Novel initiatives of the National Institutes of Health to support congenital heart disease research

Identification and Evaluation of Controlled Trials in Pediatric Cardiology: Crowdsourced Scoping Review and Creation of Accessible Searchable Database

Cardiac disease in children is associated with significant morbidity and mortality as well as increased health resource utilisation. There is a perception that there is a paucity of high-quality studies, particularly randomized controlled trials (RCTs), in the field of pediatric cardiology. We sought to identify, examine, and map the range of RCTs conducted in children with cardiac conditions, including the development of a searchable open-access database. A literature search was conducted encompassing MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to 2018. All English-language RCTs enrolling children (age 0-21 years) with cardiac conditions were included. Data extraction and risk of bias assessments were performed in duplicate via crowdsourcing for each eligible study and entered into an online database. A total of 933 RCTs met eligibility criteria. Median trial recruitment was 49 patients (interquartile range 30-86) with 18.9% of studies (n = 176) including > 100 patients. A wide variety of populations and interventions were encompassed with congenital heart disease (79.8% of RCTs) and medications (63.3% of RCTs) often studied. Just over one-half of the trials (53.4%) clearly identified a primary outcome, and fewer than half (46.6%) fully documented a robust randomization process. Trials were summarised in a searchable online database (https://pediatrics.knack.com/cardiology-rct-database#cardiology-rcts/). Contrary to a commonly held perception, there are nearly 1,000 published RCTs in pediatric cardiology. The open-access database created as part of this project provides a resource that facilitates an efficient comprehensive review of the literature for clinicians and researchers caring for children with cardiac issues.

Randomized controlled trials in children's heart surgery in the 21st century: a systematic review

OBJECTIVES

Randomized controlled trials are the gold standard for evaluating health care interventions, yet are uncommon in children's heart surgery. We conducted a systematic review of clinical trials in paediatric cardiac surgery to evaluate the scope and quality of the current international literature.

METHODS

We searched MEDLINE, CENTRAL and LILACS, and manually screened retrieved references and systematic reviews to identify all randomized controlled trials reporting the effect of any intervention on the conduct or outcomes of heart surgery in children published in any language since January 2000; secondary publications and those reporting inseparable adult data were excluded. Two reviewers independently screened studies for eligibility and extracted data; the Cochrane Risk of Bias tool was used to assess for potential biases.

RESULTS

We identified 333 trials from 34 countries randomizing 23 902 children. Most were early phase (313, 94.0%), recruiting few patients (median 45, interquartile range 28-82), and only 11 (3.3%) directly evaluated a surgical intervention. One hundred and nine (32.7%) trials calculated a sample size, 52 (15.6%) reported a CONSORT diagram, 51 (15.3%) were publicly registered and 25 (7.5%) had a Data Monitoring Committee. The overall risk of bias was low in 22 (6.6%), high in 69 (20.7%) and unclear in 242 (72.7%).

CONCLUSIONS

The recent literature in children's heart surgery contains few late-phase clinical trials. Most trials did not conform to the accepted standards of reporting, and the overall risk of bias was low in few studies. There is a need for high-quality, multicentre clinical trials to provide a robust evidence base for contemporary paediatric cardiac surgical practice.

Advances in the treatment of aortic valve disease: is it time for companion diagnostics?

PURPOSE OF REVIEW

Aortic valve disease (AVD) is a growing public health problem, and the pathogenesis underlying AVD is complex. The lack of durable bioprostheses and pharmacologic therapies remain central needs in care. The purpose of this review is to highlight recent clinical studies that impact the care of children with AVD and is to explore ongoing translational research efforts.

RECENT FINDINGS

Clinical studies have evaluated the durability of bioprosthetics and surgical strategies, tested statins during early disease, and identified new predictive biomarkers. Large animal models have demonstrated the effectiveness of a novel bioprosthetic scaffold. Mouse models of latent AVD have advanced our ability to elucidate natural history and perform preclinical studies that test new treatments in the context of early disease.

SUMMARY

Current priorities for AVD patients include identifying new pharmacologic treatments and developing durable bioprostheses. Multidisciplinary efforts are needed that bridge pediatric and adult programs, and bring together different types of expertise and leverage network and consortium resources. As our understanding of the underlying complex genetics is better defined, companion diagnostics may transform future clinical trials and ultimately improve the care of patients with AVD by promoting personalized medicine and early intervention.