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Bravo-Jaimes K, Vasquez-Loarte T, Rojas-Camayo J, Medina M, Mejia CR, Zapata-Galarza H, Berrocal M, Orozco J, Lozano D, Santivañez M, Sangay C, Rosales W, Mamani L, Macedo N, Coronado J, Huaman G, Marquez R, Li Z, Masood KM, Alejos J, Reardon L, Lin J. A new algorithm DEtectS critical Congenital Heart Disease at different altitudes: ANDES-CHD study. J Perinatol 2024; 44:373-378. [PMID: 38308011 DOI: 10.1038/s41372-024-01888-5] [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: 10/19/2023] [Revised: 01/12/2024] [Accepted: 01/18/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Neonatal pulse oximetry screening (POS) algorithms for critical congenital heart disease (CCHD) have contributed towards decreasing neonatal mortality but cannot be applied at high altitudes. New POS algorithms at high altitudes are needed. METHODS This observational, prospective study included newborns born at different altitudes from 0 to 4380 meters above the sea level in Peru. Healthy newborns underwent neonatal preductal and postductal oximetry, echocardiography and telephonic follow-up up to 12 months of age. Newborns with CCHD underwent preductal and postductal oximetry at the time of telemedicine evaluation while located at the high-altitude hospital where they were born, and their diagnoses were confirmed with echocardiography locally or after arriving to the referral center. Two new algorithms were designed using clinically accepted neonatal oximetry cutoffs or the 5th and 10th percentiles for preductal and postductal oximetry values. RESULTS A total of 502 healthy newborns and 15 newborns with CCHD were enrolled. Echocardiography and telephonic follow-up were completed in 227 (45%) and 330 healthy newborns (65%), respectively. The algorithm based on clinically accepted cutoffs had a sensitivity of 92%, specificity of 73% and false positive rate of 27% The algorithm based on the 5th and 10th percentiles had a sensitivity of 80%, specificity of 88% and false positive rate of 12%. CONCLUSIONS Two algorithms that detect CCHD at different altitudes had adequate performance but high false positive rates.
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Affiliation(s)
- Katia Bravo-Jaimes
- Department of Cardiovascular Medicine. Mayo Clinic, Jacksonville, FL, USA.
| | | | | | - Monica Medina
- Instituto Nacional de Salud del Niño de San Borja, Lima, Peru
| | | | | | | | | | | | | | | | | | | | | | - Joel Coronado
- Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Gian Huaman
- Instituto Nacional Cardiovascular, Lima, Peru
| | | | - Zhuo Li
- Department of Cardiovascular Medicine. Mayo Clinic, Jacksonville, FL, USA
| | - Kiran M Masood
- Department of Pediatrics, University of California, Los Angeles, CA, USA
| | - Juan Alejos
- Department of Pediatrics, Mattel Children´s Hospital, California, CA, USA
| | - Leigh Reardon
- Department of Pediatrics, Mattel Children´s Hospital, California, CA, USA
- Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, CA, USA
| | - Jeannette Lin
- Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, CA, USA
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Raymundo S, Wilhalme H, Chaudhary A, Karunungan K, Alejos J, Srivastava N. Pediatric risk to orthotopic heart transplant (PRO) score: Insights from United Network for Organ Sharing (UNOS) waitlist mortality findings. Pediatr Transplant 2023; 27:e14525. [PMID: 37439081 PMCID: PMC10524703 DOI: 10.1111/petr.14525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Pediatric heart transplant candidates on the waitlist have the highest mortality rate among all solid organ transplants. A risk score incorporating a candidate's individual risk factors may better predict mortality on the waitlist and optimize organ allocation to the sickest of those awaiting transplant. METHODS Using the United Network for Organ Sharing (UNOS) database, we evaluated a total of 5542 patients aged 0-18 years old on the waitlist for a single, first time, heart transplant from January 2010 to June 2019. We performed a univariate analysis on two-thirds (N = 3705) of these patients to derive the factors most associated with waitlist mortality or delisting secondary to deterioration within 1 year. Those with a p <0.2 underwent a multivariate analysis and the resulting factors were used to build a prediction model using the Fine-Grey model analysis. This predictive scoring model was then validated on the remaining one-third of the patients (N = 1852). RESULTS The Pediatric Risk to OHT (PRO) scoring model utilizes the following unique patient variables: blood type, diagnosis of congenital heart disease, weight, presence of ventilator support, presence of inotropic support, extracorporeal membrane oxygenation (ecmo) status, creatinine level, and region. A higher score indicates an increased risk of mortality. The PRO score had a predictive strength of 0.762 as measured by area under the ROC curve at 1 year. CONCLUSION The PRO score is an improved predictive model with the potential to better assess mortality for patients awaiting heart transplant.
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Affiliation(s)
| | - Holly Wilhalme
- University of California Los Angeles Department of Medicine Statistics Core
| | | | | | - Juan Alejos
- University of California Los Angeles Mattel Children’s Hospital
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3
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Lim MJ, Sim MS, Pan S, Alejos J, Federman M. Early Postoperative Volume Overload is a Predictor of 1-Year Post-Transplant Mortality in Pediatric Heart Transplant Recipients. Pediatr Cardiol 2023; 44:1014-1022. [PMID: 36949208 PMCID: PMC10224821 DOI: 10.1007/s00246-023-03134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/20/2023] [Indexed: 03/24/2023]
Abstract
Fluid restriction and diuretic management are mainstays in the postoperative management of cardiac patients, at risk of volume overload and its deleterious effects on primary cardiac function and multi-organ systems. The importance of fluid homeostasis is further emphasized among orthotopic heart transplant recipients (OHT). We sought to investigate the relationship between postoperative volume overload, mortality, and allograft dysfunction among pediatric OHT recipients within 1-year of transplantation. This is a retrospective cohort study from a single pediatric OHT center. Children under 21 years undergoing cardiac transplantation between 2010 and 2018 were included. Cumulative fluid overload (cFO) was assessed as percent fluid accumulation adjusted for preoperative body weight. Greater than 10% cFO defined those with postoperative cFO and a comparison of postoperative cFO vs. no postoperative cFO (< 5%) is reported. 102 pediatric OHT recipients were included. Early cFO at 72 h post-OHT occurred in 14% and overall cFO at 1-week post-OHT occurred in 23% of patients. Risk factors for cFO included younger age, lower weight, and postoperative ECMO. Early cFO was associated with postoperative mortality at 1-year, OR 8.6 (95% CI 1.4, 51.6), p = 0.04, independent of age and weight. There was no significant relationship between cFO and allograft dysfunction, measured by rates of clinical rejection and cardiopulmonary filling pressures within 1-year of transplant. Early postoperative volume overload is prevalent and associated with increased risk of death at 1-year among pediatric OHT recipients. It may be an important postoperative marker of transplant survival, and this relationship warrants further clinical investigation.
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Affiliation(s)
- Michelle J Lim
- Division of Critical Care, Department of Pediatrics, UC Davis School of Medicine, UC Davis Children's Hospital, 2516 Stockton Boulevard, Sacramento, CA, USA.
| | - Myung-Shin Sim
- Department of General Internal Medicine, Statistics Core, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Sylvia Pan
- Department of General Internal Medicine, Statistics Core, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Juan Alejos
- Division of Cardiology, Department of Pediatrics, UCLA Geffen School of Medicine, Mattel Children's Hospital, Los Angeles, CA, USA
| | - Myke Federman
- Division of Critical Care, Department of Pediatrics, UCLA Geffen School of Medicine, Mattel Children's Hospital, Los Angeles, CA, USA
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Amdani S, Conway J, Kleinmahon J, Auerbach S, Hsu D, Cousino MK, Kaufman B, Alejos J, Cruz JH, Lee HY, Rudraraju R, Kirklin JK, Asante-Korang A. Race and Socioeconomic Bias in Pediatric Cardiac Transplantation. JACC Heart Fail 2023; 11:19-26. [PMID: 36599545 DOI: 10.1016/j.jchf.2022.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND To date, no studies evaluated implicit bias among clinicians caring for children with advanced heart failure. OBJECTIVES This study aims to evaluate implicit racial and socioeconomic bias among pediatric heart transplant clinicians. METHODS A cross-sectional survey of transplant clinicians from the Pediatric Heart Transplant Society was conducted between June and August 2021. The survey consisted of demographic questions along with explicit and validated race and socioeconomic status (SES) implicit association tests (IATs). Implicit and explicit biases among survey group members were studied and associations were tested between implicit and explicit measures. RESULTS Of 500 members, 91 (18.2%) individuals completed the race IAT and 70 (14%) completed the SES IAT. Race IAT scores indicated moderate levels of implicit bias (mean = 0.33, d = 0.76; P < 0.001; ie, preference for White individuals). SES IAT scores indicated strong implicit bias (mean = 0.52, d = 1.53; P < 0.001; ie, preference for people from upper SES). There were weak levels of explicit race and wealth bias. There was a strong level of explicit education bias (mean = 5.22, d = 1.19; P < 0.001; ie, preference for educated people). There were nonsignificant correlations between the race and the SES IAT and explicit measures (P > 0.05 for all). CONCLUSIONS As observed across other health care disciplines, among a group of pediatric heart transplant clinicians, there is an implicit preference for individuals who are White and from higher SES, and an explicit preference for educated people. Future studies should evaluate how implicit biases affect clinician behavior and assess the impact of efforts to reduce such biases.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA.
| | - Jennifer Conway
- Department of Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jake Kleinmahon
- Department of Cardiology, Ochsner Hospital for Children, New Orleans, Louisiana, USA
| | - Scott Auerbach
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Daphne Hsu
- Department of Pediatrics, Albert Einstein College of Medicine, The Children's Hospital at Montefiore, Bronx, New York, USA
| | - Melissa K Cousino
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Beth Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, USA
| | - Juan Alejos
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Jason Hopper Cruz
- Department of Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Hannah Y Lee
- Department of Pediatrics, Program for Pediatric Cardiomyopathy, Heart Failure and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Ramaraju Rudraraju
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alfred Asante-Korang
- Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
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Amdani S, Henderson H, Everitt MD, Beasley G, Shih R, Exil V, Alejos J, Wallis G, Azeka E, Nandi D, Profita E, Spinner J, Magnetta D, Martinez H, Fenton M, Conway J, Urschel S. Clinical approach to antibody-mediated rejection from the pediatric heart transplant society. Pediatr Transplant 2022; 26:e14398. [PMID: 36377325 DOI: 10.1111/petr.14398] [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: 04/21/2022] [Revised: 09/03/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022]
Abstract
This document is designed to outline the definition, pathogenesis, diagnostic modalities and therapeutic measures to treat antibody-mediated rejection in children postheart transplant METHODS: Literature review was conducted by a Pediatric Heart Transplant Society (PHTS) working group to identify existing pediatric and adult studies on antibody-mediated rejection (AMR). In addition, the centers participating in PHTS were asked to submit their approach to diagnosis and management of pediatric AMR. This document synthesizes information gathered from both these sources to highlight a practical approach to diagnosing and managing a child with AMR postheart transplant. This document may not represent the practice at all centers in the PHTS and serves as a starting point to understand an approach to this clinical scenario.
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Affiliation(s)
- Shahnawaz Amdani
- Pediatric Heart Failure and Transplant Cardiologist, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Heather Henderson
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Melanie D Everitt
- Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Gary Beasley
- Division of Pediatric Cardiology; and The Heart Institute at Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Renata Shih
- Division of Pediatric Cardiology, University of Florida, Gainesville, Florida, USA
| | - Vernat Exil
- Carver School of Medicine, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Juan Alejos
- Division of Pediatric Cardiology, Mattel Children's Hospital, Los Angeles, California, USA
| | - Gonzalo Wallis
- Division of Pediatric Cardiology, Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Estela Azeka
- Unidade de Cardiologia, Heart Institute (InCor) University of São Paulo Medical School, Cerqueira César, Sao Paulo, Brazil
| | - Deipanjan Nandi
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Elizabeth Profita
- Stanford University, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Joseph Spinner
- Division of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Defne Magnetta
- unidade de cardiologia, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Hugo Martinez
- Division of Pediatric Cardiology; and The Heart Institute at Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Matthew Fenton
- Division of Pediatric Cardiology, Great Ormond Street Hospital, London, UK
| | - Jennifer Conway
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Simon Urschel
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Raymundo S, Escobar A, Alejos J, Satou G, Shannon K. Cardiac Tumor and Arrhythmia Induced Cardiomyopathy: Management with Pace Suppression. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1971] [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: 11/30/2022] Open
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Weisert M, Harake D, Hede S, Russell M, Alejos J, Menteer J. A multicenter survey on post-transplant lymphoproliferative disorders in pediatric heart transplant recipients: A case for development of consensus guidelines for screening, surveillance, and treatment? Pediatr Transplant 2020; 24:e13730. [PMID: 32416037 DOI: 10.1111/petr.13730] [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: 11/27/2019] [Revised: 03/23/2020] [Accepted: 04/13/2020] [Indexed: 01/29/2023]
Abstract
Post-transplant lymphoproliferative disorders (PTLD) are the main malignancy seen after pediatric heart transplant and are a significant cause of morbidity and mortality. Prior to the development of detailed guidelines, we sought to identify trends in screening, diagnosis, and treatment of pediatric PTLD. All Pediatric Heart Transplant Society (PHTS) institutions were surveyed. No identifiable patient information was shared. From 56 PHTS centers, 22 responses were received (39.3%). 100% agree PTLD cannot be diagnosed solely based on elevated Epstein-Barr virus (EBV) load. All respondents routinely screen for EBV by blood PCR, but frequency of screening varies. There was intermediate consensus regarding the use of computed tomography (CT) and/or positron emission tomography (PET) in surveillance management for PTLD. Most centers require a diagnostic biopsy before initiating new treatment for PTLD (14 of 18, 77.8%), but many reduce immune suppression based on elevated EBV without pathologic PTLD (16 of 22, 72.7%). Beyond immune modulation, rituximab is most commonly used (9 of 13, 69.2%). Consultation with oncology is common (17 of 17, 100%), but timing varies widely. Our survey highlights significant elements of agreement and significant practice variation among PHTS institutions regarding pediatric PTLD. Reduction of immune suppression prior to pathologic diagnosis of PTLD is a common management strategy. When this fails, rituximab is used, but is most often reserved until after confirmation of the diagnosis. Oncology subspecialists are commonly involved in these cases. Our findings highlight the need to develop improved guidelines for evaluation and treatment of pediatric PTLD.
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Affiliation(s)
- Molly Weisert
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Danielle Harake
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Sannya Hede
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Matthew Russell
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Juan Alejos
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - JonDavid Menteer
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
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Griffiths E, Schumacher K, DiPaola F, Chen S, Gerrish H, West S, Nandi D, McCulloch M, O'Connor M, Zangwill S, Lee T, Friedland-Little J, Carlo W, Alejos J, Lambert L, Rezvani M, Shaaban A, Ou Z, Molina K. The Fontan Liver after Cardiac Transplantation. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1271] [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: 10/24/2022] Open
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9
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Hede S, Fraschilla S, Alejos J. DEVELOPMENT & UTILITY OF A NOVEL POST-OPERATIVE PEDIATRIC HEART TRANSPLANT CLINICAL PATHWAY. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31207-9] [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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10
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Gallotti R, Drogalis-Kim DE, Satou G, Alejos J. Single-Center Experience Using Selexipag in a Pediatric Population. Pediatr Cardiol 2017; 38:1405-1409. [PMID: 28702718 DOI: 10.1007/s00246-017-1677-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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: 04/07/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare and progressive disorder. Current treatment in the pediatric population includes phosphodiesterase 5 inhibitors (PDE-5i), endothelin receptor antagonists (ERA), and both inhaled and intravenous prostacyclin pathway agonists. As of December 22, 2015 the first oral prostacyclin pathway agonist, selexipag (Uptravi®), was FDA approved in the US. In this case series, we discuss our single-center experience using selexipag in a pediatric population, composed of both patients with idiopathic PAH, and patients with congenital heart disease and PAH.
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Affiliation(s)
- Roberto Gallotti
- Department of Pediatric Cardiology, Mattel Children's Hospital UCLA, 200 UCLA Medical Plaza, Suite 224, Los Angeles, CA, 90095, USA
| | - Diana E Drogalis-Kim
- Department of Pediatric Cardiology, Mattel Children's Hospital UCLA, 200 UCLA Medical Plaza, Suite 224, Los Angeles, CA, 90095, USA
| | - Gary Satou
- Department of Pediatric Cardiology, Mattel Children's Hospital UCLA, 200 UCLA Medical Plaza, Suite 224, Los Angeles, CA, 90095, USA.,Division of Pulmonary Hypertension, Mattel Children's Hospital UCLA, Los Angeles, CA, 90095, USA
| | - Juan Alejos
- Department of Pediatric Cardiology, Mattel Children's Hospital UCLA, 200 UCLA Medical Plaza, Suite 224, Los Angeles, CA, 90095, USA. .,Division of Pulmonary Hypertension, Mattel Children's Hospital UCLA, Los Angeles, CA, 90095, USA.
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Touma M, Reemtsen B, Halnon N, Alejos J, Finn JP, Nelson SF, Wang Y. A Path to Implement Precision Child Health Cardiovascular Medicine. Front Cardiovasc Med 2017; 4:36. [PMID: 28620608 PMCID: PMC5451507 DOI: 10.3389/fcvm.2017.00036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/04/2017] [Indexed: 12/17/2022] Open
Abstract
Congenital heart defects (CHDs) affect approximately 1% of live births and are a major source of childhood morbidity and mortality even in countries with advanced healthcare systems. Along with phenotypic heterogeneity, the underlying etiology of CHDs is multifactorial, involving genetic, epigenetic, and/or environmental contributors. Clear dissection of the underlying mechanism is a powerful step to establish individualized therapies. However, the majority of CHDs are yet to be clearly diagnosed for the underlying genetic and environmental factors, and even less with effective therapies. Although the survival rate for CHDs is steadily improving, there is still a significant unmet need for refining diagnostic precision and establishing targeted therapies to optimize life quality and to minimize future complications. In particular, proper identification of disease associated genetic variants in humans has been challenging, and this greatly impedes our ability to delineate gene–environment interactions that contribute to the pathogenesis of CHDs. Implementing a systematic multileveled approach can establish a continuum from phenotypic characterization in the clinic to molecular dissection using combined next-generation sequencing platforms and validation studies in suitable models at the bench. Key elements necessary to advance the field are: first, proper delineation of the phenotypic spectrum of CHDs; second, defining the molecular genotype/phenotype by combining whole-exome sequencing and transcriptome analysis; third, integration of phenotypic, genotypic, and molecular datasets to identify molecular network contributing to CHDs; fourth, generation of relevant disease models and multileveled experimental investigations. In order to achieve all these goals, access to high-quality biological specimens from well-defined patient cohorts is a crucial step. Therefore, establishing a CHD BioCore is an essential infrastructure and a critical step on the path toward precision child health cardiovascular medicine.
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Affiliation(s)
- Marlin Touma
- Department of Pediatrics, Children's Discovery and Innovation Institute, University of California at Los Angeles, Los Angeles, CA, United States.,Cardiovascular Research Laboratory, University of California at Los Angeles, Los Angeles, CA, United States
| | - Brian Reemtsen
- Department of Cardiothoracic Surgery, University of California at Los Angeles, Los Angeles, CA, United States
| | - Nancy Halnon
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA, United States
| | - Juan Alejos
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA, United States
| | - J Paul Finn
- Department of Radiology, Cardiovascular Imaging, University of California at Los Angeles, Los Angeles, CA, United States
| | - Stanley F Nelson
- Department of Human Genetics, University of California at Los Angeles, Los Angeles, CA, United States
| | - Yibin Wang
- Cardiovascular Research Laboratory, University of California at Los Angeles, Los Angeles, CA, United States.,Department of Anesthesiology, Physiology and Medicine, University of California at Los Angeles, Los Angeles, CA, United States
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12
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Drogalis-Kim D, Jefferies J, Wilmot I, Alejos J. Right sided heart failure and pulmonary hypertension: New insights into disease mechanisms and treatment modalities. Progress in Pediatric Cardiology 2016. [DOI: 10.1016/j.ppedcard.2016.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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13
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Hanudel MR, Wesseling-Perry K, Gales B, Ramos G, Campbell V, Ethridge K, Scotti M, Elashoff DA, Alejos J, Reemtsen B, Salusky IB. Effects of acute kidney injury and chronic hypoxemia on fibroblast growth factor 23 levels in pediatric cardiac surgery patients. Pediatr Nephrol 2016; 31:661-9. [PMID: 26525200 PMCID: PMC4766020 DOI: 10.1007/s00467-015-3257-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [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: 06/17/2015] [Revised: 10/20/2015] [Accepted: 10/20/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND Fibroblast growth factor-23 (FGF23) levels are elevated in cardiopulmonary bypass (CPB)-associated acute kidney injury (AKI); however, it is unknown how much of the circulating FGF23 is intact and bioactive. Hypoxia may induce FGF23 production, yet its impact in humans is unknown. Pediatric cardiac surgery patients have both a high incidence of CPB-associated AKI and a high prevalence of chronic hypoxemia. METHODS We assessed the effects of hypoxemia and CPB-associated AKI on C-terminal FGF23 (cFGF23) and intact FGF23 (iFGF23) levels in 32 pediatric cardiac surgery patients with normal estimated glomerular filtration rate (eGFR). Plasma cFGF23 and iFGF23 were measured preoperatively and serially postoperatively. RESULTS Despite normal renal and ventricular function, preoperative cFGF23 levels were high and elevated out of proportion to iFGF23 levels. Preoperative oxygen saturation measurements correlated inversely with FGF23 levels. Preoperative cFGF23 and oxygen saturation both predicted postoperative AKI. Postoperatively, cFGF23 and iFGF23 increased by 2 h postreperfusion; iFGF23 then returned to baseline, but cFGF23 remained elevated through 24 h postreperfusion. Group status (AKI vs. non-AKI) modified the effect of time on changes in iFGF23 levels but not cFGF23 levels. CONCLUSIONS Preoperative cFGF23 may predict CPB-associated kidney dysfunction. Changes over time in cFGF23 and iFGF23 levels post-CPB differ. Chronic hypoxemia may affect FGF23 production in humans.
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Affiliation(s)
- Mark R. Hanudel
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Barbara Gales
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Georgina Ramos
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Vicky Campbell
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Kristen Ethridge
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Mary Scotti
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David A. Elashoff
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Juan Alejos
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Brian Reemtsen
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Isidro B. Salusky
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Cortez D, Sharma N, Cavanaugh J, Tuozo F, Derk G, Lundberg E, Schlegel TT, Weiner K, Kiciman N, Alejos J, Landeck B, Aboulhosn J, Miyamoto S, Batra A, McCanta AC. The spatial QRS-T angle outperforms the Italian and Seattle ECG-based criteria for detection of hypertrophic cardiomyopathy in pediatric patients. J Electrocardiol 2015; 48:826-33. [DOI: 10.1016/j.jelectrocard.2015.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Indexed: 10/23/2022]
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15
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Reardon L, Alejos J, Deng M, Nsair A, Reemtsen B, Biniwale R, Depasquale E. Transition to Adulthood: Heart Transplant (HT) Recipient Outcomes By Age Group. J Heart Lung Transplant 2015. [DOI: 10.1016/j.healun.2015.01.153] [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: 10/23/2022] Open
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16
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Reardon LC, Alejos J, Nsair A, DePasquale E. INFLUENCE OF MELD (MODEL OF END-STAGE LIVER DISEASE)_XI (EXCLUDING INR) ON PEDIATRIC POST-HEART TRANSPLANT (HT) OUTCOMES. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)60802-6] [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: 10/23/2022]
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17
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Derk G, Houser L, Miner P, Williams R, Moriarty J, Finn P, Alejos J, Aboulhosn J. Efficacy of endothelin blockade in adults with Fontan physiology. CONGENIT HEART DIS 2015; 10:E11-6. [PMID: 24890846 DOI: 10.1111/chd.12189] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [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] [Accepted: 04/11/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Phosphodiesterase-5 inhibitors have shown to improve cardiac output and functional capacity in Fontan patients. We sought to test the efficacy and safety of endothelin blockade with bosentan in adult patients with Fontan physiology. DESIGN Ten patients were enrolled and seven patients completed this single-center open-label clinical trial. Patients were treated with bosentan for 4 months. Cardiac magnetic resonance imaging (MRI), 6-minute walking distance (6MWD), brain natriuretic peptide, and New York Heart Association functional class were compared before and after treatment using paired t-test. RESULTS The 6MWD improved by 73 m, from a mean of 435 m (standard deviation [SD] = 92, standard error [SE] = 35) to 508 m (SD = 93, SE = 35) (P = .03). MRI resting aortic flow increased from 3.3 L/minute (SD = 1.27, SE = 0.73) to 4.4 L/minute (SD = 0.9, SE = 0.54) (P = .03). New York Heart Association class was unchanged in three patients, improved in three patients and worsened in one patient. Brain natriuretic peptide, aspartate aminotransferase, and alanine aminotransferase did not change significantly. Of the three patients with elevated baseline bilirubin, two normalized at the completion of the study, while the other was unchanged. Mean duration of therapy was 4.1 ± 0.51 months. Three adverse advents occurred. One patient complained of fatigue and chest pain after 87 days and withdrew from the study. After extensive workup, it was determined that her symptoms were not related to treatment. The second patient suffered palpitations and fatigue after 75 days; no concerning arrhythmias were identified and symptoms improved with increased antiarrhythmic dose. The third patient developed fatigue on therapy and decided to stop therapy; fatigue improved following drug discontinuation. There were no deaths or hospitalizations. CONCLUSIONS In this cohort of adult patients with Fontan physiology, endothelin blockade with bosentan resulted in improved 6MWD and MRI-derived resting cardiac output, suggesting a positive effect on pulmonary vascular resistance and pulmonary blood flow. Bosentan was well tolerated and hepatic function was not adversely affected.
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Affiliation(s)
- Gwendolyn Derk
- Ahmanson/UCLA Adult Congenital Heart Disease, University of California Los Angeles, Los Angeles, Calif, USA
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DePasquale E, Reardon L, Nsair A, Deng M, Alejos J. Influence of MELD (Model of End-Stage Liver Disease)_XI (eXcluding INR) on Pediatric Post-Heart Transplant (HT) Outcomes. J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.588] [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: 11/15/2022] Open
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DePasquale EC, Cheng R, Nsair A, Reardon L, Baas A, Cadeiras M, Cruz D, Halnon N, Alejos J, Deng M, Laks H, Ardehali A. CARDIAC RETRANSPLANTATION: HOW FAR HAVE WE COME? J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60807-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: 10/25/2022]
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20
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Aboulhosn JA, Derk G, Houser L, Miner P, Williams R, Moriarty J, Alejos J, Finn P. EFFICACY OF ENDOTHELIN BLOCKADE IN ADULTS WITH FONTAN PHYSIOLOGY. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)61268-1] [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: 10/27/2022]
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21
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Patel P, Moore J, Perens G, Alejos J. 610 Distinguishing Tachycardia-Mediated Cardiomyopathy and Idiopathic Dilated Cardiomyopathy. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.624] [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: 10/28/2022] Open
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22
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Su J, Kelly R, Alejos J. 798 Extracorporeal Membrane Oxygenation Support after Pediatric Heart Transplantation: Long-Term Survival Trends. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.815] [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: 10/28/2022] Open
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23
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Su J, Kelly R, Alejos J. 763 Extracorporeal Membrane Oxygenation Support after Pediatric Heart Transplantation: Predictors of Survival to Hospital Discharge. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.779] [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: 11/28/2022] Open
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25
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Mitropoulos FA, Laks H, Neelankavil J, Alejos J, Child JS, Allada V, Drant S, Kobashigawa J, Odim J, Fishbein M, Plunkett M. 840-4 Failing fontan circulation necessitating transplantation: A clinicopathologic correlation. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)91650-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Claudius I, Lan YT, Chang RK, Wetzel GT, Alejos J. Usefulness of B-type natriuretic peptide as a noninvasive screening tool for cardiac allograft pathology in pediatric heart transplant recipients. Am J Cardiol 2003; 92:1368-70. [PMID: 14636927 DOI: 10.1016/j.amjcard.2003.08.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We examined the utility of B-type natriuretic peptide (BNP) in the evaluation of pediatric orthotopic heart transplant recipients for allograft pathology by measuring the serum BNP levels at the time of either screening echocardiography and biopsy, or at the time of clinical rejection. There was a significant difference (p <0.0001) in the BNP levels in 37 patients in the group with evidence of pathology compared with those without evidence. There was also 100% sensitivity and 100% negative predictive value of BNP levels >100 pg/ml for identifying graft pathology.
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Affiliation(s)
- Ilene Claudius
- Division of Emergency and Transport Medicine, Childrens Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, California 90027, USA.
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Abstract
Numerous studies have described the pathophysiology, clinical manifestations, and treatment of the many forms of congenital heart disease (CHD), but none has specifically addressed the reasons CHD patients present to the Emergency Department (ED). The objective of this study was to provide a descriptive analysis of the ED presentations of acute and seriously ill pediatric CHD patients. We intended to capture a subset of acutely ill CHD patients who had presenting signs and symptoms that were potentially attributable to their underlying CHD. Recognizing the more common presentation patterns for patients with CHD may be of benefit. Adhering to the basic principles of airway, breathing and circulatory (ABC) management is essential when caring for critically ill CHD patients. Patients with complex CHD are often very difficult to correctly diagnose and manage in the ED. They often require extensive inpatient observation and evaluation. A low threshold for inpatient management of these high-risk patients is warranted.
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Affiliation(s)
- Eric Savitsky
- Department of Pediatric Emergency Medicine/Emergency Medicine, Emergency Medicine Residency Program, University of California-Los Angeles, Suite 300, 924 Westwood Boulevard, Los Angeles, CA 90024-1777, USA
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Abstract
The newest treatment strategies for pediatric myocarditis have evolved from an understanding of the pathophysiology of myocyte damage. Although the initial stages of viral myocarditis apparently result from the direct cytopathic effects on the atrial and ventricular myocardium, later stages of progressive decompensation result from immune-mediated myocyte destruction common to many forms of myocarditis. Despite advances in the understanding of the role of genetics, immunologic mechanisms, and infectious causes of myocarditis, supportive therapy continues to remain the cornerstone of treatment. Presently, therapies include supportive management with anticongestive agents, antiviral medications, and therapies that attempt to interrupt the immunologic cascade. Clinical studies have yet to provide convincing evidence that the use of immunosuppressants and gamma-globulin favorably alters the outcome for pediatric patients with acute myocarditis. Ventricular assist devices and heart transplantation remain as treatment options for all pediatric patients with severe myocarditis resistant to all other therapies. Although this review will focus on viral myocarditis, the supportive strategies and surgical treatment options apply to most forms of cardiomyopathy.
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Affiliation(s)
- Daniel Levi
- Department of Pediatrics, School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Levi D, Marelli D, Plunkett M, Alejos J, Bresson J, Tran J, Eisenring C, Sadeghi A, Galindo A, Fazio D, Gupta A, Burch C, George B, Laks H. Use of assist devices and ECMO to bridge pediatric patients with cardiomyopathy to transplantation. J Heart Lung Transplant 2002; 21:760-70. [PMID: 12100902 DOI: 10.1016/s1053-2498(02)00386-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pulsatile ventricular assist devices (VADs) are used to bridge adults with end-stage heart disease to transplantation. A combination of external implantable pulsatile and continuous-flow external mechanical support now can be used to bridge pediatric patients with end-stage cardiomyopathy to orthotopic heart transplantation (OHT). METHODS We reviewed consecutive pediatric patients with cardiomyopathy (n = 28) who required mechanical cardiac support from July 1995 to February 2001. All were OHT candidates with severe hemodynamic compromise despite maximal medical support. We excluded from this series patients who had undergone cardiotomy. RESULTS Nineteen patients received support from external continuous-flow devices, either with extracorporeal membrane oxygenation or with centrifugal VADs, and 9 patients received pulsatile support. Nineteen of 28 (68%) patients were successfully bridged to transplant (17) or weaned (2) from their devices after recovery. Of the patients successfully bridged to transplant or recovery, 89% are alive to date. Univariate analysis revealed that a lower bilirubin concentration after 2 days of support was associated with a favorable outcome (p = 0.006). As expected, the patients with pulsatile VADs had significantly higher rates of extubation and oral feeding. CONCLUSION Pulsatile and continuous-flow devices can complement each other to significantly extend the lives of a wide range of pediatric patients with severe cardiomyopathies.
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Affiliation(s)
- Daniel Levi
- Division of Pediatric Cardiology, UCLA Center for Health Sciences, University of California, Los Angeles, California 90095-1741, USA
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30
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Odim J, Alejos J, Alikhani A, Burch C, Laks H. Orthotopic transplantation for dextrocardia and complex congenital heart disease. J Heart Lung Transplant 2002. [DOI: 10.1016/s1053-2498(01)00509-5] [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: 11/29/2022] Open
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31
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Abstract
Acute myocarditis is characterized by the rapid development of life-threatening congestive heart failure and arrhythmias. Although the initial stages of this disorder apparently result from direct cytopathic effects on the atrial and ventricular myocardium, later stages of progressive decompensation may result from immune-mediated myocyte destruction. There has been recent improvement in understanding the role of this immunologic cascade. As a result, treatment now begins earlier in the course of the disease and can target both the virus and the immune response. Our ability to implement mechanical support in children as a bridge to transplant or recovery, even in children presenting in the final stages of their disease, has led to an improved outcome regarding morbidity and mortality.
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Affiliation(s)
- D Levi
- School of Medicine, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA 90095-1743, USA
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32
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Mehta U, Laks H, Sadeghi A, Marelli D, Odim J, Alejos J, Kim M, Atkinson JB, Bui KC. Extracorporeal membrane oxygenation for cardiac support in pediatric patients. Am Surg 2000; 66:879-86. [PMID: 10993622] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used for pediatric cardiac support in settings of expected mortality due to severe myocardial dysfunction. We reviewed the records of 34 children (<18 years) placed on ECMO between March 1995 and May 1999. Demographic, cardiac, noncardiac, and outcome variables were recorded. Data were subjected to univariate analysis to define predictors of outcome. Eighteen patients were placed on ECMO after cardiac surgery (Group A); seven of 18 were weaned off ECMO, and four survived to discharge (22%). Thirteen patients were placed on ECMO as a bridge to cardiac transplantation (Group B), six of 13 received a heart transplant, one recovered spontaneously, and six survived to discharge (46%). Three patients were placed on ECMO for failed cardiac transplantation while awaiting a second transplant (Group C); one recovered graft function, two received a second heart transplant, and two of three survived (66%). The primary cause of death was multiorgan system failure (68%). Group A patients supported on ECMO for more than 6 days did not survive. Mediastinal bleeding complications and renal failure requiring dialysis were associated with nonsurvival. We conclude that ECMO as a bridge to cardiac transplant was more successful than ECMO support after cardiotomy. Mediastinal bleeding and renal failure were associated with poor outcome. Recovery of cardiac function occurred within the first week of ECMO support if at all. Longer support did not result in survival without transplantation.
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Affiliation(s)
- U Mehta
- Ohio State University College of Medicine and Public Health, Columbus, USA
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33
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Mehta U, Laks H, Sadeghi A, Marelli D, Odim J, Alejos J, Kim M, Atkinson JB, Bui KC. Extracorporeal Membrane Oxygenation for Cardiac Support in Pediatric Patients. Am Surg 2000. [DOI: 10.1177/000313480006600918] [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] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used for pediatric cardiac support in settings of expected mortality due to severe myocardial dysfunction. We reviewed the records of 34 children (<18 years) placed on ECMO between March 1995 and May 1999. Demographic, cardiac, noncardiac, and outcome variables were recorded. Data were subjected to univariate analysis to define predictors of outcome. Eighteen patients were placed on ECMO after cardiac surgery (Group A); seven of 18 were weaned off ECMO, and four survived to discharge (22%). Thirteen patients were placed on ECMO as a bridge to cardiac transplantation (Group B), six of 13 received a heart transplant, one recovered spontaneously, and six survived to discharge (46%). Three patients were placed on ECMO for failed cardiac transplantation while awaiting a second transplant (Group C); one recovered graft function, two received a second heart transplant, and two of three survived (66%). The primary cause of death was multiorgan system failure (68%). Group A patients supported on ECMO for more than 6 days did not survive. Mediastinal bleeding complications and renal failure requiring dialysis were associated with nonsurvival. We conclude that ECMO as a bridge to cardiac transplant was more successful than ECMO support after cardiotomy. Mediastinal bleeding and renal failure were associated with poor outcome. Recovery of cardiac function occurred within the first week of ECMO support if at all. Longer support did not result in survival without transplantation.
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Affiliation(s)
- Umang Mehta
- Ohio State University College of Medicine and Public Health, Columbus, Ohio
| | - Hillel Laks
- Divisions of Cardiothoracic Surgery, UCLA Medical Center, Los Angeles
| | - Ali Sadeghi
- Divisions of Cardiothoracic Surgery, UCLA Medical Center, Los Angeles
| | - Daniel Marelli
- Divisions of Cardiothoracic Surgery, UCLA Medical Center, Los Angeles
| | - Jonah Odim
- Divisions of Cardiothoracic Surgery, UCLA Medical Center, Los Angeles
| | - Juan Alejos
- Divisions of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California
| | - Mina Kim
- Stanford University, Palo Alto, California
| | | | - Kim Chi Bui
- Divisions of Neonatology, UCLA Medical Center, Los Angeles
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Marelli D, Laks H, Meehan DA, Fazio D, Alejos J. Minimally invasive mechanical cardiac support without extracorporeal membrane oxygenation in children awaiting heart transplantation. Ann Thorac Surg 1999; 68:2320-3. [PMID: 10617024 DOI: 10.1016/s0003-4975(99)01049-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Mechanical cardiac assist for small children (< 30 kg) requiring bridge strategy to orthotopic heart transplantation often requires sternotomy for cannulation access to ensure perfusion to the aortic arch. Extracorporeal membrane oxygenation (ECMO) through neck cannulation is an option in very small (< 10 kg) patients, but the risk of stroke is increased in larger children. Another disadvantage is poor decompression of the left atrium, which can cause persistent pulmonary edema. METHODS Two cases are used to illustrate two methods of avoiding sternotomy during mechanical assist in children with dilated cardiomyopathy. One of these approaches avoids the need for extracorporeal oxygenation. RESULTS Decompression of the left-sided chambers with a left atrial cannula decreased pulmonary edema and improved pulmonary function. CONCLUSIONS Pediatric patients with dilated cardiomyopathy may benefit from a left ventricular assist technique using a centrifugal pump, which avoids the neck vessels and sternotomy, as well as ECMO.
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Affiliation(s)
- D Marelli
- Division of Cardiothoracic Surgery, University of California, Los Angeles Medical Center, 90095-1741, USA.
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Abstract
Although the cardiac effects of tacrolimus (FK506) have not been well documented, clinical cases of children on FK506 who developed hypertrophic obstructive cardiomyopathy have been reported. We report 2 cases of marked concentric hypertrophy of the left ventricular myocardium found at autospy in children on FK506.
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Affiliation(s)
- R K Chang
- Department of Pediatrics, UCLA Medical Center, Los Angeles, California 90024, USA
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McGiffin DC, Naftel DC, Kirklin JK, Morrow WR, Towbin J, Shaddy R, Alejos J, Rossi A. Predicting outcome after listing for heart transplantation in children: comparison of Kaplan-Meier and parametric competing risk analysis. Pediatric Heart Transplant Study Group. J Heart Lung Transplant 1997; 16:713-22. [PMID: 9257253] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
After listing for pediatric heart transplantation, at any point in time one of the following possibilities could have occurred; death, transplantation, removal from the list because of clinical improvement, or continuing to wait. In the setting of those competing outcomes, the Kaplan-Meier estimate portrays the time-relatedness of an event while ignoring the effect of the other possible outcomes. The competing outcomes method, however, depicts the time relatedness of an event while solving for all possible events simultaneously. The competing outcomes method may potentially provide more accurate information regarding the actual proportion of patients experience an outcome after listing.
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Affiliation(s)
- D C McGiffin
- Department of Surgery, University of Alabama at Birmingham 35294-0007, USA
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Allgood NL, Alejos J, Drinkwater DC, Laks H, Williams RG. Effectiveness of the bidirectional Glenn shunt procedure for volume unloading in the single ventricle patient. Am J Cardiol 1994; 74:834-6. [PMID: 7942565 DOI: 10.1016/0002-9149(94)90450-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- N L Allgood
- University of California, Los Angeles Medical School, Department of Pediatrics
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