1
|
VanderPluym CJ. The power of "it will be okay". Pediatr Transplant 2024; 28:e14710. [PMID: 38553813 DOI: 10.1111/petr.14710] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/10/2024] [Accepted: 01/26/2024] [Indexed: 04/02/2024]
Abstract
As caregivers for critically ill children and their families, there are moments when we find ourselves unsure of how best to offer support. The magnitude of the medical experience can cloud our communication with patients and their families. With years of counseling families through some of their most challenging and darkest hours, I aim to emphasize the profound impact of thoughtful and well-informed reassurance; how we can provide hope in hopeless situations.
Collapse
Affiliation(s)
- Christina J VanderPluym
- Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Payne RM, Burns KM, Glatz AC, Male C, Donti A, Brandão LR, Balling G, VanderPluym CJ, Bu'Lock F, Kochilas LK, Stiller B, Cnota JF, Rahkonen O, Khan A, Adorisio R, Stoica S, May L, Burns JC, Saraiva JFK, McHugh KE, Kim JS, Rubio A, Chía-Vazquez NG, Meador MR, Dyme JL, Reedy AM, Ajavon-Hartmann T, Jarugula P, Carlson-Taneja LE, Mills D, Wheaton O, Monagle P. Apixaban for Prevention of Thromboembolism in Pediatric Heart Disease. J Am Coll Cardiol 2023; 82:2296-2309. [PMID: 38057072 DOI: 10.1016/j.jacc.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Children with heart disease frequently require anticoagulation for thromboprophylaxis. Current standard of care (SOC), vitamin K antagonists or low-molecular-weight heparin, has significant disadvantages. OBJECTIVES The authors sought to describe safety, pharmacokinetics (PK), pharmacodynamics, and efficacy of apixaban, an oral, direct factor Xa inhibitor, for prevention of thromboembolism in children with congenital or acquired heart disease. METHODS Phase 2, open-label trial in children (ages, 28 days to <18 years) with heart disease requiring thromboprophylaxis. Randomization 2:1 apixaban or SOC for 1 year with intention-to-treat analysis. PRIMARY ENDPOINT a composite of adjudicated major or clinically relevant nonmajor bleeding. Secondary endpoints: PK, pharmacodynamics, quality of life, and exploration of efficacy. RESULTS From 2017 to 2021, 192 participants were randomized, 129 apixaban and 63 SOC. Diagnoses included single ventricle (74%), Kawasaki disease (14%), and other heart disease (12%). One apixaban participant (0.8%) and 3 with SOC (4.8%) had major or clinically relevant nonmajor bleeding (% difference -4.0 [95% CI: -12.8 to 0.8]). Apixaban incidence rate for all bleeding events was nearly twice the rate of SOC (100.0 vs 58.2 per 100 person-years), driven by 12 participants with ≥4 minor bleeding events. No thromboembolic events or deaths occurred in either arm. Apixaban pediatric PK steady-state exposures were consistent with adult levels. CONCLUSIONS In this pediatric multinational, randomized trial, bleeding and thromboembolism were infrequent on apixaban and SOC. Apixaban PK data correlated well with adult trials that demonstrated efficacy. These results support the use of apixaban as an alternative to SOC for thromboprophylaxis in pediatric heart disease. (A Study of the Safety and Pharmacokinetics of Apixaban Versus Vitamin K Antagonist [VKA] or Low Molecular Weight Heparin [LMWH] in Pediatric Subjects With Congenital or Acquired Heart Disease Requiring Anticoagulation; NCT02981472).
Collapse
Affiliation(s)
- R Mark Payne
- Riley Hospital for Children, Wells Center for Pediatric Research, Department of Pediatrics, Division of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | - Kristin M Burns
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andrea Donti
- IRCCS- Azienda Ospedaliera-Universitaria, Ospedale di S. Orsola, Bologna, Italy
| | - Leonardo R Brandão
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada; Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gunter Balling
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Christina J VanderPluym
- Heart Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frances Bu'Lock
- East Midlands Congenital Heart Centre and University of Leicester, University Hospitals of Leicester NHS Trust, Leicester, England
| | - Lazaros K Kochilas
- Children's Healthcare of Atlanta and the Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Centre, Medical Center-University of Freiburg, Freiburg, Germany
| | - James F Cnota
- Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Otto Rahkonen
- New Children's Hospital, Helsinki University Central Hospital, Department of Pediatric Cardiology, Helsinki, Finland
| | - Asra Khan
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Rachele Adorisio
- Heart Failure, Transplant and Mechanical Assist Devices, Bambino Gesù Hospital and Research Institute, Rome, Italy
| | - Serban Stoica
- Bristol Children's Hospital and the Heart Institute, Bristol, United Kingdom
| | - Lindsay May
- University of Utah: Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jane C Burns
- Rady Children's Hospital San Diego, University of California-San Diego, La Jolla, California, USA
| | | | - Kimberly E McHugh
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John S Kim
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Agustin Rubio
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Nadia G Chía-Vazquez
- Pediatric Cardiology Department, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Marcie R Meador
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Joshua L Dyme
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | - Alison M Reedy
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | | | | | | | - Donna Mills
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | | | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Haematology Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Haematology, Royal Children's Hospital, Melbourne, Victoria, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| |
Collapse
|
3
|
O'Connor MJ, Shezad M, Ahmed H, Amdani S, Auerbach SR, Bearl DW, Butto A, Byrnes JW, Conway J, Dykes JC, Glass L, Lantz J, Law S, Mongé MC, Morales DLS, Parent JJ, Peng DM, Ploutz MS, Puri K, Shugh S, Shwaish NS, VanderPluym CJ, Wilkens S, Wright L, Zinn MD, Lorts A. Expanding use of the HeartMate 3 ventricular assist device in pediatric and adult patients within the Advanced Cardiac Therapies Improving Outcomes Network (ACTION). J Heart Lung Transplant 2023; 42:1546-1556. [PMID: 37419295 DOI: 10.1016/j.healun.2023.06.015] [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] [Received: 10/31/2022] [Revised: 06/13/2023] [Accepted: 06/25/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND We report current outcomes in patients supported with the HeartMate 3 (HM3) ventricular assist device in a multicenter learning network. METHODS The Advanced Cardiac Therapies Improving Outcomes Network database was queried for HM3 implants between 12/2017 and 5/2022. Clinical characteristics, postimplant course, and adverse events were collected. Patients were stratified according to body surface area (BSA) (<1.4 m2, 1.4-1.8 m2, and >1.8 m2) at device implantation. RESULTS During the study period, 170 patients were implanted with the HM3 at participating network centers, with median age 15.3years; 27.1% were female. Median BSA was 1.68 m2; the smallest patient was 0.73 m2 (17.7 kg). Most (71.8%) had a diagnosis of dilated cardiomyopathy. With a median support time of 102.5days, 61.2% underwent transplantation, 22.9% remained supported on device, 7.6% died, and 2.4% underwent device explantation for recovery; the remainder had transferred to another institution or transitioned to a different device type. The most common adverse events included major bleeding (20.8%) and driveline infection (12.9%); ischemic and hemorrhagic stroke were encountered in 6.5% and 1.2% of patients, respectively. Patients with BSA <1.4 m2 had a higher incidence of infection, renal dysfunction, and ischemic stroke. CONCLUSIONS In this updated cohort of predominantly pediatric patients supported with the HM3 ventricular assist device, outcomes are excellent with <8% mortality on device. Device-related adverse events including stroke, infection, and renal dysfunction were more commonly seen in smaller patients, highlighting opportunities for improvements in care.
Collapse
Affiliation(s)
- Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Muhammad Shezad
- Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Humera Ahmed
- Heart Center, Seattle Children's Hospital, Seattle, Washington
| | - Shahnawaz Amdani
- Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Scott R Auerbach
- University of Colorado Denver, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - David W Bearl
- Pediatric Cardiology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Arene Butto
- Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jonathan W Byrnes
- Division of Pediatric Cardiology, Section of Cardiac Critical Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer Conway
- Congenital Heart Program, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - John C Dykes
- Heart Center, Lucile Salter Packard Children's Hospital Stanford, Palo Alto, California
| | - Lauren Glass
- Dell Children's Hospital, University of Texas Health, Austin, Texas
| | - Jodie Lantz
- Children's Heart Center, UT Southwestern Medical Center, Dallas, Texas
| | - Sabrina Law
- Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Michael C Mongé
- Division of Cardiovascular Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - David L S Morales
- Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - John J Parent
- Division of Pediatric Cardiology, Riley Children's Hospital, Indianapolis, Indiana
| | - David M Peng
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Michelle S Ploutz
- Pediatric Cardiology, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Kriti Puri
- Divisions of Pediatric Critical Care Medicine and Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Svetlana Shugh
- Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | | | | | - Sarah Wilkens
- Pediatric Cardiology, University of Louisville, Norton Children's Medical Group, Louisville, Kentucky
| | - Lydia Wright
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Matthew D Zinn
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Angela Lorts
- Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio
| |
Collapse
|
4
|
Kobayashi RL, VanderPluym CJ. Life on the driveline: Still finding traction in improving transplant outcomes for children with myocarditis. J Heart Lung Transplant 2023; 42:100-101. [PMID: 36336535 DOI: 10.1016/j.healun.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ryan L Kobayashi
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | - Christina J VanderPluym
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
5
|
Adachi I, Peng DM, Hollander SA, Simpson KE, Davies RR, Jacobs JP, VanderPluym CJ, Fynn-Thompson F, Wells DA, Law SP, Amdani S, Cantor R, Koehl D, Kirklin JK, Morales DL, Rossano JW. Sixth Annual Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report. Ann Thorac Surg 2022; 115:1098-1108. [PMID: 36402175 DOI: 10.1016/j.athoracsur.2022.10.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/16/2022] [Accepted: 10/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs), supported by The Society of Thoracic Surgeons, provides detailed information on pediatric patients supported with ventricular assist devices (VADs). METHODS From September 19, 2012, to December 31, 2021, there were 1355 devices in 1109 patients (<19 years) from 42 North American Hospitals. RESULTS Cardiomyopathy was the most common underlying cause (59%), followed by congenital heart disease (25%) and myocarditis (9%). Regarding device type, implantable continuous (IC) VADs were most common at 40%, followed by paracorporeal pulsatile (PP; 28%) and paracorporeal continuous (PC; 26%). Baseline demographics differed, with the PC cohort being younger, smaller, more complex (ie, congenital heart disease), and sicker at implantation (P < .0001). At 6 months after VAD implantation, a favorable outcome (transplantation, recovery, or alive on device) was achieved in 84% of patients, which was greatest among those on IC VADs (92%) and least for PC VADs (69%). Adverse events were not uncommon, with nongastrointestinal bleeding (incidence of 14%) and neurologic dysfunction (11% [stroke, 4%]), within 2 weeks after implantation being the most prevalent. Stroke and bleeding had negative impacts on overall survival (P = .002 and P < .001, respectively). CONCLUSIONS This Sixth Pedimacs Report demonstrates the continued evolution of the pediatric field. The complexity of cardiac physiologies and anatomic constraint mandates the need for multiple types of devices used (PC, PP, IC). Detailed analyses of each device type in this report provide valuable information to further advance the care of this challenging and vulnerable population.
Collapse
|
6
|
Ross C, Kumar R, Pelland-Marcotte MC, Mehta S, Kleinman ME, Thiagarajan RR, Ghbeis MB, VanderPluym CJ, Friedman KG, Porras D, Fynn-Thompson F, Goldhaber SZ, Brandão LR. Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review. Chest 2022; 161:791-802. [PMID: 34587483 PMCID: PMC8941619 DOI: 10.1016/j.chest.2021.09.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/09/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022] Open
Abstract
Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.
Collapse
Affiliation(s)
- Catherine Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Riten Kumar
- Harvard Medical School, Boston, MA,Department of Pediatrics, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | | | - Shivani Mehta
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA,College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY
| | - Monica E. Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Ravi R. Thiagarajan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Muhammad B. Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Christina J. VanderPluym
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Pediatric Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Diego Porras
- Division of Invasive Cardiology, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Samuel Z. Goldhaber
- Harvard Medical School, Boston, MA,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Leonardo R. Brandão
- Department of Paediatrics, Haematology/Oncology Division, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
7
|
Ankola AA, Bradford VR, Newburger JW, Emani S, Dionne A, Friedman K, Son MB, Henderson LA, Lee PY, Hellinger A, Hawkins B, Ventresco C, Esteso P, VanderPluym CJ. Coagulation profiles and viscoelastic testing in multisystem inflammatory syndrome in children. Pediatr Blood Cancer 2021; 68:e29355. [PMID: 34532964 DOI: 10.1002/pbc.29355] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Received: 05/04/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To characterize viscoelastic testing profiles of children with multisystem inflammatory syndrome in children (MIS-C). METHODS This single-center retrospective review included 30 patients diagnosed with MIS-C from March 1 to September 1, 2020. Thromboelastography (TEG) with platelet mapping was performed in 19 (63%) patients and compared to age- and sex-matched controls prior to cardiac surgery. Relationships between TEG parameters and inflammatory markers were assessed using correlation. RESULTS Patients with MIS-C had abnormal TEG results compared to controls, including decreased kinetic (K) time (1.1 vs. 1.7 minutes, p < .01), increased alpha angle (75.0° vs. 65.7°, p < .01), increased maximum amplitude (70.8 vs. 58.3 mm, p < .01), and decreased lysis in 30 minutes (Ly30) (1.1% vs. 3.7%, p = .03); consistent with increased clot formation rate and strength, and reduced fibrinolysis. TEG maximum amplitude was moderately correlated with erythrocyte sedimentation rate (ESR) (r = 0.60, p = .02), initial platelet count (r = 0.67, p < .01), and peak platelet count (r = 0.51, p = .03). TEG alpha angle was moderately correlated with peak platelet count (r = 0.54, p = .02). Seventeen (57%) patients received aspirin (ASA) and anticoagulation, five (17%) received only ASA, and three (10%) received only anticoagulation. No patients had a symptomatic thrombotic event. Six (20%) patients had a bleeding event, none of which was major. CONCLUSIONS Patients with MIS-C had evidence of hypercoagulability on TEG. Increased ESR and platelets were associated with higher clot strength. Patients were prophylactically treated with ASA or anticoagulation with no symptomatic thrombosis or major bleeding. Further multicenter study is required to characterize the rate of thrombosis and optimal thromboprophylaxis algorithm in this patient population.
Collapse
Affiliation(s)
- Ashish A Ankola
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Victoria R Bradford
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sirisha Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary Beth Son
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amy Hellinger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Beth Hawkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Courtney Ventresco
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Paul Esteso
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
8
|
Sperotto F, Friedman KG, Son MBF, VanderPluym CJ, Newburger JW, Dionne A. Cardiac manifestations in SARS-CoV-2-associated multisystem inflammatory syndrome in children: a comprehensive review and proposed clinical approach. Eur J Pediatr 2021; 180:307-322. [PMID: 32803422 PMCID: PMC7429125 DOI: 10.1007/s00431-020-03766-6] [Citation(s) in RCA: 219] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/25/2020] [Accepted: 07/30/2020] [Indexed: 01/03/2023]
Abstract
Initial reports on COVID-19 described children as largely spared from severe manifestations, with only 2-6% of children requiring intensive care treatment. However, since mid-April 2020, clusters of pediatric cases of severe systemic hyperinflammation and shock epidemiologically linked with COVID-19 have been reported. This condition was named as SARS-Cov-2-associated multisystem inflammatory syndrome in children and showed similarities to Kawasaki disease. Here, we present a narrative review of cases reported in literature and we discuss the clinical acute and follow-up management of these patients. Patients with SARS-Cov-2-associated multisystem inflammatory syndrome frequently presented with persistent fever, gastrointestinal symptoms, polymorphic rash, conjunctivitis, and mucosal changes. Elevated inflammatory markers and evidence of cytokine storm were frequently observed. A subset of these patients also presented with hypotension and shock (20-100%) from either acute myocardial dysfunction or systemic hyperinflammation/vasodilation. Coronary artery dilation or aneurysms have been described in 6-24%, and arrhythmias in 7-60%. Cardiac support, immunomodulation, and anticoagulation are the key aspects for the management of the acute phase. Long-term structured follow-up of these patients is required due to the unclear prognosis and risk of progression of cardiac manifestations.Conclusion: Multisystem inflammatory syndrome is a novel syndrome related to SARS-CoV-2 infection. Evidence is still scarce but rapidly emerging in the literature. Cardiac manifestations are frequent, including myocardial and coronary involvement, and need to be carefully identified and monitored over time. What is Known: • Multisystem inflammatory syndrome in children (MIS-C) has been described associated with SARS-CoV-2. What is New: • Patients with MIS-C often present with fever, gastrointestinal symptoms, and shock. • Cardiac involvement is found in a high proportion of these patients, including ventricular dysfunction, coronary artery dilation or aneurysm, and arrhythmias. • Management is based on expert consensus and includes cardiac support, immunomodulatory agents, and anticoagulation. • Long-term follow-up is required due to the unclear prognosis and risk of progression of cardiac manifestation.
Collapse
Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Women’s and Children’s Health, University of Padova, Via Giustiniani 2, Padua, Italy
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Mary Beth F. Son
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
- Division of Immunology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Christina J. VanderPluym
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| |
Collapse
|
9
|
Villa CR, VanderPluym CJ. ABCs of Stroke Prevention: Improving Stroke Outcomes in Children Supported With a Ventricular Assist Device in a Quality Improvement Network. Circ Cardiovasc Qual Outcomes 2020; 13:e006663. [PMID: 33320692 DOI: 10.1161/circoutcomes.120.006663] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, OH (C.R.V.)
| | - Christina J VanderPluym
- Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, MA (C.J.V.)
| | | |
Collapse
|
10
|
Meziab O, Marcondes L, Friedman KG, O'Leary ET, Gurvitz M, VanderPluym CJ, Walsh EP, Triedman JK, Mah DY. Difference in the prevalence of intracardiac thrombus on the first presentation of atrial fibrillation versus flutter in the pediatric and congenital heart disease population. J Cardiovasc Electrophysiol 2020; 31:3243-3250. [PMID: 33112018 DOI: 10.1111/jce.14791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Received: 05/25/2020] [Revised: 10/05/2020] [Accepted: 10/21/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Guidelines recommend trans-esophageal echocardiography (TEE) for patients with atrial fibrillation (AF) or atrial flutter (AFL) for >48 h, due to risk of intracardiac thrombus formation. With growing evidence that AFL in adults with structurally normal hearts has less thrombogenic potential compared to AF, and the need for TEE questioned, we compared prevalence of intracardiac thrombus detected by TEE in pediatric and congenital heart disease (CHD) patients presenting in AF and AFL. METHODS/RESULTS Single-center, cross-sectional analysis for unique first-time presentations of patients for either AF, AFL, or intra-atrial reentrant tachycardia (IART) between 2000 and 2019. Patients were categorized by presenting arrhythmia (AF vs. AFL/IART), with the exclusion of other forms of atrial tachycardia, hemodynamic instability, chronic anti-coagulation before TEE, and presentation for a reason other than TEE examination for thrombus. A total of 201 patients had TEE with co-diagnosis of AF or AFL. Of these, 105 patients (29 AF, 76 AFL) met inclusion criteria, with no difference in age between AF (median 24.9 years; IQR 18.6-38.3 years) and AFL/IART (23.3 years; 15.4-38.4 years). The prevalence of thrombus in the entire cohort was 9.5%, with no difference between AF (13.8%) and AFL groups (7.9%), p = .46. Patients with thrombus demonstrated no difference in age, systemic ventricular function, cardiac complexity, or CHADS2/CHA2DS2VASc score at presentation. CONCLUSIONS The risk for intracardiac thrombus is high in the pediatric and CHD population, with no apparent distinguishing factors to warrant a change in the recommendations for TEE, with all levels of cardiac complexity being at risk for clot.
Collapse
Affiliation(s)
- Omar Meziab
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Luciana Marcondes
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina J VanderPluym
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John K Triedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
11
|
VanderPluym CJ, Cantor RS, Machado D, Boyle G, May L, Griffiths E, Niebler RA, Lorts A, Rossano J, Sutcliffe DL, Lytrivi ID, Buchholz H, Fynn-Thompson F, Hawkins B, Conway J. Utilization and Outcomes of Children Treated with Direct Thrombin Inhibitors on Paracorporeal Ventricular Assist Device Support. ASAIO J 2020; 66:939-945. [PMID: 32740356 DOI: 10.1097/mat.0000000000001093] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Thrombotic and bleeding complications have historically been major causes of morbidity and mortality in pediatric ventricular assist device (VAD) support. Standard anticoagulation with unfractionated heparin is fraught with problems related to its heterogeneous biochemical composition and unpredictable pharmacokinetics. We sought to describe the utilization and outcomes in children with paracorporeal VAD support who are treated with direct thrombin inhibitors (DTIs) antithrombosis therapy. Retrospective multicenter review of all pediatric patients (aged <19 years) treated with a DTI (bivalirudin or argatroban) on paracorporeal VAD support, examining bleeding and thrombotic adverse events. From May 2012 to 2018, 43 children (21 females) at 10 centers in North America, median age 9.5 months (0.1-215 months) weighing 8.6 kg (2.8-150 kg), were implanted with paracorporeal VADs and treated with a DTI. Diagnoses included cardiomyopathy 40% (n = 17), congenital heart disease 37% (n = 16; single ventricle n = 5), graft vasculopathy 9% (n = 4), and other 14% (n = 6). First device implanted included Berlin Heart EXCOR 49% (n = 21), paracorporeal continuous flow device 44% (n = 19), and combination of devices in 7% (n = 3). Adverse events on DTI therapy included; major bleeding in 16% (n = 7) (2.6 events per 1,000 patient days of support on DTI), and stroke 12% (n = 5) (1.7 events per 1,000 patient days of support on DTI). Overall survival to transplantation (n = 30) or explantation (n = 8) was 88%. This is the largest multicenter experience of DTI use for anticoagulation therapy in pediatric VAD support. Outcomes are encouraging with lower major bleeding and stroke event rate than that reported in literature using other anticoagulation agents in pediatric VAD support.
Collapse
Affiliation(s)
- Christina J VanderPluym
- From the Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Desiree Machado
- Department of Pediatrics and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Gerald Boyle
- Center for Pediatric and Congenital Heart Disease, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lindsay May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Division of Cardiothoracic Surgery, University of Utah Health Care, Salt Lake City, Utah
| | - Robert A Niebler
- Department of Pediatrics, Section of Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joseph Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David L Sutcliffe
- Division of Cardiology, Children's Health Dallas, UT Southwestern Medical Center, Dallas, Texas
| | - Irene D Lytrivi
- From the Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Holger Buchholz
- Department of Cardiovascular Surgery, University of Alberta, Edmonton, Alberta
| | - Francis Fynn-Thompson
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Beth Hawkins
- From the Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Jennifer Conway
- Division of Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta
| |
Collapse
|
12
|
O'Connor MJ, Lorts A, Davies RR, Fynn-Thompson F, Joong A, Maeda K, Mascio CE, McConnell PI, Mongé MC, Nandi D, Peng DM, Rosenthal DN, Si MS, Sutcliffe DL, VanderPluym CJ, Viegas M, Zafar F, Zinn M, Morales DL. Early experience with the HeartMate 3 continuous-flow ventricular assist device in pediatric patients and patients with congenital heart disease: A multicenter registry analysis. J Heart Lung Transplant 2020; 39:573-579. [DOI: 10.1016/j.healun.2020.02.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/31/2020] [Accepted: 02/06/2020] [Indexed: 11/17/2022] Open
|
13
|
Esch JJ, Hellinger A, Friedman KG, VanderPluym CJ. Apixaban for treatment of intracardiac thrombosis in children with congenital heart disease. Interact Cardiovasc Thorac Surg 2020; 30:950-951. [PMID: 32221595 DOI: 10.1093/icvts/ivaa041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/05/2020] [Accepted: 02/10/2020] [Indexed: 11/13/2022] Open
Abstract
Apixaban is well studied in adults; paediatric data are extremely limited. We describe 3 children (age 2-6 years, weight 13-17 kg) with congenital heart disease who developed intracardiac thrombosis, and in whom typical treatments had failed (in 1) or were considered impractical (in 2). All were treated with apixaban 2.5 mg orally twice daily with complete (in 2) or partial (in 1) thrombus resolution and no clinical bleeding events.
Collapse
Affiliation(s)
- Jesse J Esch
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Hellinger
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christina J VanderPluym
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
14
|
Peng DM, Rosenthal DN, Zafar F, Smyth L, VanderPluym CJ, Lorts A. Collaboration and new data in ACTION: a learning health care system to improve pediatric heart failure and ventricular assist device outcomes. Transl Pediatr 2019; 8:349-355. [PMID: 31728328 PMCID: PMC6825965 DOI: 10.21037/tp.2019.07.12] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 12/21/2022] Open
Abstract
Outcomes in pediatric heart failure and ventricular assist devices (VADs) remain suboptimal. Given the complexity and limited numbers, centers cannot be expected to acquire mastery and generalizable knowledge independently. Recognizing this problem, the community has formed Advanced Cardiac Therapies Improving Outcomes Network (ACTION), a collaborative learning health care system committed to unrelenting collaboration and continuous learning to improve critical outcomes in pediatric heart failure. ACTION is inclusive of all interested parties and believes the fastest and most effective way to make progress is through working together. ACTION's approaches to collaboration and data sharing will be highlighted.
Collapse
Affiliation(s)
- David M Peng
- Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - David N Rosenthal
- Betty Irene Moore Children's Heart Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lauren Smyth
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christina J VanderPluym
- Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
15
|
Huang JY, Monagle P, Massicotte MP, VanderPluym CJ. Antithrombotic therapies in children on durable Ventricular Assist Devices: A literature review. Thromb Res 2018; 172:194-203. [DOI: 10.1016/j.thromres.2018.02.145] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/12/2018] [Accepted: 02/22/2018] [Indexed: 11/30/2022]
|
16
|
VanderPluym CJ, Cedars A, Eghtesady P, Maxwell BG, Gelow JM, Burchill LJ, Maltais S, Koehl DA, Cantor RS, Blume ED. Outcomes following implantation of mechanical circulatory support in adults with congenital heart disease: An analysis of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). J Heart Lung Transplant 2018; 37:89-99. [DOI: 10.1016/j.healun.2017.03.005] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 02/14/2017] [Accepted: 03/03/2017] [Indexed: 11/27/2022] Open
|
17
|
Rossano JW, Lorts A, VanderPluym CJ, Jeewa A, Guleserian KJ, Bleiweis MS, Reinhartz O, Blume ED, Rosenthal DN, Naftel DC, Cantor RS, Kirklin JK. Outcomes of pediatric patients supported with continuous-flow ventricular assist devices: A report from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS). J Heart Lung Transplant 2016; 35:585-90. [DOI: 10.1016/j.healun.2016.01.1228] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 01/26/2016] [Indexed: 10/22/2022] Open
|
18
|
VanderPluym CJ, Blume ED. The role of continuous flow ventricular assist device for destination therapy in children: Can it work or is it a bridge too far? Progress in Pediatric Cardiology 2016. [DOI: 10.1016/j.ppedcard.2016.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
19
|
|
20
|
Affiliation(s)
- Christina J. VanderPluym
- From the Department of Cardiology, Children’s Hospital Boston, Boston, MA (C.J.V., E.D.B.); and Department of Cardiac Surgery, Children’s Hospital Boston and the Department of Pediatrics and Surgery, Harvard Medical School, Boston, MA (F.F.-T.)
| | - Francis Fynn-Thompson
- From the Department of Cardiology, Children’s Hospital Boston, Boston, MA (C.J.V., E.D.B.); and Department of Cardiac Surgery, Children’s Hospital Boston and the Department of Pediatrics and Surgery, Harvard Medical School, Boston, MA (F.F.-T.)
| | - Elizabeth D. Blume
- From the Department of Cardiology, Children’s Hospital Boston, Boston, MA (C.J.V., E.D.B.); and Department of Cardiac Surgery, Children’s Hospital Boston and the Department of Pediatrics and Surgery, Harvard Medical School, Boston, MA (F.F.-T.)
| |
Collapse
|
21
|
VanderPluym CJ, Rebeyka I, Buchholz H. Successful bridge to transplantation for pediatric lupus cardiomyopathy. J Heart Lung Transplant 2012; 31:110-1. [DOI: 10.1016/j.healun.2011.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 08/30/2011] [Accepted: 09/02/2011] [Indexed: 10/17/2022] Open
|