative.