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Luczak-Wozniak K, Obsznajczyk K, Niszczota C, Werner B. Electrocardiographic Parameters Associated with Adverse Outcomes in Children with Cardiomyopathies. J Clin Med 2022; 11:jcm11236930. [PMID: 36498505 PMCID: PMC9738383 DOI: 10.3390/jcm11236930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/15/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022] Open
Abstract
Cardiomyopathies have a low prevalence in children and thus may lead to malignant ventricular arrhythmias or the progression of heart failure, resulting in death. In adults, the QRS-T angle derived from ECG has been associated with adverse outcomes in patients with hypertrophic and dilated cardiomyopathies. We aimed to assess the electrocardiographic parameters, including QRS-T angle, associated with adverse cardiac events in children with cardiomyopathies. Forty-two children with cardiomyopathies were included in this study: 19 with dilated cardiomyopathy, 17 with hypertrophic cardiomyopathy, and 6 with left ventricular non-compaction. Additionally, 19 control subjects were recruited. In terms of ECG parameters, the QRS-T angle was significantly greater among patients with adverse outcomes compared to patients without the end points of the study (133° vs. 65°, p < 0.001). On Kaplan−Meier survival curves, QRS-T angle > 120°, increased serum concentrations of NT-proBNP and troponin I levels as well as greater NYHA or Ross scale were associated with the greatest risk of unfavorable outcome. The QRS-T angle appears to be a valuable component of 12-lead ECG interpretation, and might be helpful in outlining patients with the greatest cardiovascular risk. Additionally, serum biomarkers such as NT-proBNP (p = 0.003) and troponin (p < 0.001) are useful in outlining patients with the worst survival.
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Affiliation(s)
- Katarzyna Luczak-Wozniak
- Department of Pediatric Cardiology and General Pediatrics, Doctoral School, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Klaudia Obsznajczyk
- Department of Pediatric Cardiology and General Pediatrics, Jozef Polikarp Brudzinski Public Pediatric Hospital, 02-091 Warsaw, Poland
| | - Cezary Niszczota
- Department of Pediatric Cardiology and General Pediatrics, Jozef Polikarp Brudzinski Public Pediatric Hospital, 02-091 Warsaw, Poland
| | - Bożena Werner
- Department of Pediatric Cardiology and General Pediatrics, Medical University of Warsaw, 02-091 Warsaw, Poland
- Correspondence: ; Tel.: +48-22-317-9588
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2
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Ramírez-Marroquín ES, Ortega-Zhindón DB, Flores-Sarria IP, Calderón-Colmenero J, García-Montes JA, Cervantes-Salazar JL. Coronary Revascularization in Patients With Cardiac Sequelae of Kawasaki Disease at a Single Center. World J Pediatr Congenit Heart Surg 2022; 13:731-736. [DOI: 10.1177/21501351221117718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Kawasaki disease (KD) is a self-limited vasculitis that mainly affects infants and preschool-age children, characterized by coronary aneurysms and/or stenoses that may lead to the occurrence of ischemia, heart attack, and sudden death. This study aimed to evaluate the clinical and surgical results of pediatric patients with KD and cardiac sequelae who underwent coronary artery bypass grafting. Methods: A retrospective study was carried out. Patients with a diagnosis of KD and cardiac sequelae who underwent coronary artery bypass grafting from January 1, 2004, through March 31, 2021, were included: preoperative characteristics and conditions. Results: Ten patients were included, with a mean age of 6.4 ± 3.7 years; 80% males. Seven (70%) had the compromise of 2 coronary arteries, the most affected being the left anterior descendent artery (36.9%) with aneurysm and the right coronary artery (36.8%) with stenosis. 40% had preoperative moderate-to-severe ventricular dysfunction. The graft most frequently used was the right internal thoracic artery (47.6%), and the most frequent coronary bypass target vessel was the left anterior descending artery (38.1%). There was no early mortality or deaths during follow-up; 90% remained in functional class I. Among the cohort as a group, there was an overall improvement in postoperative ventricular function ( P = .03). This persisted, being unchanged at subsequent follow-up ( P = .95). Conclusions: Coronary artery bypass grafting is an appropriate treatment option for children with cardiac sequelae of KD, with excellent surgical results. Furthermore, this surgical procedure avoids the deterioration of left ventricular function in pediatric age.
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Affiliation(s)
- Edgar S. Ramírez-Marroquín
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, National Institute of Cardiology Ignacio Chávez, Mexico City, México
| | - Diego B. Ortega-Zhindón
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, National Institute of Cardiology Ignacio Chávez, Mexico City, México
| | - Iris P. Flores-Sarria
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, National Institute of Cardiology Ignacio Chávez, Mexico City, México
| | - Juan Calderón-Colmenero
- Department of Pediatric Cardiology, National Institute of Cardiology Ignacio Chávez, Mexico City, México
| | - José A. García-Montes
- Department of Interventional Cardiology in Congenital Heart Disease, National Institute of Cardiology Ignacio Chávez, Mexico City, México
| | - Jorge L. Cervantes-Salazar
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, National Institute of Cardiology Ignacio Chávez, Mexico City, México
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Miyoshi T, Hosoda H, Miyake A, Sakaguchi H, Kitano M, Kurosaki KI, Shiraishi I, Nakai M, Nishimura K, Miyazato M, Kangawa K, Yoshimatsu J, Minamino N. Utility of perinatal natriuretic peptide for predicting neonatal heart failure. Pediatr Int 2022; 64:e15231. [PMID: 35831247 DOI: 10.1111/ped.15231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/16/2022] [Accepted: 04/25/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND We evaluated the significance of perinatal plasma natriuretic peptide (NP) levels in neonates with congenital heart defects (CHDs) or arrhythmias and determined whether measurement of perinatal plasma NP levels and echocardiographic assessment in utero could predict heart failure after birth. METHODS The study was conducted between 2012 and 2016 to evaluate the correlation of perinatal atrial NP (ANP) and brain NP (BNP) levels at birth with the modified Ross score after birth and the cardiovascular profile (CVP) score before birth. RESULTS A total of 122 singletons with CHDs or arrhythmias and 27 controls were analyzed. Neonatal blood sampling was performed at a median of 0.7 h (range, 0.1-1.5) after birth. The neonatal plasma ANP and BNP levels shortly after birth were significantly higher than those in the umbilical artery (UA) plasma. The ANP and BNP levels in UA and neonatal blood were correlated with the modified Ross score. The neonatal plasma ANP and BNP levels and the modified Ross scores were inversely correlated with the CVP score in neonates with CHDs or arrhythmias. The area under the receiver operating characteristic curve of UA ANP levels for predicting neonatal heart failure was highest among those for the CVP score, perinatal plasma ANP and BNP levels, and their combinations. CONCLUSIONS The plasma ANP and BNP levels increased markedly shortly after birth. Assessment of the UA plasma ANP level at birth and the CVP score in utero may be utilized to predict neonatal heart failure.
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Affiliation(s)
- Takekazu Miyoshi
- Department of Regenerative Medicine and Tissue Engineering, National Cerebral and Cardiovascular Center, Suita, Japan.,Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Hosoda
- Department of Regenerative Medicine and Tissue Engineering, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akira Miyake
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masataka Kitano
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Ken-Ichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mikiya Miyazato
- Department of Biochemistry, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenji Kangawa
- Department of Biochemistry, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jun Yoshimatsu
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naoto Minamino
- Omics Research Center, National Cerebral and Cardiovascular Center, Suita, Japan
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Sun S, Guo X, Chen Y, Shen J, Zhu D, Zhang Z, Fu L, Ji W, Li F. Left ventricular epicardial pacing achieved hyper-responsiveness in young children with dilated cardiomyopathy with left bundle branch block. ESC Heart Fail 2021; 8:4772-4779. [PMID: 34729942 PMCID: PMC8712794 DOI: 10.1002/ehf2.13657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/04/2021] [Accepted: 09/27/2021] [Indexed: 12/03/2022] Open
Abstract
Aims The management of heart failure (HF) in young children is challenging. The present study aimed to clarify the effect of left univentricular epicardial pacing on dilated cardiomyopathy with left bundle branch block (LBBB) in children. Methods and results A total of five cases (30.86 ± 16.39 months, three female) of children weighing 5.8–15 kg with dilated cardiomyopathy and LBBB were included in this study. LBBB in one child occurred after device closure of peri‐membranous ventricular septal defects, and the remaining four were idiopathically discovered early after birth. Before implantation, all children suffered from refractory HF and cardiac dilatation; the left ventricular ejection fraction was 33.48 ± 5.84% with Ross Heart Failure Classification III–IV. Electrical and mechanical dyssynchrony were observed in all children with QRS duration >140 ms and prolonged septal‐to‐left posterior wall motion delay. Left univentricular epicardial pacing was successfully implanted via left axillary minithoracotomy in the five children. Sensed atrioventricular delays (83 ± 15 ms) were optimized by velocity time integral of aortic blood flow before discharge. During the follow‐up period (10.8 ± 2.68 months), the dilated failing heart was reversed significantly in terms of decreased left ventricular dimension (55.62 ± 3.46 vs. 38.94 ± 3.69 mm, P = 0.005), while the left ventricular ejection fraction improved to 60.18 ± 8.78% (P = 0.006). Conclusions In young children with low body weight, if HF is caused by or related to LBBB, left ventricular epicardial pacing still has an excellent effect.
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Affiliation(s)
- Sijuan Sun
- Department of Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Xiaofeng Guo
- Department of Cardiology, Fujian Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yiwei Chen
- Department of Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Jie Shen
- Department of Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Diqi Zhu
- Department of Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Zhifang Zhang
- Department of Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Lijun Fu
- Department of Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Wei Ji
- Department of Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Fen Li
- Department of Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
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5
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A word on netting of angiotensin-converting enzyme inhibitor therapy in hypoplastic left heart syndrome following stage-I. Cardiol Young 2021; 31:1323-1326. [PMID: 34318741 DOI: 10.1017/s1047951121002936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
NPC-QIC Registry data showed that angiotensin-converting enzyme inhibitors were described in almost 38% for patients with single ventricle physiology after stage-I Norwood palliation. However, mortality and ventricular dysfunction or atrioventricular valve insufficiency seems to be not improved by oral application of angiotensin-converting enzyme inhibitors. The final conclusion was that despite limited evidence of benefit for patients with hypoplastic left heart syndrome, prescription of angiotensin-converting enzyme inhibitors during interstage is still common. Taking into account of the predominant cardiovascular regulation in newborns and young infants by circulating catecholamines, no real improvement is to be expected from angiotensin-converting enzyme inhibitor monotherapy. The goals of drug therapy after stage-I Norwood palliation in hypoplastic left heart syndrome are prevention of systemic right ventricle failure, balancing pulmonary and systemic blood flow, and reduction of oxygen consumption with regard to limitations of oxygen supply by the single ventricle, furthermore, avoiding harmful effects of endogenous catecholamine production in the long term on somatic and cognitive development. In this light of knowledge, we want to recommend the use of a long-acting and highly specific ß1-adrenoreceptor blocker for almost all patients after stage-I Norwood palliation and a combination with angiotensin-converting enzyme inhibitors only by indication after exclusion of potential side effects.
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Ramakrishnan S, Ghati N, Ahuja RS, Bhatt KN, Sati HC, Saxena A, Kothari SS. Efficacy and safety of propranolol in infants with heart failure due to moderate-to-large ventricular septal defect (VSD-PHF study) - A prospective randomized trial. Ann Pediatr Cardiol 2021; 14:331-340. [PMID: 34667404 PMCID: PMC8457270 DOI: 10.4103/apc.apc_94_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/10/2021] [Indexed: 01/16/2023] Open
Abstract
AIMS The utility of beta-blocker therapy in infants with heart failure (HF) due to significant left-to-right shunt lesions is not known. The study aimed to assess the efficacy and safety of propranolol in infants with HF due to moderate-to-large ventricular septal defect (VSD). METHODS The prospective randomized trial included 80 infants with HF and moderate-to-large VSD, randomly allocated to receive either conventional therapy alone (n = 40) or propranolol plus conventional therapy (n = 40). The primary endpoint was a composite of all-cause mortality, hospitalization for HF and/or chest infection, and referral for surgery. The secondary clinical outcomes were the individual components of the composite endpoint. In addition, the patients were followed up to detect safety outcomes, for example, bronchospasm, bradyarrhythmia, and worsening HF symptoms. RESULTS The addition of propranolol therapy to the conventional medications did not result in significant improvement in the primary composite endpoint (32.50% vs. 52.50%; P = 0.07). There was a trend toward improvement, but the study is underpowered for this important question. However, propranolol therapy significantly decreased the risk of hospitalization (12.50% vs. 32.50%; P = 0.03) and worsening of Ross HF class (5.41% vs. 28.21%; P = 0.01) as compared to conventional therapy (estimated number needed to treat = 5). Propranolol did not result in any significant safety concerns in these infants except bronchospasm in an infant. CONCLUSIONS Propranolol therapy in infants with significant left-to-right shunt may prevent worsening in HF symptoms and hospitalization and is well tolerated. However, it does not reduce mortality or need for surgery.
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Affiliation(s)
| | - Nirmal Ghati
- Department of Cardiology, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Ramandeep Singh Ahuja
- Department of Cardiology, Krishna Hospital and Research Centre, Haldwani, Uttarakhand, India
| | | | - Hem Chandra Sati
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shyam Sunder Kothari
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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7
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Kalia K, Walker-Smith P, Ordoñez MV, Barlatay FG, Chen Q, Weaver H, Caputo M, Stoica S, Parry A, Tulloh RMR. Does Maintenance of Pulmonary Blood Flow Pulsatility at the Time of the Fontan Operation Improve Hemodynamic Outcome in Functionally Univentricular Hearts? Pediatr Cardiol 2021; 42:1180-1189. [PMID: 33876263 PMCID: PMC8192359 DOI: 10.1007/s00246-021-02599-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/01/2021] [Indexed: 11/08/2022]
Abstract
It is unclear whether residual anterograde pulmonary blood flow (APBF) at the time of Fontan is beneficial. Pulsatile pulmonary flow may be important in maintaining a compliant and healthy vascular circuit. We, therefore, wished to ascertain whether there was hemodynamic evidence that residual pulsatile flow at time of Fontan promotes clinical benefit. 106 consecutive children with Fontan completion (1999-2018) were included. Pulmonary artery pulsatility index (PI, (systolic pressure-diastolic pressure)/mean pressure)) was calculated from preoperative cardiac catheterization. Spectral analysis charted PI as a continuum against clinical outcome. The population was subsequently divided into three pulsatility subgroups to facilitate further comparison. Median PI prior to Fontan was 0.236 (range 0-1). 39 had APBF, in whom PI was significantly greater (median: 0.364 vs. 0.177, Mann-Whitney p < 0.0001). There were four early hospital deaths (3.77%), and PI in these patients ranged from 0.214 to 0.423. There was no correlation between PI and standard cardiac surgical outcomes or systemic oxygen saturation at discharge. Median follow-up time was 4.33 years (range 0.0273-19.6), with no late deaths. Increased pulsatility was associated with higher oxygen saturations in the long term, but there was no difference in reported exercise tolerance (Ross), ventricular function, or atrioventricular valve regurgitation at follow-up. PI in those with Fontan-associated complications or the requiring pulmonary vasodilators aligned with the overall population median. Maintenance of pulmonary flow pulsatility did not alter short-term outcomes or long-term prognosis following Fontan although it tended to increase postoperative oxygen saturations, which may be beneficial in later life.
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Affiliation(s)
- K Kalia
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - P Walker-Smith
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - M V Ordoñez
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - F G Barlatay
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - Q Chen
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - H Weaver
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - M Caputo
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - S Stoica
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - A Parry
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - R M R Tulloh
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK.
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8
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Schranz D. Pharmacological Heart Failure Therapy in Children: Focus on Inotropic Support. Handb Exp Pharmacol 2020; 261:177-192. [PMID: 31707469 DOI: 10.1007/164_2019_267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pediatric heart failure is a clinical syndrome, which needs to be distinctly defined and the pathophysiological consequences considered. Pharmacological treatment depends on the disease- and age-specific myocardial characteristics. Acute and chronic low cardiac output is the result of an inadequate heart rate (rhythm), myocardial contractility, preload and afterload, and also ventriculo-ventricular interaction, synchrony, atrio-ventricular and ventricular-arterial coupling. The treatment of choice is curing the cause of heart failure, if possible.Acute HF therapy is still based to the use of catecholamines and inodilators. The cornerstone of chronic HF treatment consists of blocking the endogenous, neuro-humoral axis, in particular the adrenergic and renin-angiotensin-aldosterone system.Before neprilysin inhibitors are used in young children, their potential side-effect for inducing Alzheimer disease needs to be clarified. The focus of the current review is put on the differential use of the inotropic drugs as epinephrine, norepinephrine, dopamine and dobutamine, and also the inodilators milrinone and levosimendan. Considering effects and side-effects of any cardiac stimulating treatment strategy, co-medication with ß-blockers, angiotensin converting inhibitors (ACEIs), angiotensin blockers (ARBs) and mineralocorticoid receptor antagonists (MRAs) is not a contradiction, but a senseful measure, even still during the acute inotropic treatment.Missing sophisticated clinical trials using accurate entry criteria and clinically relevant endpoints, there is especially in cardiovascular diagnosis and treatment of young children a compromise of evidence-based versus pathophysiology-based procedures. But based on the pharmacological and pathophysiological knowledge a hypothesis-driven individualized treatment is already currently possible and therefore indicated.
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Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center, Johann Wolfgang Goethe University Clinic, Frankfurt, Germany.
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9
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Abstract
Pediatric heart failure (PHF) affects 0.87 to 7.4 per 100,000 children. It has a 5-year mortality or heart transplant rate of 40%. Diagnosis often is delayed because initial symptoms are similar to common pediatric illnesses. Disease progression is tracked by symptoms, echocardiogram, and biomarkers. Treatment is extrapolated from mostly adult heart failure (HF) literature. Recent studies demonstrate differences between pediatric and adult HF pathophysiology. Increased collaboration among PHF programs is advancing the management of PHF. Unfortunately, there are patients who ultimately require heart transplantation, with increasing numbers supported by a ventricular assist device as a bridge to transplantation.
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Affiliation(s)
- Kae Watanabe
- Northwestern University, 225 East Chicago Avenue, Box 21, Chicago, IL 60611-2605, USA.
| | - Renata Shih
- University of Florida, 1600 Southwest Archer Road PO Box 100296, Gainesville, FL 32610, USA
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10
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Ragusa R, Di Molfetta A, Amodeo A, Trivella MG, Caselli C. Pathophysiology and molecular signalling in pediatric heart failure and VAD therapy. Clin Chim Acta 2020; 510:751-759. [PMID: 32949569 DOI: 10.1016/j.cca.2020.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
Heart Failure (HF) is a progressive clinical syndrome characterized by molecular and structural abnormalities that result in impaired ventricular filling and a reduced blood ejection. In pediatric patients, HF represents an important cause of morbidity and mortality, but underlying cause, presentation and disease course remains unclear in many cases. It is evident that a child is not a "small adult" and findings are not comparable. The adoption of a standardized clinical and surgical tools as well as increased biomolecular research and therapeutic trials targeting pediatric patients with HF would greatly improve the management of this special class of patients. This review examines the most current information about the pathophysiology and molecular mechanisms related to HF in children to identify gaps in our knowledge base to further improve clinical care and outcomes.
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Affiliation(s)
- Rosetta Ragusa
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Institute of Clinical Physiology, CNR, Pisa, Italy
| | - Arianna Di Molfetta
- Department of Cardiothoracic Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Antonio Amodeo
- Department of Cardiothoracic Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy
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11
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Liu H, Zhang CH, Ammanamanchi N, Suresh S, Lewarchik C, Rao K, Uys GM, Han L, Abrial M, Yimlamai D, Ganapathy B, Guillermier C, Chen N, Khaladkar M, Spaethling J, Eberwine JH, Kim J, Walsh S, Choudhury S, Little K, Francis K, Sharma M, Viegas M, Bais A, Kostka D, Ding J, Bar-Joseph Z, Wu Y, Yechoor V, Moulik M, Johnson J, Weinberg J, Reyes-Múgica M, Steinhauser ML, Kühn B. Control of cytokinesis by β-adrenergic receptors indicates an approach for regulating cardiomyocyte endowment. Sci Transl Med 2020; 11:11/513/eaaw6419. [PMID: 31597755 PMCID: PMC8132604 DOI: 10.1126/scitranslmed.aaw6419] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 06/10/2019] [Accepted: 08/30/2019] [Indexed: 12/28/2022]
Abstract
One million patients with congenital heart disease (CHD) live in the United States. They have a lifelong risk of developing heart failure. Current concepts do not sufficiently address mechanisms of heart failure development specifically for these patients. Here, analysis of heart tissue from an infant with tetralogy of Fallot with pulmonary stenosis (ToF/PS) labeled with isotope-tagged thymidine demonstrated that cardiomyocyte cytokinesis failure is increased in this common form of CHD. We used single-cell transcriptional profiling to discover that the underlying mechanism of cytokinesis failure is repression of the cytokinesis gene ECT2, downstream of β-adrenergic receptors (β-ARs). Inactivation of the β-AR genes and administration of the β-blocker propranolol increased cardiomyocyte division in neonatal mice, which increased the number of cardiomyocytes (endowment) and conferred benefit after myocardial infarction in adults. Propranolol enabled the division of ToF/PS cardiomyocytes in vitro. These results suggest that β-blockers could be evaluated for increasing cardiomyocyte division in patients with ToF/PS and other types of CHD.
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Affiliation(s)
- Honghai Liu
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Cheng-Hai Zhang
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Niyatie Ammanamanchi
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Sangita Suresh
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Christopher Lewarchik
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Krithika Rao
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Gerrida M Uys
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Lu Han
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Maryline Abrial
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Dean Yimlamai
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Balakrishnan Ganapathy
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Christelle Guillermier
- Division of Genetics and Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Nathalie Chen
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Mugdha Khaladkar
- Department of Biology, School of Arts and Sciences, University of Pennsylvania, 301A/B Lynch Laboratory, 433 S University Avenue, Philadelphia, PA 19104, USA
| | - Jennifer Spaethling
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - James H Eberwine
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Junhyong Kim
- Department of Biology, School of Arts and Sciences, University of Pennsylvania, 301A/B Lynch Laboratory, 433 S University Avenue, Philadelphia, PA 19104, USA
| | - Stuart Walsh
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Sangita Choudhury
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Kathryn Little
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Kimberly Francis
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Mahesh Sharma
- Division of Cardiothoracic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Melita Viegas
- Pediatric Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh and Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Abha Bais
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15201, USA
| | - Dennis Kostka
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15201, USA.,Department of Computational & Systems Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.,Pittsburgh Center for Evolutionary Biology and Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Jun Ding
- Computational Biology Department and Machine Learning Department, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Ziv Bar-Joseph
- Computational Biology Department and Machine Learning Department, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Yijen Wu
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15201, USA.,Rangos Research Center Animal Imaging Core, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Vijay Yechoor
- Diabetes and Beta Cell Biology Center, Division of Endocrinology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15238, USA
| | - Mousumi Moulik
- Division of Cardiology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Jennifer Johnson
- Division of Cardiology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA.,Neonatal-Perinatal Medicine, UPMC Magee-Womens Hospital, Pittsburgh, PA 15213, USA
| | - Jacqueline Weinberg
- Division of Cardiology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Miguel Reyes-Múgica
- Division of Pediatric Pathology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Matthew L Steinhauser
- Division of Genetics and Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Bernhard Kühn
- Richard King Mellon Foundation Institute for Pediatric Research and Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA. .,McGowan Institute of Regenerative Medicine, Pittsburgh, PA 15219, USA.,Pediatric Institute for Heart Regeneration and Therapeutics, Pittsburgh, PA 15224, USA
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12
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Abstract
BACKGROUND Beta-blockers are an essential part of standard therapy in adult congestive heart failure and therefore, are expected to be beneficial in children. However, congestive heart failure in children differs from that in adults in terms of characteristics, aetiology, and drug clearance. Therefore, paediatric needs must be specifically investigated. This is an update of a Cochrane review previously published in 2009. OBJECTIVES To assess the effect of beta-adrenoceptor-blockers (beta-blockers) in children with congestive heart failure. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and LILACS up to November 2015. Bibliographies of identified studies were checked. No language restrictions were applied. SELECTION CRITERIA Randomised, controlled, clinical trials investigating the effect of beta-blocker therapy on paediatric congestive heart failure. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and assessed data from the included trials. MAIN RESULTS We identified four new studies for the review update; the review now includes seven studies with 420 participants. Four small studies with 20 to 30 children each, and two larger studies of 80 children each, showed an improvement of congestive heart failure with beta-blocker therapy. A larger study with 161 participants showed no evidence of benefit over placebo in a composite measure of heart failure outcomes. The included studies showed no significant difference in mortality or heart transplantation rates between the beta-blocker and control groups. No significant adverse events were reported with beta-blockers, apart from one episode of complete heart block. A meta-analysis of left ventricular ejection fraction (LVEF) and fractional shortening (LVFS) data showed a very small improvement with beta-blockers. However, there were vast differences in the age, age range, and health of the participants (aetiology and severity of heart failure; heterogeneity of diagnoses and co-morbidities); there was a range of treatments across studies (choice of beta-blocker, dosing, duration of treatment); and a lack of standardised methods and outcome measures. Therefore, the primary outcomes could not be pooled in meta-analyses. AUTHORS' CONCLUSIONS There is not enough evidence to support or discourage the use of beta-blockers in children with congestive heart failure, or to propose a paediatric dosing scheme. However, the sparse data available suggested that children with congestive heart failure might benefit from beta-blocker treatment. Further investigations in clearly defined populations with standardised methodology are required to establish guidelines for therapy. Pharmacokinetic investigations of beta-blockers in children are also required to provide effective dosing in future trials.
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Affiliation(s)
- Samer Alabed
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - Ammar Sabouni
- KasrAlAiny School of Medicine, Cairo University, Cairo, Egypt
| | - Suleiman Al Dakhoul
- Department of Medicine, The Wirral University Teaching Hospitals, Upton, Wirral, UK
| | - Yamama Bdaiwi
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
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13
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Bajcetic M, de Wildt SN, Dalinghaus M, Breitkreutz J, Klingmann I, Lagler FB, Keatley-Clarke A, Breur JM, Male C, Jovanovic I, Szatmári A, Ablonczy L, Burckhardt BB, Cawello W, Kleine K, Obarcanin E, Spatenkova L, Swoboda V, van der Meulen M, Wagner P, Walsh J, Läer S. Orodispersible minitablets of enalapril for use in children with heart failure (LENA): Rationale and protocol for a multicentre pharmacokinetic bridging study and follow-up safety study. Contemp Clin Trials Commun 2019; 15:100393. [PMID: 31249901 PMCID: PMC6586986 DOI: 10.1016/j.conctc.2019.100393] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/23/2019] [Accepted: 06/04/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction Treatment of paediatric heart failure is based on paradigms extensively tested in the adult population assuming similar underlying pathophysiological mechanisms. Angiotensin converting enzyme inhibitors (ACEI) like enalapril are one of the cornerstones of treatment and commonly used off-label in children. Dose recommendations have been extrapolated from adult experience, but the relationship between dose and pharmacokinetics (PK) in (young) children is insufficiently studied. Furthermore, appropriate paediatric formulations are lacking. Within the European collaborative project LENA, a novel formulation of enalapril orodispersible minitablets (ODMT), suitable for paediatric administration, will be tested in (young) children with heart failure due to either dilated cardiomyopathy or congenital heart disease in two pharmacokinetic bridging studies. Paediatric PK data of enalapril and its active metabolite enalaprilat will be obtained. In a follow-up study, the safety of enalapril ODMTs will be demonstrated in patients on long-term treatment of up to 10 months. Furthermore, additional information about pharmacodynamics (PD) and ODMT acceptability will be collected in all three studies. Methods and Analysis Phase II/III, open-label, multicentre study. Children with dilated cardiomyopathy (DCM) (n = 25; 1 month to less than 12 years) or congenital heart disease (CHD) (n = 60; 0 to less than 6 years) requiring or already on ACEI will be included. Exclusion criteria include severe heart failure precluding ACEI use, hypotension, renal impairment, hypersensitivity to ACEI. For those naïve to ACEI up-titration to an optimal dose will be performed, those already on ACEI will be switched to an expected equivalent dose of enalapril ODMT and optimised. In the first 8 weeks of treatment, a PK profile will be obtained at the first dose (ACEI naïve patients) or when an optimal dose is reached. Furthermore, population PK will be done with concentrations detected over the whole treatment period. PD and safety data will be obtained at least at 2-weeks intervals. Subsequently, an intended number of 85 patients will be followed-up up to 10 months to demonstrate long-term safety, based on the occurrence of (severe) adverse events and monitoring of vital signs and renal function. Ethics and dissemination Clinical Trial Authorisation and a favourable ethics committee opinion were obtained in all five participating countries. Results of the studies will be submitted for publication in a peer-reviewed journal. Trial registration numbers EudraCT 2015-002335-17, EudraCT 2015-002396-18, EudraCT 2015-002397-21.
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Affiliation(s)
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michiel Dalinghaus
- Division of Pediatric Cardiology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | | | | | | | | | - Johannes Mpj Breur
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Christoph Male
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ida Jovanovic
- Univerzitetska Dečja Klinika (UDK), Belgrade, Serbia
| | - Andras Szatmári
- Göttsegen György Hungarian Institute of Cardiology (HPHC), Budapest, Hungary
| | - László Ablonczy
- Göttsegen György Hungarian Institute of Cardiology (HPHC), Budapest, Hungary
| | - Bjoern B Burckhardt
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Willi Cawello
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Emina Obarcanin
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Vanessa Swoboda
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Marijke van der Meulen
- Division of Pediatric Cardiology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Peter Wagner
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Stephanie Läer
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
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15
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Sachdeva S, Jacobsen RM, Woods RK, Mitchell ME, Cava JR, Ghanayem NS, Frommelt PC, Bartz PJ, Tweddell JS. Anatomic Repair of Congenitally Corrected Transposition of the Great Arteries: Single-Center Intermediate-Term Experience. Pediatr Cardiol 2017; 38:1696-1702. [PMID: 28918529 DOI: 10.1007/s00246-017-1715-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/31/2017] [Indexed: 01/15/2023]
Abstract
We present our experience for patients who have undergone an anatomic repair (AR) for congenitally corrected transposition of the great arteries (CCTGA) at the Children's Hospital of Wisconsin. A retrospective chart review of patients who underwent AR for CCTGA from 2001 to 2015 was performed. The cohort consisted of 15 patients (74% male). Median age of anatomic repair was 15 months (range 4.5-45.6 months). Four patients had a bidirectional Glenn (BDG) prior to AR. At the time of AR,-9 (60%) underwent Senning/Rastelli procedure, 4 (26.6%) had double switch operation, and 2 (13.3%) underwent only Senning with VSD closure. Median duration of follow-up was 5.5 years (0.05-14 years). Reoperations prior to discharge included BDG, revision of pulmonary venous baffle, closure of residual VSD, and pacemaker placement. Late reoperations included left ventricular outflow tract obstruction repair, conduit replacement, melody valve placement, and pacemaker implantation. At their most recent follow-up, no patient had heart failure symptoms and only 1 had severely diminished function that improved with cardiac resynchronization therapy. Moderate mitral regurgitation was noted in 15% (2/13), and severe in 7% (1/13). Moderate tricuspid regurgitation was noted in 15% (2/13). One patient, 7% (1/13), developed moderate aortic insufficiency. There was a 100% survival at the time of the most recent follow-up. Patients with CCTGA who have undergone AR have excellent functional status and mid-term survival but reinterventions are common. Longer term studies are needed to determine both the extent and spectrum of reinterventions as well as long term survival.
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Affiliation(s)
| | | | | | | | - Joseph R Cava
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | | | | | - Peter J Bartz
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - James S Tweddell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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16
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Behandlung der chronischen Herzinsuffizienz im Kindesalter. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0370-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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17
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Abstract
OBJECTIVES The objectives of this study were to compare the quality-of-life scores of Malaysian children with CHD and their healthy siblings, to determine the level of agreement between proxy-reports and child self-reports, and to examine variables that have an impact on quality of life in those with CHD. METHODS Parental-proxy scores of the Pediatric Quality of Life Inventory 4.0 core scales were obtained for 179 children with CHD and 172 siblings. Intra-class coefficients were derived to determine the levels of proxy-child agreement in 66 children aged 8-18 years. Multiple regression analysis was used to determine factors that impacted Pediatric Quality of Life Inventory scores. RESULTS Proxy scores were lower in children with CHD than siblings for all scales except physical health. Maximum differences were noted in children aged 5-7 years, whereas there were no significant differences in the 2-4 and 13-18 years age groups. Good levels of proxy-child agreement were found in children aged 8-12 years for total, psychosocial health, social, and school functioning scales (correlation coefficients 0.7-0.8). In children aged 13-18 years, the level of agreement was poor to fair for emotional and social functioning. The need for future surgery and severity of symptoms were associated with lower scores. CONCLUSION Differences in proxy perception of quality of life appear to be age related. The level of proxy-child agreement was higher compared with other reported studies, with lower levels of agreement in teenagers. Facilitating access to surgery and optimising control of symptoms may improve quality of life in this group of children.
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18
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Hinton RB, Ware SM. Heart Failure in Pediatric Patients With Congenital Heart Disease. Circ Res 2017; 120:978-994. [PMID: 28302743 DOI: 10.1161/circresaha.116.308996] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/27/2016] [Accepted: 12/28/2016] [Indexed: 12/14/2022]
Abstract
Heart failure (HF) is a complex clinical syndrome resulting from diverse primary and secondary causes and shared pathways of disease progression, correlating with substantial mortality, morbidity, and cost. HF in children is most commonly attributable to coexistent congenital heart disease, with different risks depending on the specific type of malformation. Current management and therapy for HF in children are extrapolated from treatment approaches in adults. This review discusses the causes, epidemiology, and manifestations of HF in children with congenital heart disease and presents the clinical, genetic, and molecular characteristics that are similar or distinct from adult HF. The objective of this review is to provide a framework for understanding rapidly increasing genetic and molecular information in the challenging context of detailed phenotyping. We review clinical and translational research studies of HF in congenital heart disease including at the genome, transcriptome, and epigenetic levels. Unresolved issues and directions for future study are presented.
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Affiliation(s)
- Robert B Hinton
- From the Department of Pediatrics and Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis
| | - Stephanie M Ware
- From the Department of Pediatrics and Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis.
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19
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El Amrousy D, Hodeib H, Suliman G, Hablas N, Salama ER, Esam A. Diagnostic and Prognostic Value of Plasma Levels of Cardiac Myosin Binding Protein-C as a Novel Biomarker in Heart Failure. Pediatr Cardiol 2017; 38:418-424. [PMID: 27878630 DOI: 10.1007/s00246-016-1532-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 11/12/2016] [Indexed: 02/05/2023]
Abstract
Heart failure (HF) has high morbidity and mortality in children. This study aimed to investigate the value of cardiac myosin binding protein-C (cMyBP-C) as a diagnostic and prognostic biomarker in children with heart failure. This study was a prospective case-control study that involved 50 children with acute HF and 25 healthy children of matched age and sex as a control group. cMyBP-C plasma levels were measured in patients with HF at the time of admission and 1 month after treatment. Echocardiographic assessment was done for all children. All patients were followed up for a period of 3 months. There was a significant increase in plasma levels of cMyBP-C (ng/ml) in patients with HF at admission (122.44 ± 41.01) as compared to patients after treatment (71.38 ± 49.68) and to control group (24.40 ± 9.83). This increase was associated with increased severity of HF according to pediatric Ross classification of HF. Significant increase in plasma levels of cMyBP-C at admission and its persistent increase after treatment were associated with adverse outcome of mortality and readmission. Plasma levels of cMyBP-C were significantly correlated with echocardiographic and clinical assessment of heart failure. Plasma levels of cMyBP-C were a good biomarker for diagnosis of HF with sensitivity 100% and specificity 96% at cutoff point of 45 ng/ml. Its value in predicting adverse outcome in HF patients was obtained by ROC curve with sensitivity of 90% and specificity 93% at a cutoff point of 152 ng/ml cMyBP-C at admission. cMyBP-C may be a novel useful diagnostic and prognostic biomarker in children with heart failure and determination of severity of HF in these patients.
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Affiliation(s)
- Doaa El Amrousy
- Pediatric Department, Tanta University Hospital, El Motasem Street, Tanta, Egypt.
| | - Hossam Hodeib
- Clinical Pathology Department, Tanta University Hospital, Tanta, Egypt
| | - Ghada Suliman
- Clinical Pathology Department, Tanta University Hospital, Tanta, Egypt
| | - Nahed Hablas
- Pediatric Department, Tanta University Hospital, El Motasem Street, Tanta, Egypt
| | | | - Ahmed Esam
- Anesthesiology and ICU Department, Tanta University Hospital, Tanta, Egypt
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20
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Ramírez-Marroquín S, Curi-Curi PJ, Calderón-Colmenero J, García-Montes JA, Cervantes-Salazar JL. Common Arterial Trunk Repair by Means of a Handmade Bovine Pericardial-Valved Woven Dacron Conduit. World J Pediatr Congenit Heart Surg 2016; 8:69-76. [PMID: 28033080 DOI: 10.1177/2150135116674439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Surgical repair of common arterial trunk (CAT) by means of a homograft conduit has become a standard practice. We report our experience in the correction of this heart disease with a handmade bovine pericardial-valved woven Dacron conduit as an alternative procedure to homografts, with a focus on early, mid-term, and long-term results. METHODS We designed a retrospective study that included 15 patients with a mean age of 1.5 years (range: three months to eight years), who underwent primary repair of simple CAT. Right ventricular outflow tract was reconstructed in all the cases with this handmade graft that was explanted at the time of its biological stenotic degeneration. A peeling procedure was performed at this time, in order to reconstruct the right ventricle-to-pulmonary artery continuity. RESULTS Overall mortality was 13.3% (one death at the early postoperative primary repair and the other at the mid-term postoperative peeling reoperation). Actuarial survival rate was 93.3%, 86.7%, and 86.7% at 5, 10, and 15 years, respectively. All of the 14 survivors developed stenosis of the handmade conduit at the mid-term period (8 ± 3 years), but after the peeling procedure, 13 survivors remain asymptomatic to date. CONCLUSIONS Primary repair of common arterial trunk using a handmade conduit can be performed with very low perioperative mortality and satisfactory mid-term and long-term results, which can be favorably compared with those reported with the use of homografts. When graft obstruction develops, peeling procedure is a good option because it does not affect the overall survival, although long-term outcomes warrant further follow-up.
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Affiliation(s)
- Samuel Ramírez-Marroquín
- 1 Department of Pediatric Cardiac and Congenital Heart Disease Surgery, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Pedro José Curi-Curi
- 1 Department of Pediatric Cardiac and Congenital Heart Disease Surgery, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Juan Calderón-Colmenero
- 2 Department of Pediatric Cardiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - José Antonio García-Montes
- 2 Department of Pediatric Cardiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Jorge Luis Cervantes-Salazar
- 1 Department of Pediatric Cardiac and Congenital Heart Disease Surgery, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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21
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The evolution of medical therapy for children with heart failure. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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22
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Biomarkers in pediatric heart failure. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Schranz D, Voelkel NF. "Nihilism" of chronic heart failure therapy in children and why effective therapy is withheld. Eur J Pediatr 2016; 175:445-55. [PMID: 26895877 PMCID: PMC4806719 DOI: 10.1007/s00431-016-2700-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 12/06/2015] [Accepted: 01/26/2016] [Indexed: 12/11/2022]
Abstract
UNLABELLED Major advances in chronic heart failure (cHF) therapy have been achieved and documented in adult patients, while research regarding the mechanisms and therapy of cHF in children has lagged behind. Based on receptor physiological studies and pharmacological knowledge, treatment with specific ß1-adrenergic receptor blocker (ARB), tissue angiotensin-converting enzyme inhibitor (ACE-I), and mineralocorticoid antagonists have to be recommended in children despite lack of sufficient data derived from prospective randomized studies. At our institution, bisoprolol, lisinopril, and spironolactone have been firmly established to treat systolic cHF, hypoplastic left heart syndrome (HLHS) following hybrid approach and congenital left-right shunt diseases, latest in patients where surgery has to be delayed. Chronic therapy with long-acting diuretics and fluid restriction are not advocated because short-term effects are achieved at the expense of further neuro-humoral stimulation. It remains unclear why diuretics are recommended although evidence-based studies, documenting long-term benefit, are missing. However, that is true for all currently used drugs for pediatric cHF. CONCLUSION This review focuses on the prevailing "nihilism" of cHF therapy in children with the goal to encourage physicians to treat pediatric cHF with a rationally designed therapy, which combines available agents that have been shown to improve survival in adult patients with cHF. Because of the lack of clinical trials, which generate the needed evidence, surrogate variables like heart and respiratory rate, weight gain, image-derived data, and biomarkers should be monitored and used instead. The recommended pharmacological therapy for systolic heart failure is also provided as the basis for utilizing reversible pulmonary arterial banding (PAB) as a novel strategy in young children with dilative cardiomyopathy (DCM) with preserved right ventricular function. WHAT IS KNOWN • Heart failure (HF) in children is a serious public health concern. • HF has numerous etiologies, but unspecific symptoms. • HF interplays among neuro-humoral, and molecular abnormalities. • Pediatric cHF-therapy is currently based on loop-diuretics, fluid restriction and digoxin. What is New: • Cardiac function analysis has to include cardiac synchrony and VVI. • Considering enormous potential of cardiac regeneration, therapy has to extend with selective ß1-ARB, tissue ACE-I and mineralocorticoid blockers, loop-diuretics avoided as ever possible. • Inhibition of the endogenous neuro-humoral stimulation is monitored by surrogate parameters as heart and breath rate and systolic and diastolic blood pressure. • Advocated HF therapy serves for regenerative strategies as reversible Pulmonary Artery Banding in DCM.
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Affiliation(s)
- Dietmar Schranz
- />Pediatric Heart Center, Justus-Liebig University Clinic, Feulgenstr. 12, 30385 Giessen, Germany
| | - Norbert F. Voelkel
- />School of Pharmacy, Virginia Commonwealth University, Richmond, VA USA
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Chronic Heart Failure. Pediatr Crit Care Med 2016; 17:S20-34. [PMID: 26945326 DOI: 10.1097/pcc.0000000000000624] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Heart failure is a serious complication that can occur in patients with a variety of congenital and acquired disorders including congenital heart disease, cardiomyopathy, and myocarditis. Furthermore, heart failure patients comprise an increasing number of ICU admissions. Thus, it is important for those caring for patients with critical cardiovascular disease to have a thorough understanding of the medications used for the treatment of heart failure. The aim of this review is to provide an overview, rationale, indications, and adverse effects of medications used in the treatment of chronic heart failure. DATA SOURCES PubMed, Medline, Cochrane Database of Systemic Reviews. STUDY SELECTION Studies were selected on their relevance for pediatric heart failure. When limited data on pediatric heart failure were available, studies in adult patients were selected. DATA EXTRACTION Relevant findings from studies were selected by the authors. DATA SYNTHESIS The rationale for the efficacy of most heart failure medications used in pediatric patients is extrapolated from studies in adult heart failure. Commonly used medications for chronic heart failure include β-receptor antagonists (e.g., carvedilol and metoprolol), and medications aimed at blocking the renin-angiotensin-aldosterone system (e.g., angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone receptor antagonists). In addition, diuretics are useful for symptoms of fluid overload. For patients with impaired perfusion, inotropic agents are useful acutely, but may be associated with worse outcomes when used chronically. Newer medications that have been recently approved in adults (e.g., serelaxin, ivabradine, and neprilysin inhibitor [angiotensin receptor blocker]) may prove to be important in pediatric heart failure. CONCLUSIONS Heart failure patients are in an important population of critically ill children. The pharmacologic approach to these patients is aimed at treating symptoms of congestion and/or poor perfusion and improving long-term outcomes.
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Vigneswaran TV, Brown JR, Breuer J, Burch M. Parvovirus B19 myocarditis in children: an observational study. Arch Dis Child 2016; 101:177-80. [PMID: 26613943 DOI: 10.1136/archdischild-2014-308080] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 11/04/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND The advent of PCR testing for the presence of viral genomes has led to the identification of parvovirus B19 (PVB19) as a causative agent of myocarditis. METHODS The clinical presentation, course and outcome of children with PVB19 myocarditis was ascertained through a retrospective review. The PVB19 viral genome was detected by PCR from whole blood or endomyocardial biopsy specimens in patients presenting with new onset heart failure. RESULTS Seventeen patients presented at a median age of 1.3 years (range: 0.4-15.4 years) in cardiac failure with a mean fractional shortening of 15±3%. Eleven patients required mechanical ventilation and intravenous inotropes and seven required extra-corporeal mechanical oxygenation. Four of the five deaths occurred in patients who had a short prodromal illness of less than 48 hours. All patients with ST segment elevation died (n=4). All non-fulminant cases survived. Event-free survival occurred in 11/17 (65%) patients. Five (29%) patients died and one patient underwent heart transplantation. Complete recovery of cardiac function occurred within a median of 12 months (range: 1-48) in five patients. There was incomplete recovery in five patients and one patient had persistent dilated cardiomyopathy. CONCLUSIONS PVB19 can cause a devastating myocarditis in children. Children with fulminant myocarditis, ST segment changes or a short prodrome have the worst outcome. Transplantation may be considered, but is rarely required in the acute period if mechanical circulatory support is utilised. If the initial presentation is survived, recovery of the myocardium can occur even in those who had fulminant myocarditis.
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Affiliation(s)
- Trisha V Vigneswaran
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Julianne R Brown
- Departments of Microbiology, Virology and Infection Prevention and Control, Camelia Botnar Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK NIHR Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London, London, UK
| | - Judith Breuer
- Departments of Microbiology, Virology and Infection Prevention and Control, Camelia Botnar Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK UCL Division of Infection and Immunity, University College London, London, UK
| | - Michael Burch
- Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Alabed S, Sabouni A, Al Dakhoul S, Bdaiwi Y, Frobel-Mercier AK. Beta-blockers for congestive heart failure in children. Cochrane Database Syst Rev 2016:CD007037. [PMID: 26820557 DOI: 10.1002/14651858.cd007037.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Beta-blockers are an essential part of standard therapy in adult congestive heart failure and therefore, are expected to be beneficial in children. However, congestive heart failure in children differs from that in adults in terms of characteristics, aetiology, and drug clearance. Therefore, paediatric needs must be specifically investigated. This is an update of a Cochrane review previously published in 2009. OBJECTIVES To assess the effect of beta-adrenoceptor-blockers (beta-blockers) in children with congestive heart failure. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and LILACS up to November 2015. Bibliographies of identified studies were checked. No language restrictions were applied. SELECTION CRITERIA Randomised, controlled, clinical trials investigating the effect of beta-blocker therapy on paediatric congestive heart failure. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and assessed data from the included trials. MAIN RESULTS We identified four new studies for the review update; the review now includes seven studies with 420 participants. Four small studies with 20 to 30 children each, and two larger studies of 80 children each, showed an improvement of congestive heart failure with beta-blocker therapy. A larger study with 161 participants showed no evidence of benefit over placebo in a composite measure of heart failure outcomes. The included studies showed no significant difference in mortality or heart transplantation rates between the beta-blocker and control groups. No significant adverse events were reported with beta-blockers, apart from one episode of complete heart block. A meta-analysis of left ventricular ejection fraction (LVEF) and fractional shortening (LVFS) data showed a very small improvement with beta-blockers.However, there were vast differences in the age, age range, and health of the participants (aetiology and severity of heart failure; heterogeneity of diagnoses and co-morbidities); there was a range of treatments across studies (choice of beta-blocker, dosing, duration of treatment); and a lack of standardised methods and outcome measures. Therefore, the primary outcomes could not be pooled in meta-analyses. AUTHORS' CONCLUSIONS There is not enough evidence to support or discourage the use of beta-blockers in children with congestive heart failure, or to propose a paediatric dosing scheme. However, the sparse data available suggested that children with congestive heart failure might benefit from beta-blocker treatment. Further investigations in clearly defined populations with standardised methodology are required to establish guidelines for therapy. Pharmacokinetic investigations of beta-blockers in children are also required to provide effective dosing in future trials.
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Affiliation(s)
- Samer Alabed
- Department of Cardiovascular Science, The University of Sheffield, Sheffield, UK
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May LJ, Montez-Rath ME, Yeh J, Axelrod DM, Chen S, Maeda K, Almond CSD, Rosenthal DN, Hollander SA, Sutherland SM. Impact of ventricular assist device placement on longitudinal renal function in children with end-stage heart failure. J Heart Lung Transplant 2015; 35:449-56. [PMID: 26653933 DOI: 10.1016/j.healun.2015.10.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/21/2015] [Accepted: 10/30/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although ventricular assist devices (VADs) restore hemodynamics in those with heart failure, reversibility of end-organ dysfunction with VAD support is not well characterized. Renal function often improves in adults after VAD placement, but this has not been comprehensively explored in children. METHODS Sixty-three children on VAD support were studied. Acute kidney injury (AKI) was defined by Kidney Disease: Improving Global Outcomes criteria. Estimated glomerular filtration rate (eGFR) was determined by the Schwartz method. Generalized linear mixed-effects models compared the pre-VAD and post-VAD eGFR for the cohort and sub-groups with and without pre-VAD renal dysfunction (pre-VAD eGFR < 90 ml/min/1.73 m(2)). RESULTS The pre-VAD eGFR across the cohort was 84.0 ml/min/1.73 m(2) (interquartile range [IQR] 62.3-122.7), and 55.6% (34 of 63) had pre-VAD renal dysfunction. AKI affected 60.3% (38 of 63), with similar rates in those with and without pre-existing renal dysfunction. Within the cohort, the nadir eGFR occurred 1 day post-operatively (62.9 ml/min/1.73 m(2); IQR, 51.2-88.9 ml/min/1.73 m(2); p < 0.001). By Day 5, however, the eGFR exceeded the baseline (99.0 ml/min/1.73 m(2); IQR, 59.3-146.7 ml/min/1.73 m(2); p = 0.03) and remained significantly higher through the first post-operative week. After adjusting for age, gender, and AKI, the eGFR continued to increase throughout the entire 180-day study period (β = 0.0025; 95% confidence interval, 0.0015-0.0036; p < 0.001). Patients with pre-VAD renal dysfunction experienced the greatest improvement in the eGFR (β = 0.0051 vs β = 0.0013, p < 0.001). CONCLUSIONS Renal dysfunction is prevalent in children with heart failure undergoing VAD placement. Although peri-operative AKI is common, renal function improves substantially in the first post-operative week and for months thereafter. This is particularly pronounced in those with pre-VAD renal impairment, suggesting that VADs may facilitate recovery and maintenance of kidney function in children with advanced heart failure.
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Affiliation(s)
- Lindsay J May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Justin Yeh
- Division of Pediatric Cardiology, Department of Pediatrics, University of California San Diego, La Jolla, California
| | - David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Katsuhide Maeda
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - Christopher S D Almond
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Seth A Hollander
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Scott M Sutherland
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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High sensitivity troponin T in adult congenital heart disease. Int J Cardiol 2015; 195:7-14. [DOI: 10.1016/j.ijcard.2015.05.077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/21/2015] [Accepted: 05/14/2015] [Indexed: 11/23/2022]
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Morgan C, Al-Aklabi M, Garcia Guerra G. Chronic kidney disease in congenital heart disease patients: a narrative review of evidence. Can J Kidney Health Dis 2015; 2:27. [PMID: 26266042 PMCID: PMC4531493 DOI: 10.1186/s40697-015-0063-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/09/2015] [Indexed: 11/10/2022] Open
Abstract
Purpose of review Patients with congenital heart disease have a number of risk factors for the development of chronic kidney disease (CKD). It is well known that CKD has a large negative impact on health outcomes. It is important therefore to consider that patients with congenital heart disease represent a population in whom long-term primary and secondary prevention strategies to reduce CKD occurrence and progression could be instituted and significantly change outcomes. There are currently no clear guidelines for clinicians in terms of renal assessment in the long-term follow up of patients with congenital heart disease. Consolidation of knowledge is critical for generating such guidelines, and hence is the purpose of this view. This review will summarize current knowledge related to CKD in patients with congenital heart disease, to highlight important work that has been done to date and set the stage for further investigation, development of prevention strategies, and re-evaluation of appropriate renal follow-up in patients with congenital heart disease. Sources of information The literature search was conducted using PubMed and Google Scholar. Findings Current epidemiological evidence suggests that CKD occurs in patients with congenital heart disease at a higher frequency than the general population and is detectable early in follow-up (i.e. during childhood). Best evidence suggests that approximately 30 to 50 % of adult patients with congenital heart disease have significantly impaired renal function. The risk of CKD is higher with cyanotic congenital heart disease but it is also present with non-cyanotic congenital heart disease. Although significant knowledge gaps exist, the sum of the data suggests that patients with congenital heart disease should be followed from an early age for the development of CKD. Implications There is an opportunity to mitigate CKD progression and negative renal outcomes by instituting interventions such as stringent blood pressure control and reduction of proteinuria. There is a need to invest time, thought and money to fill existing knowledge gaps to improve health outcomes in this population. This review should serve as an impetus for generation of follow-up guidelines of kidney health evaluation in patients with congenital heart disease.
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Affiliation(s)
- Catherine Morgan
- Division of Nephrology, Department of Pediatrics, 4-557 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Mohammed Al-Aklabi
- Division of Cardiac Surgery, Department of Medicine, 4A7.C Mazankowski Heart Institute, 8440 - 112 Street, Edmonton, AB T6G 2B7 Canada
| | - Gonzalo Garcia Guerra
- Division of Pediatric Critical Care, Department of Pediatrics, 4-548 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, AB T6G 1C9 Canada
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Abstract
Heart failure in children is a complex clinical syndrome with multiple aetiologies. The underlying disorders that lead to heart failure in children differ significantly from those in adults. Some clinical biomarkers for heart failure status and prognosis appear to be useful in both age groups. This review outlines the use and the present status of biomarkers for heart failure in paediatric cardiology. Furthermore, clinical scenarios in which development of new biomarkers might address management or prognosis are discussed. Finally, strategies for proteomic discovery of novel biomarkers and application to practice are described.
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A novel pediatric treatment intensity score: development and feasibility in heart failure patients with ventricular assist devices. J Heart Lung Transplant 2015; 34:509-15. [DOI: 10.1016/j.healun.2014.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 09/17/2014] [Accepted: 10/29/2014] [Indexed: 11/18/2022] Open
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Abstract
With the ever increasing younger population in tropical countries, the number of children with heart failure is increasing. However, the etiology of heart failure in this region varies considerably from that in the temperate region, with infectious causes leading the list. In this review, we have summarized the important causes of heart failure seen in the pediatric population in tropical regions.
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Presentation, diagnosis, and medical management of heart failure in children: Canadian Cardiovascular Society guidelines. Can J Cardiol 2014; 29:1535-52. [PMID: 24267800 DOI: 10.1016/j.cjca.2013.08.008] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 08/15/2013] [Accepted: 08/15/2013] [Indexed: 01/03/2023] Open
Abstract
Pediatric heart failure (HF) is an important cause of morbidity and mortality in childhood. This article presents guidelines for the recognition, diagnosis, and early medical management of HF in infancy, childhood, and adolescence. The guidelines are intended to assist practitioners in office-based or emergency room practice, who encounter children with undiagnosed heart disease and symptoms of possible HF, rather than those who have already received surgical palliation. The guidelines have been developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and are accompanied by practical Recommendations for their application in the clinical setting, supplemented by online material. This work does not include Recommendations for advanced management involving ventricular assist devices, or other device therapies.
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Associations between fibroblast growth factor 23 and cardiac characteristics in pediatric heart failure. Pediatr Nephrol 2013; 28:2035-42. [PMID: 23740037 PMCID: PMC3755096 DOI: 10.1007/s00467-013-2515-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 05/06/2013] [Accepted: 05/16/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND In adults with heart failure, elevated levels of fibroblast growth factor 23 (FGF23) are associated with mortality. Data on FGF23 levels in pediatric heart failure are lacking. PATIENTS AND METHODS We conducted a cross-sectional study of 17 healthy children (mean age 13 years) and 20 pediatric patients with heart failure (mean age 12 years) who underwent echocardiography and for whom the following measurements were taken: plasma FGF23 and parathyroid hormone (PTH) and serum phosphate, creatinine and N-terminal prohormone brain natriuretic peptide (NT-proBNP). Symptom severity was assessed with the New York Heart Association and the Ross classification systems. RESULTS Of the 20 patients, 11 had dilated cardiomyopathy, four had congenital heart disease, three had hypertrophic cardiomyopathy, one had a failing heart transplant and one had pulmonary hypertension. Mean phosphate levels in these patients were within the reported reference range for healthy children. Median PTH levels were in the normal range in patients and controls. The median FGF23 level was higher in patients versus controls (110.9 vs. 66.4 RU/ml; P = 0.03) and higher in patients on diuretics versus other patients (222.4 vs. 82.1 RU/ml; P = 0.01). Levels of FGF23 and NT-proBNP were directly correlated (r = 0.47, P = 0.04), and patients with greater physical functional impairment had higher FGF23 levels (142.5 in those with moderate-severe limitation vs. 92.8 RU/ml in those with no limitation; P = 0.05). Among patients with dilated cardiomyopathy, higher FGF23 levels were associated with a greater left ventricular end-diastolic diameter (r = 0.63, P = 0.04). CONCLUSION FGF23 levels are elevated in children with heart failure and are associated with diuretic use, severity of heart failure and left ventricular dilation.
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The Ross classification for heart failure in children after 25 years: a review and an age-stratified revision. Pediatr Cardiol 2012; 33:1295-300. [PMID: 22476605 DOI: 10.1007/s00246-012-0306-8] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 03/14/2012] [Indexed: 01/03/2023]
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.
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37
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Inuzuka R, Tatebe S, Wakiguchi S, Nakajima H, Ohtsu H, Dimopoulos K, Aotsuka H. B-type natriuretic peptide at the early stage of univentricular circulation reflects inadequate adaptation to volume overload. Int J Cardiol 2012; 159:88-93. [DOI: 10.1016/j.ijcard.2011.02.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Revised: 01/14/2011] [Accepted: 02/06/2011] [Indexed: 11/24/2022]
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Miyamoto SD, Stauffer BL, Nakano S, Sobus R, Nunley K, Nelson P, Sucharov CC. Beta-adrenergic adaptation in paediatric idiopathic dilated cardiomyopathy. Eur Heart J 2012; 35:33-41. [PMID: 22843448 DOI: 10.1093/eurheartj/ehs229] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although the pathophysiology and treatment of adult heart failure (HF) are well studied, HF in children remains poorly understood. In adults, adrenergic receptor (AR)-mediated adaptation plays a central role in cardiac abnormalities in HF, and these patients respond well to β-blocker (BB) therapy. However, in children with HF, there is a growing body of literature suggesting a lack of efficacy of adult HF therapies. Due to these unanticipated differences in response to therapy and the paucity of data regarding the molecular adaptation of the paediatric heart, we investigated the molecular characteristics of HF in children. METHODS AND RESULTS Explanted hearts from adults and children with idiopathic dilated cardiomyopathy and non-failing controls were used in the study. Our results show that the molecular characteristics of paediatric HF are strikingly different from their adult counterparts. These differences include: (i) down-regulation of β1- and β2-AR in children, whereas β2-AR expression is maintained in adults; (ii) up-regulation of connexin43 in children, whereas down-regulation is observed in adults; (iii) no differences in phosphatase expression, whereas up-regulation is observed in adults; (iv) no decrease in the phosphorylation of phospholamban at the Ser16 or Thr17 sites in children, which are known characteristics of adult HF. CONCLUSION There is a different adaptation of β-AR and adrenergic signalling pathways in children with HF compared with adults. Our results begin to address the disparities in cardiovascular research specific to children and suggest that age-related differences in adaptation could influence the response to therapy. These findings could lead to a paradigm shift in the contemporary management of children with HF.
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Affiliation(s)
- Shelley D Miyamoto
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
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Outcome of biventricular repair in infants with multiple left heart obstructive lesions. Pediatr Cardiol 2012; 33:506-12. [PMID: 22159427 DOI: 10.1007/s00246-011-0142-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Accepted: 11/03/2011] [Indexed: 10/14/2022]
Abstract
The decision to perform biventricular repair for infants with multiple obstructive or hypoplastic left heart lesions (LHL) and borderline left ventricle (LV) may be controversial. This study sought to assess the mortality and morbidity of patients with LHL after biventricular repair and to determine the growth of the left-sided cardiac structures. Retrospective analysis of 39 consecutive infants with LHL who underwent biventricular repair was performed. The median age at surgery was 7 days (range 1-225 days), and the median follow-up period was 34 months (range 1-177 months). Between diagnosis and the end of the follow-up period, the size of the aortic annulus (z-score -4.1 ± 2.8 vs. -0.1 ± 2.7) and the LV (LV end-diastolic diameter z-score -1.7 ± 2.8 vs. 0.21 ± 1.7) normalized. During the follow-up period, 23 patients required 39 reinterventions (62%) consisting of redo surgery for 21 patients (57%) and catheter-guided reinterventions for 8 patients (22%). At the end of the follow-up period, 25 of 34 patients were doing subjectively well; 10 children (29%) received cardiac medication; 12 (35%) presented with failure to thrive (weight ≤ P3) and 5 (15%) with pulmonary hypertension. The overall mortality rate was 13%. Biventricular repair for patients with multiple LHL results in sufficient growth of the left-sided cardiac structures. Nevertheless, residual or newly developing obstructive lesions and pulmonary hypertension are frequent, causing significant morbidity that requires reintervention.
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Ramírez S, Curi-Curi PJ, Calderón-Colmenero J, García J, Britton C, Erdmenger J, Buendía A, Cervantes-Salazar JL. Resultados del reimplante coronario para la corrección del origen anómalo de la coronaria izquierda a partir de la arteria pulmonar. Rev Esp Cardiol 2011; 64:681-7. [DOI: 10.1016/j.recesp.2011.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 04/19/2011] [Indexed: 10/18/2022]
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Hayabuchi Y, Inoue M, Watanabe N, Sakata M, Ohnishi T, Kagami S. Serum concentration of heart-type fatty acid-binding protein in children and adolescents with congenital heart disease. Circ J 2011; 75:1992-7. [PMID: 21617322 DOI: 10.1253/circj.cj-10-1256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Serum heart-type fatty acid-binding protein (H-FABP) is widely applied as a marker of cardiac myocyte injury. Recently, it has been reported that levels of H-FABP are elevated in adult patients with chronic heart failure and thus provide useful prognostic information. The aim of the present study was to examine the relationships between serum H-FABP levels and pathophysiological characteristics in children and adolescents with congenital heart disease (CHD). METHODS AND RESULTS Serum H-FABP levels were preoperatively and postoperatively measured in 238 consecutive patients with CHD aged 1-31 years. The relationships between H-FABP levels and severity of heart failure, circulatory status and laboratory data were cross-sectionally analyzed. Multivariate regression analysis indicated that serum H-FABP levels are independently affected by age, New York Heart Association functional class, creatine kinase MB, creatinine and arterial oxygen saturation (standard regression coefficients, -0.378, 0.237, 0.422, 0.615, and -0.210, respectively). Neither left ventricular ejection fraction nor B-type natriuretic peptide correlated with H-FABP levels. CONCLUSIONS H-FABP could serve as a new monitoring tool to provide information that will guide the optimal therapy and management of CHD patients.
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Abstract
The purpose of this article is to provide a brief but systematic overview of heart failure and cardiomyopathy in children and the anesthetic management of these patients. We will begin with disease definitions and descriptions of the disorders. Our review will include the epidemiology and etiology of the more prevalent underlying causes of heart failure, the principal pathophysiology of the specific cardiomyopathies, as well as the common therapies in use today in both inpatient and outpatient settings. Important implications for anesthetic management will be highlighted.
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Affiliation(s)
- David N Rosenthal
- Pediatric Cardiology, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
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43
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Abstract
Congenital heart disease is the commonest birth defect, and advances in modern medicine mean 90% of these children now survive to adulthood. Therefore, many children present to their local hospital requiring general anesthesia for common childhood conditions. They pose a challenge for anesthesia because perioperative morbidity and mortality is greater compared with other children. It is impossible to prescribe a formula for anesthetizing children with heart disease because of the complexity of heart defects and the variety of noncardiac surgery. There is also a lack of high-quality data of efficacy of one anesthetic technique over another. Much data come from case series or isolated case reports. In a rapidly advancing field such as cardiac surgery, studies of long-term complications may be out of date by the time they are published, limiting applicability of the results. Because of these factors, claims of efficacy and safety of various approaches to managing children with heart disease for noncardiac surgery must be interpreted cautiously. This narrative review aims to present the evidence concerning a range of anesthetic techniques, the long-term complications of congenital heart disease and suggest a physiological and evidence-based approach to managing these children.
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Affiliation(s)
- Michelle C White
- Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Marlborough Street, Bristol, UK.
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44
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Wong DTH, George K, Wilson J, Manlhiot C, McCrindle BW, Adeli K, Kantor PF. 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 2011; 107:573-8. [PMID: 21295174 DOI: 10.1016/j.amjcard.2010.10.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 10/11/2010] [Accepted: 10/11/2010] [Indexed: 01/03/2023]
Abstract
We sought to determine prospectively whether serial assessment of the natriuretic peptide prohormone, amino-terminal pro-B-type natriuretic peptide (NT-pro-BNP), correlated with clinical severity and outcomes in children hospitalized for acute decompensated heart failure (ADHF). Patients (>1 month of age) admitted from 2005 to 2007 with ADHF requiring intravenous vasoactive/diuretic therapy for ADHF were eligible. Serum NT-pro-BNP levels were obtained within 24 hours of admission and at prespecified intervals, and clinical caregivers were blinded to these levels. End points included hospital discharge, death or cardiac transplantation, and care escalation including the need for mechanical circulatory support (MCS) was noted. Twenty-four patients were enrolled: 22 survived to hospital discharge and 2 died. Ten required MCS (of which 6 underwent cardiac transplantation). Two patients underwent transplantation without MCS. For the entire cohort, NT-pro-BNP levels peaked at days 2 to 3 after admission, with a subsequent gradual decrease until discharge. However, for those who did require MCS, NT-pro-BNP failed to decrease consistently until after MCS initiation. At discharge, NT-pro-BNP levels were significantly decreased from admission levels but remained well above normal for all patients. Single-point NT-pro-BNP levels on admission did not correlate with independently assessed clinical scores of heart failure severity or predict the need for MCS in this cohort. In conclusion, serial NT-pro-BNP levels demonstrated an incremental trend after 48 hours in patients who went on to require MCS but decreased in all other patients and may therefore assist the decision to initiate or avoid MCS after admission for pediatric ADHF.
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Affiliation(s)
- Derek T H Wong
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Eastern Ontario, Ottawa, Canada
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Rusconi PG, Ludwig DA, Ratnasamy C, Mas R, Harmon WG, Colan SD, Lipshultz SE. Serial measurements of serum NT-proBNP as markers of left ventricular systolic function and remodeling in children with heart failure. Am Heart J 2010; 160:776-83. [PMID: 20934575 DOI: 10.1016/j.ahj.2010.07.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 07/09/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increasing serum levels of N-terminal pro-hormone brain natriuretic peptide (NT-proBNP) are associated with worsening heart failure (HF) in adults. We determined whether changes in NT-proBNP level are associated with changes in symptoms and left ventricular (LV) systolic function and remodeling in children with HF secondary to dilated cardiomyopathy. METHODS We retrospectively examined associations between serum NT-proBNP levels and NYHA/Ross functional class, LV systolic and diastolic diameter (LVSD-z and LVDD-z), LV ejection fraction (LVEF), and LV shortening fraction (LVSF-z) using generalized linear mixed models. Fluctuation in functional class of subjects was also modeled using logistic regression and receiver operating characteristic (ROC) curves. RESULTS In 36 children (14 males), a 10-fold increase in NT-proBNP serum levels was associated (P < .001) with a 9.8% decrease in LVEF, a 3.25-unit drop in LVSF-z, a 1.53-unit increase in LVDD-z, a 2.64-unit increase in LVSD-z, and an increased odds of being in functional class III/IV (OR 85.5; 95% CI, 10.9 to 671.0). An NT-proBNP level greater than 1000 pg/mL identified children constantly or intermittently in functional class III-IV with 95% sensitivity and 80% specificity. The reliability of a single NT-proBNP value was 0.61, but the means for two and three NT-proBNP values were 0.76 and 0.82, respectively. CONCLUSIONS In children with HF, NT-proBNP is associated with cardiac symptoms and indices of LV systolic dysfunction and remodeling. NT-proBNP >1000 pg/mL identifies highly symptomatic children. Within subject serial measurements of NT-proBNP are needed for a reliable and accurate determination of disease status and/or course.
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Abstract
Heart transplantation has become standard therapy for end-stage heart failure in children with cardiomyopathy as well as complex congenital heart disease, and has a significant effect on survival and quality of life. The indications for listing and referral for transplantation are outlined. Evaluation for heart transplantation is discussed, including full pretransplant assessment. ABO incompatible listing and HLA sensitization are discussed, and listing algorithms are outlined for different countries.
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Hsu DT, Zak V, Mahony L, Sleeper LA, Atz AM, Levine JC, Barker PC, Ravishankar C, McCrindle BW, Williams RV, Altmann K, Ghanayem NS, Margossian R, Chung WK, Border WL, Pearson GD, Stylianou MP, Mital S. Enalapril in infants with single ventricle: results of a multicenter randomized trial. Circulation 2010; 122:333-40. [PMID: 20625111 DOI: 10.1161/circulationaha.109.927988] [Citation(s) in RCA: 202] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitor therapy improves clinical outcome and ventricular function in adults with heart failure. Infants with single-ventricle physiology have poor growth and are at risk for abnormalities in ventricular systolic and diastolic function. The ability of angiotensin-converting enzyme inhibitor therapy to preserve ventricular function and improve somatic growth and outcomes in these infants is unknown. METHODS AND RESULTS The Pediatric Heart Network conducted a double-blind trial involving 230 infants with single-ventricle physiology randomized to receive enalapril (target dose 0.4 mg . kg(-1) . d(-1)) or placebo who were followed up until 14 months of age. The primary end point was weight-for-age z score at 14 months. The primary analysis was intention to treat. A total of 185 infants completed the study. There were 24 and 21 withdrawals or deaths in the enalapril and placebo groups, respectively (P=0.74). Weight-for-age z score was not different between the enalapril and placebo groups (mean+/-SE -0.62+/-0.13 versus -0.42+/-0.13, P=0.28). There were no significant group differences in height-for-age z score, Ross heart failure class, brain natriuretic peptide concentration, Bayley scores of infant development, or ventricular ejection fraction. The incidence of death or transplantation was 13% and did not differ between groups. Serious adverse events occurred in 88 patients in the enalapril group and 87 in the placebo group. CONCLUSIONS Administration of enalapril to infants with single-ventricle physiology in the first year of life did not improve somatic growth, ventricular function, or heart failure severity. The results of this randomized trial do not support the routine use of enalapril in this population.
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Affiliation(s)
- Daphne T Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, 3415 Bainbridge Ave., Bronx, NY 10457, USA.
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Curi-Curi P, Cervantes J, Soulé M, Erdmenger J, Calderón-Colmenero J, Ramírez S. Early and Midterm Results of an Alternative Procedure to Homografts in Primary Repair of Truncus Arteriosus Communis. CONGENIT HEART DIS 2010; 5:262-70. [DOI: 10.1111/j.1747-0803.2010.00410.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
OBJECTIVE To determine the incidence of vasodilatory shock (VDS) in children after cardiopulmonary bypass (CPB), and to describe this syndrome of post-CPB VDS in children. DESIGN Prospective, observational. SETTING Pediatric and neonatal intensive care units in a tertiary care, children's hospital. PATIENTS Three hundred children undergoing CPB. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Three hundred subjects undergoing CPB were evaluated for clinical evidence of VDS following CPB. The incidence of post-CPB VDS was 3%. Characteristics of children who developed VDS: higher peak lactate (6.2 +/- 2.6 vs. 3.0 +/- 2.1 mmol/L; p = 0.0002), higher peak serum blood urea nitrogen (18.5 +/- 4.6 vs. 15.6 +/- 7.2 mg/dL; p = 0.04), lower urine output (1.7 +/- 0.8 vs. 2.6 +/- 0.2 mL/kg/hr; p = 0.04), and fewer intensive care unit free days (14.9 +/- 9.0 vs. 21.1 +/- 7.2 days; p = 0.01). Univariate predictors for the development of post-CPB VDS included children who had heart transplantation (HT) (relative risk [RR], 9.8; 95% confidence interval [CI], 2.7-35.2) or ventricular assist device (VAD) placed (RR, 17.9; 95% CI, 3.8-84.1), a cardiomyopathy diagnosis (RR, 8.5; 95% CI, 2.3-31), age >12 years (RR, 4.5; 95% CI, 1.2-17.0), CPB time >180 minutes (RR, 7.1; 95% CI, 1.9-26.2), and preoperative ventricular dysfunction (RR, 3.7; 95% CI, 1.0-13.4). By stratified analysis, the only independent predictor for the development of VDS was undergoing HT/VAD. CONCLUSIONS Post-CPB VDS is uncommon in children. However, children who undergo HT or VAD placement are at high risk for developing post-CPB VDS. Recognition that the overall incidence of post-CPB is low-except in the HT/VAD population-may help guide therapy in the pediatric post-CPB patient.
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Abstract
BACKGROUND Beta-blockers are an essential part of standard therapy in adult congestive heart failure and are therefore also expected to be beneficial in children. However, congestive heart failure in children differs strongly from that in adults in terms of characteristics and aetiology; also, an increased drug clearance has been reported. Paediatric needs have therefore to be specifically investigated. OBJECTIVES To assess the effect of beta-adrenoceptor-blockers in children with congestive heart failure. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 4 2007), MEDLINE (1966 to January 2008), EMBASE (1980 to January 2008), and LILACS (1980 to January 2008). Bibliographies of identified studies were checked. No language restrictions were applied. SELECTION CRITERIA Randomised, controlled clinical trials investigating the effect of beta-blocker therapy on paediatric congestive heart failure. DATA COLLECTION AND ANALYSIS Two authors independently extracted and assessed data from the included trials. MAIN RESULTS Three studies with an overall number of 203 participants were identified. Two small studies, with 20 and 22 children respectively, showed an improvement of congestive heart failure, while a larger study with 161 participants showed no evidence of benefit over placebo in the composite measure of heart failure outcomes which was the main outcome measure of the trial (56% improvement in both the placebo and the treatment group, p=0.74). However, study populations showed vast differences with regard to treatment (choice of beta-blocker, dosing, duration of treatment), age and age range of the participants and in particular with regard to condition (aetiology and severity of heart failure; homogeneity of condition in the study population). In addition methods and outcome measures differed strongly and were not standardised. The results can therefore not be compared against each other. AUTHORS' CONCLUSIONS There are not enough data to recommend or discourage the use of beta-blockers in children with congestive heart failure. Further investigations in clearly defined populations with standardised methodology are required to establish guidelines for therapy. Pharmacokinetic investigations of beta-blockers in children are required to provide effective dosing in future trials.
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Affiliation(s)
- Anne-Kristina Frobel
- Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-University , 26.22.02.21, Universitaetsstr. 1, Duesseldorf, Germany, 40225.
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