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Sperotto F, Lang N, Nathan M, Kaza A, Hoganson DM, Valencia E, Odegard K, Allan CK, da Cruz EM, Del Nido PJ, Emani SM, Baird C, Maschietto N. Transcatheter Palliation With Pulmonary Artery Flow Restrictors in Neonates With Congenital Heart Disease: Feasibility, Outcomes, and Comparison With a Historical Hybrid Stage 1 Cohort. Circ Cardiovasc Interv 2023; 16:e013383. [PMID: 38113289 DOI: 10.1161/circinterventions.123.013383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/31/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Neonates with complex congenital heart disease and pulmonary overcirculation have been historically treated surgically. However, subcohorts may benefit from less invasive procedures. Data on transcatheter palliation are limited. METHODS We present our experience with pulmonary flow restrictors (PFRs) for palliation of neonates with congenital heart disease, including procedural feasibility, technical details, and outcomes. We then compared our subcohort of high-risk single ventricle neonates palliated with PFRs with a similar historical cohort who underwent a hybrid Stage 1. Cox regression was used to evaluate the association between palliation strategy and 6-month mortality. RESULTS From 2021 to 2023, 17 patients (median age, 4 days; interquartile range [IQR], 2-8; median weight, 2.5 kilograms [IQR, 2.1-3.3]) underwent a PFR procedure; 15 (88%) had single ventricle physiology; 15 (88%) were high-risk surgical candidates. All procedures were technically successful. At a median follow-up of 6.2 months (IQR, 4.0-10.8), 13 patients (76%) were successfully bridged to surgery (median time since PFR procedure, 2.6 months [IQR, 1.1-4.4]; median weight, 4.9 kilograms [IQR, 3.4-5.8]). Pulmonary arteries grew adequately for age, and devices were easily removed without complications. The all-cause mortality rate before target surgery was 24% (n=4). Compared with the historical hybrid stage 1 cohort (n=23), after adjustment for main confounding (age, weight, intact/severely restrictive atrial septum or left ventricle to coronary fistulae), the PFR procedure was associated with a significantly lower all-cause 6-month mortality risk (adjusted hazard ratio, 0.26 [95% CI, 0.08-0.82]). CONCLUSIONS Transcatheter palliation with PFR is feasible, safe, and represents an effective strategy for bridging high-risk neonates with congenital heart disease to surgical palliation, complete repair, or transplant while allowing for clinical stabilization and somatic growth.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Nora Lang
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, Germany (N.L.)
| | - Meena Nathan
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Aditya Kaza
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - David M Hoganson
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Eleonore Valencia
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Kirsten Odegard
- Department of Cardiac Anesthesia (K.O.), Boston Children's Hospital, Harvard Medical School, MA
| | - Catherine K Allan
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Eduardo M da Cruz
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
| | - Pedro J Del Nido
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Sitaram M Emani
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Christopher Baird
- Department of Cardiac Surgery (M.N., A.K., D.M.H., P.J.D.N., S.M.E., C.B.), Boston Children's Hospital, Harvard Medical School, MA
| | - Nicola Maschietto
- Department of Cardiology (F.S., N.L., E.V., C.K.A., E.M.d.C., N.M.), Boston Children's Hospital, Harvard Medical School, MA
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2
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Rogers-Vizena CR, Saldanha FYL, Sideridis GD, Allan CK, Livingston KA, Nussbaum L, Weinstock PH. High-Fidelity Cleft Simulation Maintains Improvements in Performance and Confidence: A Prospective Study. J Surg Educ 2023; 80:1859-1867. [PMID: 37679288 DOI: 10.1016/j.jsurg.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE High-fidelity simulation has a growing role in plastic surgical education. This study tests the hypothesis that cleft lip repair simulation followed by structured debriefing improves performance and self-confidence and that gains are maintained. DESIGN Prospective, single-blinded interventional study with repeated measures. Trainees performed cleft lip repair on a high-fidelity simulator followed by debriefing, immediately completed a second repair, and returned 3 months later for a third session. Anonymized simulation videos were rated using the modified Objective Structured Assessment of Technical Skills (OSATS) and the Unilateral Cleft Lip Repair competency assessment tool (UCLR). Self-assessed cleft lip knowledge/confidence and procedural self-confidence were surveyed after each simulation. SETTING Boston Children's Hospital, a tertiary care academic hospital in Boston, MA, USA. PARTICIPANTS All trainees rotating through the study setting were eligible. Twenty-six participated; 21 returned for follow-up. RESULTS Significant improvements (p < 0.05) occurred between the first and second simulations for OSATS, UCLR, and procedural self-confidence. Significant improvement occurred between the second and third simulations cleft lip knowledge/confidence. Compared to the first simulation, improvements were maintained at the third simulation for all variables. Training level moderately correlated with score for UCLR for the first simulation (r = 0.55, p < 0.01), deteriorated somewhat with the second (r = 0.35, p = 0.08), and no longer corelated by the third (r = 0.02, p = 0.92). CONCLUSIONS Objective performance and subjective self-assessed knowledge and confidence improve with high-fidelity simulation plus structured debriefing and improvement is maintained. Differences in procedure-specific performance seen with increasing training level are reduced with simulation, suggesting it may accelerate knowledge and skill acquisition.
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Affiliation(s)
- Carolyn R Rogers-Vizena
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts; Boston Children's Hospital Immersive Design Systems, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Francesca Y L Saldanha
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Georgios D Sideridis
- Harvard Medical School, Boston, Massachusetts; Institutional Centers for Clinical & Translational Research, Boston Children's Hospital, Boston, Massachusetts
| | - Catherine K Allan
- Boston Children's Hospital Immersive Design Systems, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Katie A Livingston
- Boston Children's Hospital Immersive Design Systems, Boston, Massachusetts
| | - Lisa Nussbaum
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Peter H Weinstock
- Boston Children's Hospital Immersive Design Systems, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Anesthesia, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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3
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Moynihan KM, Beke DM, Imprescia A, Agus MSD, Kleinman M, Hansen A, Bullock K, Taylor M, Smith-Millman M, Wolbrink TA, Weinstock P, Allan CK. A Multimodal Approach to Training Coronavirus Disease (COVID-19) Processes Across Four Intensive Care Units. Clin Simul Nurs 2023; 76:39-46. [PMID: 35308178 PMCID: PMC8919769 DOI: 10.1016/j.ecns.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Coronavirus disease (COVID-19) required innovative training strategies for emergent aerosol generating procedures in intensive care units. This manuscript summarizes institutional operationalization of COVID-specific training, standardized across four intensive care units. Methods & Results An interdisciplinary team collaborated with the Simulator Program and OpenPediatrics refining logistics using process maps, walkthroughs and simulation. A multimodal approach to information dissemination, high-volume team training in modified resuscitation practices and technical skill acquisition included instructional videos, training superusers, small-group simulation using a flipped classroom approach with rapid cycle deliberate practice, interactive webinars, and cognitive aids. Institutional data on application of this model are presented. Conclusion Success was founded in interdisciplinary collaboration, resource availability and institutional buy in.
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Key Words
- AGPs, aerosol generating procedures
- Aerosols
- COVID-19
- COVID-19, Coronavirus disease
- CPR, cardiopulmonary resuscitation
- CRM, crisis resource management
- Communication
- ECMO, Extracorporeal membrane oxygenation
- HCPs, health care providers
- ICU, intensive care unit
- Information dissemination
- Intensive care units, pediatric
- Intubation, intratracheal
- PPE, personal protective equipment
- Simulation training
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Affiliation(s)
- Katie M. Moynihan
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Corresponding author
| | - Dorothy M. Beke
- Department of Nursing, Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA, USA,OPENPediatrics Program, Boston Children's Hospital, Boston, MA, USA
| | - Annette Imprescia
- Department of Nursing, Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA, USA,Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, MA, USA,OPENPediatrics Program, Boston Children's Hospital, Boston, MA, USA
| | - Michael SD Agus
- Harvard Medical School, Boston, MA, USA,Division of Medical Critical Care, Boston Children's Hospital, Boston, MA, USA
| | - Monica Kleinman
- Harvard Medical School, Boston, MA, USA,Department of Anesthesiology, Critical Care, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Anne Hansen
- Harvard Medical School, Boston, MA, USA,Department of Neonatology, Boston Children's Hospital, Boston, MA, USA
| | - Kevin Bullock
- Department of Respiratory Care, Therapy, Boston Children's Hospital, Boston, MA, USA
| | - Matt Taylor
- Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, MA, USA
| | - Marlena Smith-Millman
- Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, MA, USA
| | - Traci A. Wolbrink
- Harvard Medical School, Boston, MA, USA,Department of Anesthesiology, Critical Care, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA,OPENPediatrics Program, Boston Children's Hospital, Boston, MA, USA
| | - Peter Weinstock
- Harvard Medical School, Boston, MA, USA,Department of Anesthesiology, Critical Care, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA,Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, MA, USA
| | - Catherine K. Allan
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, MA, USA
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4
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Kwiatkowski DM, Ball MK, Savorgnan FJ, Allan CK, Dearani JA, Roth MD, Roth RZ, Sexson KS, Tweddell JS, Williams PK, Zender JE, Levy VY. Neonatal Congenital Heart Disease Surgical Readiness and Timing. Pediatrics 2022; 150:189888. [PMID: 36317977 DOI: 10.1542/peds.2022-056415d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- David M Kwiatkowski
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Molly K Ball
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Fabio J Savorgnan
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Catherine K Allan
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kristen S Sexson
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - James S Tweddell
- Department of Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patricia K Williams
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jill E Zender
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
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5
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Penk JS, Reddy S, Polito A, Cisco MI, Allan CK, Bembea M, Giglia TM, Cheng HH, Thiagarajan RR, Dalton HJ. Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society: Part 2. Pediatr Crit Care Med 2019; 20:1034-1039. [PMID: 31517728 PMCID: PMC7433702 DOI: 10.1097/pcc.0000000000002104] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To make recommendations on improving understanding of bleeding and thrombosis with pediatric extracorporeal life support including future research directions. DATA SOURCES Evaluation of literature and consensus conferences of pediatric critical care and extracorporeal life support experts. STUDY SELECTION A team of 10 experts with pediatric cardiac and extracorporeal membrane oxygenation experience and expertise met through the Pediatric Cardiac Intensive Care Society to review current knowledge and make recommendations for future research to establish "best practice" for anticoagulation management related to extracorporeal life support. DATA EXTRACTION/DATA SYNTHESIS This white paper focuses on clinical understanding and limitations of current strategies to monitor anticoagulation. For each test of anticoagulation, limitations of current knowledge are addressed and future research directions suggested. CONCLUSIONS No consensus on best practice for anticoagulation monitoring exists. Structured scientific evaluation to answer questions regarding anticoagulation monitoring and bleeding and thrombotic events should occur in multicenter studies using standardized approaches and well-defined endpoints. Outcomes related to need for component change, blood product administration, healthcare outcome, and economic assessment should be incorporated into studies. All centers should report data on patient receiving extracorporeal life support to a registry.
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Affiliation(s)
- Jamie S. Penk
- Division of Pediatric Cardiology, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Sushma Reddy
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, CA
| | - Angelo Polito
- Division of Neonatalogy and Pediatric Intensive Care, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Michael I Cisco
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Catherine K. Allan
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Therese M. Giglia
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Henry H. Cheng
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Ravi R. Thiagarajan
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Heidi J. Dalton
- Department of Pediatrics, INOVA Fairfax Hospital, Falls Church, VA
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6
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McBride ME, Almodovar MC, Florez AR, Imprescia A, Su L, Allan CK. Applying Educational Theory to Interdisciplinary Education in Pediatric Cardiac Critical Care. World J Pediatr Congenit Heart Surg 2019; 10:742-749. [PMID: 31663840 DOI: 10.1177/2150135119881370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
At the 14th Annual International Meeting for the Pediatric Cardiac Intensive Care Society, the authors presented a simulation workshop for junior multidisciplinary providers focused on cardiopulmonary interactions. We provide an overview of educational theories of particular relevance to curricular design for simulation-based or enhanced activities. We then demonstrate how these theories are applied to curriculum development for individuals to teams and for novice to experts. We review the role of simulation in cardiac intensive care education and the education theories that support its use. Finally, we demonstrate how a conceptual framework, SIMZones, can be applied to design effective simulation-based teaching.
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Affiliation(s)
- Mary E McBride
- Divisions of Cardiology and Critical Care Medicine, Departments of Pediatrics and Medical Education, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Melvin C Almodovar
- Department of Pediatrics, Holtz Children's Hospital/Jackson Health System, University of Miami Medical School, Miami, FL, USA
| | - Amy R Florez
- Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA
| | | | - Lillian Su
- Department of Pediatrics, Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Catherine K Allan
- Department of Cardiology and Simulator Program, Boston Children's Hospital, Harvard University, Boston, MA, USA
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7
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Goldsmith MP, Allan CK, Callahan R, Kaza AK, Mah DY, Salvin JW, Gauvreau K, Porras D. Acute coronary artery obstruction following surgical repair of congenital heart disease. J Thorac Cardiovasc Surg 2019; 159:1957-1965.e1. [PMID: 31982128 DOI: 10.1016/j.jtcvs.2019.09.073] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 09/13/2019] [Accepted: 09/13/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Acute coronary artery obstruction is a rare complication of congenital heart disease surgery but imposes a high burden of morbidity and mortality. Previous case series have described episodes in specific congenital heart lesions or surgical repairs but have not examined the complication in all-comers to congenital heart surgery. We hypothesize that shorter time from a clinically recognized postoperative sentinel event suggestive of coronary ischemia to diagnosis of coronary obstruction is associated with improved clinical outcomes. METHODS This was a single-center, retrospective review of patients diagnosed with acute coronary artery obstruction by angiography following surgical repair of congenital heart disease between January 2000 and June 2016. RESULTS In total, 34 patients were identified. The most common procedures associated with coronary artery obstruction were the Norwood procedure, arterial switch operation, and aortic valve repair/replacement. In total, 79% required mechanical circulatory support, 41% died, and 27% were listed for heart transplant. Patients who died or were listed for heart transplant had longer median sentinel-event-to-cardiac-catheterization time (28 [6-168] hours vs 10 [3-56] hours, P = .001), and longer median sentinel-event-to-intervention time (32 [11-350] hours vs 13 [5-59] hours, P = .003). Patients with hypoplastic left heart syndrome were at greater risk of death or transplant listing (odds ratio, 9.23, P = .03). CONCLUSIONS Time from clinically relevant postoperative sentinel event to diagnosis of coronary artery obstruction by angiography was associated with transplant-listing-free survival. Clinicians should maintain a high index of suspicion for coronary obstruction and consider early catheterization and coronary angiography for patients in whom post-operative coronary compromise is suspected.
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Affiliation(s)
- Michael P Goldsmith
- Division of Cardiac Critical Care, Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Catherine K Allan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Ryan Callahan
- Division of Invasive Cardiology, Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Douglas Y Mah
- Division of Electrophysiology, Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Joshua W Salvin
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | | | - Diego Porras
- Division of Invasive Cardiology, Department of Cardiology, Boston Children's Hospital, Boston, Mass.
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8
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Abstract
This review article will discuss the indications for and outcomes of neonates with congenital heart disease who receive extracorporeal membrane oxygenation (ECMO) support. Most commonly, ECMO is used as a perioperative bridge to recovery or temporary support for those after cardiac arrest or near arrest in patients with congenital or acquired heart disease. What had historically been considered a contraindication to ECMO, is evolving and more of the sickest and most complicated babies are cared for on ECMO. Given that, it is imperative for aggressive survellience for long-term morbidity in survivors, particularly neurodevelopmental outcomes.
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Affiliation(s)
- Kiona Y Allen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 21, 225 E Chicago Ave, Chicago, IL 60610.
| | - Catherine K Allan
- Department of Cardiology, Harvard Medical School Boston Children's Hospital, Boston, MA
| | - Lillian Su
- Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Mary E McBride
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 21, 225 E Chicago Ave, Chicago, IL 60610
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9
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Emani SS, Allan CK, Forster T, Fisk AC, Lagrasta C, Zheleva B, Weinstock P, Thiagarajan RR. Simulation training improves team dynamics and performance in a low-resource cardiac intensive care unit. Ann Pediatr Cardiol 2018; 11:130-136. [PMID: 29922009 PMCID: PMC5963226 DOI: 10.4103/apc.apc_117_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction: Although simulation training has been utilized quite extensively in highincome medical environments, its feasibility and effect on team performance in lowresource pediatric Cardiac Intensive Care Unit (CICU) environments has not been demonstrated. We hypothesized that lowfidelity simulationbased crisis resource management training would lead to improvements in team performance in such settings. Methods: In this prospective observational study, the effect of simulation on team dynamics and performance was assessed in 23 healthcare providers in a pediatric CICU in Southeast Asia. A 5day training program was utilized consisting of various didactic sessions and simulation training exercises. Improvements in team dynamics were assessed using participant questionnaires, expert evaluations, and video analysis of time to intervention and frequency of closedloop communication. Results: In subjective questionnaires, participants noted significant (P < 0.05) improvement in team dynamics and performance over the training period. Video analysis revealed a decrease in time to intervention and significant (P < 0.05) increase in frequency of closedloop communication because of simulation training. Conclusions: This study demonstrates the feasibility and effectiveness of simulationbased training in improving team dynamics and performance in lowresource pediatric CICU environments, indicating its potential role in eliminating communication barriers in these settings.
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Affiliation(s)
| | - Catherine K Allan
- Simulator Program, Boston Children's Hospital, Boston, MA, USA.,Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Tess Forster
- Simulator Program, Boston Children's Hospital, Boston, MA, USA
| | - Anna C Fisk
- Department of Nursing, Boston Children's Hospital, Boston, MA, USA
| | | | | | - Peter Weinstock
- Simulator Program, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA
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10
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Costello JM, Dunbar-Masterson C, Allan CK, Gauvreau K, Newburger JW, McGowan FX, Wessel DL, Mayer JE, Salvin JW, Dionne RE, Laussen PC. Impact of Empiric Nesiritide or Milrinone Infusion on Early Postoperative Recovery After Fontan Surgery. Circ Heart Fail 2014; 7:596-604. [DOI: 10.1161/circheartfailure.113.001312] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
We sought to determine whether empirical nesiritide or milrinone would improve the early postoperative course after Fontan surgery. We hypothesized that compared with milrinone or placebo, patients assigned to receive nesiritide would have improved early postoperative outcomes.
Methods and Results—
In a single-center, randomized, double-blinded, placebo-controlled, multi-arm parallel-group clinical trial, patients undergoing primary Fontan surgery were assigned to receive nesiritide, milrinone, or placebo. A loading dose of study drug was administered on cardiopulmonary bypass followed by a continuous infusion for ≥12 hours and ≤5 days after cardiac intensive care unit admission. The primary outcome was days alive and out of the hospital within 30 days of surgery. Secondary outcomes included measures of cardiovascular function, renal function, resource use, and adverse events. Among 106 enrolled subjects, 35, 36, and 35 were randomized to the nesiritide, milrinone, and placebo groups, respectively, and all were analyzed based on intention to treat. Demographics, patient characteristics, and operative factors were similar among treatment groups. No significant treatment group differences were found for median days alive and out of the hospital within 30 days of surgery (nesiritide, 20 [minimum to maximum, 0–24]; milrinone, 18 [0–23]; placebo, 20 [0–23];
P
=0.38). Treatment groups did not significantly differ in cardiac index, arrhythmias, peak lactate, inotropic scores, urine output, duration of mechanical ventilation, intensive care or chest tube drainage, or adverse events.
Conclusions—
Compared with placebo, empirical perioperative nesiritide or milrinone infusions are not associated with improved early clinical outcomes after Fontan surgery.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00543309.
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Affiliation(s)
- John M. Costello
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - Carolyn Dunbar-Masterson
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - Catherine K. Allan
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - Kimberlee Gauvreau
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - Jane W. Newburger
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - Francis X. McGowan
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - David L. Wessel
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - John E. Mayer
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - Joshua W. Salvin
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - Roger E. Dionne
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
| | - Peter C. Laussen
- From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children’s Hospital, Harvard Medical School, MA; and Children’s National Medical Center, George Washington University, Washington, DC (D.L.W.)
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11
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Laussen PC, Allan CK, Larovere JM. Risky business: human factors in critical care. World J Pediatr Congenit Heart Surg 2013; 2:468-71. [PMID: 23803998 DOI: 10.1177/2150135111406943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Remarkable achievements have occurred in pediatric cardiac critical care over the past two decades. The specialty has become well defined and extremely resource intense. A great deal of focus has been centered on optimizing patient outcomes, particularly mortality and early morbidity, and this has been achieved through a focused and multidisciplinary approach to management. Delivering high-quality and safe care is our goal, and during the Risky Business symposium and simulation sessions at the Eighth International Conference of the Pediatric Cardiac Intensive Care Society in Miami, December 2010, human factors, systems analysis, team training, and lessons learned from malpractice claims were presented.
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Affiliation(s)
- Peter C Laussen
- Department of Cardiology, Children's Hospital Boston, Boston, MA, USA
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Cheng HH, Almodovar MC, Laussen PC, Wypij D, Polito A, Brown DW, Emani SM, Pigula FA, Allan CK, Costello JM. Outcomes and risk factors for mortality in premature neonates with critical congenital heart disease. Pediatr Cardiol 2011; 32:1139-46. [PMID: 21713439 DOI: 10.1007/s00246-011-0036-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 06/15/2011] [Indexed: 11/29/2022]
Abstract
We sought to describe contemporary outcomes and identify risk factors for hospital mortality in premature neonates with critical congenital heart disease who were referred for early intervention. Neonates who were born before 37 weeks' gestation with critical congenital heart disease and admitted to our institution from 2002 to 2008 were included in this retrospective cohort study. Critical congenital heart disease was defined as a defect requiring surgical or transcatheter cardiac intervention or a defect resulting in death within the first 28 days of life. Logistic regression analyses were performed to identify risk factors for mortality before hospital discharge. The study included 180 premature neonates, of whom 37 (21%) died during their initial hospitalization, including 6 (4%) before cardiac intervention and 31 (17%) after cardiac intervention. For the 174 patients undergoing cardiac intervention, independent risk factors for mortality were a 5 min Apgar score ≤ 7, need for preintervention mechanical ventilation, and Risk Adjustment in Congenital Heart Surgery category ≥ 4 or not assignable. Mortality for premature infants with critical congenital heart disease who are referred for early intervention remains high. Patients with lower Apgar scores who receive preintervention mechanical ventilation and undergo more complex procedures are at greatest risk.
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Affiliation(s)
- Henry H Cheng
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA
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13
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Teele SA, Allan CK, Laussen PC, Newburger JW, Gauvreau K, Thiagarajan RR. Management and outcomes in pediatric patients presenting with acute fulminant myocarditis. J Pediatr 2011; 158:638-643.e1. [PMID: 21195415 DOI: 10.1016/j.jpeds.2010.10.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 09/14/2010] [Accepted: 10/08/2010] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To investigate factors associated with mechanical circulatory support and survival in patients with acute fulminant myocarditis (AFM). STUDY DESIGN Retrospective cohort of AFM patients admitted to the cardiac intensive care unit during 1996-2008. AFM was defined as distinct onset of symptoms ≤14 days before admission, rapid-onset cardiogenic shock, and normal left ventricular size. Demographic and physiological variables were compared between patients treated with extracorporeal membrane oxygenation (ECMO) and those who were not and between survivors and nonsurvivors. RESULTS Twenty patients (median age 12.7 years) met inclusion criteria. Seventeen patients (85%) survived to hospital discharge. One underwent heart transplantation. Ten (50%) patients required ECMO, and 7 (70%) of these survived. On admission, patients requiring ECMO had elevated lactate (9 vs 1 mmol/L), creatinine (0.8 vs 0.6 mg/dL), and aspartate aminotransferase (256 vs 35 IU/L) (all P < .05) and a trend towards increased incidence of dysrhythmias (80% vs 30%, P = .07). During hospitalization, non-survivors had higher peak lactate (10 vs 3 mmol/L), creatinine (1.5 vs 0.8 mg/dL), and aspartate aminotransferase (3007 vs 156 IU/L) (all P < .05) compared with survivors. CONCLUSIONS Patients with AFM with end organ dysfunction or arrhythmias on admission may require mechanical circulatory support. The transplant-free survival rate in this critically ill cohort was excellent (80%).
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Affiliation(s)
- Sarah A Teele
- Department of Cardiology, Children's Hospital Boston, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA.
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14
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Allan CK, Newburger JW, McGrath E, Elder J, Psoinos C, Laussen PC, del Nido PJ, Wypij D, McGowan FX. The relationship between inflammatory activation and clinical outcome after infant cardiopulmonary bypass. Anesth Analg 2010; 111:1244-51. [PMID: 20829561 DOI: 10.1213/ane.0b013e3181f333aa] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) induces a systemic inflammatory response. The magnitude and consequences in infants remain unclear. We assessed the relationship between inflammatory state and clinical outcomes in infants undergoing CPB. METHODS Plasma concentrations of interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor α, IL-1β, and C-reactive protein (CRP) were measured pre-CPB and immediately post-CPB, and at 6, 12, and 24 hours post-CPB in infants ≤9 months old. Perioperative clinical data were collected prospectively. RESULTS Diagnoses of 93 patients included transposition of the great arteries (40), tetralogy of Fallot (28), ventricular septal defect (21), truncus arteriosus (2), and complete atrioventricular canal (2). The median age was 37 days (range = 2 to 264). Pre-CPB IL-6 and CRP were higher in younger infants but were not associated with postoperative inflammatory mediator concentrations or measured clinical outcomes. IL-6 increased post-CPB (median 3.2 pg/mL pre-CPB, 24.2 post-CPB, 95.4 at 6 hours, and 90.3 at 24 hours; all P < 0.001). CRP increased post-CPB, peaking at 24 hours (median 27.5 at 24 hours, 0.3 pre-CPB; P < 0.001). IL-10 and IL-8 increased immediately post-CPB. After adjusting for age and diagnosis, postoperative IL-6 and IL-8 correlated with intensive care unit length of stay and postoperative blood product administration and, for IL-8, 24-hour lactate. CONCLUSIONS Greater preoperative cytokine and CRP production in younger infants did not correlate with postoperative outcomes; correlation between postoperative inflammatory mediator production and clinical course was statistically significant but clinically modest. We conclude that in infants undergoing low-to-moderate-complexity cardiac surgery in a single high-volume center, the contribution of inflammatory mediator production to postoperative morbidity is relatively limited.
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Affiliation(s)
- Catherine K Allan
- Department of Cardiology, Children's Hospital, Boston, MA 02115, USA.
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15
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Costello JM, Polito A, Brown DW, McElrath TF, Graham DA, Thiagarajan RR, Bacha EA, Allan CK, Cohen JN, Laussen PC. Birth before 39 weeks' gestation is associated with worse outcomes in neonates with heart disease. Pediatrics 2010; 126:277-84. [PMID: 20603261 DOI: 10.1542/peds.2009-3640] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Recent studies have revealed increased morbidity and mortality rates in term neonates without birth defects who were delivered before 39 weeks of completed gestation. We sought to determine if a similar association exists between gestational age at delivery and adverse outcomes in neonates with critical congenital heart disease, with particular interest in those born at 37 to 38 weeks' gestation. PATIENTS AND METHODS We studied 971 consecutive neonates who had critical congenital heart disease and a known gestational age and were admitted to our cardiac ICU from 2002 through 2008. Gestational age was stratified into 5 groups: >41, 39 to 40, 37 to 38, 34 to 36, and <34 completed weeks. Multivariate logistic regression analyses were used to evaluate mortality and a composite morbidity variable. Multivariate Poisson regression was used to evaluate duration of ventilation, intensive care, and hospitalization. RESULTS Compared with the referent group of neonates who were delivered at 39 to 40 completed weeks' gestation, neonates born at 37 to 38 weeks had increased mortality (6.9% vs 2.6%; adjusted P = .049) and morbidity (49.7% vs 39.7%; adjusted P = .02) rates and tended to require a longer duration of mechanical ventilation (adjusted P = .05). Patients born after 40 or before 37 weeks also had greater adjusted mortality rates, and those born before 37 weeks had increased morbidity rates and required more days of mechanical ventilation and intensive care. CONCLUSIONS For neonates with critical congenital heart disease, delivery before 39 weeks' gestation is associated with greater mortality and morbidity rates and more resource use. With respect to neonatal mortality, the ideal gestational age for delivery of these patients may be 39 to 40 completed weeks.
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Affiliation(s)
- John M Costello
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA.
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16
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Bautista-Hernandez V, Thiagarajan RR, Fynn-Thompson F, Rajagopal SK, Nento DE, Yarlagadda V, Teele SA, Allan CK, Emani SM, Laussen PC, Pigula FA, Bacha EA. Preoperative extracorporeal membrane oxygenation as a bridge to cardiac surgery in children with congenital heart disease. Ann Thorac Surg 2009; 88:1306-11. [PMID: 19766826 DOI: 10.1016/j.athoracsur.2009.06.074] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2009] [Revised: 06/21/2009] [Accepted: 06/22/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND The efficacy of extracorporeal membrane oxygenation (ECMO) in bridging children with unrepaired heart defects to a definitive or palliative surgical procedure has been rarely reported. The goal of this study is to report our institutional experience with ECMO used to provide preoperative stabilization after acute cardiac or respiratory failure in patients with congenital heart disease before cardiac surgery. METHODS A retrospective review of the ECMO database at Children's Hospital Boston was undertaken. Children with unrepaired congenital heart disease supported with ECMO for acute cardiac or respiratory failure as bridge to a definitive or palliative cardiac surgical procedure were identified. Data collection included patient demographics, indication for ECMO, details regarding ECMO course and complications, and survival to hospital discharge. RESULTS Twenty-six patients (18 male, 8 female) with congenital heart disease were bridged to surgical palliation or anatomic repair with ECMO. Median age and weight at ECMO cannulation were, respectively, 0.12 months (range, 0 to 193) and 4 kg (range, 1.8 to 67 kg). Sixteen patients (62%) survived to hospital discharge. Variables associated with mortality included inability to decannulate from ECMO after surgery (p = 0.02) and longer total duration of ECMO (p = 0.02). No difference in outcomes was found between patients with single and biventricular anatomy. CONCLUSIONS Extracorporeal membrane oxygenation, used as a bridge to surgery, represents a useful modality to rescue patients with failing circulation and unrepaired complex heart defects.
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Abstract
BACKGROUND There has been little research about the causes of death after congenital heart surgery. METHODS To determine whether mode of death differs after congenital heart surgery, we evaluated the cause of death for 100 consecutive postoperative deaths at our institution. Mode of death was determined based on retrospective chart review including available autopsy reports. Low output states were categorized into ventricular failure; inadequate postoperative physiology (technically adequate surgery and ventricular function, but persistent low cardiac output); pulmonary hypertension; and atrioventricular valve regurgitation. RESULTS There was considerable anatomic diversity among patients who died; 46 patients had single-ventricle physiology. The vast majority of patients (n = 79) were in the intensive care unit before surgery. Surgical repairs were revised at initial operation in 22 cases; 7 patients died in the operating room. Seventy-three patients had technically adequate surgical procedures, 23 had residual anatomic defects, and 4 were indeterminate. Thirty patients underwent additional surgical and 9 catheter-based procedures, although some were classified as rescue procedures performed to address minor anatomic or physiologic abnormalities as a last hope to rescue the patient from impending demise. Of 100 deaths, most (n = 52) were due to low cardiac output: 24 inadequate postoperative physiology, 19 ventricular failure, 8 pulmonary hypertension, and 1 valvar regurgitation. Other significant causes of death included sudden cardiac arrest (n = 11), sepsis (n = 11), and procedural complications (n = 8). CONCLUSIONS More than half of the deaths were due to low cardiac output, but not exclusively ventricular failure.
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Affiliation(s)
- Marsha Ma
- Tufts University School of Medicine, Boston, Massachusetts, USA
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18
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Allan CK, Thiagarajan RR, del Nido PJ, Roth SJ, Almodovar MC, Laussen PC. Indication for initiation of mechanical circulatory support impacts survival of infants with shunted single-ventricle circulation supported with extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2007; 133:660-7. [PMID: 17320562 DOI: 10.1016/j.jtcvs.2006.11.013] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Revised: 10/26/2006] [Accepted: 11/01/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The use of extracorporeal membrane oxygenation to support patients with shunted single-ventricle physiology has been controversial. Variable survivals are reported in a number of small case series. We sought to evaluate outcomes and identify predictors of survival for patients with shunted single-ventricle physiology who require extracorporeal membrane oxygenation support. METHODS We retrospectively reviewed the medical records of all patients aged less than 1 year with shunted single-ventricle physiology who were supported with extracorporeal membrane oxygenation at Children's Hospital Boston between 1996 and 2005. Survivors and nonsurvivors were compared with respect to demographics, diagnosis, operative variables, indication for extracorporeal membrane oxygenation, and extracorporeal membrane oxygenation variables. RESULTS Forty-four infants with shunted single-ventricle physiology were supported with extracorporeal membrane oxygenation. Diagnoses included hypoplastic left heart syndrome (24), other single-ventricle lesions (12), and pulmonary atresia/intact ventricular septum or a variant (8). Overall survival to discharge was 48%. Indication for extracorporeal membrane oxygenation was the strongest predictor of survival to discharge, with 81% of patients cannulated for hypoxemia but only 29% of those cannulated for hypotension surviving to discharge. Specifically, patients cannulated for shunt obstruction had the highest survival (83%). CONCLUSIONS Overall survival to discharge for patients with shunted single-ventricle physiology is similar to survival reported in the Extracorporeal Life Support Organization registry for all infants supported with cardiac extracorporeal membrane oxygenation. Thus, shunted single-ventricle physiology should not be considered a contraindication to extracorporeal membrane oxygenation. Patients cannulated for hypoxemia, particularly shunt thrombosis, had markedly improved survival compared with those supported primarily for hypotension/cardiovascular collapse. Survival did not differ depending on anatomic diagnosis.
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Affiliation(s)
- Catherine K Allan
- Department of Cardiology, Children's Hospital Boston and Harvard Medical School, Boston, Mass 02115, USA.
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Abstract
OBJECTIVES The goal of this study was to evaluate the utility of extracorporeal membrane oxygenation (ECMO) to resuscitate patients following critical cardiac events in the catheterization laboratory. DESIGN Retrospective review of medical records. SETTING Cardiac intensive care unit and cardiac catheterization laboratory at a tertiary care children's hospital. PATIENTS Pediatric patients cannulated emergently for ECMO in the cardiac catheterization laboratory (n = 22). INTERVENTIONS ECMO was initiated emergently in the cardiac catheterization laboratory for progressive hemodynamic deterioration due to low cardiac output syndrome or catheter-induced complications. MEASUREMENTS AND MAIN RESULTS Twenty-two patients were cannulated for ECMO in the catheterization laboratory between 1996 and 2004. Median age was 33 months (range 0-192), median weight 14.8 kg (2.4-75), and median duration of ECMO 84 hrs (2-343). Indications included catheter-induced complication (n = 14), severe low cardiac output syndrome (n = 7), and hypoxemia (n = 1). Three patients (14%) were cannulated in the catheterization laboratory before catheterization for low cardiac output or hypoxemia. During cannulation, 19 patients (86%) were receiving chest compressions; median duration of cardiopulmonary resuscitation was 29 mins (20-57). Eighteen patients (82%) survived to discharge (five of whom underwent cardiac transplantation) and four (18%) died. Of 19 patients who received cardiopulmonary resuscitation during cannulation, 15 (79%) survived to discharge and nine (47%) sustained neurologic injury. There was no significant difference between survivors and nonsurvivors in age, weight, duration of cardiopulmonary resuscitation or ECMO support, pH, or lactate levels. CONCLUSIONS ECMO is a technically feasible and highly successful tool in the resuscitation of pediatric patients following critical events in the cardiac catheterization laboratory.
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Affiliation(s)
- Catherine K Allan
- Department of Cardiology, Children's Hospital, Boston and Harvard Medical School, Boston, MA
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20
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Costello JM, Thiagarajan RR, Dionne RE, Allan CK, Booth KL, Burmester M, Wessel DL, Laussen PC. Initial experience with fenoldopam after cardiac surgery in neonates with an insufficient response to conventional diuretics. Pediatr Crit Care Med 2006; 7:28-33. [PMID: 16395071 DOI: 10.1097/01.pcc.0000194046.47306.fb] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Fenoldopam, a selective dopamine-1 receptor agonist, causes systemic vasodilation and increased renal blood flow and tubular sodium excretion. We hypothesized that urine output would improve when fenoldopam was added to conventional diuretic therapy after neonatal cardiopulmonary bypass. DESIGN Retrospective cohort study using a time-series design. SETTING Pediatric cardiac intensive care unit. PATIENTS All neonates who received fenoldopam to promote diuresis after cardiac surgery requiring cardiopulmonary bypass from February 2002 through December 2004. INTERVENTIONS Fenoldopam infusion for inadequate urine output despite conventional diuretics. MEASUREMENTS Demographics, diagnostic information, and surgical procedures were recorded. Urine output, fluid balance, inotrope scores, diuretic doses, and other clinical variables that may influence diuresis were recorded for the 24-hr period immediately preceding fenoldopam initiation and during the initial 24 hrs of drug administration. MAIN RESULTS A total of 25 neonates received fenoldopam to promote diuresis after the modified Norwood (n = 14), arterial switch (n = 4), or other operations (n = 7). Heart rate, conventional diuretic dosing, and fluid intake were similar during the 24-hr periods of conventional therapy and fenoldopam use (p = not significant for all), whereas inotrope scores decreased during the study (p = .021). There was a small but statistically significant increase in blood pressure during the 48-hr study period. Median urine output was 3.6 mL x kg(-1) x hr(-1) (range, 0.2-7.2 mL x kg(-1) x hr(-1)) during the 24-hr period of conventional therapy and 5.8 mL x kg(-1) x hr(-1) (range, 1.6-11.7 mL x kg(-1) x hr(-1)) during the initial 24 hrs of fenoldopam administration (Wilcoxon's signed-rank test, p = .001). CONCLUSIONS Fenoldopam may improve urine output in neonates who are failing to achieve an adequate negative fluid balance despite conventional diuretic therapy after cardiac surgery and cardiopulmonary bypass. This study is limited by its retrospective design and the possibility that urine output improved spontaneously during the treatment period. A randomized, placebo-controlled clinical trial will be required to confirm these findings.
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Affiliation(s)
- John M Costello
- Division of Cardiac Intensive Care, Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA
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