Introduction: Infants have the highest risk to die from heart failure. However, innovations like beta-blocker treatment introduced more than 50 years ago are not recorded in the guidelines if the clinical trials are missing or be ignored, like propranolol in infants with severe heart failure to congenital heart disease.

Methods: We re-analyse our data with propranolol and the ACE-inhibitor captopril in infants with severe heart failure due to congenital heart disease as published 20 years ago and the current long-term follow up data.

Results: Propranolol but not Captopril significantly reduces clinical heart failure and neurohormonal activation of the renin angiotensin aldosterone system. Propranolol significantly improve dysautonomia measured by heart rate variability. In contrast to grown up with congenital heart disease – preoperatively treated with digoxin and diuretics - our patients up to the age of 15 years – preoperatively treated with propranolol without frusemide – have normal myocardial function and heart rate variability.

Discussion: The evidence-based data of propranolol to treat severe heart failure in infants with congenital heart disease are the best we have. There is no reason to withheld infants from this effective therapy of early life stress due to heart failure.

Conclusion: Further studies are needed to proof the impact of propranolol in infants with severe heart failure on long-term neurodevelopment, endothelial- and myocardial function.