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Perry T, Rosenthal DN, Lorts A, Zafar F, Zhang W, VanderPluym C, Dewitt AG, Reichle G, Banerjee M, Schumacher KR. Mechanical Ventilation and Outcomes of Children Who Undergo Ventricular Assist Device Placement: 2014-2020 Linked Analysis From the Advanced Cardiac Therapies Improving Outcomes Network and Pediatric Cardiac Critical Care Consortium Registries. Pediatr Crit Care Med 2024:00130478-990000000-00333. [PMID: 38619330 DOI: 10.1097/pcc.0000000000003520] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 04/16/2024]
Abstract
OBJECTIVES Placement of a ventricular assist device (VAD) improves outcomes in children with advanced heart failure, but adverse events remain important consequences. Preoperative mechanical ventilation (MV) increases mortality, but it is unknown what impact prolonged postoperative MV has. DESIGN Advanced Cardiac Therapies Improving Outcomes Network (ACTION) and Pediatric Cardiac Critical Care Consortium (PC4) registries were used to identify and link children with initial VAD placement admitted to the cardiac ICU (CICU) from August 2014 to July 2020. Demographics, cardiac diagnosis, preoperative and postoperative CICU courses, and outcomes were compiled. Univariable and multivariable statistics assessed association of patient factors with prolonged postoperative MV. Multivariable logistic regression sought independent associations with outcomes. SETTING Thirty-five pediatric CICUs across the United States and Canada. PATIENTS Children on VADs included in both registries. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred forty-eight ACTION subjects were linked to a matching patient in PC4. Median (interquartile) age 7.7 years (1.5-15.5 yr), weight 21.3 kg (9.1-58 kg), and 56% male. Primary diagnosis was congenital heart disease (CHD) in 35%. Pre-VAD explanatory variables independently associated with prolonged postoperative MV included: age (incidence rate ratio [IRR], 0.95; 95% CI, 0.93-0.96; p < 0.01); preoperative MV within 48 hours (IRR, 2.76; 95% CI, 1.59-4.79; p < 0.01), 2-7 days (IRR, 1.82; 95% CI, 1.15-2.89; p = 0.011), and greater than 7 days before VAD implant (IRR, 2.35; 95% CI, 1.62-3.4; p < 0.01); and CHD (IRR, 1.96; 95% CI, 1.48-2.59; p < 0.01). Each additional day of postoperative MV was associated with greater odds of mortality (odds ratio [OR], 1.09 per day; p < 0.01) in the full cohort. We identified an associated greater odds of mortality in the 102 patients with intracorporeal devices (OR, 1.24; 95% CI, 1.04-1.48; p = 0.014), but not paracorporeal devices (77 patients; OR, 1.04; 95% CI, 0.99-1.09; p = 0.115). CONCLUSIONS Prolonged MV after VAD placement is associated with greater odds of mortality in intracorporeal devices, which may indicate inadequacy of cardiopulmonary support in this group. This linkage provides a platform for future analyses in this population.
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Affiliation(s)
- Tanya Perry
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David N Rosenthal
- Department of Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA
| | - Angela Lorts
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Farhan Zafar
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Wenying Zhang
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI
| | | | - Aaron G Dewitt
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Garrett Reichle
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Mousumi Banerjee
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI
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Schumacher KR, Cedars A, Allen K, Goldberg D, Batazzi A, Reichle G, DiPaola F, Selewski D, Cousino M, Rosenthal DN. Achieving Consensus: Severity-Graded Definitions of Fontan-Associated Complications to Characterize Fontan Circulatory Failure. J Card Fail 2024:S1071-9164(24)00075-7. [PMID: 38452996 DOI: 10.1016/j.cardfail.2024.02.015] [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: 10/04/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Fontan physiology leads to chronic changes in other organ systems that may affect long-term survival and the success of heart transplantation. Inadequate assessment and treatment of the extra-cardiac effects of Fontan may contribute to poor outcomes. Severity-graded/ordinal consensus definitions of Fontan complications are lacking, which limits understanding of how Fontan-specific morbidity affects patients' outcomes. METHODS AND RESULTS A panel of Fontan patient and physiology experts, including pediatric, adult congenital, heart failure, and critical-care cardiology as well as pediatric nephrology, hepatology and psychology, convened to develop definitions of Fontan complications. Definitions were created by using a severity-graded ordinal scale: grade 1, mild; grade 2, moderate; grade 3, severe; grade 4, disabling or life threatening. Following definition creation, a second panel of 21 experts in Fontan circulatory failure used a modified Delphi methodology to modify and vote on definitions until consensus (> 90% agreement without recommended further modification) was reached on final definitions. After 3 rounds of modifications and voting, consensus agreement was achieved on all Fontan-specific definitions. The defined complications and morbidities of Fontan include: anatomic Fontan pathway obstruction, cyanosis, systemic venous abnormalities resulting from venous insufficiency, atrial arrhythmia, ventricular arrhythmia, bradycardia, chronic pleural effusions, chronic ascites, protein-losing enteropathy, plastic bronchitis, hemoptysis and pulmonary hemorrhage, sleep apnea, Fontan-associated liver disease, portal and hepatic variceal disease, acute kidney injury affecting clinical treatment, polycythemia, thrombotic disease, recurrent or severe bacterial infection, skin atrophy, adrenal insufficiency, physical impact of previous stroke, mood/behavior disorder, and neurodevelopmental disorder. CONCLUSION Consensus and severity-graded definitions of Fontan-specific cardiac and extra-cardiac complications were achieved and are available for use in research. They will allow future robust analyses of Fontan patient outcomes.
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Affiliation(s)
- Kurt R Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI.
| | | | - Kiona Allen
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Evanston, IL
| | - David Goldberg
- University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Adrianna Batazzi
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI
| | - Garrett Reichle
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI
| | - Frank DiPaola
- University of Virginia, UVA Health Children's Health, Charlottesville, VA
| | - David Selewski
- Medical University of South Carolina, MUSC Children's Health, Charleston, SC
| | - Melissa Cousino
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI
| | - David N Rosenthal
- Stanford University, Lucille Packard Children's Hospital, Stanford, CA
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Bansal N, D'Souza N, Wisotzkey BL, Albers E, Shih R, Exil V, McQueen M, Hillenburg JP, Azeka E, Law S, Peng DM, O'Connor M, Gajarski R, Vanderpluym C, Lorts A, Barnes A, Sojka M, Bano M, Keating M, Rosenthal DN, Conway J, Schroeder K, Nandi D. Successful implementation of telehealth visits in the paediatric heart failure and heart transplant population. Cardiol Young 2024; 34:531-534. [PMID: 37518866 DOI: 10.1017/s1047951123001312] [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] [Indexed: 08/01/2023]
Abstract
The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) and Pediatric Heart Transplant Society (PHTS) convened a working group at the beginning of 2020 during the COVID-19 pandemic, with the aim of using telehealth as an alternative medium to provide quality care to a high-acuity paediatric population receiving advanced cardiac therapies. An algorithm was developed to determine appropriateness, educational handouts were developed for both patients and providers, and post-visit surveys were collected. Telehealth was found to be a viable modality for health care delivery in the paediatric heart failure and transplant population and has promising application in the continuity of follow-up, medication titration, and patient education/counselling domains.
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Affiliation(s)
- Neha Bansal
- Division of Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - Nikita D'Souza
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bethany L Wisotzkey
- Division of Pediatric Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Erin Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Renata Shih
- Division of Pediatric Cardiology, Congenital Heart Center, University of Florida, FL, USA
| | - Vernat Exil
- Division of Pediatric Cardiology, Saint Louis University, Cardinal Glennon Children's Hospital, MO, USA
| | | | | | - Estela Azeka
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sabrina Law
- Division of Pediatric Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - David M Peng
- Division of Cardiology, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Matthew O'Connor
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert Gajarski
- Division of Cardiology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | | | - Angela Lorts
- Division of Cardiology, Cincinnati Hospital Medical Center, Cincinnati, OH, USA
| | - Aliessa Barnes
- Division of Cardiology, Children's Mercy Hospital, University of Missouri, Kansas City, MO, USA
| | - Melanie Sojka
- The Willis J Potts Heart Center, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Maria Bano
- Division of Pediatric Cardiology, UT Southwestern Medical Center, TX, USA
| | | | - David N Rosenthal
- Stanford Children's Health, Division of Pediatric Cardiology at Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | - Deipanjan Nandi
- Division of Cardiology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
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Bansal N, Jeewa A, Watanabe K, Richmond ME, Alzubi A, D'Souza N, Bano M, Lorts A, Rosenthal DN, Taylor K, O'Shea C, Smyth L, Koehl D, Zhao H, Hollander SA. Reducing donor acceptance practice variation - Learnings from a discussion forum. Pediatr Transplant 2024; 28:e14635. [PMID: 37957127 DOI: 10.1111/petr.14635] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/26/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE Although waitlist mortality is unacceptably high, nearly half of donor heart offers are rejected by pediatric heart transplant centers. The Advanced Cardiac Therapy Improving Outcome Network (ACTION) and Pediatric Heart Transplant Society (PHTS) convened a multi-institutional donor decision discussion forum (DDDF) aimed at assessing donor acceptance practices and reducing practice variation. METHODS A 1-h-long virtual DDDF for providers across North America, the United Kingdom, and Brazil was held monthly. Each session typically included two case presentations posing a real-world donor decision challenge. Attendees were polled before the presenting center's decision was revealed. Group discussion followed, including a review of relevant literature and PHTS data. Metrics of participation, participant agreement with presenting center decisions, and impact on future decision-making were collected and analyzed. RESULTS Over 2 years, 41 cases were discussed. Approximately 50 clinicians attended each call. Risk factors influencing decision-making included donor quality (10), size discrepancy (8), and COVID-19 (8). Donor characteristics influenced 63% of decisions, recipient factors 35%. Participants agreed with the decision made by the presenting center only 49% of the time. Post-presentation discussion resulted in 25% of participants changing their original decision. Survey conducted reported that 50% respondents changed their donor acceptance practices. CONCLUSION DDDF identified significant variation in pediatric donor decision-making among centers. DDDF may be an effective format to reduce practice variation, provide education to decision-makers, and ultimately increase donor utilization.
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Affiliation(s)
- Neha Bansal
- Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, New York, USA
| | - Aamir Jeewa
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kae Watanabe
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Marc E Richmond
- Division of Pediatric Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Anaam Alzubi
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nikita D'Souza
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Maria Bano
- Department of Pediatric Cardiology, UT Southwestern, Dallas, Texas, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | - Lauren Smyth
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Hong Zhao
- Kirklin Solutions, Hoover, Alabama, USA
| | - Seth A Hollander
- Stanford University School of Medicine, Palo Alto, California, USA
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5
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Torpoco Rivera DM, Hollander SA, Almond C, Profita E, Dykes JC, Raissadati A, Lee J, Sacks LD, Kleiman ZI, Lee E, Rosenthal A, Rosenthal DN, Nasirov T, Ma M, Martin E, Chen S. An integrated program to expand donor utilization in pediatric heart transplantation: Case report of successful transplant with multiple donor risk factors. Pediatr Transplant 2024; 28:e14584. [PMID: 37470130 DOI: 10.1111/petr.14584] [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: 03/29/2023] [Revised: 06/20/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Pediatric heart transplantation (HT) continues to be limited by the shortage of donor organs, distance constraints, and the number of potential donor offers that are declined due to the presence of multiple risk factors. METHODS We report a case of successful pediatric HT in which multiple risk factors were mitigated through a combination of innovative donor utilization improvement strategies. RESULTS An 11-year-old, 25-kilogram child with cardiomyopathy and pulmonary hypertension, on chronic milrinone therapy and anticoagulated with apixaban, was transplanted with a heart from a Hepatitis C virus positive donor and an increased donor-to-recipient weight ratio. Due to extended geographic distance, an extracorporeal heart preservation system (TransMedics™ OCS Heart) was used for procurement. No significant bleeding was observed post-operatively, and she was discharged by post-operative day 15 with normal biventricular systolic function. Post-transplant Hepatitis C virus seroconversion was successfully treated. CONCLUSIONS Heart transplantation in donors with multiple risk factor can be achieved with an integrative team approach and should be taken into consideration when evaluating marginal donors in order to expand the current limited donor pool in pediatric patients.
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Affiliation(s)
- Diana M Torpoco Rivera
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christopher Almond
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth Profita
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - John C Dykes
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Alireza Raissadati
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Joanne Lee
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Loren D Sacks
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Zachary I Kleiman
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ellen Lee
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ayelet Rosenthal
- Department of Pediatrics, Division of Infectious Disease, Stanford University School of Medicine, Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Teimour Nasirov
- Department of Cardiothoracic Surgery, Division of Pediatric Heart Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Division of Pediatric Heart Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elisabeth Martin
- Department of Cardiothoracic Surgery, Division of Pediatric Heart Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sharon Chen
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
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Chubb H, Mah DY, Shah M, Lin KY, Peng DM, Hale BW, May L, Etheridge S, Goodyer W, Ceresnak SR, Motonaga KS, Rosenthal DN, Almond CS, McElhinney DB, Dubin AM. Multicenter Study of Survival Benefit of Cardiac Resynchronization Therapy in Pediatric and Congenital Heart Disease. JACC Clin Electrophysiol 2023:S2405-500X(23)00836-8. [PMID: 38206260 DOI: 10.1016/j.jacep.2023.11.008] [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: 01/31/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Evidence for the efficacy of cardiac resynchronization therapy (CRT) in pediatric and congenital heart disease (CHD) has been limited to surrogate outcomes. OBJECTIVES This study aimed to assess the impact of CRT upon the risk of transplantation or death in a retrospective, high-risk, controlled cohort at 5 quaternary referral centers. METHODS Both CRT patients and control patients were <21 years of age or had CHD; had systemic ventricular ejection fraction <45%; symptomatic heart failure; and significant electrical dyssynchrony (QRS duration z score >3 or single-site ventricular pacing >40%) at enrollment. Patients with CRT were matched with control patients via 1:1 propensity score matching. CRT patients were enrolled at CRT implantation; control patients were enrolled at the outpatient clinical encounter where inclusion criteria were first met. The primary endpoint was transplantation or death. RESULTS In total, 324 control patients and 167 CRT recipients were identified. Mean follow-up was 4.2 ± 3.7 years. Upon propensity score matching, 139 closely matched pairs were identified (20 baseline indices). Of the 139 matched pairs, 52 (37.0%) control patients and 31 (22.0%) CRT recipients reached the primary endpoint. On both unadjusted and multivariable Cox regression analysis, the risk reduction associated with CRT for the primary endpoint was significant (HR: 0.40; 95% CI: 0.25-0.64; P < 0.001; and HR: 0.44; 95% CI: 0.28-0.71; P = 0.001, respectively). On longitudinal assessment, the CRT group had significantly improved systemic ventricular ejection fraction (P < 0.001) and shorter QRS duration (P = 0.015), sustained to 5 years. CONCLUSIONS In pediatric and CHD patients with symptomatic systolic heart failure and electrical dyssynchrony, CRT was associated with improved heart transplantation-free survival.
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Affiliation(s)
- Henry Chubb
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Boston Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston Massachusetts, USA
| | - Maully Shah
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly Y Lin
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David M Peng
- Department of Cardiology, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Benjamin W Hale
- Department of Cardiology, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsay May
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Susan Etheridge
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - William Goodyer
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Scott R Ceresnak
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Kara S Motonaga
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Christopher S Almond
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Doff B McElhinney
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
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Conway J, Amdani S, Morales DLS, Lorts A, Rosenthal DN, Jacobs JP, Rossano J, Koehl D, Kirklin JK, Auerbach SR. Widening care gap in VAD therapy. J Heart Lung Transplant 2023; 42:1710-1724. [PMID: 37591455 DOI: 10.1016/j.healun.2023.08.009] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/24/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The removal of the HeartWare ventricular assist device (HVAD) due to pump malfunctions and inferior outcomes compared to HeartMate 3 (HM3) in adults has created a care gap for younger patients. It is unclear if the reported HVAD survival differs by age and if the initial experience with HM3 can bridge the gap. METHODS Using the Society of Thoracic Surgeons (STS) Intermacs and Pedimacs registries, durable ventricular assist device (VAD) implants between September 2012 and December 2021 were identified. Young adults (YA) were defined as <40 years old in Intermacs. Patients were excluded if they had an isolated right VAD (RVAD) or were implanted as destination therapy (DT). Survival analysis by Kaplan-Meier (KM) and competing outcomes curves was performed, and 1-year survival is reported. RESULTS The Intermacs cohort consisted of YA (n = 1226; HVAD 818; HM3 408) with a median age of YA of 32.07 (26.66-36.27) years and weight (wt) of 83.2 (68-104.2) kg. Most had cardiomyopathy (CM) (92.2%). The Pedimacs cohort was 668 patients (median age 9.47 [1.82-14.23] years, wt 27.2 [10-57.05] kg), and most also had CM (70.5%). Device breakdown included HVAD (n = 326), Berlin EXCOR (n = 277), and HM3 (n = 65). HVAD survival differed by age in adults, with YA fairing better than adults >40 years old (88.8% vs 79.4% at 1 year, p < 0.0001). YA survival was also better compared to Pedimacs patient (88.9% vs 83.7%, p = 0.0002), but when competing events were analyzed, mortality was similar to YA (9.2% vs 9.6%, p = 0.1) with a higher proportion of patient undergoing transplant at 1 year in Pedimacs (74% vs 31.3%, p < 0.0001). Survival by device differed between HVAD and HM3 in YA (88.8% vs 94.4%, p = 0.0025). This difference in device survival was not seen in all children (83.7% vs 87.3%, p = 0.21), including those ≥25 kg. Adverse event profiles also differed across the groups with adults seeing less adverse events with the HM3, but the same was not found (including stroke) in the pediatric cohort. Survival outcomes for patients between 10 and 25 kg were similar with the HVAD compared to the Berlin Heart EXCOR (p = 0.4290), with similarities in stroke risk. CONCLUSION The removal of the HVAD device may result in a care gap in younger patient whose survival outcomes do not mirror that of older adults. The HM3 can fill a portion of this gap with good survival, but there remains a subset of pediatric patients that, based on initial HM3 use, will no longer have access to intracorporeal support and therefore, despite reasonable outcomes with the Berlin Heart EXCOR, will not be able to be discharged home. Lastly, it is essential that future changes to the availability of devices take into account the various patient populations that utilize the device to avoid unintended consequences of access inequality.
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Affiliation(s)
- Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.
| | - Shahnawaz Amdani
- Division of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - David L S Morales
- Cincinnati Children's Hospital Medical Center, The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela Lorts
- Cincinnati Children's Hospital Medical Center, The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David N Rosenthal
- Department of Pediatrics, Stanford University and Lucille Packard Children's Hospital, Palo Alto, California
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Joseph Rossano
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Scott R Auerbach
- Division of Cardiology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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Lee JY, Kidambi S, Zawadzki RS, Rosenthal DN, Dykes JC, Nasirov T, Ma M. Weight Matching in Infant Heart Transplantation: A National Registry Analysis. Ann Thorac Surg 2023; 116:1241-1248. [PMID: 35835207 PMCID: PMC10321673 DOI: 10.1016/j.athoracsur.2022.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/07/2021] [Revised: 04/26/2022] [Accepted: 05/31/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Infants account for a significant proportion of pediatric heart transplantation but also suffer from a high waitlist mortality. Donor oversizing by weight-based criteria is common practice in transplantation and is prevalent in this group. We sought to analyze the impact of oversizing on outcomes in infants. METHODS Infant heart transplantations reported to the United Network for Organ Sharing from January 1994 to September 2019 were retrospectively analyzed. 2384 heart transplantation recipients were divided into quintiles (Q1-Q5) on the basis of donor-to-recipient weight ratio (DRWR). Multivariate Cox regression was used to estimate the effect of DRWR. The primary end point was graft survival at 1 year. RESULTS The median DRWR for each quintile was 0.90 (0.37-1.04), 1.17 (1.04-1.29), 1.43 (1.29-1.57), 1.74 (1.58-1.97), and 2.28 (1.97-5.00). Pairwise comparisons showed improved survival for Q3 and Q4 over each of the bottom 2 quintiles and the top quintile. Regression analyses found that Q3 and Q4 were protective against graft failure compared with the bottom 2 quintiles. There was no difference in hazard among the top 3 quintiles. Significant covariates included primary diagnosis, ischemia time, serum bilirubin level, transplantation year, mechanical ventilation at transplantation, and extracorporeal membrane oxygenation at transplantation. Sex, female-to-male transplantation, and mechanical circulatory support at transplantation were not significant in univariate analyses. CONCLUSIONS Modest oversizing by DRWR (1.29-1.97) is associated with increased survival and lower risk in infant heart transplantation. Additional investigation is needed to establish best practices for size matching in this population.
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Affiliation(s)
- James Y Lee
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Sumanth Kidambi
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Roy S Zawadzki
- Department of Statistics, Donald Bren School of Information and Computer Sciences, University of California, Irvine, California
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - John C Dykes
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Teimour Nasirov
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Michael Ma
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California.
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9
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O'Connor AM, Cassedy A, Wray J, Brown KL, Cohen M, Franklin RCG, Gaynor JW, MacGloin H, Mahony L, Mussatto K, Newburger JW, Rosenthal DN, Teitel D, Ernst MM, Wernovsky G, Marino BS. Differences in Quality of Life in Children Across the Spectrum of Congenital Heart Disease. J Pediatr 2023; 263:113701. [PMID: 37640230 DOI: 10.1016/j.jpeds.2023.113701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/14/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To create complexity groups based upon a patient's cardiac medical history and to test for group differences in health-related quality of life (HRQOL). METHODS Patients 8-18 years with congenital heart disease (CHD) and parent-proxies from the Pediatric Cardiac Quality of Life Inventory (PCQLI) Testing Study were included. Outcome variables included PCQLI Total, Disease Impact, and Psychosocial Impact scores. Using a patient's medical history (cardiac, neurologic, psychological, and cognitive diagnosis), latent class analysis (LCA) was used to create CHD complexity groups. Covariates included demographics and burden of illness (number of: school weeks missed, physician visits in the past year, and daily medications). Generalized estimation equations tested for differences in burden of illness and patient and parent-proxy PCQLI scores. RESULTS Using 1482 CHD patients (60% male; 84% white; age 12.3 ± 3.0 years), latent class analysis (LCA) estimates showed 4 distinct CHD complexity groups (Mild, Moderate 1, Moderate 2, and Severe). Increasing CHD complexity was associated with increased risk of learning disorders, seizures, mental health problems, and history of stroke. Greater CHD complexity was associated with greater burden of illness (P < .01) and lower patient- and parent-reported PCQLI scores (P < .001). CONCLUSIONS LCA identified 4 congenital heart disease (CHD) complexity groupings. Increasing CHD complexity was associated with higher burden of illness and worse patient- and parent-reported HRQOL.
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Affiliation(s)
- Amy M O'Connor
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Division of Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Amy Cassedy
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Jo Wray
- Department of Pediatric Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kate L Brown
- Department of Pediatric Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mitchell Cohen
- Division of Cardiology, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ; Division of Cardiology, Department of Pediatrics, Inova Children's Hospital, Falls Church, VA
| | - Rodney C G Franklin
- Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Helen MacGloin
- Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Lynn Mahony
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Jane W Newburger
- Division of Cardiology, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - David N Rosenthal
- Division of Cardiology, Department of Pediatrics, Lucille Packard Children's Hospital Stanford, Palo Alto, CA
| | - David Teitel
- Division of Cardiology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Michelle M Ernst
- Division of Behavior Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gil Wernovsky
- Division of Cardiology, Departments of Pediatrics and Critical Care Medicine, Children's National Hospital, Washington, DC; Division of Cardiac Critical Care, Departments of Pediatrics and Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Bradley S Marino
- Divisions of Pediatric Cardiology and Critical Care Medicine, Department of Heart, Vascular & Thoracic, Children's Institute, Cleveland Clinic Children's, Cleveland, OH
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10
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Cousino MK, May LJ, Smyth L, McQueen M, Thompson K, Hunter T, Ventresco C, Fields K, Murray J, Machado DS, Shezad M, Zafar F, Rosenthal DN, Lorts A, Blume ED. Patient and parent-reported outcomes in paediatric ventricular assist device support: a multi-center ACTION learning network feasibility and pilot experience. Cardiol Young 2023; 33:2258-2266. [PMID: 36655506 DOI: 10.1017/s1047951122004048] [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] [Indexed: 01/20/2023]
Abstract
BACKGROUND Patient- and proxy-reported outcomes (PROs) are an important indicator of healthcare quality and can be used to inform treatment. Despite the widescale use of PROs in adult cardiology, they are underutilised in paediatric cardiac care. This study describes a six-center feasibility and pilot experience implementing PROs in the paediatric and young adult ventricular assist device population. METHODS The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) is a collaborative learning network comprised of 55 centres focused on improving clinical outcomes and the patient/family experience for children with heart failure and those supported by ventricular assist devices. The development of ACTION's PRO programme via engagement with patient and parent stakeholders is described. Pilot feasibility, patient/parent and clinician feedback, and initial PRO findings of patients and families receiving paediatric ventricular assist support across six centres are detailed. RESULTS Thirty of the thirty-five eligible patients (85.7%) were enrolled in the PRO programme during the pilot study period. Clinicians and participating patients/parents reported positive experiences with the PRO pilot programme. The most common symptoms reported by patients/parents in the first month post-implant period included limitations in activities, dressing change distress, and post-operative pain. Poor sleep, dressing change distress, sadness, and fatigue were the most common symptoms endorsed >30 days post-implant. Parental sadness and worry were notable throughout the entirety of the post-implant experience. CONCLUSIONS This multi-center ACTION learning network-based PRO programme demonstrated initial success in this six-center pilot study experience and yields important next steps for larger-scale PRO collection, research, and clinical intervention.
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Affiliation(s)
- Melissa K Cousino
- Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Lindsay J May
- Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Lauren Smyth
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Katherine Thompson
- Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Tiffany Hunter
- Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | | | - Katrina Fields
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jenna Murray
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Desiree S Machado
- Department of Pediatric Cardiac Critical Care, Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Muhammad Shezad
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
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11
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Schramm JE, Dykes JC, Hopper RK, Feinstein JA, Rosenthal DN, Kameny RJ. Pulmonary Vasodilator Therapy in Pediatric Patients on Ventricular Assist Device Support: A Single-Center Experience and Proposal for Use. ASAIO J 2023; 69:1025-1030. [PMID: 37556563 DOI: 10.1097/mat.0000000000002023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/11/2023] Open
Abstract
Pediatric precapillary pulmonary hypertension can develop in response to systemic atrial hypertension. Systemic atrial decompression following ventricular assist device (VAD) implantation may not sufficiently lower pulmonary vascular resistance (PVR) to consider heart transplant candidacy. Prostacyclins have been used in adult VAD patients with success, but pediatric data on safety and efficacy in this population are limited. We sought to describe our center's experience to show its safety and to present our current protocol for perioperative use. We reviewed our use of prostacyclin therapy in pediatric patients on VAD support with high PVR from 2016 to 2021. Of the 17 patients who met inclusion, 12 survived to transplant and 1 is alive with VAD in situ . All patients survived posttransplant. With continuous intravenous (IV) epoprostenol or treprostinil therapy, there were no bleeding complications or worsening of end-organ function. A significant reduction was observed in vasoactive inotropic scores by 49% in the first 24 hours post-prostacyclin initiation. The proportion of patients surviving to transplant in this high-risk cohort is favorable. In conclusion, prostacyclins may be safe to use in patients with elevated PVR as part of their VAD and transplant course and may provide a transplant option in those otherwise not candidates.
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Affiliation(s)
- Jennifer E Schramm
- From the Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John C Dykes
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Rachel K Hopper
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Rebecca J Kameny
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
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12
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Boucek K, Alzubi A, Zafar F, O'Connor MJ, Mehegan M, Mokshagundam D, Davies RR, Adachi I, Lorts A, Rosenthal DN. Taking ACTION: A Prognostic Tool for Pediatric Ventricular Assist Device Mortality. ASAIO J 2023; 69:602-609. [PMID: 37261722 DOI: 10.1097/mat.0000000000001899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
We sought to develop a contemporary risk assessment tool for use in pediatric ventricular assist device (VAD) candidates to estimate risk for mortality on the device using readily available preimplantation clinical data. Training and testing datasets were created from Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry data on patients supported with a VAD from 2012 to 2021. Potential risk factors for mortality were assessed and incorporated into a simplified risk prediction model utilizing an open-source, gradient-boosted decision tree machine learning library, known as random forest. Predictive performance was assessed by the area under the receiver operating characteristic curve in the testing dataset. Nine significant risk factors were included in the final predictive model which demonstrated excellent discrimination with an area under the curve of 0.95. In addition to providing a framework for establishing pediatric-specific risk profiles, our model can help inform team expectations, guide optimal patient selection, and ultimately improve patient outcomes.
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Affiliation(s)
- Katerina Boucek
- From the Pediatric Cardiology, Ocshner Hospital for Children, New Orleans, Los Angeles
| | - Anaam Alzubi
- Cardiac Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Farhan Zafar
- Cardiac Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Matthew J O'Connor
- Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mary Mehegan
- Pediatric Cardiology, St. Louis Children's Hospital, St. Louis, Missouri
| | - Deepa Mokshagundam
- Pediatric Cardiology, St. Louis Children's Hospital, St. Louis, Missouri
| | - Ryan R Davies
- Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Iki Adachi
- Surgery and Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Angela Lorts
- Cardiac Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
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13
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Lubert AM, Cedars A, Almond CS, Amdani S, Conway J, Friedland-Little JM, Gajarski RJ, Kindel SJ, Lorts A, Morales DLS, O'Connor MJ, Peng DM, Rosenthal DN, Smyth L, Sutcliffe DL, Schumacher KR. Considerations for Advanced Heart Failure Consultation in Individuals With Fontan Circulation: Recommendations From ACTION. Circ Heart Fail 2023; 16:e010123. [PMID: 36786204 DOI: 10.1161/circheartfailure.122.010123] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Individuals with Fontan circulation are at risk of late mortality from both cardiac and noncardiac causes. Despite the known risk of mortality, referral indications for advanced heart failure care vary between centers, and many individuals die from Fontan circulation-related complications either after late consideration for advanced heart failure therapies or having never seen a heart failure specialist. There is a critical need for guidelines to direct appropriately timed referral for advanced heart failure consultation. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Fontan Committee has developed recommended thresholds for advanced heart failure referral to guide primary cardiologists. These recommendations are divided into 4 categories of clinical Fontan circulatory dysfunction including (1) cardiac/systemic ventricular dysfunction, (2) Fontan pathway dysfunction, (3) lymphatic dysfunction, and (4) extracardiac dysfunction.
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Affiliation(s)
- Adam M Lubert
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, OH (A.M.L., A.L., D.L.S.M., L.S.)
| | - Ari Cedars
- Johns Hopkins University, Baltimore, MD (A.C.)
| | - Christopher S Almond
- Stanford University School of Medicine (Pediatrics) and Stanford Children's Health, Palo Alto, CA (C.S.A., D.N.R.)
| | | | - Jennifer Conway
- Stollery Children's Hospital, Edmonton, Alberta, Canada (J.C.)
| | | | | | - Steven J Kindel
- Children's Hospital of Wisconsin and Herma Heart Institute, Medical College of Wisconsin, Milwaukee (S.J.K.)
| | - Angela Lorts
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, OH (A.M.L., A.L., D.L.S.M., L.S.)
| | - David L S Morales
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, OH (A.M.L., A.L., D.L.S.M., L.S.)
| | | | - David M Peng
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor (D.M.P., K.R.S.)
| | - David N Rosenthal
- Stanford University School of Medicine (Pediatrics) and Stanford Children's Health, Palo Alto, CA (C.S.A., D.N.R.)
| | - Lauren Smyth
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, OH (A.M.L., A.L., D.L.S.M., L.S.)
| | | | - Kurt R Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor (D.M.P., K.R.S.)
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14
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Nandi D, Auerbach SR, Bansal N, Buchholz H, Conway J, Esteso P, Kaufman BD, Lal AK, Law SP, Lorts A, May LJ, Mehegan M, Mokshagundam D, Morales DLS, O'Connor MJ, Rosenthal DN, Shezad MF, Simpson KE, Sutcliffe DL, Vanderpluym C, Wittlieb-Weber CA, Zafar F, Cripe L, Villa CR. Initial multicenter experience with ventricular assist devices in children and young adults with muscular dystrophy: An ACTION registry analysis. J Heart Lung Transplant 2023; 42:246-254. [PMID: 36270923 DOI: 10.1016/j.healun.2022.09.003] [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: 01/21/2022] [Revised: 08/19/2022] [Accepted: 09/06/2022] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Cardiac disease results in significant morbidity and mortality in patients with muscular dystrophy (MD). Single centers have reported their ventricular assist device (VAD) experience in specific MDs and in limited numbers. This study sought to describe the outcomes associated with VAD therapy in an unselected population across multiple centers. METHODS We examined outcomes of patients with MD and dilated cardiomyopathy implanted with a VAD at Advanced Cardiac Therapies Improving Outcomes Network (ACTION) centers from 9/2012 to 9/2020. RESULTS A total of 19 VADs were implanted in 18 patients across 12 sites. The majority of patients had dystrophinopathy (66%) and the median age at implant was 17.2 years (range 11.7-29.5). Eleven patients were non-ambulatory (61%) and 6 (33%) were on respiratory support pre-VAD. Five (28%) patients were implanted as a bridge to transplant, 4 of whom survived to transplant. Of 13 patients implanted as bridge to decision or destination therapy, 77% were alive at 1 year and 69% at 2 years. The overall frequencies of positive outcome (transplanted or alive on device) at 1 year and 2 years were 84% and 78%, respectively. Two patients suffered a stroke, 2 developed sepsis, 1 required tracheostomy, and 1 experienced severe right heart failure requiring right-sided VAD. CONCLUSIONS This study demonstrates the potential utility of VAD therapies in patients with muscular dystrophy. Further research is needed to further improve outcomes and better determine which patients may benefit most from VAD therapy in terms of survival and quality of life.
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Affiliation(s)
| | - Scott R Auerbach
- University of Colorado Denver, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - Neha Bansal
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | | | | | - Paul Esteso
- Boston Children's Hospital, Boston, Massachusetts
| | - Beth D Kaufman
- Lucile Packard Children's Hospital, Palo Alto, California
| | - Ashwin K Lal
- Primary Children's Hospital, Salt Lake City, Utah
| | - Sabrina P Law
- Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Irving Medical Center, New York, New York
| | - Angela Lorts
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Mary Mehegan
- St. Louis Children's Hospital, St Louis, Missouri
| | | | | | | | | | | | - Kathleen E Simpson
- University of Colorado Denver, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | | | | | | | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Linda Cripe
- Nationwide Children's Hospital, Columbus, Ohio
| | - Chet R Villa
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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15
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Lee JY, Zawadzki RS, Kidambi S, Rosenthal DN, Dykes JC, Nasirov T, Ma M. Evaluating predicted heart mass in adolescent heart transplantation. J Heart Lung Transplant 2022; 41:1790-1797. [PMID: 36210265 PMCID: PMC10321674 DOI: 10.1016/j.healun.2022.08.027] [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] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/06/2022] [Accepted: 08/27/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Predicted Heart Mass (PHM) has emerged as an attractive size matching metric in adult cardiac transplantation. However, since PHM was derived from a healthy adult cohort, its generalizability to the pediatric population is unclear. We hypothesize that PHM can be extended to older adolescents, and potentially broaden the donor pool available to this group. METHODS The United Network for Organ Sharing database was retrospectively analyzed for patients aged 13 to 18 undergoing heart transplantation. Recipients were divided into quintiles (Q1-Q5) based on donor-to-recipient predicted heart mass ratios (PHMR). Primary end-point was graft survival at 5 years. RESULTS Two thousand sixty-one adolescent heart transplant recipients between January 1994 and September 2019 were retrospectively analyzed. The median PHMR's for each quintile was 0.84 (0.59-0.92), 0.97 (0.92-1.02), 1.08 (1.02-1.14), 1.21 (1.14-1.30), and 1.44 (1.30-2.31). Kaplan-Meier survival curves demonstrated comparable survival across all quintiles of PHMR (p = 0.9). Multivariate Cox regression showed no significant difference in graft failure of the outer quintiles when compared to the middle quintile (Q1: 1.04 HR, p = 0.80; Q2: 1.02 HR, p = 0.89; Q4: 1.19 HR, p = 0.28; Q5: 1.02 HR, p = 0.89). Significant covariates included transplant year (HR: 0.95, p < 0.0001), serum bilirubin (HR: 1.04, p = 0.0004), ECMO at transplantation (HR: 2.85, p < 0.0001), and underlying diagnosis of dilated cardiomyopathy (vs congenital heart disease, HR: 0.66, p = 0.0004). CONCLUSIONS Matching by PHM is not associated with survival or risk in adolescent heart transplant recipients. Our results underscore the ongoing need to develop an improved size-matching method in pediatric heart transplantation.
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Affiliation(s)
- James Y Lee
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Roy S Zawadzki
- Department of Statistics, Donald Bren School of Information and Computer Sciences, University of California, Irvine, California
| | - Sumanth Kidambi
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - John C Dykes
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Teimour Nasirov
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Michael Ma
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California.
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16
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Peng DM, Shezad MF, Lorts A, Gajarski RJ, VanderPluym C, Murray JM, Hawkins B, Villa CR, Zafar F, Rosenthal DN. Decreased Risk of Strokes in Children with Ventricular Assist Devices Within ACTION. Pediatr Cardiol 2022; 43:1379-1382. [PMID: 35247057 DOI: 10.1007/s00246-022-02863-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/24/2022] [Indexed: 11/30/2022]
Abstract
We sought to characterize strokes in children with ventricular assist devices. Of 407 patients in the ACTION registry (4/1/18-5/3/2021), 45 (11%) experienced 52 strokes (45 ischemic and 7 hemorrhagic). Median time to stroke was 23.5 days and 19/52 (37%) occurred ≤ 10 days. Stroke rate was 0.09 and 0.63 strokes per patient-year for implantable continuous and paracorporeal devices, respectively. Patients with stroke were younger, more likely to have congenital heart disease and have been on extracorporeal membrane oxygenation at time of VAD. Based on these data, ACTION is now focused on decreasing strokes in these higher-risk patients with particular attention to the peri-implant period.
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Affiliation(s)
- David M Peng
- University of Michigan Congenital Heart Center, CS Mott Children's Hospital, Ann Arbor, MI, USA.
| | - Muhammad F Shezad
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Jenna M Murray
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | | | - Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David N Rosenthal
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
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17
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Nasirov T, Dykes JC, Hollander SA, Almond CS, Reinhartz O, Maeda K, Martin E, Murray J, Chen S, Chen CY, Kaufman BD, Bernstein D, Profita EL, Rosenthal DN, Ma M. PEDS3: Twenty Years of Pediatric Ventricular Assist Device Support at a Single Institution. ASAIO J 2022. [DOI: 10.1097/01.mat.0000841104.02767.6a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Hayward C, Adachi I, Baudart S, Davis E, Feller ED, Kinugawa K, Klein L, Li S, Lorts A, Mahr C, Mathew J, Morshuis M, Müller M, Ono M, Pagani FD, Pappalardo F, Rich J, Robson D, Rosenthal DN, Saeed D, Salerno C, Sauer AJ, Schlöglhofer T, Tops L, VanderPluym C. Global Best Practices Consensus: Long-term Management of HeartWare Ventricular Assist Device Patients. J Thorac Cardiovasc Surg 2022; 164:1120-1137.e2. [DOI: 10.1016/j.jtcvs.2022.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/24/2022] [Accepted: 03/24/2022] [Indexed: 11/15/2022]
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Chen CY, Montez-Rath ME, May LJ, Maeda K, Hollander SA, Rosenthal DN, Krawczeski CD, Sutherland SM. Hemodynamic Predictors of Renal Function After Pediatric Left Ventricular Assist Device Implantation. ASAIO J 2021; 67:1335-1341. [PMID: 34860188 PMCID: PMC8647769 DOI: 10.1097/mat.0000000000001460] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although renal function often improves after pediatric left ventricular assist device (LVAD) implantation, recovery is inconsistent. We aimed to identify hemodynamic parameters associated with improved renal function after pediatric LVAD placement. A single-center retrospective cohort study was conducted in patients less than 21 years who underwent LVAD placement between June 2004 and December 2015. The relationship between hemodynamic parameters and estimated glomerular filtration rate (eGFR) was assessed using univariate and multivariate modeling. Among 54 patients, higher preoperative central venous pressure (CVP) was associated with eGFR improvement after implantation (p = 0.012). However, 48 hours postimplantation, an increase in CVP from baseline was associated with eGFR decline over time (p = 0.01). In subgroup analysis, these associations were significant only for those with normal pre-ventricular assist device renal function (p = 0.026). In patients with preexisting renal dysfunction, higher absolute CVP values 48 and 72 hours after implantation predicted better renal outcome (p = 0.005). Our results illustrate a complex relationship between ventricular function, volume status, and renal function. Additionally, they highlight the challenge of using CVP to guide management of renal dysfunction in pediatric heart failure. Better methods for evaluating right heart function and volume status are needed to improve our understanding of how hemodynamics impact renal function in this population.
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Affiliation(s)
- Chiu-Yu Chen
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Lindsay J May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Seth A Hollander
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Catherine D Krawczeski
- Division of Pediatric Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Scott M Sutherland
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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20
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Amdani S, Boyle GJ, Cantor RS, Conway J, Godown J, Kirklin JK, Koehl D, Lal AK, Law Y, Lorts A, Rosenthal DN. Significance of pre and post-implant MELD-XI score on survival in children undergoing VAD implantation. J Heart Lung Transplant 2021; 40:1614-1624. [PMID: 34598872 DOI: 10.1016/j.healun.2021.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Derangements in liver and renal function often accompany end-stage heart failure. We sought to assess the utility of an objective risk assessment tool, the Model for End-stage Liver Disease eXcluding INR (MELD-XI), to identify pediatric patients at increased risk for adverse outcomes post-ventricular assist device (VAD) implantation. METHODS The Pedimacs database was queried for all pediatric patients who underwent VAD implantation from September 19, 2012 to December 31, 2019. Pre-implant and early (1-week) post-implant MELD-XI scores were used to stratify patients into low, intermediate and high score cohorts. Comparison of pre-implant characteristics and post-implant outcomes were conducted across groups. Multiphase parametric hazard modeling was utilized to identify independent predictors of post-implant mortality. RESULTS A total of 742 patients had a calculable MELD-XI score pre-implant. When stratified by MELD-XI scores pre-implant, patients in the high MELD-XI score cohort (score >13.6) had inferior survival and increased bleeding, renal dysfunction and respiratory failure post-implant compared to intermediate and low score cohorts. Risk factors for mortality post-VAD implantation were: increasing MELD-XI scores (HR 1.1 per 1 unit rise), Pedimacs profile 1 (HR 1.6), congenital heart disease (HR 2.3) and being on a percutaneous VAD (HR 2.7). Importantly, MELD-XI score was a better predictor of post-VAD implant mortality than bilirubin or creatinine alone, neither of which were significant in the final model. Patients with increasing or continued high MELD-XI scores early post-implant had the worst survival. CONCLUSION The MELD-XI is an easily calculated score that serves as a promising risk assessment tool in identifying children at risk for poor outcomes post VAD implantation.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
| | - Gerard J Boyle
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer Conway
- Department of Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Justin Godown
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashwin K Lal
- Division of Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Yuk Law
- Department of Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Angela Lorts
- Department of Cardiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - David N Rosenthal
- Department of Cardiology, Stanford University, Palo Alto, California
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21
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Hollander SA, Kaufman BD, Bui C, Gregori B, Murray JM, Sacks L, Ryan KR, Ma M, Rosenthal DN, Char D. Compassionate Deactivation of Pediatric Ventricular Assist Devices: A Review of 14 Cases. J Pain Symptom Manage 2021; 62:523-528. [PMID: 33910026 DOI: 10.1016/j.jpainsymman.2021.01.125] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/21/2021] [Accepted: 01/27/2021] [Indexed: 11/16/2022]
Abstract
CONTEXT Compassionate deactivation (CD) of ventricular assist device (VAD) support is a recognized option for children when the burden of therapy outweighs the benefits. OBJECTIVES To describe the prevalence, indications, and outcomes of CD of children supported by VADs at the end of life. METHODS Review of cases of CD at our institution between 2011 and 2020. To distinguish CD from other situations where VAD support is discontinued, patients were excluded from the study if they died during resuscitation (including extracorporeal membrane oxygenation), experienced brain or circulatory death prior to deactivation, or experienced a non-survivable brain injury likely to result in imminent death regardless of VAD status. RESULTS Of 24 deaths on VAD, 14 (58%) were CD. Median age was 5.7 (interquartile range (IQR) 0.6, 11.6) years; 6 (43%) had congenital heart disease; 4 (29%) were on a device that can be used outside of the hospital. CD occurred after 40 (IQR: 26, 75) days of support; none while active transplant candidates. CD discussions were initiated by the caregiver in 6 (43%) cases, with the remainder initiated by a medical provider. Reasons for CD were multifactorial, including end-organ injury, infection, and stroke. CD occurred with endotracheal extubation and/or discontinuation of inotropes in 12 (86%) cases, and death occurred within 10 (IQR: 4, 23) minutes of CD. CONCLUSION CD is the mode of death in more than half of our VAD non-survivors and is pursued for reasons primarily related to noncardiac events. Caregivers and providers both initiate CD discussions. Ventilatory and inotropic support is often withdrawn at time of CD with ensuing death.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA.
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Christine Bui
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Bianca Gregori
- Department of Social Work, Lucile Packard Children's Hospital Stanford (B.G.), Palo Alto, California, USA
| | - Jenna M Murray
- Solid Organ Transplant Services, Lucile Packard Children's Hospital Stanford (J.M.M), Palo Alto, California, USA
| | - Loren Sacks
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Kathleen R Ryan
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine (M.M.), Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Danton Char
- Department of Anesthesia, Stanford University School of Medicine (D.C.), Palo Alto, California, USA
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22
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O'Connor MJ, Lorts A, Kwiatkowski D, Butts R, Barnes A, Jeewa A, Knoll C, Fenton M, McQueen M, Cousino MK, Shugh S, Rosenthal DN. Learning networks in pediatric heart failure and transplantation. Pediatr Transplant 2021; 25:e14073. [PMID: 34138489 DOI: 10.1111/petr.14073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Learning networks have emerged in medicine as a novel organizational structure that contains elements of quality improvement, education, and research with the goal of effecting rapid improvements in clinical care. In this article, the concept of a learning network is defined and highlighted in the field of pediatric heart failure and transplantation. METHODS Learning networks are defined, with particular attention paid to the recent creation of the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) for children with heart failure and those being supported with ventricular assist devices (VAD). RESULTS The mission, goals, and organizational structure of ACTION are described, and recent initiatives promoted by ACTION are highlighted, such as stroke reduction initiatives, practice harmonization protocols, and use of ACTION data to support the recent US Food and Drug Administration approval of newer VAD for pediatric patients. CONCLUSIONS The learning network, exemplified by ACTION, is distinguished from traditional clinical research collaboratives by contributions in research, quality improvement, patient-reported outcomes, and education, and serves as an effective vehicle to drive clinical improvement in the care of children with advanced heart failure.
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Affiliation(s)
- Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Ryan Butts
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Medical Center of Dallas, Dallas, TX, USA
| | | | - Aamir Jeewa
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christopher Knoll
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Matthew Fenton
- Great Ormond Street Hospital for Children Foundation Trust, London, UK
| | | | | | - Svetlana Shugh
- Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
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23
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Dykes JC, Rosenthal DN, Bernstein D, McElhinney DB, Chrisant MRK, Daly KP, Ameduri RK, Knecht K, Richmond ME, Lin KY, Urschel S, Simmonds J, Simpson KE, Albers EL, Khan A, Schumacher K, Almond CS, Chen S. Clinical and hemodynamic characteristics of the pediatric failing Fontan. J Heart Lung Transplant 2021; 40:1529-1539. [PMID: 34412962 DOI: 10.1016/j.healun.2021.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 12/21/2020] [Revised: 07/02/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022] Open
Abstract
AIM To describe the clinical and hemodynamic characteristics of Fontan failure in children listed for heart transplant. METHODS In a nested study of the Pediatric Heart Transplant Society, 16 centers contributed information on Fontan patients listed for heart transplant between 2005and 2013. Patients were classified into four mutually exclusive phenotypes: Fontan with abnormal lymphatics (FAL), Fontan with reduced systolic function (FRF), Fontan with preserved systolic function (FPF), and Fontan with "normal" hearts (FNH). Primary outcome was waitlist and post-transplant mortality. RESULTS 177 children listed for transplant were followed over a median 13 (IQR 4-31) months, 84 (47%) were FAL, 57 (32%) FRF, 22 (12%) FNH, and 14 (8%) FPF. Hemodynamic characteristics differed between the 4 groups: Fontan pressure (FP) was most elevated with FPF (median 22, IQR 18-23, mmHg) and lowest with FAL (16, 14-20, mmHg); cardiac index (CI) was lowest with FRF (2.8, 2.3-3.4, L/min/m2). In the entire cohort, 66% had FP >15 mmHg, 21% had FP >20 mmHg, and 10% had CI <2.2 L/min/m2. FRF had the highest risk of waitlist mortality (21%) and FNH had the highest risk of post-transplant mortality (36%). CONCLUSIONS Elevated Fontan pressure is more common than low cardiac output in pediatric failing Fontan patients listed for transplant. Subtle hemodynamic differences exist between the various phenotypes of pediatric Fontan failure. Waitlist and post-transplant mortality risks differ by phenotype.
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Affiliation(s)
- John C Dykes
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University.
| | - David N Rosenthal
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University
| | - Daniel Bernstein
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University
| | - Doff B McElhinney
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University; Department of Cardiovascular Surgery, Stanford University
| | | | - Kevin P Daly
- Boston Children's Hospital, Harvard Medical School
| | | | - Kenneth Knecht
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences
| | - Marc E Richmond
- Morgan Stanley Children's Hospital, Columbia University College of Physicians & Surgeons
| | - Kimberly Y Lin
- Children's Hospital of Philadelphia, University of Pennsylvania
| | | | | | | | - Erin L Albers
- Seattle Children's Hospital, University of Washington
| | - Asma Khan
- Ann and Robert H Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | | | - Christopher S Almond
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University
| | - Sharon Chen
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University
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24
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Lorts A, Conway J, Schweiger M, Adachi I, Amdani S, Auerbach SR, Barr C, Bleiweis MS, Blume ED, Burstein DS, Cedars A, Chen S, Cousino-Hood MK, Daly KP, Danziger-Isakov LA, Dubyk N, Eastaugh L, Friedland-Little J, Gajarski R, Hasan A, Hawkins B, Jeewa A, Kindel SJ, Kogaki S, Lantz J, Law SP, Maeda K, Mathew J, May LJ, Miera O, Murray J, Niebler RA, O'Connor MJ, Özbaran M, Peng DM, Philip J, Reardon LC, Rosenthal DN, Rossano J, Salazar L, Schumacher KR, Simpson KE, Stiller B, Sutcliffe DL, Tunuguntla H, VanderPluym C, Villa C, Wearden PD, Zafar F, Zimpfer D, Zinn MD, Morales IRD, Cowger J, Buchholz H, Amodeo A. ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association. J Heart Lung Transplant 2021; 40:709-732. [PMID: 34193359 DOI: 10.1016/j.healun.2021.04.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Angela Lorts
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio.
| | | | - Martin Schweiger
- Universitäts-Kinderspitals Zürich - Herzchirurgie, Zurich, Switzerland
| | - Iki Adachi
- Texas Children's Hospital, Houston, Texas
| | | | - Scott R Auerbach
- Anschutz Medical Campus, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado
| | - Charlotte Barr
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | - Mark S Bleiweis
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | | | - Ari Cedars
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sharon Chen
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Kevin P Daly
- Boston Children's Hospital, Boston, Massachusetts
| | - Lara A Danziger-Isakov
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Nicole Dubyk
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lucas Eastaugh
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Asif Hasan
- Freeman Hospital, Newcastle upon Tyne, UK
| | - Beth Hawkins
- Boston Children's Hospital, Boston, Massachusetts
| | - Aamir Jeewa
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Steven J Kindel
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | - Jodie Lantz
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sabrina P Law
- Morgan Stanley Children's Hospital of New York Presbyterian, New York, New York
| | - Katsuhide Maeda
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Jacob Mathew
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Jenna Murray
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Robert A Niebler
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | | | - David M Peng
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joseph Philip
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | - David N Rosenthal
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Joseph Rossano
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Kurt R Schumacher
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | | | - David L Sutcliffe
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Chet Villa
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Matthew D Zinn
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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25
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Niebler RA, Amdani S, Blume B, Cantor RS, Deng L, Kirklin JK, Lorts A, Morales DL, Rosenthal DN, Ghanayem NS. Stroke in pediatric ventricular assist device patients-a pedimacs registry analysis. J Heart Lung Transplant 2021; 40:662-670. [PMID: 33824064 DOI: 10.1016/j.healun.2021.03.008] [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] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 02/19/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Cerebralvascular accidents (CVA) are common complications of pediatric ventricular assist devices (VADs). We employed the Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) to investigate rates, risk factors, and outcomes of CVA in pediatric patients supported on VAD. METHODS Analysis of Pedimacs (September 2012-June 2019) data to determine rates of all neurologic events and specifically CVA. Risk factors were determined by a multiphase parametric hazard model. Outcomes of patients with CVA were compared with patients without CVA. RESULTS We included 662 patients in our analysis. In total, 87 CVA events occurred in 71 patients (10.7%). The proportion of patients with CVA was highest in the paracorporeal pulsatile group (16.9%) followed by the paracorporeal continuous group (10.4%). However, the rate of CVA was lower in the paracorporeal pulsatile group compared to the paracorporeal continuous group (6.4 vs 11.1 events/100 patient months), which reflects differences in support duration. Ascites, higher patient profile groups, and implants within small volume centers were associated with the occurrence of CVA. Our analysis found that the recent era (i.e., June 2017), and intracorporeal continuous implants were protective. Mortality was higher in patients following a CVA diagnosis compared to those without a CVA diagnosis. CONCLUSIONS CVA continues to be a problem in pediatric VAD support, though the overall percent is now <11%. Data from the most recent era are encouraging, but CVA is still significantly associated with mortality. Future efforts should focus on pre-implant and early support periods.
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Affiliation(s)
- Robert A Niebler
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
| | - Shahnawaz Amdani
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Betsy Blume
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Ryan S Cantor
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Luqin Deng
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David N Rosenthal
- Department of Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Nancy S Ghanayem
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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26
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Adamson GT, Profita EL, Quinonez ZA, McElhinney DB, Rosenthal DN, Ma M. Alternative to heart-lung transplantation for end-stage tetralogy of Fallot with major aortopulmonary collaterals: Simultaneous heart transplantation and pulmonary artery reconstruction. J Heart Lung Transplant 2021; 40:392-394. [PMID: 33674153 DOI: 10.1016/j.healun.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Gregory T Adamson
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California.
| | - Elizabeth L Profita
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Zoel A Quinonez
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Stanford University School of Medicine, Palo Alto, California
| | - Doff B McElhinney
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California; Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Michael Ma
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Palo Alto, California
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27
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Stidham J, Feingold B, Almond CS, Burstein DS, Krack P, Price JF, Schumacher KR, Spinner JA, Rosenthal DN, Lorts A, Godown J. Establishing Baseline Metrics of Heart Failure Medication Use in Children: A Collaborative Effort from the ACTION Network. Pediatr Cardiol 2021; 42:315-323. [PMID: 33044586 DOI: 10.1007/s00246-020-02485-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
Heart failure metrics specific to the pediatric population are required to successfully implement quality improvement initiatives in children with heart failure. Medication use at the time of discharge following admission for decompensated heart failure has been identified as a potential quality metric in this population. This study aimed to report medication use at discharge in the current era for children admitted with acute decompensated heart failure. All patients < 21 years of age with an index admission (1/1/2011-12/31/2019) for acute heart failure and a coexisting diagnosis of cardiomyopathy were identified from the Pediatric Health Information System. Medication use patterns were described and compared across age groups and centers. A total of 2288 patients were identified for inclusion. An angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker (ACEi/ARB) was prescribed in 1479 (64.6%), beta blocker in 1132 (49.5%), and mineralocorticoid receptor antagonist (MRA) in 864 (37.8%) patients at discharge. The use of ACEi/ARB at discharge has decreased over time (64.6% vs. 69.6%, p = 0.001) and the use of beta blockers has increased (49.5% vs. 36.8%, p < 0.001) compared to a historical cohort (2001-2010). There is considerable variability in medication use across centers with an overall increase in beta blocker and decrease in ACEi/ARB use over time. Collaborative efforts are needed to standardize care and define quality metrics to identify best practices in the management of pediatric heart failure.
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Affiliation(s)
- Joseph Stidham
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian Feingold
- Division of Pediatric Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher S Almond
- Department of Pediatrics (Pediatric Cardiology), Stanford University, Palo Alto, CA, USA
| | - Danielle S Burstein
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Paige Krack
- Division of Pediatric Cardiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Jack F Price
- Division of Pediatric Cardiology, Texas Children's Hospital, Houston, TX, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Joseph A Spinner
- Division of Pediatric Cardiology, Texas Children's Hospital, Houston, TX, USA
| | - David N Rosenthal
- Department of Pediatrics (Pediatric Cardiology), Stanford University, Palo Alto, CA, USA
| | - Angela Lorts
- Division of Pediatric Cardiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Justin Godown
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Zafar F, Conway J, Bleiweis MS, Al-Aklabi M, Ameduri R, Barnes A, Bearl DW, Buchholz H, Church S, Do NL, Duffy V, Dykes JC, Eghtesady P, Fisher L, Friedland-Little J, Fuller S, Fynn-Thompson F, George K, Gossett JG, Griffiths ER, Griselli M, Hawkins B, Honjo O, Jeewa A, Joong A, Kindel S, Kouretas P, Lorts A, Machado D, Maeda K, Maurich A, May LJ, McConnell P, Mehegan M, Mongé M, Morales DLS, Murray J, Niebler RA, O'Connor M, Peng DM, Phelps C, Philip J, Ploutz M, Profsky M, Reichhold A, Rosenthal DN, Said AS, Schumacher KR, Si MS, Simpson KE, Sparks J, Louis JS, Steiner ME, VanderPluym C, Villa C. Berlin Heart EXCOR and ACTION post-approval surveillance study report. J Heart Lung Transplant 2021; 40:251-259. [PMID: 33579597 DOI: 10.1016/j.healun.2021.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 08/21/2020] [Revised: 01/04/2021] [Accepted: 01/14/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Berlin Heart EXCOR Pediatric (EXCOR) ventricular assist device (VAD) was introduced in North America nearly 2 decades ago. The EXCOR was approved under Humanitarian Device Exemption status in 2011 and received post-market approval (PMA) in 2017 from Food and Drug Administration. Since the initial approval, the field of pediatric mechanical circulatory support has changed, specifically with regard to available devices, anticoagulation strategies, and the types of patients supported. This report summarizes the outcomes of patients supported with EXCOR from the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry. These data were part of the PMA surveillance study (PSS) required by the Food and Drug Administration. METHODS ACTION is a learning collaborative of over 40 pediatric heart failure programs worldwide, which collects data for all VAD implantations as one of its initiatives. All patients in North America with EXCOR implants reported to ACTION from 2018 to 2020 (n = 72) who had met an outcome were included in the EXCOR PSS group. This was compared with a historical, previously reported Berlin Heart EXCOR study group (Berlin Heart study [BHS] group, n = 320, 2007‒2014). RESULTS Patients in the PSS group were younger, were smaller in weight/body surface area, were more likely to have congenital heart disease, and were less likely to receive a bi-VAD than those in the BHS group. Patients in the PSS group were less likely to be in Interagency Registry for Mechanically Assisted Circulatory Support Profile 1 and were supported for a longer duration. The primary anticoagulation therapy for 92% of patients in the PSS group was bivalirudin. Success, defined as being transplanted, being weaned for recovery, or being alive on a device at 180 days after implantation, was 86% in the PSS group compared with 76% in the BHS group. Incidence of stroke was reduced by 44% and the frequency of pump exchange by 40% in the PSS group compared with those in the BHS group. Similarly, all other adverse events, including major bleeding, were reduced in the PSS group. CONCLUSIONS The PSS data, collected through ACTION, highlight the improvement in outcomes for patients supported with EXCOR compared with the outcomes in a historical cohort. These findings may be the result of changes in patient care practices over time and collaborative learning.
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Affiliation(s)
- Farhan Zafar
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio.
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Mark S Bleiweis
- University of Florida Health Shands Children's Hospital, Gainesville, Florida
| | - Mohammed Al-Aklabi
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Rebecca Ameduri
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | | | - David W Bearl
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Holger Buchholz
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | - Nhue L Do
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Vicky Duffy
- Nationwide Children's Hospital, Columbus, Ohio
| | - John C Dykes
- Lucile Packard Children's Hospital Stanford, Stanford Children's Health, Palo Alto, California
| | | | | | | | | | | | - Kristen George
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Massimo Griselli
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | - Beth Hawkins
- Boston Children's Hospital, Boston, Massachusetts
| | - Osami Honjo
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aamir Jeewa
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anna Joong
- Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Steven Kindel
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Peter Kouretas
- UCSF Benioff Children's Hospital, San Francisco, California
| | - Angela Lorts
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Desiree Machado
- University of Florida Health Shands Children's Hospital, Gainesville, Florida
| | - Katsuhide Maeda
- Lucile Packard Children's Hospital Stanford, Stanford Children's Health, Palo Alto, California
| | - Andrea Maurich
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Mary Mehegan
- St. Louis Children's Hospital, St. Louis, Missouri
| | - Michael Mongé
- Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - David L S Morales
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Jenna Murray
- Lucile Packard Children's Hospital Stanford, Stanford Children's Health, Palo Alto, California
| | - Robert A Niebler
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | | | - David M Peng
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | - Joseph Philip
- University of Florida Health Shands Children's Hospital, Gainesville, Florida
| | | | | | | | - David N Rosenthal
- Lucile Packard Children's Hospital Stanford, Stanford Children's Health, Palo Alto, California
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Kurt R Schumacher
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Ming-Sing Si
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Kathleen E Simpson
- Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Jim St Louis
- Children's Mercy Kansas City, Kansas City, Missouri
| | - Marie E Steiner
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | | | - Chet Villa
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
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Almond CS, Chen S, Dykes JC, Kwong J, Burstein DS, Rosenthal DN, Kipps AK, Teuteberg J, Murray JM, Kaufman BD, Hollander SA, Profita E, Yarlagadda VY, Sacks LD, Chen CY. The Stanford acute heart failure symptom score for patients hospitalized with heart failure. J Heart Lung Transplant 2020; 39:1250-1259. [DOI: 10.1016/j.healun.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/24/2020] [Accepted: 08/02/2020] [Indexed: 11/17/2022] Open
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Hollander SA, Nandi D, Bansal N, Godown J, Zafar F, Rosenthal DN, Lorts A, Jeewa A. A coordinated approach to improving pediatric heart transplant waitlist outcomes: A summary of the ACTION November 2019 waitlist outcomes committee meeting. Pediatr Transplant 2020; 24:e13862. [PMID: 32985785 DOI: 10.1111/petr.13862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 06/24/2020] [Revised: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
The number of children needing heart transplantation continues to rise. Although improvements in heart failure therapy, particularly durable mechanical support, have reduced waitlist mortality, the number of children who die while waiting for a suitable donor organ remains unacceptably high. Roughly, 13% of children and 25% of infants on the heart transplant waitlist will not survive to transplantation. With this in mind, the Advanced Cardiac Therapies Improving Outcomes Collaborative Learning Network (ACTION), through its Waitlist Outcomes Committee, convened a 2-day symposium in Ann Arbor, Michigan, from 2-3 November 2019, to better understand the factors that contribute to pediatric heart transplant waitlist mortality and to focus future efforts on improving the organ allocation rates for children needing heart transplantation. Using improvement science methodology, the heart failure-transplant trajectory was broken down into six key steps, after which modes of failure and opportunities for improvement at each step were discussed. As a result, several projects aimed at reducing waitlist mortality were initiated.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Deipanjan Nandi
- Division of Pediatrics (Cardiology), Nationwide Children's Hospital, Columbus, OH, USA
| | - Neha Bansal
- Division of Pediatrics Cardiology, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Justin Godown
- Department of Pediatrics (Cardiology), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Aamir Jeewa
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, USA
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Knoll C, Kaufman B, Chen S, Murray J, Cohen H, Sourkes BM, Rosenthal DN, Hollander SA. Palliative Care Engagement for Pediatric Ventricular Assist Device Patients: A Single-Center Experience. ASAIO J 2020; 66:929-932. [PMID: 32740354 DOI: 10.1097/mat.0000000000001092] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 01/07/2023] Open
Abstract
Outcomes in pediatric patients with ventricular assist devices (VADs) for advanced heart failure (HF) are improving, but the risk of associated morbidity and mortality remains substantial. Few data exist on the involvement of pediatric palliative care (PPC) in this high-risk patient population. We aimed to characterize the extent of palliative care involvement in the care of patients requiring VAD placement at our institution. Single-center retrospective chart review analyzing all VAD patients at a large pediatric center over a 4 year period. Timing and extent of palliative care subspecialty involvement were analyzed. Between January 2014 and December 2017, 55 HF patients underwent VAD implantation at our institution. Pediatric palliative care utilization steadily increased over consecutive years (2014: <10% of patients, 2015: 20% of patients, 2016: 50% of patients, and 2017: 65% of patients) and occurred in 42% (n = 23) of all patients. Of these, 57% (n = 13) occurred before VAD placement while 43% (n = 10) occurred after implantation. Patients who died during their VAD implant hospitalization (24%, n = 13) were nearly twice as likely to have PPC involvement (62%) as those who reached transplant (38%). Of those who died, patients who had PPC involved in their care were more likely to limit resuscitation efforts before their death. Four patients had advanced directives in place before VAD implant, of which three had PPC consultation before device placement. Three families (5%) refused PPC involvement when offered. Pediatric palliative care utilization is increasing in VAD patients at our institution. Early PPC involvement occurred in the majority of patients and appears to lead to more frequent discussion of goals-of-care and advanced directives.
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Affiliation(s)
- Christopher Knoll
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Beth Kaufman
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Sharon Chen
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Jenna Murray
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Harvey Cohen
- Division of Hematology/Oncology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Barbara M Sourkes
- Division of Pediatric Critical Care, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - David N Rosenthal
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Seth A Hollander
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
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Hollander SA, Ogawa MT, Hopper RK, Liu E, Chen S, Rosenthal DN, Feinstein JA. Treprostinil improves hemodynamics and symptoms in children with mild pulmonary hypertension awaiting heart transplantation. Pediatr Transplant 2020; 24:e13742. [PMID: 32428328 DOI: 10.1111/petr.13742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Received: 01/16/2020] [Revised: 03/05/2020] [Accepted: 04/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Treprostinil, a prostacyclin analog, is a safe and effective therapy for children with PAH; however, the use of this agent in children with mild PVR elevations related to HF, including those with SV congenital heart disease awaiting HT, is understudied. We describe the hemodynamic and symptomatic changes in pediatric patients awaiting HT treated with treprostinil. METHODS Single-center retrospective review of all patients was listed for HT who received treprostinil during the listing period. Changes in hemodynamic and functional indices between the baseline catheterization (prior to drug initiation), and prior to HT, and patient outcomes were analyzed. RESULTS Among 16/17 (94%) who survived to HT, 8 (50%) were female, and 10 (63%) had SV physiology. The median age at drug initiation was 9 (IQR: 1, 14) years. The median duration of therapy prior to HT was 253 (IQR: 148, 504) days. Treprostinil significantly decreased PVR (3.8 vs 3.1 WU, P = .03), while mLA or mPCW pressure did not change (11 vs 13 mm Hg, P = .9). HF symptoms improved in 9/15 (60%) patients without VAD support prior to drug initiation, including 4/10 (40%) who did not receive a VAD any point while awaiting HT. CONCLUSIONS Treprostinil may be used safely in patients with mild PAH awaiting HT, including those with SV disease. PVR falls without substantial increases in mLA/mPCW pressure. HF symptoms improve in some patients.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Michelle T Ogawa
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Rachel K Hopper
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Esther Liu
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Sharon Chen
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
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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
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Gossett JG, Amdani S, Khulbey S, Punnoose AR, Rosenthal DN, Smith J, Smits J, Dipchand AI, Kirk R, Miera O, Davies RR. Review of interactions between high-risk pediatric heart transplant recipients and marginal donors including utilization of risk score models. Pediatr Transplant 2020; 24:e13665. [PMID: 32198806 DOI: 10.1111/petr.13665] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Received: 11/29/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Donor organ acceptance practices vary among pediatric heart transplant professionals. We sought to understand what is known about the interactions between the "high-risk" recipient and the "marginal donor," and how donor risk scores can impact this discussion. METHODS A systematic review of published literature on pediatric HTx was undertaken with the assistance of a medical librarian. Two authors independently assessed search results, and papers were reviewed for inclusion. RESULTS We found that there are a large number of individual factors, and clusters of factors, that have been used to label individual recipients "high-risk" and individual donors "marginal." The terms "high-risk recipient" and "marginal donor" have been used broadly in the literature making it virtually impossible to make comparisons between publications. In general, the data support that patients who could be easily agreed to be "sicker recipients" are at more risk compared to those who are clearly "healthier," albeit still "sick enough" to need transplantation. Given this variability in the literature, we were unable to define how being a "high-risk" recipient interplays with accepting a "marginal donor." Existing risk scores are described, but none were felt to adequately predict outcomes from factors available at the time of offer acceptance. CONCLUSIONS We could not determine what makes a donor "marginal," a recipient "high-risk," or how these factors interplay within the specific recipient-donor pair to determine outcomes. Until there are better risk scores predicting outcomes at the time of organ acceptance, programs should continue to evaluate each organ and recipient individually.
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Affiliation(s)
- Jeffrey G Gossett
- University of California Benioff Children's Hospitals, San Francisco, CA, USA
| | | | | | | | | | | | - Jacqueline Smits
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Richard Kirk
- Division of Pediatric Cardiology, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Oliver Miera
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum, Berlin, Germany
| | - Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Butler A, Chapman G, Johnson JN, Amodeo A, Böhmer J, Camino M, Davies RR, Dipchand AI, Godown J, Miera O, Pérez-Blanco A, Rosenthal DN, Zangwill S, Kirk R. Behavioral economics-A framework for donor organ decision-making in pediatric heart transplantation. Pediatr Transplant 2020; 24:e13655. [PMID: 31985140 DOI: 10.1111/petr.13655] [Citation(s) in RCA: 9] [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: 11/30/2019] [Accepted: 12/09/2019] [Indexed: 12/18/2022]
Abstract
The high discard rate of pediatric donor hearts presents a major challenge for children awaiting heart transplantation. Recent literature identifies several factors that contribute to the disparities in pediatric donor heart usage, including regulatory oversight, the absence of guidelines on pediatric donor heart acceptance, and variation among transplant programs. However, a likely additional contributor to this issue are the behavioral factors influencing transplant team decisions in donor offer scenarios, a topic that has not yet been studied in detail. Behavioral economics and decision psychology provide an excellent foundation for investigating decision-making in the pediatric transplant setting, offering key insights into the behavior of transplant professionals. We conducted a systematic review of published literature in pediatric heart transplant related to behavioral economics and the psychology of decision-making. In this review, we draw on paradigms from these two domains in order to examine how existing aspects of the transplant environment, including regulatory oversight, programmatic variation, and allocation systems, may precipitate potential biases surrounding donor offer decisions. Recognizing how human decision behavior influences donor acceptance is a first step toward improving utilization of potentially viable pediatric donor hearts.
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Affiliation(s)
| | | | | | | | - Jens Böhmer
- The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA
| | - Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Justin Godown
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oliver Miera
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum, Berlin, Germany
| | | | | | | | - Richard Kirk
- Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA
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Chubb H, Rosenthal DN, Almond CS, Ceresnak SR, Motonaga KS, Arunamata AA, Long J, Trela AV, Hanisch D, McElhinney DB, Dubin AM. Impact of Cardiac Resynchronization Therapy on Heart Transplant-Free Survival in Pediatric and Congenital Heart Disease Patients. Circ Arrhythm Electrophysiol 2020; 13:e007925. [PMID: 32202126 DOI: 10.1161/circep.119.007925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 11/16/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) studies in pediatric or congenital heart disease patients have shown an improvement in ejection fraction and heart failure symptoms. However, a survival benefit of CRT in this population has not been established. This study aimed to evaluate the impact of CRT upon heart transplant-free survival in pediatric and congenital heart disease patients, using a propensity score-matched (PSM) analysis. METHODS This single-center study compared CRT patients (implant date, 2004-2017) and controls, matched by 1:1 PSM using 21 comprehensive baseline indices for risk stratification. CRT patients were <21 years of age or had congenital heart disease, had systemic ventricular ejection fraction <45%, symptomatic heart failure, and had significant electrical dyssynchrony, all before CRT implant. Controls were screened from nonselective imaging and ECG databases. Controls were retrospectively enrolled when they achieved the same inclusion criteria at an outpatient clinical encounter, within the same time period. RESULTS Of 133 patients who received CRT during the study period, 84 met all study inclusion criteria. One hundred thirty-three controls met all criteria at an outpatient encounter. Following PSM, 63 matched CRT-control pairs were identified with no significant difference between groups across all baseline indices. Heart transplant or death occurred in 12 (19%) PSM-CRT subjects and 37 (59%) PSM-controls with a median follow-up of 2.7 years (quartiles, 0.8-6.1 years). CRT was associated with markedly reduced risk of heart transplant or death (hazard ratio, 0.24 [95% CI, 0.12-0.46]; P<0.001). There was no CRT procedural mortality and 1 system infection at 54 months post-implant. CONCLUSIONS In pediatric and congenital heart disease patients with symptomatic systolic heart failure and electrical dyssynchrony, CRT was associated with improved heart transplant-free survival. Visual Overview: A visual overview is available for this article.
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Affiliation(s)
- Henry Chubb
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA.,Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery (H.C., D.B.M.), Stanford University, CA
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Christopher S Almond
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Scott R Ceresnak
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Kara S Motonaga
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Alisa A Arunamata
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Jin Long
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Anthony V Trela
- Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford, Palo Alto, CA (A.V.T., D.H.)
| | - Debra Hanisch
- Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford, Palo Alto, CA (A.V.T., D.H.)
| | - Doff B McElhinney
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA.,Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery (H.C., D.B.M.), Stanford University, CA
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
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Ahmed H, Chen S, Yarlagadda V, Almond C, Murray J, Rosenthal DN, Ma M, Dykes J, Maeda K. RAPID AORTIC HOMOGRAFT DEGENERATION AND VAD SUPPORT IN A NEONATE WITH SINGLE VENTRICLE HEART DISEASE. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)33492-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Dykes J, Ahmed H, Power A, Murray J, Chen CY, Chen S, Rosenthal DN, Maeda K, Almond C. RECENT TRENDS IN RIGHT HEART MECHANICAL SUPPORT STRATEGIES IN CHILDREN REQUIRING LVAD SUPPORT. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31679-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Power A, Schultz L, Dennis K, Rizzuto S, Hollander AM, Rosenthal DN, Almond CS, Hollander SA. Growth stunting in single ventricle patients after heart transplantation. Pediatr Transplant 2020; 24:e13634. [PMID: 31845499 DOI: 10.1111/petr.13634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 08/16/2019] [Revised: 10/09/2019] [Accepted: 11/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Malnutrition is common among children with single ventricle (SV) congenital heart disease (CHD). The impact of heart transplantation (HT) on nutritional status in SV patients is understudied. Our aim was to evaluate anthropometric changes in SV patients after HT, compared with those transplanted for cardiomyopathy (CM). METHODS We performed a single-center retrospective chart review of SV and CM patients < 18 years who underwent HT from January 01, 2010 to December 05, 2017. Wasting and stunting were defined as z-scores for weight-for-age or height-for-age ≤-2, respectively. Changes in these indices between HT and 3 years post-HT were analyzed. RESULTS Of 86 eligible patients, 28 (33%) had SV CHD and 58 (67%) had CM. Data were available at 3 years post-HT for 57 patients. At transplant, wasting was equally present in SV versus CM patients (7/28, 25% vs. 9/58, 16%, P = .22), which remained true at 3 years post-HT (2/16, 13% vs. 3/41, 7%, P = .61). At transplant, stunting was more common in SV than CM patients (17/28, 61% vs. 8/58, 14%, P < .001). At 3 years post-HT, 6 of 16 (38%) SV patients and 3 of 41 (7%) CM patients remained stunted (P = .01). Among all patients, wasting decreased from transplant to end-point (19% vs. 9%, P = .05), but stunting did not (29% vs. 16%, P = .2), such that wasting and stunting were associated at transplant (P < .001) but not at end-point (P = .17). CONCLUSIONS Longitudinal growth remains impaired for several years after HT in SV patients, even when weight gain is achieved, suggesting that some factors contributing to growth impairment persist despite resolution of SV physiology.
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Affiliation(s)
- Alyssa Power
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Lisa Schultz
- Nutrition Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Katelin Dennis
- Nutrition Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Sandra Rizzuto
- Rehabilitation Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Amanda M Hollander
- Rehabilitation Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | | | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
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Wilkens SJ, Priest J, Kaufman BD, Barkoff L, Rosenthal DN, Hollander SA. Pediatric waitlist and heart transplant outcomes in patients with syndromic anomalies. Pediatr Transplant 2020; 24:e13643. [PMID: 31891211 DOI: 10.1111/petr.13643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 06/25/2019] [Revised: 09/11/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE We sought to determine whether the presence of a systemic SA with potential complicating factors affects waitlist and post-HT outcomes in pediatric patients. METHODS This is a single-center retrospective review of pediatric patients listed for HT between January 1, 2009, and July 1, 2018. Patients were selected based on the presence of any underlying syndromes, which included chromosomal anomalies, skeletal myopathies, connective tissue disorders, mitochondrial disease,and other systemic disorders. Waitlist and post-HT outcomes were compared to those without SA. RESULTS A total of 243 patients were listed for HT, of which 21 (9%) patients had associated SA. Of those, 16 (76%) survived to transplant, 3 (14%) died while on the waitlist, 1 (5%) improved and was removed from the waitlist, and 1 (5%) patient is currently listed. Waitlist survival was not different between those with/without an associated syndrome (P = 1.0). Among those who survived to HT, there was no difference in listing days (70 vs 90, P = .8), survival to hospital discharge [14 (93%) vs 150 (95%), P = .6], post-HT intubation days (2 vs 2 days, P = .6), or post-HT hospital length of stay (18 vs 18 days, P = .8). Overall survival during the study period post-HT was not different between groups (P = .8). CONCLUSION A SA was present in 9% of pediatric patients wait-listed for HT, but was not associated with an increased waitlist mortality or post-HT hospital morbidity or long-term survival. For several anomalies, HT is safe and feasible.
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Affiliation(s)
- Sarah J Wilkens
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - James Priest
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Beth D Kaufman
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Lynsey Barkoff
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - David N Rosenthal
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Seth A Hollander
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
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Chen AC, Ramirez FD, Rosenthal DN, Couch SC, Berry S, Stauffer KJ, Brabender J, McDonald N, Lee D, Barkoff L, Nourse SE, Kazmucha J, Wang CJ, Olson I, Selamet Tierney ES. Healthy Hearts via Live Videoconferencing: An Exercise and Diet Intervention in Pediatric Heart Transplant Recipients. J Am Heart Assoc 2020; 9:e013816. [PMID: 31973598 PMCID: PMC7033874 DOI: 10.1161/jaha.119.013816] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Pediatric heart transplant recipients have high‐risk cardiovascular profiles that can affect their long‐term outcomes; however, promoting exercise and healthy diet has not been a major focus in the field. The objective of this study was to test the feasibility and impact of a supervised exercise and diet intervention delivered via live videoconferencing in this population. Methods and Results Patients 8 to 19 years of age at least 1 year post heart transplantation were enrolled. The 12‐ to 16‐week intervention phase included live video–supervised exercise (×3/week) and nutrition (×1/week) sessions. The 12‐ to 16‐week maintenance phase included ×1/week live video–supervised exercise and nutrition sessions and ×2/week self‐directed exercise sessions. Cardiac, vascular, nutritional, and functional health indices were obtained at baseline, after intervention, and after maintenance. Fourteen patients (median age, 15.2; interquartile range, 14.3–16.7 years) at a median of 3.3 (interquartile range, 1.5–9.7) years after heart transplant completed the intervention. Patients attended 89.6±11% of exercise and 88.4±10% of nutrition sessions during the intervention and 93.4±11% of exercise and 92.3±11% of nutrition sessions during maintenance. After intervention, body mass index percentile (median, −27%; P=0.02), endothelial function (median, +0.29; P=0.04), maximum oxygen consumption (median, +2 mL/kg per minute; P=0.002). Functional Movement Screening total score (median, +2.5; P=0.002) and daily consumption of saturated fat (median, −6 g; P=0.02) improved significantly. After maintenance, improvements in maximum oxygen consumption (median, +3.2 mL/kg per minute; P=0.02) and Functional Movement Screening total score (median, +5; P=0.002) were sustained. Conclusions In pediatric heart transplant recipients, a live video–supervised exercise and diet intervention is feasible. Our results demonstrate excellent adherence with significant improvements in cardiovascular and functional health. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02519946.
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Affiliation(s)
- Angela C Chen
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | | | - David N Rosenthal
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | - Sarah C Couch
- Department of Rehabilitation, Exercise and Nutrition Sciences University of Cincinnati Medical Center Cincinnati OH
| | | | - Katie J Stauffer
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | - Jerrid Brabender
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | - Nancy McDonald
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | - Donna Lee
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | - Lynsey Barkoff
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | - Susan E Nourse
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | - Jeffrey Kazmucha
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | - C Jason Wang
- Division of General Pediatrics, and Center for Policy, Outcomes and Prevention Stanford University Palo Alto CA
| | - Inger Olson
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
| | - Elif Seda Selamet Tierney
- Division of Pediatric Cardiology Department of Pediatrics Stanford University Medical Center Palo Alto CA
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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.
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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
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 392] [Impact Index Per Article: 78.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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Knoll C, Chen S, Murray JM, Dykes JC, Yarlagadda VV, Rosenthal DN, Almond CS, Maeda K, Shin AY. A Quality Bundle to Support High-Risk Pediatric Ventricular Assist Device Implantation. Pediatr Cardiol 2019; 40:1159-1164. [PMID: 31087144 DOI: 10.1007/s00246-019-02123-1] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/03/2019] [Indexed: 11/27/2022]
Abstract
Pediatric ventricular assist device (VAD) implantation outcomes are increasingly promising for children with dilated cardiomyopathy and advanced decompensated heart failure (ADHF). VAD placement in patients with clinical features such as complex congenital cardiac anatomy, small body size, or major comorbidities remains problematic. These comorbidities have been traditionally prohibitive for VAD consideration leaving these children as a treatment-orphaned population. Here we describe the quality bundle surrounding these patients with ADHF considered high risk for VAD implantation at our institution. Over a 7-year period, a quality bundle aimed at the peri-operative care for children with high-risk features undergoing VAD implantation was incrementally implemented at a tertiary children's hospital. Patients were considered high risk if they were neonates (< 30 days), had single-ventricle physiology, non-dilated cardiomyopathy, biventricular dysfunction, or significant comorbidities. The quality improvement bundle evolved to include (1) structured team-based peri-operative evaluation, (2) weekly VAD rounds addressing post-operative device performance, (3) standardized anticoagulation strategies, and (4) a multidisciplinary system for management challenges. These measures aimed to improve communication, standardize management, allow for ongoing process improvement, and incorporate principles of a high-reliability organization. Between January 2010 and December 2017, 98 patients underwent VAD implantation, 48 (49%) of which had high-risk comorbidities and a resultant cohort survival-to-transplant rate of 65%. We report on the evolution of a quality improvement program to expand the scope of VAD implantation to patients with high-risk clinical profiles. This quality bundle can serve as a template for future large-scale collaborations to improve outcomes in these treatment-orphaned subgroups.
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Affiliation(s)
- Christopher Knoll
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
| | - Sharon Chen
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Jenna M Murray
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - John C Dykes
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Vamsi V Yarlagadda
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - David N Rosenthal
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Christopher S Almond
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Andrew Y Shin
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
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45
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May LJ, Liu X, Tesoro T, Yang J, Lo C, Chen S, Murray J, Rosenthal DN, Massicotte P, Michelson AD, Almond CS. Usefulness of anti-platelet therapy testing in children supported with a ventricular assist device. J Heart Lung Transplant 2019; 38:781-783. [DOI: 10.1016/j.healun.2019.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 03/30/2019] [Accepted: 03/30/2019] [Indexed: 11/16/2022] Open
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Kaufman BD, Hollander SA, Zhang Y, Chen S, Bernstein D, Rosenthal DN, Almond CS, Murray JM, Burgart AM, Cohen HJ, Kirkpatrick JN, Blume ED. Compassionate deactivation of ventricular assist devices in children: A survey of pediatric ventricular assist device clinicians' perspectives and practices. Pediatr Transplant 2019; 23:e13359. [PMID: 30734422 DOI: 10.1111/petr.13359] [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] [Received: 08/30/2018] [Revised: 11/29/2018] [Accepted: 01/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study's objective was to investigate compassionate ventricular assist device deactivation (VADdeact) in children from the perspective of the pediatric heart failure provider. BACKGROUND Pediatric VAD use is a standard therapy for advanced heart failure. Serious adverse events may affect relative benefit of continued support, leading to consideration of VADdeact. Perspectives and practices regarding VADdeact have been studied in adults but not in children. METHODS A web-based anonymous survey of clinicians for pediatric VAD patients (<18 years) was sent to list-serves for the ISHLT Pediatric Council, the International Consortium of Circulatory Assist Clinicians Pediatric Taskforce, and the Pediatric Cardiac Intensivist Society. RESULTS A total of 106 respondents met inclusion criteria of caring for pediatric VAD patients. Annual VAD volume per clinician ranged from <4 (33%) to >9 (20%). Seventy percent of respondents had performed VADdeact of a child. Response varied to VADdeact requests by parent or patient and was influenced by professional degree and region of practice. Except for the scenario of intractable suffering, no consensus on VADdeact appropriateness was reported. Age of child thought capable of making informed requests for VADdeact varied by subspecialty. The majority of respondents (62%) do not feel fully informed of relevant legal issues; 84% reported that professional society supported guidelines for VADdeact in children had utility. CONCLUSION There is limited consensus regarding indications for VADdeact in children reported by pediatric VAD provider survey respondents. Knowledge gaps related to legal issues are evident; therefore, professional guidelines and educational resources related to pediatric VADdeact are needed.
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Affiliation(s)
- Beth D Kaufman
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Yulin Zhang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sharon Chen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Daniel Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Christopher S Almond
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jenna M Murray
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Alyssa M Burgart
- Anesthesiology, Perioperative and Pain Medicine, Stanford Center for Biomedical Ethics, Stanford University, Palo Alto, California
| | - Harvey J Cohen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - James N Kirkpatrick
- Division of Cardiology, Department of Bioethics and Humanities, University of Washington Medical Center, Seattle, Washington
| | - Elizabeth D Blume
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
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Vaikunth SS, Concepcion W, Daugherty T, Fowler M, Lutchman G, Maeda K, Rosenthal DN, Teuteberg J, Woo YJ, Lui GK. Short-term outcomes of en bloc combined heart and liver transplantation in the failing Fontan. Clin Transplant 2019; 33:e13540. [PMID: 30891780 DOI: 10.1111/ctr.13540] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [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: 11/13/2018] [Revised: 03/09/2019] [Accepted: 03/15/2019] [Indexed: 12/18/2022]
Abstract
Patients with failing Fontan physiology and liver cirrhosis are being considered for combined heart and liver transplantation. We performed a retrospective review of our experience with en bloc combined heart and liver transplantation in Fontan patients > 10 years old from 2006 to 18 per Institutional Review Board approval. Six females and 3 males (median age 20.7, range 14.2-41.3 years) underwent en bloc combined heart and liver transplantation. Indications for heart transplant included ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, and/or lymphatic abnormalities. Indication for liver transplant included portal hypertension and cirrhosis. Median Fontan/single ventricular end-diastolic pressure was 18/12 mm Hg, respectively. Median Model for End-Stage Liver Disease excluding International Normalized Ratio score was 10 (7-26), eight patients had a varices, ascites, splenomegaly, thrombocytopenia score of ≥ 2, and all patients had cirrhosis. Median cardiopulmonary bypass and donor ischemic times were 262 (178-307) and 287 (227-396) minutes, respectively. Median intensive care and hospital stay were 19 (5-96) and 29 (13-197) days, respectively. Survival was 100%, and rejection was 0% at 30 days and 1 year post-transplant. En bloc combined heart and liver transplantation is an acceptable treatment in the failing Fontan patient with liver cirrhosis.
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Waldo Concepcion
- Department of Transplant Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Tami Daugherty
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California
| | - Michael Fowler
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Glen Lutchman
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Teuteberg
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - George K Lui
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California.,Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
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Morales DL, Rossano JW, VanderPluym C, Lorts A, Cantor R, St. Louis JD, Koeh D, Sutcliffe DL, Adachi I, Kirklin JK, Rosenthal DN, Blume ED. Third Annual Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report: Preimplant Characteristics and Outcomes. Ann Thorac Surg 2019; 107:993-1004. [DOI: 10.1016/j.athoracsur.2019.01.038] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/25/2019] [Indexed: 12/11/2022]
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Hollander SA, Schultz LM, Dennis K, Hollander AM, Rizzuto S, Murray JM, Rosenthal DN, Almond CS. Impact of ventricular assist device implantation on the nutritional status of children awaiting heart transplantation. Pediatr Transplant 2019; 23:e13351. [PMID: 30628144 DOI: 10.1111/petr.13351] [Citation(s) in RCA: 15] [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: 10/24/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Malnutrition is common in pediatric heart failure and is associated with mortality. The effect of VAD support on malnutrition in children is unknown. We sought to compare the prevalence and severity of malnutrition at HT in children on VAD support vs OMT to inform decisions regarding support strategies. METHODS Retrospective chart review involving all patients <18 years who underwent HT at Stanford between 1/1/2011 and 3/1/2018. Malnutrition diagnosis and severity were defined by ASPEN guidelines using the lowest age-adjusted z-score for weight (WAZ), height (HAZ), and BMI (BMIZ) when the patient was euvolemic. Changes in z-scores from baseline to HT and across groups were analyzed. RESULTS A total of 104 patients (52 in each group) were included. Among all patients, WAZ (-0.9 vs 0.3, P < 0.001) and BMIZ (0 vs 0.6, P < 0.001) improved while HAZ (-0.9 vs -0.9, P = 0.4) did not. Compared to children on OMT, children on VAD experienced greater increases in WAZ (0.8 vs 0.3, P < 0.001) and BMIZ (0.7 vs 0.2, P < 0.003) at HT. The prevalence of moderate-to-severe malnutrition decreased in VAD patients (40% to 19%, P < 0.001) and increased in OMT patients (37% to 46%, P < 0.001), leading to a lower prevalence of moderate-to-severe malnutrition at HT (19% vs 46%, P = 0.003). CONCLUSIONS Malnutrition is common in pediatric HT candidates. Compared to children on OMT, children on VAD support had greater improvement in nutritional status while awaiting HT, and a lower prevalence of malnutrition at HT.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Lisa M Schultz
- Nutrition Services, Lucile Packard Children's Hospital, Stanford, California
| | - Katelin Dennis
- Nutrition Services, Lucile Packard Children's Hospital, Stanford, California
| | - Amanda M Hollander
- Rehabilitation Services, Lucile Packard Children's Hospital, Stanford, California
| | - Sandra Rizzuto
- Rehabilitation Services, Lucile Packard Children's Hospital, Stanford, California
| | - Jenna M Murray
- Solid Organ Transplant Services, Lucile Packard Children's Hospital, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Christopher S Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
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Oren D, Chau P, Manning M, Kwong J, Kaufman BD, Maeda K, Rosenthal DN, Hollander SA. Heart transplantation in two adolescents with Danon disease. Pediatr Transplant 2019; 23:e13335. [PMID: 30536852 DOI: 10.1111/petr.13335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 08/08/2018] [Revised: 10/24/2018] [Accepted: 11/08/2018] [Indexed: 12/01/2022]
Abstract
Danon disease (DD) is an X-linked dominant disorder caused by a mutation in the lysosomal-associated membrane protein-2 (LAMP-2) gene coding for the LAMP-2 protein. We report two cases of successful heart transplantation (HT) in adolescent brothers with DD, including one who was bridged to HT for 34 days with a HeartWare left ventricular assist device. In both patients, the post-transplant course was complicated by profound skeletal muscle weakness that resolved with corticosteroid withdrawal. These cases highlight that both HT and ventricular assist device support are feasible in patients with DD. Corticosteroid use may exacerbate skeletal myopathy, and therefore, steroid minimization may be warranted whenever possible.
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Affiliation(s)
- Daniel Oren
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Peter Chau
- Department of Pediatrics (Cardiology), Loma Linda Medical Center, Loma Linda, California
| | - Melanie Manning
- Department of Pediatrics (Medical Genetics) and Pathology, Stanford University Medical Center, Stanford University, Stanford, California
| | - Joann Kwong
- Rehabilitation Services, Lucile Packard Children's Hospital, Stanford, California
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Stanford University, Stanford, California
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Stanford University, Stanford, California
| | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Stanford University, Stanford, California
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