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Lemley BA, Okunowo O, Ampah SB, Wu L, Shinohara RT, Goldberg DJ, Rychik J, Glatz AC, Amaral S, O'Byrne ML. Effect of patient factors, center, and era on Fontan timing: An observational study using the Pediatric Health Information Systems Database. Am Heart J 2024; 271:156-163. [PMID: 38412896 DOI: 10.1016/j.ahj.2024.02.019] [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: 02/02/2024] [Accepted: 02/21/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND There are no consensus guidelines defining optimal timing for the Fontan operation, the last planned surgery in staged palliation for single-ventricle heart disease. OBJECTIVES Identify patient-level characteristics, center-level variation, and secular trends driving Fontan timing. METHODS A retrospective observational study of subjects who underwent Fontan from 2007 to 2021 at centers in the Pediatric Health Information Systems database was performed using linear mixed-effects modeling in which age at Fontan was regressed on patient characteristics and date of operation with center as random effect. RESULTS We included 10,305 subjects (40.4% female, 44% non-white) at 47 centers. Median age at Fontan was 3.4 years (IQR 2.6-4.4). Hypoplastic left heart syndrome (-4.4 months, 95%CI -5.5 to -3.3) and concomitant conditions (-2.6 months, 95%CI -4.1 to -1.1) were associated with younger age at Fontan. Subjects with technology-dependence (+4.6 months, 95%CI 3.1-6.1) were older at Fontan. Black (+4.1 months, 95%CI 2.5-5.7) and Asian (+8.3 months, 95%CI 5.4-11.2) race were associated with older age at Fontan. There was significant variation in Fontan timing between centers. Center accounted for 10% of variation (ICC 0.10, 95%CI 0.07-0.14). Center surgical volume was not associated with Fontan timing (P = .21). Operation year was associated with age at Fontan, with a 3.1 month increase in age for every 5 years (+0.61 months, 95%CI 0.48-0.75). CONCLUSIONS After adjusting for patient-level characteristics there remains significant inter-center variation in Fontan timing. Age at Fontan has increased. Future studies addressing optimal Fontan timing are warranted.
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Affiliation(s)
- Bethan A Lemley
- Division of Cardiology, Lurie Children's Hospital and Department of Pediatrics, Feinberg School of Medicine Northwestern University, Chicago IL.
| | - Oluwatimilehin Okunowo
- Department of Computational and Quantitative Medicine, Division of Biostatistics, Beckman Research Institute of City of Hope, Duarte, CA
| | - Steve B Ampah
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lezhou Wu
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Russell T Shinohara
- Department of Biostatistics Epidemiology and Informatics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - David J Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Jack Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology, St. Louis Children's Hospital and Department of Pediatrics Washington University School of Medicine, St. Louis MO
| | - Sandra Amaral
- Division of Nephrology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA; Clinical Futures, The Children's Hospital of Philadelphia and Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
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Quinn BP, Gunnelson LC, Kotin SG, Gauvreau K, Yeh MJ, Hasan B, Lozier J, Barry OM, Shahanavaz S, Batlivala SP, Salavitabar A, Foerster S, Goldstein B, Divekar A, Holzer R, Nicholson GT, O'Byrne ML, Whiteside W, Bergersen L. Catheterization for Congenital Heart Disease Adjustment for Risk Method II. Circ Cardiovasc Interv 2024; 17:e012834. [PMID: 38258562 DOI: 10.1161/circinterventions.123.012834] [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: 03/03/2023] [Accepted: 12/08/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Current metrics used to adjust for case mix complexity in congenital cardiac catheterization are becoming outdated due to the introduction of novel procedures, innovative technologies, and expanding patient subgroups. This study aims to develop a risk adjustment methodology introducing a novel, clinically meaningful adverse event outcome and incorporating a modern understanding of risk. METHODS Data from diagnostic only and interventional cases with defined case types were collected for patients ≤18 years of age and ≥2.5 kg at all Congenital Cardiac Catheterization Project on Outcomes participating centers. The derivation data set consisted of cases performed from 2014 to 2017, and the validation data set consisted of cases performed from 2019 to 2020. Severity level 3 adverse events were stratified into 3 tiers by clinical impact (3a/b/c); the study outcome was clinically meaningful adverse events, severity level ≥3b (3bc/4/5). RESULTS The derivation data set contained 15 224 cases, and the validation data set included 9462 cases. Clinically meaningful adverse event rates were 4.5% and 4.2% in the derivation and validation cohorts, respectively. The final risk adjustment model included age <30 days, Procedural Risk in Congenital Cardiac Catheterization risk category, and hemodynamic vulnerability score (C statistic, 0.70; Hosmer-Lemeshow P value, 0.83; Brier score, 0.042). CONCLUSIONS CHARM II (Congenital Heart Disease Adjustment for Risk Method II) risk adjustment methodology allows for equitable comparison of clinically meaningful adverse events among institutions and operators with varying patient populations and case mix complexity performing pediatric cardiac catheterization.
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Affiliation(s)
- Brian P Quinn
- Department of Cardiology, Boston Children's Hospital, MA (B.P.Q., L.C.G., S.G.K., K.G., M.J.Y., L.B.)
| | - Lauren C Gunnelson
- Department of Cardiology, Boston Children's Hospital, MA (B.P.Q., L.C.G., S.G.K., K.G., M.J.Y., L.B.)
| | - Sarah G Kotin
- Department of Cardiology, Boston Children's Hospital, MA (B.P.Q., L.C.G., S.G.K., K.G., M.J.Y., L.B.)
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, MA (B.P.Q., L.C.G., S.G.K., K.G., M.J.Y., L.B.)
| | - Mary J Yeh
- Department of Cardiology, Boston Children's Hospital, MA (B.P.Q., L.C.G., S.G.K., K.G., M.J.Y., L.B.)
| | - Babar Hasan
- Division of Cardio-Thoracic Sciences, Sindh Institute of Urology and Transplantation, Pakistan (B.H.)
| | - John Lozier
- Division of Pediatric Cardiology, UH Rainbow Babies and Children's Hospital, Cleveland, OH (J.L.)
| | - Oliver M Barry
- Division of Pediatric Cardiology, Columbia University Medical Center, New York Presbyterian/Morgan Stanley Children's Hospital (O.M.B.)
| | - Shabana Shahanavaz
- Cincinnati Children's Hospital-Heart Institute and Department of Pediatrics, University of Cincinnati College of Medicine, OH (S.S., S.P.B.)
| | - Sarosh P Batlivala
- Cincinnati Children's Hospital-Heart Institute and Department of Pediatrics, University of Cincinnati College of Medicine, OH (S.S., S.P.B.)
| | - Arash Salavitabar
- The Heart Center, Nationwide Children's Hospital, Columbus, OH (A.S.)
| | - Susan Foerster
- Division of Pediatric Cardiology, Children's Wisconsin, Milwaukee (S.F.)
| | - Bryan Goldstein
- Heart Institute, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, PA (B.G.)
| | - Abhay Divekar
- Division of Pediatric Cardiology, UT Southwestern Medical Center, Children's Medical Center Dallas, TX (A.D.)
| | - Ralf Holzer
- Division of Pediatric Cardiology, Department of Pediatrics, University of California Davis, Sacramento (R.H.)
| | - George T Nicholson
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center, Nashville, TN (G.T.N.)
| | - Michael L O'Byrne
- Division of Cardiology, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania (M.L.O.)
| | - Wendy Whiteside
- Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor (W.W.)
| | - Lisa Bergersen
- Department of Cardiology, Boston Children's Hospital, MA (B.P.Q., L.C.G., S.G.K., K.G., M.J.Y., L.B.)
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Lemley BA, Wu L, Roberts AL, Shinohara RT, Quarshie WO, Qureshi AM, Smith CL, Dori Y, Gillespie MJ, Rome JJ, Glatz AC, Amaral S, O'Byrne ML. Trends in Ductus Arteriosus Stent Versus Blalock-Taussig-Thomas Shunt Use and Comparison of Cost, Length of Stay, and Short-Term Outcomes in Neonates With Ductal-Dependent Pulmonary Blood Flow: An Observational Study Using the Pediatric Health Information Systems Database. J Am Heart Assoc 2023; 12:e030575. [PMID: 38038172 PMCID: PMC10727347 DOI: 10.1161/jaha.123.030575] [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: 05/19/2023] [Accepted: 10/09/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND The modified Blalock-Taussig-Thomas shunt is the gold standard palliation for securing pulmonary blood flow in infants with ductal-dependent pulmonary blood flow. Recently, the ductus arteriosus stent (DAS) has become a viable alternative. METHODS AND RESULTS This was a retrospective multicenter study of neonates ≤30 days undergoing DAS or Blalock-Taussig-Thomas shunt placement between January 1, 2017 and December 31, 2020 at hospitals reporting to the Pediatric Health Information Systems database. We performed generalized linear mixed-effects modeling to evaluate trends in intervention and intercenter variation, propensity score adjustment and inverse probability weighting with linear mixed-effects modeling to analyze length of stay and cost of hospitalization, and generalized linear mixed modeling to analyze differences in 30-day outcomes. There were 1874 subjects (58% male, 61% White) from 45 centers (29% DAS). Odds of DAS increased with time (odds ratio [OR] 1.23, annually, P<0.01 [95% CI, 1.10-1.38]) with significant intercenter variation (median OR, 3.81 [95% CI, 2.74-5.91]). DAS was associated with shorter hospital length of stay (ratio of geometric means, 0.76 [95% CI, 0.63-0.91]), shorter intensive care unit length of stay (ratio of geometric means, 0.77 [95% CI, 0.61-0.97]), and less expensive hospitalization (ratio of geometric means, 0.70 [95% CI, 0.56-0.87]). Intervention was not significantly associated with odds of 30-day transplant-free survival (OR,1.18 [95% CI, 0.70-1.99]) or freedom from catheter reintervention (OR, 1.02 [95% CI, 0.65-1.58]), but DAS was associated with 30-day freedom from composite adverse outcome (OR, 1.51 [95% CI, 1.11-2.05]). CONCLUSIONS Use of DAS is increasing, but there is variability across centers. Though odds of transplant-free survival and reintervention were not significantly different after DAS, and DAS was associated with shorter length of stay and lower in-hospital costs.
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Affiliation(s)
- Bethan A. Lemley
- Division of CardiologyLurie Children’s HospitalChicagoILUSA
- Department of PediatricsFeinberg School of Medicine Northwestern UniversityChicagoILUSA
| | - Lezhou Wu
- Department of Biomedical and Health InformaticsChildren’s Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Amy L. Roberts
- Division of CardiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of Pediatrics Perelman School of Medicine at The University of PennsylvaniaPhiladelphiaPAUSA
| | - Russell T. Shinohara
- Department of Biostatistics, Epidemiology, and InformaticsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - William O. Quarshie
- Division of CardiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of Pediatrics Perelman School of Medicine at The University of PennsylvaniaPhiladelphiaPAUSA
| | - Athar M. Qureshi
- Division of CardiologyTexas Children’s HospitalHoustonTXUSA
- Department of Pediatrics Baylor College of MedicineHoustonTXUSA
| | - Christopher L. Smith
- Division of CardiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of Pediatrics Perelman School of Medicine at The University of PennsylvaniaPhiladelphiaPAUSA
| | - Yoav Dori
- Division of CardiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of Pediatrics Perelman School of Medicine at The University of PennsylvaniaPhiladelphiaPAUSA
| | - Matthew J. Gillespie
- Division of CardiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of Pediatrics Perelman School of Medicine at The University of PennsylvaniaPhiladelphiaPAUSA
| | - Jonathan J. Rome
- Division of CardiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of Pediatrics Perelman School of Medicine at The University of PennsylvaniaPhiladelphiaPAUSA
| | - Andrew C. Glatz
- Division of CardiologySt. Louis Children’s HospitalSt. LouisMOUSA
- Department of PediatricsWashington University School of MedicineSt. LouisMOUSA
| | - Sandra Amaral
- Division of NephrologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of PediatricsPerelman School of Medicine at The University of PennsylvaniaPhiladelphiaPAUSA
| | - Michael L. O'Byrne
- Division of CardiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of Pediatrics Perelman School of Medicine at The University of PennsylvaniaPhiladelphiaPAUSA
- Clinical Futures, The Children’s Hospital of Philadelphia and Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research CenterPerelman School of Medicine at The University of PennsylvaniaPhiladelphiaPAUSA
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Lai KC, Richardson T, Berman D, DeMauro SB, King BC, Lagatta J, Lee HC, Lewis T, Noori S, O'Byrne ML, Patel RM, Slaughter JL, Lakshmanan A. Current Trends in Invasive Closure of Patent Ductus Arteriosus in Very Low Birth Weight Infants in United States Children's Hospitals, 2016-2021. J Pediatr 2023; 263:113712. [PMID: 37659587 DOI: 10.1016/j.jpeds.2023.113712] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/10/2023] [Revised: 08/18/2023] [Accepted: 08/29/2023] [Indexed: 09/04/2023]
Abstract
OBJECTIVE To describe the current practices in invasive patent ductus arteriosus (PDA) closure (surgical ligation or transcatheter occlusion) in very low birth weight (VLBW) infants and changes in patient characteristics and outcomes from 2016 to 2021 among US children's hospitals. STUDY DESIGN We evaluated a retrospective cohort of VLBW infants (birth weight 400-1499 g and gestational age 22-31 weeks) who had invasive PDA closure within 6 months of age from 2016 to 2021 in children's hospitals in the Pediatric Health Information System. Changes in patient characteristics and outcomes over time were evaluated using generalized linear models and generalized linear mixed models. RESULTS 2418 VLBW infants (1182 surgical ligation; 1236 transcatheter occlusion) from 42 hospitals were included. The proportion of infants receiving transcatheter occlusion increased from 17.2% in 2016 to 84.4% in 2021 (P < .001). In 2021, 28/42 (67%) hospitals had performed transcatheter occlusion in > 80% of their VLBW infants needing invasive PDA closure, compared with only 2/42 (5%) in 2016. Although median postmenstrual age (PMA) at PDA closure did not change for the overall cohort, PMA at transcatheter occlusion decreased from 38 weeks in 2016 to 31 weeks by 2020, P < .001. Among those infants not intubated prior to PDA closure, extubation within 3 days postprocedure increased over time (yearly adjusted odds ratios of 1.26 [1.08-1.48]). Length of stay and mortality did not change over time. CONCLUSION We report rapid adoption of transcatheter occlusion for PDA among VLBW infants in US children's hospitals over time. Transcatheter occlusions were performed at younger PMA over time.
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Affiliation(s)
- Kuan-Chi Lai
- Division of Neonatology, Children's Hospital Los Angeles and University of Southern California, Los Angeles, CA.
| | | | - Darren Berman
- Division of Cardiology, Children's Hospital Los Angeles and University of Southern California, Los Angeles, CA
| | - Sara B DeMauro
- Division of Neonatology, The Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Brian C King
- Division of Newborn Medicine, UPMC Children's Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, PA
| | - Joanne Lagatta
- Division of Neonatology, Children's Wisconsin and Medical College of Wisconsin, Milwaukee, WI
| | - Henry C Lee
- Division of Neonatology, Rady Children's Hospital and University of California San Diego, San Diego, CA
| | - Tamorah Lewis
- Division of Neonatology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Shahab Noori
- Division of Neonatology, Children's Hospital Los Angeles and University of Southern California, Los Angeles, CA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Ravi M Patel
- Division of Neonatology, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
| | - Jonathan L Slaughter
- Division of Neonatology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Ashwini Lakshmanan
- Division of Neonatology, Children's Hospital Los Angeles and University of Southern California, Los Angeles, CA; Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA
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Zampi JD, Heinrich KP, Bergersen L, Goldstein BH, Batlivala SP, Fuller S, Glatz AC, O'Byrne ML, Marino B, Afton K, Lowery R, Yu S, Goldberg CS. Neurocognitive function and health-related quality of life in adolescents and young adults with CHD with pulmonary valve dysfunction. Cardiol Young 2023:1-8. [PMID: 38031461 DOI: 10.1017/s1047951123003979] [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: 12/01/2023]
Abstract
BACKGROUND Neurocognitive impairment and quality of life are two important long-term challenges for patients with complex CHD. The impact of re-interventions during adolescence and young adulthood on neurocognition and quality of life is not well understood. METHODS In this prospective longitudinal multi-institutional study, patients 13-30 years old with severe CHD referred for surgical or transcatheter pulmonary valve replacement were enrolled. Clinical characteristics were collected, and executive function and quality of life were assessed prior to the planned pulmonary re-intervention. These results were compared to normative data and were compared between treatment strategies. RESULTS Among 68 patients enrolled from 2016 to 2020, a nearly equal proportion were referred for surgical and transcatheter pulmonary valve replacement (53% versus 47%). Tetralogy of Fallot was the most common diagnosis (59%) and pulmonary re-intervention indications included stenosis (25%), insufficiency (40%), and mixed disease (35%). There were no substantial differences between patients referred for surgical and transcatheter therapy. Executive functioning deficits were evident in 19-31% of patients and quality of life was universally lower compared to normative sample data. However, measures of executive function and quality of life did not differ between the surgical and transcatheter patients. CONCLUSION In this patient group, impairments in neurocognitive function and quality of life are common and can be significant. Given similar baseline characteristics, comparing changes in neurocognitive outcomes and quality of life after surgical versus transcatheter pulmonary valve replacement will offer unique insights into how treatment approaches impact these important long-term patient outcomes.
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Affiliation(s)
- Jeffrey D Zampi
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | | | - Lisa Bergersen
- Division of Pediatric Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Bryan H Goldstein
- UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, Heart Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Stephanie Fuller
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew C Glatz
- Division of Pediatric Cardiology, St. Louis Children's and Washington University Heart Center, St. Louis, MO, USA
| | - Michael L O'Byrne
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bradley Marino
- Department of Pediatrics, Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Katherine Afton
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Ray Lowery
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Caren S Goldberg
- Department of Pediatrics, University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
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Rome JJ, O'Byrne ML. Hybrid Palliation for Critical Left Heart Obstruction Is Versatile: Risk Factors Still Impede Optimal Outcome. J Am Coll Cardiol 2023; 82:1442-1444. [PMID: 37758439 DOI: 10.1016/j.jacc.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/18/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Jonathan J Rome
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Division of Cardiology at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Michael L O'Byrne
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Division of Cardiology at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Niccum M, Gupta M, Rome JJ, O'Byrne ML. Coil Embolization of a Ruptured Mycotic Coronary Artery Aneurysm in a Pediatric Patient. JACC Case Rep 2023; 21:101967. [PMID: 37719297 PMCID: PMC10500331 DOI: 10.1016/j.jaccas.2023.101967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/12/2023] [Accepted: 07/11/2023] [Indexed: 09/19/2023]
Abstract
Mycotic coronary artery aneurysms are rare but have a high risk of mortality. Traditional management is surgical, but percutaneous intervention can be performed in patients with high surgical risk. In this report, we describe a case of mycotic coronary aneurysm in a pediatric patient successfully managed with percutaneous coil embolization. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Maria Niccum
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mudit Gupta
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan J. Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael L. O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center and Leonard Davis Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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O'Byrne ML, Song L, Huang J, Lemley B, Goldberg D, Gardner MM, Ravishankar C, Rome JJ, Glatz AC. Attributable mortality benefit of digoxin treatment in hypoplastic left heart syndrome after the Norwood operation: An instrumental variable-based analysis using data from the Pediatric Health Information Systems Database. Am Heart J 2023; 263:35-45. [PMID: 37169122 DOI: 10.1016/j.ahj.2023.05.005] [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: 02/11/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Observational studies have demonstrated an association between the use of digoxin and reduced interstage mortality after Norwood operation for hypoplastic left heart syndrome (HLHS). Digoxin use has increased significantly but remains variable between different hospitals, independent of case-mix. Instrumental variable analyses have the potential to overcome unmeasured confounding, the major limitation of previous observational studies and to generate an estimate of the attributable benefit of treatment with digoxin. METHODS A cohort of neonates with HLHS born from January 1, 2007 to December 31, 2021 who underwent Norwood operation at Pediatric Health Information Systems Database hospitals and survived >14 days after operation were studied. Using hospital-specific, 6-month likelihood of administering digoxin as an instrumental variable, analyses adjusting for both unmeasured confounding (using the instrumental variable) and measured confounders with multivariable logistic regression were performed. RESULTS The study population included 5,148 subjects treated at 47 hospitals of which 63% were male and 46% non-Hispanic white. Of these, 44% (n = 2,184) were prescribed digoxin. Treatment with digoxin was associated with superior 1-year transplant-free survival in unadjusted analyses (85% vs 82%, P = .02). This survival benefit persisted in an instrumental-variable analysis (OR: 0.71, 95% CI: 0.54-0.94, P = .01), which can be converted to an absolute risk reduction of 5% (number needed to treat of 20). CONCLUSIONS In this observational study of patients with HLHS after Norwood using instrumental variable techniques, a significant benefit in 1-year transplant-free survival attributable to digoxin was demonstrated. In the absence of clinical trial data, this should encourage the use of digoxin in this vulnerable population.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center For Pediatric Clinical Effectiveness, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA.
| | - Lihai Song
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bethan Lemley
- Division of Cardiology, Department of Pediatrics, Lurie Children's Hospital, Feinberg School of Medicine Northwestern University, Chicago, IL
| | - David Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Monique M Gardner
- Division of Cardiac Critical Care, The Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chitra Ravishankar
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology St. Louis Children's Hospital and Department of Pediatrics Washington University Medical School, St. Louis, MO
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Ruppel H, O'Byrne ML, Foglia EE. Mitigating Risks for Racial Bias in Pulse Oximetry on Children-Reply. JAMA Pediatr 2023; 177:982-983. [PMID: 37459108 DOI: 10.1001/jamapediatrics.2023.2295] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/06/2023]
Affiliation(s)
- Halley Ruppel
- School of Nursing, Department of Family and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael L O'Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth E Foglia
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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10
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Gartenberg AJ, Okunowo O, Dori Y, Smith CL, Gaynor JW, Mascio CE, Rome JJ, Gillespie MJ, Glatz AC, O'Byrne ML. Association of Interstage Monitoring Era and Likelihood of Hemodynamic Compromise at Intervention for Recoarctation Following the Norwood Operation. J Am Heart Assoc 2023:e029112. [PMID: 37421284 PMCID: PMC10382097 DOI: 10.1161/jaha.122.029112] [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: 12/05/2022] [Accepted: 05/10/2023] [Indexed: 07/10/2023]
Abstract
Background Intensive monitoring has been associated with a lower death rate between the Norwood operation and superior cavopulmonary connection, possibly due to early identification and effective treatment of residual anatomic lesions like recoarctation before lasting harm occurs. Methods and Results Neonates undergoing a Norwood operation and receiving interstage care at a single center between January 1, 2005, and September 18, 2020, were studied. In those with recoarctation, we evaluated association of era ([1] preinterstage monitoring, [2] a transitional phase, [3] current era) and likelihood of hemodynamic compromise (progression to moderate or greater ventricular dysfunction/atrioventricular valve regurgitation, initiation/escalation of vasoactive/respiratory support, cardiac arrest preceding catheterization, or interstage death with recoarctation on autopsy). We also analyzed whether era was associated with technical success of transcatheter recoarctation interventions, major adverse events, and transplant-free survival. A total of 483 subjects were studied, with 22% (n=106) treated for recoarctation during the interstage period. Number of catheterizations per Norwood increased (P=0.005) over the interstage eras, with no significant change in the proportion of subjects with recoarctation (P=0.36). In parallel, there was a lower likelihood of hemodynamic compromise in subjects with recoarctation that was not statistically significant (P=0.06), with a significant difference in the proportion with ventricular dysfunction at intervention (P=0.002). Rates of technical success, procedural major adverse events, and transplant-free survival did not differ (P>0.05). Conclusions Periods with interstage monitoring were associated with increased referral for catheterization but also reduced likelihood of ventricular dysfunction (and a suggestion of lower likelihood of hemodynamic compromise) in subjects with recoarctation. Further study is needed to guide optimal interstage care of this vulnerable population.
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Affiliation(s)
- Ari J Gartenberg
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Oluwatimilehin Okunowo
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit The Children's Hospital of Philadelphia Philadelphia PA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - J William Gaynor
- Division of Cardiothoracic Surgery The Children's Hospital of Philadelphia and Department of Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery Department of Surgery West Virginia University Children's Hospital West Virginia University Medical School Morgantown WV
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology St. Louis Children's Hospital St. Louis MO
- Department of Pediatrics Washington University School of Medicine St. Louis MO
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
- Clinical Futures, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
- Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
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11
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O'Byrne ML. Commentary on: "Broad- Versus Narrow-Spectrum Perioperative Antibiotics and Outcomes in Pediatric Heart Disease Surgery: Analysis of the Vizient Clinical Data Base". J Pediatric Infect Dis Soc 2023; 12:319-321. [PMID: 37389892 DOI: 10.1093/jpids/piad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 05/10/2023] [Accepted: 05/22/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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12
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Gartenberg AJ, Krishnamurthy G, Srinivasan A, Escobar FA, Brownell JN, Mamula P, O'Byrne ML, Dori Y, Smith CL. Intrahepatic and Periduodenal Embolization for Protein-Losing Enteropathy Patients With Congenital Heart Disease. J Am Coll Cardiol 2023; 81:2476-2478. [PMID: 37344050 DOI: 10.1016/j.jacc.2023.04.033] [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] [Received: 11/09/2022] [Revised: 03/27/2023] [Accepted: 04/24/2023] [Indexed: 06/23/2023]
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13
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O'Byrne ML. Patient-Reported Outcomes in Tetralogy of Fallot: The Potential of the CORRELATE Cohort. J Am Coll Cardiol 2023; 81:1951-1953. [PMID: 37164528 DOI: 10.1016/j.jacc.2023.03.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/08/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology and Clinical Futures, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA; Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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14
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Barry OM, Gudausky TM, Balzer DT, Bocks ML, Boe BA, Callahan R, El-Said H, Farias MJ, Foerster S, Goldstein BH, Holzer RJ, Janssen D, Levy P, O'Byrne ML, Rahman G, Sathanandam S, Shahanavaz S, Whiteside W, Turner ME. Safety and Short-Term Outcomes for Infants < 2.5 kg Undergoing PDA Device Closure: A C3PO Registry Study. Pediatr Cardiol 2023:10.1007/s00246-023-03147-4. [PMID: 36995404 DOI: 10.1007/s00246-023-03147-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 12/28/2022] [Accepted: 03/11/2023] [Indexed: 03/31/2023]
Abstract
To evaluate short-term procedural outcomes and safety for infants < 2.5 kg who underwent catheterization with intended patent ductus arteriosus (PDA) device closure in a multi-center registry, as performance of this procedure becomes widespread. A multi-center retrospective review was performed using data from the Congenital Cardiac Catheterization Project on Outcomes (C3PO) registry. Data were collected for all intended cases of PDA closure in infants < 2.5 kg from April 2019 to December 2020 at 13 participating sites. Successful device closure was defined as device placement at the conclusion of the catheterization. Procedural outcomes and adverse events (AE) were described, and associations between patient characteristics, procedural outcomes and AEs were analyzed. During the study period, 300 cases were performed with a median weight of 1.0 kg (range 0.7-2.4). Successful device closure was achieved in 98.7% of cases with a 1.7% incidence of level 4/5 AEs, including one periprocedural mortality. Neither failed device placement nor adverse events were significantly associated with patient age, weight or institutional volume. Higher incidence of adverse events associated with patients who had non-cardiac problems (p = 0.017) and cases with multiple devices attempted (p = 0.064). Transcatheter PDA closure in small infants can be performed with excellent short-term outcomes and safety across institutions with variable case volume.
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Affiliation(s)
- Oliver M Barry
- Division of Pediatric Cardiology, New York-Presbyterian - Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CHN-253, New York, NY, 10032, USA.
| | - Todd M Gudausky
- Division of Pediatric Cardiology, Medical College of Wisconsin and Herma Heart Institute at Children's Wisconsin, Milwaukee, WI, USA
| | | | | | - Brian A Boe
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Susan Foerster
- Division of Pediatric Cardiology, Medical College of Wisconsin and Herma Heart Institute at Children's Wisconsin, Milwaukee, WI, USA
| | | | | | - Dana Janssen
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | | | | | | | | | | | | | - Mariel E Turner
- Division of Pediatric Cardiology, New York-Presbyterian - Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CHN-253, New York, NY, 10032, USA
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15
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Wong-Siegel J, Glatz AC, McCracken C, Downing TE, Goldstein BH, Petit CJ, Qureshi AM, Nicholson GT, Law MA, Meadows J, Shahanavaz S, O'Byrne ML, Batlivala SP, Beshish A, Mascio CE, Romano JC, Stack KO, Asztalos I, Zampi J. CUMULATIVE RADIATION EXPOSURE IN NEONATES WITH SYMPTOMATIC TETRALOGY OF FALLOT REQUIRING EARLY INTERVENTION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02059-4] [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: 03/06/2023]
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16
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O'Byrne ML, Wilensky R, Glatz AC. Incorporating economic analysis in interventional cardiology research. Catheter Cardiovasc Interv 2023; 101:122-130. [PMID: 36480805 DOI: 10.1002/ccd.30506] [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: 07/19/2022] [Revised: 11/08/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022]
Abstract
Evaluative research in interventional cardiology has focused on clinical and technical outcomes. Inclusion of economic data can enhance evaluative research by quantifying the relative economic burden incurred by different therapies. When combined with clinical outcomes, cost data can provide a measure of value (e.g., marginal cost-effectiveness). In some select situations, cost data can also be used as surrogates for complexity of care and morbidity. In this narrative review, we aim to provide a framework for the application of cost data in clinical trials and observational research, detailing how to incorporate this kind of data into interventional cardiology research.
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Affiliation(s)
- Michael L O'Byrne
- Department of Pediatrics, Division of Cardiology and Clinical Futures, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute For Healthcare Economics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Wilensky
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Internal Medicine, Division of Cardiology, The Hospital of The University of Pennsylvania, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, and St. Louis Children's Hospital, St. Louis, Missouri, USA
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17
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Janson CM, Shah MJ, Kennedy KF, Iyer VR, Behere S, Sweeten TL, O'Byrne ML. Association of Weight With Ablation Outcomes in Pediatric Wolff-Parkinson-White: Analysis of the NCDR IMPACT Registry. JACC Clin Electrophysiol 2023; 9:73-84. [PMID: 36697203 DOI: 10.1016/j.jacep.2022.08.023] [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: 02/15/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Guidelines for electrophysiology study (EPS) and catheter ablation in Wolff-Parkinson-White (WPW) are age based, but size may be a more relevant factor in determination of outcomes. OBJECTIVES The goal of this study was to evaluate the association of patient weight with outcomes of catheter ablation for pediatric WPW. METHODS A multicenter retrospective cohort study was performed on children aged 1 to 21 years with WPW and first-time EPS from April 2016 to December 2019 recorded in the IMPACT (Improving Pediatric and Adult Congenital Treatment) registry, excluding those with congenital heart disease, cardiomyopathy, and >1 ablation target. A weight threshold of 30 kg was selected, representing 1 SD below the cohort mean. The primary outcome was major adverse events (MAEs); additional outcomes included deferred ablation, use of cryoablation, and ablation success. RESULTS A total of 4,456 subjects from 84 centers were evaluated, with 14% weighing <30 kg. Subjects weighing <30 kg were more likely to have preprocedural supraventricular tachycardia (45% vs 29%; P < 0.001) and less likely to have right septal accessory pathways (25% vs 33%; P < 0.001). MAEs were rare, although with higher incidence in the <30 kg cohort (0.3% vs 0.05%; P = 0.04). No difference was seen in likelihood of deferred ablation (9% vs 12%; P = 0.07) or use of cryoablation (11% vs 11%; P = 0.70). Success was higher in the <30 kg cohort: 95% vs 92% (P = 0.009). This effect persisted after adjusting for covariates (odds ratio: 1.6; 95% CI: 1.01-2.70; P = 0.046). CONCLUSIONS Weight <30 kg was associated with a small but elevated risk of MAEs. Rates of deferred ablation and cryoablation were similar. Adjusting for factors (including accessory pathway type and location), weight <30 kg remained an independent predictor of acute success.
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Affiliation(s)
- Christopher M Janson
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Maully J Shah
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin F Kennedy
- Mid America Heart Institute and St. Luke's Health System, Kansas City, Missouri, USA
| | - V Ramesh Iyer
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shashank Behere
- Division of Cardiology, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Tammy L Sweeten
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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18
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Yeh MJ, Bergersen L, Gauvreau K, Barry OM, Batlivala SP, Bjornlund E, Boe B, Caneo LF, Croti UA, Doyle T, Furnaz S, Moraes RC, O'Byrne ML, de Oliveira Paes E, Palacios-Macedo A, Pechilkov D, Sandoval NF, Sen S, Stajevic M, Travessa MAF, Jenkins KJ. COVID-19 international experience in paediatric patients with congenital heart disease. Heart 2022; 109:710-718. [PMID: 36598072 DOI: 10.1136/heartjnl-2022-321208] [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] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE As COVID-19 continues to affect the global population, it is crucial to study the impact of the disease in vulnerable populations. This study of a diverse, international cohort aims to provide timely, experiential data on the course of disease in paediatric patients with congenital heart disease (CHD). METHODS Data were collected by capitalising on two pre-existing CHD registries, the International Quality Improvement Collaborative for Congenital Heart Disease: Improving Care in Low- and Middle-Income Countries and the Congenital Cardiac Catheterization Project on Outcomes. 35 participating sites reported data for all patients under 18 years of age with diagnosed CHD and known COVID-19 illness during 2020 identified at their institution. Patients were classified as low, moderate or high risk for moderate or severe COVID-19 illness based on patient anatomy, physiology and genetic syndrome using current published guidelines. Association of risk factors with hospitalisation and intensive care unit (ICU) level care were assessed. RESULTS The study included 339 COVID-19 cases in paediatric patients with CHD from 35 sites worldwide. Of these cases, 84 patients (25%) required hospitalisation, and 40 (12%) required ICU care. Age <1 year, recent cardiac intervention, anatomical complexity, clinical cardiac status and overall risk were all significantly associated with need for hospitalisation and ICU admission. A multivariable model for ICU admission including clinical cardiac status and recent cardiac intervention produced a c-statistic of 0.86. CONCLUSIONS These observational data suggest risk factors for hospitalisation related to COVID-19 in paediatric CHD include age, lower functional cardiac status and recent cardiac interventions. There is a need for further data to identify factors relevant to the care of patients with CHD who contract COVID-19 illness.
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Affiliation(s)
- Mary J Yeh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lisa Bergersen
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Oliver M Barry
- The Congenital Heart Center, New York Presbyterian/Morgan Stanley Children's Hospital, New York, New York, USA
| | - Sarosh P Batlivala
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center Heart Institute, Cincinnati, Ohio, USA
| | - Elsa Bjornlund
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Brian Boe
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Luiz Fernando Caneo
- Department of Cardiovascular Surgery, Instituto do Coracao do Hospital das Clinicas de Universidade de São Paulo, São Paulo, Brazil
| | - Ulisses A Croti
- Department of Pediatrics and Pediatric Surgery, CardioPedBrasil Children's Heart Center, Hospital da Criança e Maternidade FUNFARME/FAMERP São José do Rio Preto, São Paulo, Brazil
| | - Thomas Doyle
- Division of Pediatric Cardiology, Monroe Carell Junior Children's Hospital at Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shumaila Furnaz
- Research Department, National Institute of Cardiovascular Disease, Karachi, Pakistan
| | - Rodrigo Cesar Moraes
- Dr. Carlos Alberto Studart Gomes Hospital, Hospital de Messejana, Fortaleza, Brazil
| | - Michael L O'Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Alexis Palacios-Macedo
- Department of Pediatric Cardiac Surgery, American British Cowdray Medical Center IAP, Mexico City, Mexico
| | - Dimitar Pechilkov
- Department of Pediatric Cardiology, Multiprofile Hospital for Active Treatment National Cardiology Hospital, Sofiâ, Bulgaria
| | - Nestor Fernando Sandoval
- Department of Cardiac Surgery, Fundación Cardioinfantil de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Supratim Sen
- Department of Pediatric Cardiology, Narayana Health SRCC Children's Hospital, Mumbai, Maharashtra, India
| | - Mila Stajevic
- Department for Pediatric Cardiothoracic Surgery, Mother and Children Health Institute, Belgrade, Siberia, Russian Federation
| | | | - Kathy J Jenkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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19
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Yeh MJ, Gauvreau K, Armstrong AK, Batlivala SP, Callahan R, Gudausky TM, Hainstock MR, Hasan B, Nicholson GT, O'Byrne ML, Shahanavaz S, Trucco S, Zampi JD, Bergersen L. Early Postoperative Congenital Cardiac Catheterization Outcomes: A Multicenter Study. Ann Thorac Surg 2022:S0003-4975(22)01528-4. [PMID: 36481325 DOI: 10.1016/j.athoracsur.2022.11.028] [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] [Received: 06/30/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Early postoperative catheterizations (EPOCs) within 6 weeks after a congenital heart surgical procedure can treat residual lesions and provide important clinical information. However, EPOCs are often assumed to impose additional risk on a vulnerable patient population. This study aimed to describe the EPOC population, evaluate procedural safety, compare EPOC patients with procedure-matched non-EPOC patients, and determine risk factors for poor outcomes using data from the Congenital Cardiac Catheterization Project on Outcomes registry. METHODS In a retrospective cohort, demographic, clinical, and procedural characteristics were analyzed for diagnostic and interventional catheterizations performed in 13 participating institutions from January 2014 to December 2017, excluding patients after heart transplant. The primary outcome was a high-severity adverse event (AE). Three distinct analyses included (1) describing the full cohort and EPOC patients, (2) comparing EPOC patients with and without a high-severity AE, and (3) comparing EPOC patients with controls matched on case type. RESULTS This study included 17,776 catheterizations, with 1399 EPOCs. The high-severity AE rate was 6.4% overall, 8.9% in the EPOC cohort, and 8.4% in matched controls (P = .74). The association between EPOC status and high-severity AE was not significant in a multivariable model (P = .17). In EPOCs with a high-severity AE, median procedure duration was 30 minutes longer (P < .001), and median time from surgical procedure to catheterization was 3 days longer (P = .05). CONCLUSIONS EPOC was not associated with additional risk. Individual patient characteristics of size and hemodynamic vulnerability may serve as informative predictors. Timely catheterization may preempt further clinical deterioration, and intraprocedure duration optimization may correlate with improved outcomes.
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Affiliation(s)
- Mary J Yeh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Sarosh P Batlivala
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Todd M Gudausky
- Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin; Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Michael R Hainstock
- Division of Pediatric Cardiology, University of Virginia Children's Heart Center, Charlottesville, Virginia
| | - Babar Hasan
- Department of Pediatric and Child Health, The Aga Khan University, Karachi, Pakistan
| | - George T Nicholson
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael L O'Byrne
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shabana Shahanavaz
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sara Trucco
- Division of Pediatric Cardiology, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey D Zampi
- Division of Pediatric Cardiology, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Lisa Bergersen
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.
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20
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Dietzman TW, Soria S, DePaolo J, Gillespie MJ, Mascio C, Dori Y, O'Byrne ML, Rome JJ, Glatz AC. Influence of Antegrade Pulmonary Blood Flow on Outcomes of Superior Cavopulmonary Connection. Ann Thorac Surg 2022; 114:1771-1777. [PMID: 35341786 DOI: 10.1016/j.athoracsur.2022.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 11/14/2021] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND We sought to characterize short- and long-term outcomes after superior cavopulmonary connection (SCPC) in children eligible for inclusion of antegrade pulmonary blood flow (APBF) in the SCPC circuit, exploring whether maintaining APBF was associated with outcomes. METHODS This was a retrospective cohort study of patients with single-ventricle heart disease and APBF who underwent SCPC at our center between January 1, 2000, and September 30, 2017. Patients were divided into 2 groups: APBF eliminated (APBF-), and APBF maintained (APBF+) at the time of SCPC. RESULTS Of 149 patients, 108 (72.5%) were in APBF- and 41 (27.5%) were in APBF+. Of those in APBF+, 5 (12.2%) subsequently had APBF eliminated after SCPC. Patients in APBF+ had a higher prevalence of chest tube duration >10 days and underwent more interventions during the post-SCPC hospitalization (1.9% vs 12%; P = .008 for both) but had shorter surgical support times at SCPC (P < .0001). There were no differences in post-SCPC intensive care unit or hospital length of stay. During the study period, 82 patients (76%) in APBF- and 22 patients (54%) in APBF+ underwent Fontan completion. Patients in APBF+ had a greater weight gain from SCPC to Fontan (6.7 [1.8-22] kg vs 8.15 [4.4-20.6] kg; P = .012) and a shorter hospital length of stay after Fontan (9 [4-107] days vs 7.5 [4-14] days; P = .044). CONCLUSIONS Short-term morbidity associated with maintaining APBF at the time of SCPC is modest, but longer term outcomes suggest potential benefits in those in whom APBF can be successfully maintained.
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Affiliation(s)
- Thomas W Dietzman
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Stefania Soria
- Division of Cardiology, Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
| | - John DePaolo
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Matthew J Gillespie
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yoav Dori
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jonathan J Rome
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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21
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Nash D, Katcoff H, Faerber J, Iyer VR, Shah MJ, O'Byrne ML, Janson C. Impact of Device Miniaturization on Insertable Cardiac Monitor Use in the Pediatric Population: An Analysis of the MarketScan Commercial and Medicaid Databases. J Am Heart Assoc 2022; 11:e024112. [PMID: 35929446 PMCID: PMC9496290 DOI: 10.1161/jaha.121.024112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Insertable cardiac monitors (ICMs) are effective in the detection of paroxysmal arrhythmias. In 2014, the first miniaturized ICM was introduced with a less invasive implant technique. The impact of this technology on ICM use in pediatric patients has not been evaluated. We hypothesized an increase in annual pediatric ICM implants starting in 2014 attributable to device miniaturization. Methods and Results A retrospective observational study was conducted using administrative claims from MarketScan Medicaid and commercial insurance claims databases. Use of ICM between January 2013 and December 2018 was measured (normalized to the total enrolled population ≤18 years) and compared with balancing measures (Holter ambulatory monitors, cardiac event monitors, encounters with syncope diagnosis, implantation of implantable cardioverter‐defibrillator/pacemaker). Secondary analyses included evaluations of subsequent interventions and complications. The study cohort included 33 532 185 individual subjects, of which 769 (0.002%) underwent ICM implantation. Subjects who underwent ICM implantation were 52% male sex, with a median age of 16 years (interquartile range, 10–17 years). A history of syncope was present in 71%, palpitations in 43%, and congenital heart disease in 28%. Following release of the miniaturized ICM, use of ICMs increased from 5 procedures per million enrollees in 2013 to 11 per million between 2015 and 2018 (P<0.001), while balancing measures remained static. Of 394 subjects with ≥1 year of follow‐up after implantation, interventions included catheter ablation in 24 (6%), pacemaker implantation in 15 (4%), and implantable cardioverter‐defibrillator implantation in 7 (2%). Conclusions Introduction of the miniaturized ICM was followed by a rapid increase in pediatric use. The effects on outcomes and value deserve further attention.
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Affiliation(s)
- Dustin Nash
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Jennifer Faerber
- Data Science and Biostatistics Unit The Children's Hospital of Philadelphia PA
| | - V Ramesh Iyer
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Maully J Shah
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
| | - Christopher Janson
- Division of Cardiology The Children's Hospital of Philadelphia PA.,Department of Pediatrics The Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
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22
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Smith CL, Dori Y, O'Byrne ML, Glatz AC, Gillespie MJ, Rome JJ. Transcatheter Thoracic Duct Decompression for Multicompartment Lymphatic Failure After Fontan Palliation. Circ Cardiovasc Interv 2022; 15:e011733. [PMID: 35708032 DOI: 10.1161/circinterventions.121.011733] [Citation(s) in RCA: 1] [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 Lymphatic embolization therapy has proven effective for Fontan failure from plastic bronchitis or protein-losing enteropathy but not when multiple lymphatic compartments are involved; furthermore, embolization does not alter the underlying pathophysiology of lymphatic dysfunction. A technique for transcatheter thoracic duct decompression (TDD), rerouting the thoracic duct to the pulmonary venous atrium to treat multicompartment lymphatic failure is described and early outcomes presented. METHODS Initially covered stents were used to channel the innominate vein flow inside of the cavopulmonary pathway into the pulmonary venous atrium. A modified approach was developed where covered stents redirected innominate vein directly to the left atrium via an extravascular course. Baseline and follow-up data on all patients undergoing TDD were reviewed. RESULTS Twelve patients underwent TDD between March 2018 and February 2021 at a median age of 12 (range: 2-22) years. Lymphatic failure occurred in median of 3 compartments per patient (protein-losing enteropathy, ascites, pleural effusions, plastic bronchitis); 10 patients had lymphatic embolizations before TDD. TDD method was intra-Fontan tunnel in 4, direct approach in 7, and other in 1. There were no major procedural complications; 6 patients underwent subsequent procedures, most commonly to treat endoleaks. Lymphatic failure resolved in 6 patients, improved in 2, and was unchanged in 4 at 6 (range: 1-20) months follow-up. One patient died after TDD from Fontan failure. CONCLUSIONS TDD is a promising new treatment for the failing Fontan physiology from multicompartment lymphatic failure. Additional work is needed to refine the technique and define optimal candidates.
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Affiliation(s)
- Christopher L Smith
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Yoav Dori
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Michael L O'Byrne
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Andrew C Glatz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Matthew J Gillespie
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Jonathan J Rome
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
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23
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Lemley BA, Wu L, Roberts AL, Shinohara RT, Smith CL, Dori Y, Rome JJ, Gillespie MJ, Glatz AC, O'Byrne ML. Abstract 45: Trends In Ductal Arteriosus Stent Versus Blalock-Thomas-Taussig Shunt Utilization In Neonates With Ductal-dependent Pulmonary Blood Flow. Circ Cardiovasc Qual Outcomes 2022. [DOI: 10.1161/circoutcomes.15.suppl_1.45] [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: 11/16/2022]
Abstract
Background:
Neonates with cyanotic congenital heart disease (CHD) and ductal-dependent pulmonary blood flow require a life-saving intervention soon after birth. The modified Blalock-Thomas-Taussig shunt (BTTS) is a well-established palliative intervention for securing pulmonary blood flow. More recently, development of the ductus arteriosus stent (DAS) has presented an alternative option. There is no consensus regarding the optimal strategy. Observational studies have not demonstrated clear differences in mortality or unplanned reintervention for cyanosis between DAS and BTTS, with DAS associated with shorter length of stay but greater likelihood of other reinterventions.
Objective:
To examine trends in DAS versus BTTS utilization in a cohort of US neonates with cyanotic CHD.
Methods:
An observational study of neonates undergoing DAS or BTTS within 30 days of birth discharged 1/2017-12/2020 was performed using the Pediatric Health Information Systems database. Mixed-effects multivariate regression was used to adjust for patient characteristics and center-level covariance.
Results:
A total of 2143 subjects from 39 centers were studied (29% DAS). The proportion of DAS increased over the study period (PANEL A). Prematurity (OR 2.0, p<0.001), genetic anomalies (OR 1.2, p=0.02), and pulmonary atresia (OR 2.1, p<0.001) were associated with increased odds of performing DAS over of BTTS. Adjusting for measurable confounders, the odds of DAS increased significantly over time (OR 1.3 per year, p<0.001, PANEL B). However, there was significant intra-hospital practice variation not explained by differences in case-mix (MOR 3.48, 95% CI 2.58-5.15).
Conclusion:
Utilization of DAS is increasing overall. However, there remains significant variability in practice across US pediatric hospitals. Studies guiding optimal patient selection for DAS and BTTS are warranted.
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Affiliation(s)
| | - Lezhou Wu
- Children's Hosp of Philadelphia, Philadelphia, PA
| | | | | | | | - Yoav Dori
- Children's Hosp of Philadelphia, Philadelphia, PA
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24
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O'Byrne ML, Glatz AC, Huang YSV, Kelleman MS, Petit CJ, Qureshi AM, Shahanavaz S, Nicholson GT, Batlivala S, Meadows JJ, Zampi JD, Law MA, Romano JC, Mascio CE, Chai PJ, Maskatia S, Asztalos IB, Beshish A, Pettus J, Pajk AL, Healan SJ, Eilers LF, Merritt T, McCracken CE, Goldstein BH. Comparative Costs of Management Strategies for Neonates With Symptomatic Tetralogy of Fallot. J Am Coll Cardiol 2022; 79:1170-1180. [PMID: 35331412 DOI: 10.1016/j.jacc.2021.12.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 10/07/2021] [Revised: 11/22/2021] [Accepted: 12/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recent data have demonstrated that overall mortality and adverse events are not significantly different for primary repair (PR) and staged repair (SR) approaches to management of neonates with symptomatic tetralogy of Fallot (sTOF). Cost data can be used to compare the relative value (cost for similar outcomes) of these approaches and are a potentially more sensitive measure of morbidity. OBJECTIVES This study sought to compare the economic costs associated with PR and SR in neonates with sTOF. METHODS Data from a multicenter retrospective cohort study of neonates with sTOF were merged with administrative data to compare total costs and cost per day alive over the first 18 months of life in a propensity score-adjusted analysis. A secondary analysis evaluated differences in department-level costs. RESULTS In total, 324 subjects from 6 centers from January 2011 to November 2017 were studied (40% PR). The 18-month cumulative mortality (P = 0.18), procedural complications (P = 0.10), hospital complications (P = 0.94), and reinterventions (P = 0.22) did not differ between PR and SR. Total 18-month costs for PR (median $179,494 [IQR: $121,760-$310,721]) were less than for SR (median: $222,799 [IQR: $167,581-$327,113]) (P < 0.001). Cost per day alive (P = 0.005) and department-level costs were also all lower for PR. In propensity score-adjusted analyses, PR was associated with lower total cost (cost ratio: 0.73; P < 0.001) and lower department-level costs. CONCLUSIONS In this multicenter study of neonates with sTOF, PR was associated with lower costs. Given similar overall mortality between treatment strategies, this finding suggests that PR provides superior value.
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Affiliation(s)
- Michael L O'Byrne
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center For Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Andrew C Glatz
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center For Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yuan-Shung V Huang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael S Kelleman
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher J Petit
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA; Division of Cardiology, Morgan Stanley Children's Hospital of New York, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Athar M Qureshi
- Lillie Frank Abercrombie Section on Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Shabana Shahanavaz
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA; Heart Center, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - George T Nicholson
- Division of Cardiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Shawn Batlivala
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Jeffery J Meadows
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jeffrey D Zampi
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark A Law
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jennifer C Romano
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher E Mascio
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul J Chai
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shiraz Maskatia
- Betty Irene Moore Children's Heart Center, Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ivor B Asztalos
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Asaad Beshish
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joelle Pettus
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amy L Pajk
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Steven J Healan
- Division of Cardiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lindsay F Eilers
- Lillie Frank Abercrombie Section on Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Taylor Merritt
- Heart Center, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Courtney E McCracken
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Bryan H Goldstein
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA; Heart Institute, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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25
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Berger JH, Faerber JA, Chen F, Lin KY, Brothers JA, O'Byrne ML. Adherence With Lipid Screening Guidelines in Children With Acquired and Congenital Heart Disease: An Observational Study Using Data From The MarketScan Commercial and Medicaid Databases. J Am Heart Assoc 2022; 11:e024197. [PMID: 35301862 PMCID: PMC9075474 DOI: 10.1161/jaha.121.024197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Universal lipid screening in children provides an opportunity to mitigate the lifetime risk of atherosclerosis, particularly in children with chronic conditions that are predisposed to early atherosclerosis. In response, national guidelines recommend additional early screening in a subset of cardiac conditions. The penetration of such guidelines has not been evaluated. Methods and Results We performed a retrospective study of a geographically representative sample of US children using the MarketScan Commercial and Medicaid claims databases. The study population was children with cardiac disease between ages 2 and 18 years and ≥3 years of continuous coverage from January 1, 2013, to June 30, 2018, divided into 4 major strata of heart disease. We assessed the likelihood of screening between these classifications and compared with healthy children and calculated multivariate models to identify patient factors associated with screening likelihood. Of the eligible 8.4 million children, 155 000 children had heart disease, of which 1.8% (31 216) had high‐risk conditions. Only 17.5% of healthy children underwent lipid screening. High‐risk children were more likely to be screened (odds ratio [OR], 2.1; 95% CI, 2.09–2.19; P<0.001) than standard‐risk children, but that likelihood varied depending on strata of cardiac disease (22%–77%). Timing of screening also varied, with most occurring between ages 9 and 11 years. Among cardiac conditions, heart transplantation (OR, 16.8; 95% CI, 14.4–19.7) and cardiomyopathy (OR, 2.9; 95% CI, 2.8–3.1) were associated with the highest likelihood of screening. Conclusions Children with cardiac disease are more likely to undergo recommended lipid screening than healthy children, but at lower rates and later ages than recommended, highlighting the importance of quality improvement and advocacy for this vulnerable population.
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Affiliation(s)
- Justin H Berger
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Jennifer A Faerber
- Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Feiyan Chen
- Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Kimberly Y Lin
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Julie A Brothers
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Data Science and Biostatistics Unit The Children's Hospital of Philadelphia Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA.,Leonard Davis Institute for Health Economics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
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26
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Chaszczewski KJ, Nicholson GT, Shahanavaz S, Dori Y, Gillespie MJ, O'Byrne ML, Rome JJ, Glatz AC. Stent Angioplasty for Post-Operative Coronary Artery Stenosis in Infants. World J Pediatr Congenit Heart Surg 2022; 13:203-207. [PMID: 35238698 DOI: 10.1177/21501351221074617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION While frequently performed in the adult population, percutaneous coronary artery stent angioplasty (CSA) in infants is rare. CSA in infants is challenging because of limited options in terms of appropriately sized (length and diameter) stents, concern about stenting vessels with significant growth potential and limited data regarding durability of benefit. We report a multicenter case series of infants who underwent CSA. METHODS A multicenter, retrospective case series of infants who underwent percutaneous CSA to treat post-operative coronary artery stenoses was performed. RESULTS Six infants from 3 institutions who underwent post-operative CSA were identified. The anatomic diagnoses were d-transposition of the great arteries in 3 cases, anomalous left coronary artery from the pulmonary artery in 2 and supravalvar aortic stenosis in 1. All infants were critically ill at the time of CSA. Diameters of coronary artery stents used ranged from 2.25 to 2.75 mm. There were no procedural complications. All stents were patent immediately after placement and the clinical condition improved or stabilized in all patients. Follow-up angiography was available for 3 patients at 4 to 16 months post-CSA, at which time 67% (2/3) remained patent. CONCLUSION CSA is a feasible and effective therapy for critically ill infants with post-surgical coronary obstruction. Treatment appears to allow at least short-term reperfusion to facilitate recovery of ventricular function and potential development of collateral circulation when longer-term stent patency is not achieved. Longer-term stent patency and coronary artery health remain unanswered questions.
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Affiliation(s)
- Kasey J Chaszczewski
- 5506Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,Section of Pediatric Cardiology, The Herma Heart Institute, Milwaukee, WI, USA.,6572Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - George T Nicholson
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Shabana Shahanavaz
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA. Work completed at: Department of Pediatrics, Division of Cardiology, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Yoav Dori
- 6572Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew J Gillespie
- 6572Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael L O'Byrne
- 6572Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,6567Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan J Rome
- 6572Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew C Glatz
- 6572Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,6567Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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27
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Vaiyani D, Saravanan M, Dori Y, Pinto E, Gillespie MJ, Rome JJ, Goldberg DJ, Smith CL, O'Byrne ML, DeWitt AG, Ravishankar C. Post-operative Chylothorax in Patients with Repaired Transposition of the Great Arteries. Pediatr Cardiol 2022; 43:685-690. [PMID: 34841467 DOI: 10.1007/s00246-021-02774-z] [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: 06/25/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
Patients with dextro-transposition of the great arteries (d-TGA) require surgical repair as neonates. These patients are at risk for post-operative chylothorax. We sought to describe the presentation, imaging, and outcomes after intervention for patients with d-TGA with post-operative chylothorax. A retrospective chart review was performed in patients with repaired d-TGA who were referred from 1/1/2013 to 4/1/2020 for evaluation of chylothorax. Patient history, lymphatic imaging, and interventional data were collected. Impact of intervention on lymphatic drainage was evaluated with a student's t-test. Eight patients met inclusion criteria for this study. Five patients had a history of central venous thrombus leading to thoracic duct outlet occlusion. Five patients underwent intervention, two were managed conservatively, and one was not a candidate for intervention. Chylothorax resolved in six patients. There was a significant difference in output from 7 days prior to first intervention (114 mL/kg/day) compared to 28 days following final intervention (27 mL/kg/day, p = 0.034). There were no procedural complications. Chylothorax in patients with repaired transposition of the great arteries is often amenable to intervention. Early surveillance and management of central venous thrombosis may reduce the burden of lymphatic disease in these patients.
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Affiliation(s)
- Danish Vaiyani
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Madhumitha Saravanan
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Erin Pinto
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Matthew J Gillespie
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Jonathan J Rome
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - David J Goldberg
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Christopher L Smith
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael L O'Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Aaron G DeWitt
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
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28
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O'Byrne ML, Faerber JA, Katcoff H, Huang J, Edelson JB, Finkelstein DM, Lemley BA, Janson CM, Avitabile CM, Glatz AC, Goldberg DJ. Prevalent pharmacotherapy of US Fontan survivors: A study utilizing data from the MarketScan Commercial and Medicaid claims databases. Am Heart J 2022; 243:158-166. [PMID: 34582777 PMCID: PMC8819625 DOI: 10.1016/j.ahj.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 06/30/2021] [Accepted: 09/23/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Survivors of Fontan palliation are at life-long risk of thrombosis, arrhythmia, and circulatory failure. To our knowledge, no studies have evaluated current United States pharmaceutical prescription practice in this population. METHODS A retrospective observational study evaluating the prevalent use of prescription medications in children and adolescents with hypoplastic left heart syndrome or tricuspid atresia after Fontan completion (identified using ICD9/10 codes) was performed using data contained in the MarketScan Commercial and Medicaid databases for the years 2013 through 2018. Cardiac pharmaceuticals were divided by class. Anticoagulant agents other than platelet inhibitors, which are not uniformly a prescription medication, were also studied. Associations between increasing age and the likelihood of a filled prescription for each class of drug were evaluated. Annualized retail costs of pharmaceutical regimens were calculated. RESULTS A cohort of 4,056 subjects (median age 12 years [interquartile range: 8-16], 61% male, 60% commercial insurance) was identified. Of the cohort, 50% received no prescription medications. Angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) (38%), diuretics (15%), and mineralocorticoid receptor antagonists (8%) were prescribed with the highest frequency. Pulmonary vasodilators were received by 6% of subjects. Older age was associated with increased likelihood of filled prescriptions for anticoagulants (P = .008), antiarrhythmic agents, digoxin, ACEi/ARB, and beta blockers (each P < .0001), but also lower likelihood of filled prescriptions for pulmonary vasodilators, conventional diuretics (both P < .0001), and mineralocorticoid receptor antagonists (P = .02). CONCLUSIONS Pharmaceuticals typically used to treat heart failure and pulmonary hypertension are the most commonly prescribed medications following Fontan palliation. While the likelihood of treatment with a particular class of medication is associated with the age of the patient, determining the optimal regimen for individual patients and the population at large is an important knowledge gap for future research.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness at The Children's Hospital of Philadelphia, Philadelphia, PA; Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA.
| | - Jennifer A Faerber
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hannah Katcoff
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan B Edelson
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA
| | - David M Finkelstein
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Bethan A Lemley
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christopher M Janson
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Catherine M Avitabile
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness at The Children's Hospital of Philadelphia, Philadelphia, PA
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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29
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Quinn BP, Yeh M, Gauvreau K, Ali F, Balzer D, Barry O, Batlivala S, Berman D, Foerster S, Goldstein B, Hainstock M, Holzer R, Janssen D, O'Byrne ML, Shirley L, Trucco S, Whiteside W, Bergersen L. Procedural Risk in Congenital Cardiac Catheterization (PREDIC 3T). J Am Heart Assoc 2021; 11:e022832. [PMID: 34935425 PMCID: PMC9075192 DOI: 10.1161/jaha.121.022832] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Advancements in the field, including novel procedures and multiple interventions, require an updated approach to accurately assess patient risk. This study aims to modernize patient hemodynamic and procedural risk classification through the creation of risk assessment tools to be used in congenital cardiac catheterization. Methods and Results Data were collected for all cases performed at sites participating in the C3PO (Congenital Cardiac Catheterization Project on Outcomes) multicenter registry. Between January 2014 and December 2017, 23 119 cases were recorded in 13 participating institutions, of which 88% of patients were <18 years of age and 25% <1 year of age; a high‐severity adverse event occurred in 1193 (5.2%). Case types were defined by procedure(s) performed and grouped on the basis of association with the outcome, high‐severity adverse event. Thirty‐four unique case types were determined and stratified into 6 risk categories. Six hemodynamic indicator variables were empirically assessed, and a novel hemodynamic vulnerability score was determined by the frequency of high‐severity adverse events. In a multivariable model, case‐type risk category (odds ratios for category: 0=0.46, 1=1.00, 2=1.40, 3=2.68, 4=3.64, and 5=5.25; all P≤0.005) and hemodynamic vulnerability score (odds ratio for score: 0=1.00, 1=1.27, 2=1.89, and ≥3=2.03; all P≤0.006) remained independent predictors of patient risk. Conclusions These case‐type risk categories and the weighted hemodynamic vulnerability score both serve as independent predictors of patient risk for high‐severity adverse events. This contemporary procedure‐type risk metric and weighted hemodynamic vulnerability score will improve our understanding of patient and procedural outcomes.
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Affiliation(s)
- Brian P Quinn
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Mary Yeh
- Department of Cardiology Boston Children's Hospital Boston MA
| | | | - Fatima Ali
- Section of Pediatric Cardiology Department of Pediatrics and Child Health The Aga Khan University Hospital Karachi Pakistan
| | - David Balzer
- Division of Pediatric Cardiology St. Louis Children's Hospital St. Louis MO
| | - Oliver Barry
- The Congenital Heart Center New York Presbyterian/Morgan Stanley Children's Hospital New York NY
| | - Sarosh Batlivala
- The Heart Institute Cincinnati Children's Hospital Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Darren Berman
- The Heart Center Nationwide Children's Hospital Columbus OH
| | - Susan Foerster
- Division of Pediatric Cardiology Children's Wisconsin Milwaukee WI
| | - Bryan Goldstein
- Heart Institute UPMC Children's Hospital of Pittsburgh Pittsburgh PA.,Department of Pediatrics University of Pittsburgh School of Medicine Pittsburgh PA
| | - Michael Hainstock
- Division of Pediatric Cardiology University of Virginia Children's HospitalUniversity of Virginia Charlottesville VA
| | - Ralf Holzer
- Division of Pediatric Cardiology Department of Pediatrics Weill Cornell Medicine New York NY
| | - Dana Janssen
- Division of Pediatric Cardiology Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center Nashville TN
| | - Michael L O'Byrne
- Division of Cardiology Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Lauren Shirley
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Sara Trucco
- Heart Institute UPMC Children's Hospital of Pittsburgh Pittsburgh PA.,Department of Pediatrics University of Pittsburgh School of Medicine Pittsburgh PA
| | - Wendy Whiteside
- Division of Pediatric Cardiology University of Michigan Medical School Ann Arbor MI
| | - Lisa Bergersen
- Department of Cardiology Boston Children's Hospital Boston MA
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30
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Janson CM, Millenson ME, Okunowo O, Dai D, Christmyer Z, Tan RB, Ramesh Iyer V, Shah MJ, O'Byrne ML. Incidence of life-threatening events in children with Wolff-Parkinson-White syndrome: Analysis of a large claims database. Heart Rhythm 2021; 19:642-647. [PMID: 34902591 DOI: 10.1016/j.hrthm.2021.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 10/07/2021] [Revised: 12/06/2021] [Accepted: 12/06/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Previous estimates of life-threatening event (LTE) risk in Wolff-Parkinson-White (WPW) syndrome are limited by selection bias inherent to tertiary referral-based cohorts. OBJECTIVE This analysis sought to measure LTE incidence in children with WPW syndrome in a large contemporary representative population. METHODS A retrospective cohort study was conducted using claims data from the IBM MarketScan Research Databases, evaluating patients with WPW syndrome (age 1-18 years) from any encounter between January 1, 2013, and December 31, 2018. Subjects with congenital heart disease and cardiomyopathy were excluded. The primary outcome was diagnosis of ventricular fibrillation (VF); a composite outcome, LTE, was defined as occurrence of VF and/or cardiac arrest. VF and LTE rates were compared to matched representative controls without WPW syndrome (3:1 ratio). RESULTS The prevalence of WPW syndrome was 0.03% (8733/26,684,581) over a median follow-up of 1.6 years (interquartile range 0.7-2.9 years). Excluding congenital heart disease/cardiomyopathy, 6946 subjects were analyzed. LTE occurred in 49 subjects, including VF in 20. The incidence of VF was 0.8 events per 1000 person-years, and the incidence of LTE was 1.9 events per 1000 person-years. There were no occurrences of VF in controls; the rate of LTE was 70 times higher in patients with WPW syndrome (0.7%; 95% confidence interval 0.5%-0.9%) than in controls (0.01%; 95% confidence interval 0%-0.02%). CONCLUSION The use of a large claims data set allowed for an evaluation of VF and LTE risk in an unselected pediatric population with WPW syndrome. The observed range of 0.8-1.9 events per 1000 person-years is consistent with prior reports from selected populations. A comparison of event rates to matched controls confirms and quantifies the significant elevation in VF and LTE risk in pediatric WPW syndrome.
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Affiliation(s)
- Christopher M Janson
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Marisa E Millenson
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
| | - Oluwatimilehin Okunowo
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dingwei Dai
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
| | - Zane Christmyer
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Reina Bianca Tan
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - V Ramesh Iyer
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maully J Shah
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael L O'Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania
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31
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Lemley BA, Biko DM, Dewitt AG, Glatz AC, Goldberg DJ, Saravanan M, O'Byrne ML, Pinto E, Ravishankar C, Rome JJ, Smith CL, Dori Y. Intrahepatic Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography: Potential Imaging Signature for Protein-Losing Enteropathy in Congenital Heart Disease. J Am Heart Assoc 2021; 10:e021542. [PMID: 34569246 PMCID: PMC8649156 DOI: 10.1161/jaha.121.021542] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 12/05/2022]
Abstract
Background Protein‐losing enteropathy (PLE) is a significant cause of morbidity and mortality in congenital heart disease patients with single ventricle physiology. Intrahepatic dynamic contrast‐enhanced magnetic resonance lymphangiography (IH‐DCMRL) is a novel diagnostic technique that may be useful in characterizing pathologic abdominal lymphatic flow in the congenital heart disease population and in diagnosing PLE. The objective of this study was to characterize differences in IH‐DCMRL findings in patients with single ventricle congenital heart disease with and without PLE. Methods and Results This was a single‐center retrospective study of IH‐DCMRL findings and clinical data in 41 consecutive patients, 20 with PLE and 21 without PLE, with single ventricle physiology referred for lymphatic evaluation. There were 3 distinct duodenal imaging patterns by IH‐DCMRL: (1) enhancement of the duodenal wall with leakage into the lumen, (2) enhancement of the duodenal wall without leakage into the lumen, and (3) no duodenal involvement. Patients with PLE were more likely to have duodenal involvement on IH‐DCMRL than patients without PLE (P<0.001). Conclusions IH‐DCMRL findings of lymphatic enhancement of the duodenal wall and leakage of lymph into the duodenal lumen are associated with PLE. IH‐DCMRL is a useful new modality for characterizing pathologic abdominal lymphatic flow in PLE and might be useful as a risk‐assessment tool for PLE in at‐risk patients.
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Affiliation(s)
- Bethan A Lemley
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Dave M Biko
- Department of Radiology Children's Hospital of Philadelphia Philadelphia PA.,Department of Radiology Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Aaron G Dewitt
- Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA.,Division of Critical Care The Children's Hospital of Philadelphiae Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - David J Goldberg
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Madhumitha Saravanan
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Erin Pinto
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Chitra Ravishankar
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Jonathan J Rome
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Christopher L Smith
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Yoav Dori
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
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Chaszczewski KJ, Huang J, Fuller S, Smith CL, Dori Y, Glatz AC, Gillespie MJ, Rome JJ, O'Byrne ML. Impact of Transcatheter Pulmonary Artery Intervention Following Superior Cavopulmonary Connection on Pulmonary Artery Growth. World J Pediatr Congenit Heart Surg 2021; 12:635-642. [PMID: 34597205 DOI: 10.1177/21501351211033238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Balloon and stent angioplasty of the pulmonary arteries (PAs) are frequently performed following superior cavopulmonary connection (SCPC), not only to normalize the caliber of the affected PA but also in hopes of maximizing downstream growth over time. There are limited data on the impact on subsequent PA growth prior to total cavopulmonary connection (TCPC). METHODS A single-center, retrospective cohort study was performed on children who underwent transcatheter (TC) PA intervention following SCPC between January 1, 2010, and December 31, 2018. Growth of treated and contralateral PAs was measured at the lobar bifurcation (distal branch PA [DBPA]) and in the proximal lower lobe (lower lobe branch [LLB]) on serial angiograms. Growth rate was evaluated using a mixed-effect model clustered by individual patient with an interaction term for treated PA and time to evaluate for differential growth rates between treated and contralateral PAs. RESULTS Thirty-five patients underwent TC PA intervention following SCPC, at a median of 70 days (interquartile range: 19-297 days) postoperatively. Significant growth was seen at both DBPA and LLB for raw (0.8 mm/year, 95% CI: 0.6-1.0, P < .001 for both) and body surface area (BSA) adjusted measures (8.4mm/m2/year, 95% CI: 5.6-11.2, P < .001; 7.9 mm/m2/year, 95% CI: 5.5-10.2, P < .001). The growth rate of the treated vessel was not significantly different from that of the contralateral vessel at the DBPA or LLB positions for raw (P = .71, .70) or BSA-adjusted measurements (P = .86, .64). CONCLUSION Transcatheter PA intervention was associated with normal distal PA growth rate relative to the untreated side.
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Affiliation(s)
- Kasey J Chaszczewski
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Jing Huang
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia and Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA, USA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA, USA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, PA, USA
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O'Byrne ML, Glatz AC. Managing confounding and effect modification in pediatric/congenital interventional cardiology research. Catheter Cardiovasc Interv 2021; 98:1159-1166. [PMID: 34420250 DOI: 10.1002/ccd.29925] [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: 05/20/2021] [Revised: 07/27/2021] [Accepted: 08/01/2021] [Indexed: 11/08/2022]
Abstract
Measuring the effect of a treatment on outcomes is an important goal for research in pediatric/congenital interventional cardiology. The breadth of anatomic and physiologic variations, patient ages, and genetic syndromes and noncardiac comorbid conditions all represent sources of potential confounding and effect modification that are major obstacles to this goal. If not accounted for, these factors can obscure the "true" treatment effect and lead to spurious conclusions about the relative efficacy and/or safety of therapies. In this review, we discuss the importance of confounding and effect modification in pediatric/congenital interventional cardiology research. We define these terms and discuss strategies (both in study design and data analysis) to mitigate error introduced by confounding and effect modification. The importance of confounding by indication in pediatric/congenital cardiology is discussed along with specific methods to address it.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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O'Byrne ML, Kennedy KF, Steven JM, Hill KD, Chamberlain RC, Millenson ME, Smith CL, Dori Y, Gillespie MJ, Rome JJ, Glatz AC. Outcomes of Operator-Directed Sedation and Anesthesiologist Care in the Pediatric/Congenital Catheterization Laboratory: A Study Utilizing Data From the IMPACT Registry. JACC Cardiovasc Interv 2021; 14:401-413. [PMID: 33602437 DOI: 10.1016/j.jcin.2020.10.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/15/2020] [Accepted: 10/13/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to assess contemporary use of operator directed sedation (ODS) and anesthesiologist care (AC) in the pediatric/congenital cardiac catheterization laboratory (PCCL), specifically evaluating whether the use of operator-directed sedation was associated with increased risk of major adverse events. BACKGROUND The safety of ODS relative to AC during PCCL procedures has been questioned. METHODS A multicenter, retrospective cohort study was performed studying procedures habitually performed with ODS or AC at IMPACT (Improving Adult and Congenital Treatment) registry hospitals using ODS for ≥5% of cases. The risks for major adverse events (MAE) for ODS and AC cases were compared, adjusted for case mix. Current recommendations were evaluated by comparing the ratio of observed to expected MAE for cases in which ODS was inappropriate (inconsistent with those guidelines) with those for similar risk AC cases, as well as those in which ODS or AC was appropriate. RESULTS Of the hospitals submitting data to IMPACT, 28 of 101 met inclusion criteria. Of the 7,042 cases performed using ODS at these centers, 88% would be inappropriate. Use of ODS was associated with lower likelihood of MAE both in observed results (p < 0.0001) and after adjusting for case-mix (odds ratio: 0.81; p = 0.006). Use of AC was also associated with longer adjusted fluoroscopy and procedure times (p < 0.0001 for both). The observed/expected ratio for ODS cases with high pre-procedural risk (inappropriate for ODS) was significantly lower than that for AC cases with comparable pre-procedural risk. Across a range of pre-procedural risks, there was no stratum in which risk for MAE was lower for AC than ODS. CONCLUSIONS Across a range of hospitals, ODS was used safely and with improved efficiency. Clinical judgment better identified cases in which ODS could be used than pre-procedural risk score. This should inform future guidelines for the use of ODS and AC in the catheterization laboratory.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Kevin F Kennedy
- Mid America Heart Institute St. Luke's Health System, Kansas City, Missouri, USA
| | - James M Steven
- Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia and Department of Anesthesia Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin D Hill
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Reid C Chamberlain
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Marisa E Millenson
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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35
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O'Byrne ML, Huang J, Asztalos I, Smith CL, Dori Y, Gillespie MJ, Rome JJ, Glatz AC. Pediatric/Congenital Cardiac Catheterization Quality: An Analysis of Existing Metrics. JACC Cardiovasc Interv 2021; 13:2853-2864. [PMID: 33357522 DOI: 10.1016/j.jcin.2020.09.002] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/19/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to enumerate and categorize quality metrics relevant to the pediatric/congenital cardiac catheterization laboratory (PCCL). BACKGROUND Diagnostic and interventional catheterization procedures are an increasingly important part of the care of young patients with cardiac disease. Measurement of the performance of PCCL programs in a stringent and consistent fashion is a crucial step toward improving outcomes. To the best of our knowledge, a systematic evaluation of current quality metrics in PCCL has not been performed previously. METHODS Potential metrics were evaluated by: 1) a systematic review of peer-reviewed research; 2) a review of metrics from organizations interested in quality improvement, patient safety, and/or PCCL programs; and 3) a survey of U.S. PCCL cardiologists. Collected metrics were grouped on 2 dimensions: 1) Institute of Medicine domains; and 2) the Donabedian structure/process/outcome framework. Survey responses were dichotomized between favorable and unfavorable responses and then compared within and between categories. RESULTS In the systematic review, 6 metrics were identified (from 9 publications), all focused on safety either as an outcome (adverse events [AEs], mortality, and failure to rescue along with radiation exposure) or as a structure (procedure volume or operator experience). Four organizations measure quality metrics of PCCL programs, of which only 1 publicly reports data. For the survey, 229 cardiologists from 118 hospital programs responded (66% of individuals and 72% of hospital programs). The highest favorable ratings were for safety metrics (p < 0.001), of which major AEs, failure to rescue, and procedure-specific AEs had the highest ratings. Of respondents, 67% stated that current risk adjustment were not effective. Favorability ratings for hospital characteristics, PCCL characteristics, and quality improvement processes were significantly lower than for safety and less consistent within categories. CONCLUSIONS There is a limited number of PCCL quality metrics, primarily focused on safety. Confidence in current risk adjustment methodology is low. The knowledge gaps identified should guide future research in the development of new quality metrics.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania, USA; Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ivor Asztalos
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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36
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Faerber JA, Huang J, Zhang X, Song L, DeCost G, Mascio CE, Ravishankar C, O'Byrne ML, Naim MY, Kawut SM, Goldmuntz E, Mercer-Rosa L. Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach. Front Cardiovasc Med 2021; 8:685855. [PMID: 34368247 PMCID: PMC8339319 DOI: 10.3389/fcvm.2021.685855] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/21/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair. Methods: We conducted a single-center prospective cohort study of children <2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication. Results: Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment (N = 22, 13.6%), cardiac catheterization (N = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) (N = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models. Conclusions: Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.
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Affiliation(s)
- Jennifer A Faerber
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jing Huang
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Xuemei Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Grace DeCost
- School of Public Health, Brown University, Providence, RI, United States
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Michael L O'Byrne
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA, United States
| | - Maryam Y Naim
- Departments of Anesthesiology, Critical Care Medicine and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Steven M Kawut
- Departments of Medicine and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Smith CL, Liu M, Saravanan M, Dewitt AG, Biko DM, Pinto EM, Escobar FA, Krishnamurthy G, Brownell JN, Mamula P, Glatz AC, Gillespie MJ, O'Byrne ML, Ravishankar C, Rome JJ, Dori Y. Liver lymphatic anatomy and role in systemic lymphatic disease. Eur Radiol 2021; 32:112-121. [PMID: 34165621 PMCID: PMC8660706 DOI: 10.1007/s00330-021-08098-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/07/2021] [Accepted: 05/26/2021] [Indexed: 11/26/2022]
Abstract
Objectives To characterize hepatic to systemic lymphatic connections in patients with systemic lymphatic disease using intra-hepatic lymphangiography and to compare outcomes after lymphatic intervention. Methods In this retrospective study, patients with intra-hepatic lymphangiography from May 2014 – April 2019 at our institution were included. Imaging review was performed and hepatic lymphatic connections and flow patterns were characterized. Clinical data were reviewed and comparisons between patients undergoing lymphatic intervention with or without abnormal hepatic lymphatics were performed. Results During the study period, 105 patients underwent intra-hepatic lymphangiography. Primary clinical presentation included ascites (19/105), chylothorax (27/105), plastic bronchitis (PB) (17/105), and protein losing enteropathy (PLE) (42/105). Five categories of hepatic lymphatic connections and flow patterns were identified (%): normal (25%, 26/105), hepatoperitoneal (12%, 13/105), hepatopulmonary (10.5%, 11/105), hepatomesenteric (7.5%, 8/105), and hepatoduodenal (41%, 43/105) with four patients having more than one abnormal pattern. A comparison between clinical presentation and imaging category revealed an increased likelihood of having ascites with hepatoperitoneal (p < .0001), chylothorax/PB with hepatopulmonary (p = .01), and PLE with hepatoduodenal (p < .001) connections. Seventy-six patients had a lymphatic intervention, 24% with normal, and 76% with abnormal liver lymphatics. There was no difference in length of hospital stay or mortality between the two groups, but there was a prolonged time to symptom resolution (p = .006) and persistent symptoms after 6 months (5% vs 44%, p = .002) in the group with abnormal liver lymphatics. Conclusion We identified five liver lymphatic imaging categories with a substantial correlation to presenting lymphatic disease. Abnormal imaging patterns correlated with increased morbidity. Evaluation of liver lymphatics should be considered in patients with a systemic lymphatic disease if central lymphatic imaging is normal. Key Points • We identified five liver lymphatic imaging patterns: normal, hepatoperitoneal, hepatomesenteric, hepatopulmonary, and hepatoduodenal. • Imaging patterns were correlated with disease presentation (normal – chylothorax/PB, hepatoperitoneal – ascites/chylothorax, hepatopulmonary – chylothorax/PB, hepatoduodenal – PLE). • Abnormal imaging patterns correlated with increased morbidity. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08098-z.
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Affiliation(s)
- Christopher L Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA. .,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Mandi Liu
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Madhumitha Saravanan
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Aaron G Dewitt
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - David M Biko
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Department of Radiology, The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Erin M Pinto
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Fernando A Escobar
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Department of Radiology, The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Ganesh Krishnamurthy
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Department of Radiology, The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Jefferson N Brownell
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Gastroenterology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Petar Mamula
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Gastroenterology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Andrew C Glatz
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Matthew J Gillespie
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael L O'Byrne
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Chitra Ravishankar
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Jonathan J Rome
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
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Janson CM, Shah MJ, Kennedy KF, Iyer VR, Sweeten TL, Glatz AC, Steven JM, O'Byrne ML. Comparison of Outcomes of Pediatric Catheter Ablation by Anesthesia Strategy: A Report From the NCDR IMPACT Registry. Circ Arrhythm Electrophysiol 2021; 14:e009849. [PMID: 34137629 DOI: 10.1161/circep.121.009849] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Christopher M Janson
- Division of Cardiology, Department of Pediatrics (C.M.J., M.J.S., V.R.I., T.L.S., A.C.G., M.L.O.)
| | - Maully J Shah
- Division of Cardiology, Department of Pediatrics (C.M.J., M.J.S., V.R.I., T.L.S., A.C.G., M.L.O.)
| | - Kevin F Kennedy
- University of Pennsylvania. Mid America Heart Institute, St Luke's Health System, Kansas City, MO (K.F.K.)
| | - V Ramesh Iyer
- Division of Cardiology, Department of Pediatrics (C.M.J., M.J.S., V.R.I., T.L.S., A.C.G., M.L.O.)
| | - Tammy L Sweeten
- Division of Cardiology, Department of Pediatrics (C.M.J., M.J.S., V.R.I., T.L.S., A.C.G., M.L.O.)
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics (C.M.J., M.J.S., V.R.I., T.L.S., A.C.G., M.L.O.).,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia (A.C.G., M.L.O.)
| | - James M Steven
- Department of Anesthesia and Critical Care, Department of Anesthesia (J.M.S.)
| | - Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics (C.M.J., M.J.S., V.R.I., T.L.S., A.C.G., M.L.O.).,Center for Pediatric Clinical Effectiveness and Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research (M.L.O.).,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia (A.C.G., M.L.O.)
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Berger JH, Chen F, Faerber JA, O'Byrne ML, Brothers JA. Adherence with lipid screening guidelines in standard- and high-risk children and adolescents. Am Heart J 2021; 232:39-46. [PMID: 33229294 PMCID: PMC7854880 DOI: 10.1016/j.ahj.2020.10.058] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 06/16/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022]
Abstract
Because atherosclerosis begins in childhood, universal lipid screening is recommended with special attention to conditions predisposing to early atherosclerosis. Data about real-world penetration of these guidelines is not available. METHODS Retrospective cohort study using MarketScan® commercial and Medicaid insurance claims databases, a geographically representative sample of U.S. children. Subjects who passed through the 9- to 11-year window and had continuous insurance coverage between 1/1/2013 and 12/31/2016 were studied. Multivariable models were calculated, evaluating the association between other patient factors and the likelihood of screening. The primary hypothesis was that screening rates would be low, but that high-risk conditions would be associated with a higher likelihood of screening. RESULTS In total, 572,522 children (51% male, 33% black, 11% Hispanic, 51% Medicaid) were studied. The prevalence of high-risk conditions was 2.2%. In unadjusted and adjusted analyses, these subjects were more likely to be screened than standard-risk subjects (47% vs. 20%, OR: 3.7, 95% CI 3.5-3.8, P < .001). Within this group, the diagnosis-specific likelihood of screening varied (26-69%). Endocrinopathies (OR 5.4, 95% CI 5.2-5.7), solid organ transplants (OR 5.0, 95% CI 3.8-6.6), and metabolic disease (OR 3.9, 95% CI 3.1-5.0, all P < .001) were associated with the highest likelihood of undergoing screening. CONCLUSIONS Despite national recommendations, lipid screening was performed in a minority of children. Though subjects with high-risk conditions had a higher likelihood of screening, rates remained low. This study highlights the need for research and advocacy regarding obstacles to lipid screening of children in the United States.
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Affiliation(s)
- Justin H Berger
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Feiyan Chen
- Healthcare Analytics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer A Faerber
- Healthcare Analytics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; Leonard Davis Institute for Health Economics and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA
| | - Julie A Brothers
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Fuller S, Ramachandran A, Awh K, Faerber JA, Patel PA, Nicolson SC, O'Byrne ML, Mascio CE, Kim YY. Comparison of outcomes of pulmonary valve replacement in adult versus paediatric hospitals: institutional influence†. Eur J Cardiothorac Surg 2020; 56:891-897. [PMID: 30957859 DOI: 10.1093/ejcts/ezz102] [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: 10/22/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Controversy exists in ascertaining the ideal location for adults with congenital heart disease requiring surgical intervention. In this study, we sought to compare the perioperative management between our paediatric and adult hospitals and to determine how clinical factors and the location affect the length of stay after pulmonary valve replacement. METHODS A retrospective analysis of patients, ≥18 years of age, undergoing pulmonary valve replacement was conducted at our paediatric and adult hospitals between 1 January 2000 and 30 October 2014. Patients with previous Ross or concomitant left heart procedures were excluded. Descriptive statistics were used to assess demographics and clinical characteristics. Inverse probability weight-adjusted models were used to determine differences in the number of surgical complications, duration of mechanical ventilation and postoperative length of stay between paediatric and adult hospitals. Additional models were calculated to identify factors associated with prolonged length of stay. RESULTS There were altogether 98 patients in the adult (48 patients) and paediatric (50 patients) hospitals. Patients in the adult hospital were older with more comorbidities (arrhythmia, hypertension, depression and a history of cardiac arrest, all P < 0.05). Those at the paediatric hospital had better preoperative right ventricular function and less tricuspid regurgitation. The cardiopulmonary bypass time, the length of intubation and the length of stay were higher at the adult hospital, despite no difference in the number of complications between locations. Factors contributing to the increased length of stay include patient characteristics and postoperative management strategies. There were no deaths. CONCLUSIONS Pulmonary valve replacement may be performed safely with no deaths and with a comparable complication rate at both hospitals. Patients undergoing surgery at the adult hospital have longer intubation times and length of stay. Opportunities exist to streamline management strategies.
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Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abhinay Ramachandran
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine Awh
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer A Faerber
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yuli Y Kim
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Divison of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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O'Byrne ML, Glatz AC, Faerber JA, Seshadri R, Millenson ME, Mi L, Shinohara RT, Dori Y, Gillespie MJ, Rome JJ, Kawut SM, Groeneveld PW. Interhospital Variation in the Costs of Pediatric/Congenital Cardiac Catheterization Laboratory Procedures: Analysis of Data From the Pediatric Health Information Systems Database. J Am Heart Assoc 2020; 8:e011543. [PMID: 31023121 PMCID: PMC6512131 DOI: 10.1161/jaha.118.011543] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Cardiac catheterization is an important but costly component of health care for young patients with cardiac disease. Measurement of variation in their cost between hospitals and identification of the reasons for this variation may help reduce cost without compromising quality. Methods and Results Using data from Pediatric Health Information Systems Database from January 2007 to December 2015, the costs of 9 procedures were measured. Mixed‐effects multivariable models were used to generate case‐mix–adjusted estimates of each hospital's cost for each procedure and measure interhospital variation. Procedures (n=35 637) from 43 hospitals were studied. Median costs varied from $8249 (diagnostic catheterization after orthotopic heart transplantation) to $38 909 (transcatheter pulmonary valve replacement). There was marked variation in the cost of procedures between hospitals with 3.5‐ to 8.9‐fold differences in the case‐mix–adjusted cost between the most and least expensive hospitals. No significant correlation was found between hospitals’ procedure‐specific mortality rates and costs. Higher procedure volume was not associated with lower cost except for diagnostic procedures in heart transplant patients and pulmonary artery angioplasty. At the hospital level, the proportion of cases that were outliers (>95th percentile) was significantly associated with rank in terms of cost (Spearman's ρ ranging from 0.37 to 0.89, P<0.01). Conclusions Large‐magnitude hospital variation in cost was not explained by case‐mix or volume. Further research is necessary to determine the degree to which variation in cost is the result of differences in the efficiency of the delivery of healthcare services and the rate of catastrophic adverse outcomes and resultant protracted and expensive hospitalizations.
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Affiliation(s)
- Michael L O'Byrne
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA.,3 Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
| | - Andrew C Glatz
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Jennifer A Faerber
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Roopa Seshadri
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Marisa E Millenson
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Lanyu Mi
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Russell T Shinohara
- 4 Department of Biostatistics Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Yoav Dori
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Matthew J Gillespie
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Jonathan J Rome
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Steven M Kawut
- 5 Division of Pulmonology and Critical Care Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- 3 Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,6 Division of General Internal Medicine Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,7 Corporal Michael J. Crescenz VA Medical Center Philadelphia PA
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O'Byrne ML, DeCost G, Katcoff H, Savla JJ, Chang J, Goldmuntz E, Groeneveld PW, Rossano JW, Faerber JA, Mercer-Rosa L. Resource Utilization in the First 2 Years Following Operative Correction for Tetralogy of Fallot: Study Using Data From the Optum's De-Identified Clinformatics Data Mart Insurance Claims Database. J Am Heart Assoc 2020; 9:e016581. [PMID: 32691679 PMCID: PMC7792257 DOI: 10.1161/jaha.120.016581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization. Measuring resource utilization, specifically cost and length of stay, provides an integrated measure of morbidity not appreciable in traditional outcomes. Methods and Results We conducted a retrospective cohort study, using de‐identified commercial insurance claims data, of 269 children who underwent operative correction of tetralogy of Fallot from January 2004 to September 2015 with ≥2 years of continuous follow‐up (1) to describe resource utilization for the incident hospitalization and subsequent 2 years, (2) to determine whether prolonged length of stay (>7 days) in the incident hospitalization was associated with increased subsequent resource utilization, and (3) to explore whether there was regional variation in resource utilization with both direct comparisons and multivariable models adjusting for known covariates. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization (total cost as well as counts of outpatient visits, hospitalizations, and catheterizations) after hospital discharge (P<0.0001 for each), though the number of subsequent operative and transcatheter interventions were not significantly different. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each. Conclusions This study is the first to report short‐ and medium‐term resource utilization following tetralogy of Fallot operative correction. It also demonstrates that prolonged length of stay in the initial hospitalization is associated with increased subsequent resource utilization. This should motivate research to determine whether these differences are because of modifiable factors.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
| | - Grace DeCost
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jill J Savla
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Joyce Chang
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Division of Rheumatology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Elizabeth Goldmuntz
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- Division of General Internal Medicine Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Corporal Michael J. Crescenz VA Medical Center Philadelphia PA
| | - Joseph W Rossano
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jennifer A Faerber
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Laura Mercer-Rosa
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
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O'Byrne ML, Faerber JA, Katcoff H, Frank DB, Davidson A, Giglia TM, Avitabile CM. Variation in the use of pulmonary vasodilators in children and adolescents with pulmonary hypertension: a study using data from the MarketScan® insurance claims database. Pulm Circ 2020; 10:2045894020933083. [PMID: 35154663 PMCID: PMC8826280 DOI: 10.1177/2045894020933083] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/13/2020] [Indexed: 12/15/2022] Open
Abstract
Despite progress in pharmacotherapy in pediatric pulmonary hypertension, real-world
patterns of directed pulmonary hypertension therapy have not been studied in the current
era. A retrospective observational study of children (≤18 years) with pulmonary
hypertension was performed using data from the MarketScan® Commercial and Medicaid claims
databases. Associations between etiology of pulmonary hypertension and pharmaceutical
regimen were evaluated, as were the associations between subject social and geographic
characteristics (insurance-type, race, and/or census region) and regimen. Annualized costs
of single- and multi-class regimens were calculated. In total, 873 subjects were studied,
of which 94% received phosphodiesterase-5 inhibitors, 31% endothelin receptor antagonist,
9% prostacyclin analogs, and 7% calcium channel blockers. Monotherapy was used in 72% of
subjects. Phosphodiesterase-5 inhibitors monotherapy was the most common regimen (93%).
Subjects with idiopathic pulmonary hypertension, congenital heart disease, and
unclassified pulmonary hypertension receive more than one agent and were more likely to
receive both endothelin receptor antagonist and prostacyclin analogs than other forms of
pulmonary hypertension. Compared to recipients of public insurance, subjects with
commercial insurance were more likely to receive more intense therapy
(p = 0.003), which was confirmed in multivariable analysis (OR: 1.4,
p = 0.03). Receipt of commercial insurance was also associated with
increased annual costs across all subjects (p < 0.001) and for the
most common specific regimens. The majority of children with pulmonary hypertension
receive phosphodiesterase monotherapy, followed by phosphodiesterase–endothelin receptor
antagonist two drug regimens, and finally the addition of prostacyclin analogs for
three-drug therapy. However, even after adjustment for measurable confounders, commercial
insurance was associated with higher intensity care and higher costs (even within specific
classes of pulmonary vasodilators). The effect of these associations on clinical outcome
cannot be discerned from the current data set, but patterns of treatment deserve further
attention.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer A Faerber
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah Katcoff
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - David B Frank
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alex Davidson
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Therese M Giglia
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine M Avitabile
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Smith CL, Saul D, Goldfarb SB, Biko DM, O'Byrne ML. Compression of the left mainstem bronchus by patent ductus arteriosus in neonates under consideration for ductal stenting. Catheter Cardiovasc Interv 2020; 95:1158-1162. [PMID: 31957932 DOI: 10.1002/ccd.28735] [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: 10/23/2019] [Revised: 01/02/2020] [Accepted: 01/08/2020] [Indexed: 12/19/2022]
Abstract
Stent angioplasty of patent ductus arteriosus has been shown to be a viable alternative to operative shunt placement in cyanotic neonates. With broader implementation of this strategy, novel complications are bound to arise. We present a series of cases evaluated for ductal stent angioplasty in which a dilated and torturous ductus arteriosus compressed the left mainstem bronchus. After reviewing our recent experience with ductal stenting and isolated Blalock-Taussig shunts, our best estimate of the incidence of bronchial compression by the dilated ductus is 4.6% (3/64, 95% confidence interval 1.0-12.9%). Awareness of the airway and other nonvascular contents of the thorax is an important consideration prior to ductal stenting.
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Affiliation(s)
- Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Saul
- Department of Radiology, The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samuel B Goldfarb
- Division of Pulmonology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M Biko
- Department of Radiology, The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Leonard Davis Institute and Center For Cardiovascular Outcomes, Quality, and Evaluative Research, The University of Pennsylvania, Philadelphia, Pennsylvania
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Tomasulo CE, Gillespie MJ, Munson D, Demkin T, O'Byrne ML, Dori Y, Smith CL, Rome JJ, Glatz AC. Incidence and fate of device-related left pulmonary artery stenosis and aortic coarctation in small infants undergoing transcatheter patent ductus arteriosus closure. Catheter Cardiovasc Interv 2020; 96:889-897. [PMID: 32339400 DOI: 10.1002/ccd.28942] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/28/2020] [Accepted: 04/14/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To evaluate short- and middle-term outcomes after transcatheter patent ductus arteriosus (TC-PDA) closure in small infants, specifically device-related left pulmonary artery (LPA) stenosis and aortic coarctation, risk factors, and changes over time. BACKGROUND Recent studies have demonstrated successful transcatheter PDA (TC-PDA) closure in small infants. LPA stenosis and aortic coarctation have been seen after TC-PDA, but it is not clear whether device-related LPA/aortic obstruction persists. METHODS A single-center retrospective study of infants ≤4 kg who underwent TC-PDA closure from February 1, 2007 to September 1, 2018 was performed, evaluating the incidence and risk factors for LPA stenosis and coarctation. RESULTS Forty-four patients underwent successful TC-PDA with Amplatzer Vascular Plug II (AVPII; n = 30), Amplatzer Duct Occluder II-Additional Sizes (n = 10), Amplatzer Duct Occluder I (n = 3), and coil-filled AVPI (n = 1) devices, all via an antegrade approach. Median birthweight and procedural weight were 890 g (range: 490-3,250) and 2.8 kg (range: 1.2-4.0), respectively. Median follow-up was 0.7 years (range: 2 days-7 years). Thirty-eight patients had post-procedure echocardiograms assessing LPA/aortic obstruction. Of those, 17 had LPA flow acceleration/stenosis (≥1.5 m/s), which improved or resolved in all patients with available follow-up; 3 developed mild coarctation (>2 m/s), which improved in the two with more than short-term follow-up; 4 developed mild flow acceleration (1.5-2 m/s) in the descending aorta, which resolved in three and increased in one (2.4 m/s). Flow acceleration in the LPA was associated with younger procedural age, larger PDA minimal diameter, and placement of a device other than the AVPII. There was no device-related mortality or need for reintervention. CONCLUSION TC-PDA in small infants is effective, without significant complications. Device-related LPA/aortic obstruction can improve with time/growth.
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Affiliation(s)
- Catherine E Tomasulo
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David Munson
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Taylor Demkin
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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O'Byrne ML, Peyvandi S. Decisions, Decisions, Decisions…: A Novel Approach Helps Evaluate Potential Benefit of Fetal Aortic Valvuloplasty. Circ Cardiovasc Qual Outcomes 2020; 13:e006636. [PMID: 32252550 DOI: 10.1161/circoutcomes.120.006636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Department of Pediatrics, Leonard Davis Institute, and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, (M.L.O.)
| | - Shabnam Peyvandi
- Division of Cardiology, Departments of Pediatrics and Epidemiology & Biostatistics, UCSF Benioff Children's Hospital, San Francisco, CA (S.P.)
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47
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Ghosh RM, Griffis HM, Glatz AC, Rome JJ, Smith CL, Gillespie MJ, Whitehead KK, O'Byrne ML, Biko DM, Ravishankar C, Dewitt AG, Dori Y. Prevalence and Cause of Early Fontan Complications: Does the Lymphatic Circulation Play a Role? J Am Heart Assoc 2020; 9:e015318. [PMID: 32223393 PMCID: PMC7428641 DOI: 10.1161/jaha.119.015318] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [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: 02/02/2023]
Abstract
Background Recent studies suggest that lymphatic congestion plays a role in development of late Fontan complications, such as protein‐losing enteropathy. However, the role of the lymphatic circulation in early post‐Fontan outcomes is not well defined. Methods and Results This was a retrospective, single‐center study of patients undergoing first‐time Fontan completion from 2012 to 2017. The primary outcome was early Fontan complication ≤6 months after surgery, a composite of death, Fontan takedown, extracorporeal membrane oxygenation, chest tube drainage >14 days, cardiac catheterization, readmission, or transplant. Complication causes were assigned to 1 of 4 groups: (1) Fontan circuit obstruction, (2) ventricular dysfunction or atrioventricular valve regurgitation, (3) persistent pleural effusions in the absence of Fontan obstruction or ventricular dysfunction, and (4) chylothorax or plastic bronchitis. T2‐weighted magnetic resonance imaging sequences were used to assess for lymphatic perfusion abnormality. The cohort consisted of 238 patients. Fifty‐eight (24%) developed early complications: 20 of 58 (34.5%) in group 1, 8 of 58 (14%) in group 2, 18 of 58 (31%) in group 3, and 12 of 58 (20%) in group 4. Preoperative T2 imaging was available for 126 (53%) patients. Patients with high‐grade lymphatic abnormalities had 6 times greater odds of developing early complications (P=0.001). Conclusions There is substantial morbidity in the early post‐Fontan period. Half of those who developed early complications had lymphatic failure or persistent effusions unrelated to structural or functional abnormalities. Preoperative T2 imaging demonstrated that patients with higher‐grade lymphatic perfusion abnormalities were significantly more likely to develop early complications. This has implications for risk stratification and optimization of patients before Fontan palliation.
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Affiliation(s)
- Reena M Ghosh
- Division of Cardiology Children's Hospital of Philadelphia PA
| | - Heather M Griffis
- Center for Pediatric Clinical Effectiveness Children's Hospital of Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology Children's Hospital of Philadelphia PA.,Center for Pediatric Clinical Effectiveness Children's Hospital of Philadelphia PA
| | - Jonathan J Rome
- Division of Cardiology Children's Hospital of Philadelphia PA
| | | | | | | | - Michael L O'Byrne
- Division of Cardiology Children's Hospital of Philadelphia PA.,Center for Pediatric Clinical Effectiveness Children's Hospital of Philadelphia PA
| | - David M Biko
- Department of Radiology Children's Hospital of Philadelphia PA
| | | | - Aaron G Dewitt
- Division of Cardiac Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Yoav Dori
- Division of Cardiology Children's Hospital of Philadelphia PA
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48
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O'Byrne ML, Smith CL, Gillespie MJ. Device Closure of Patent Ductus Arteriosus in Adults. Can J Cardiol 2020; 36:795-796. [PMID: 32173055 DOI: 10.1016/j.cjca.2019.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 12/12/2022] Open
Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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49
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Nam HH, Herz C, Lasso A, Drouin S, Posada A, Morray B, O'Byrne ML, Paniagua B, Joffe D, Mackensen B, Rogers L, Fichtinger G, Jolley MA. Simulation of Transcatheter Atrial and Ventricular Septal Defect Device Closure Within Three-Dimensional Echocardiography-Derived Heart Models on Screen and in Virtual Reality. J Am Soc Echocardiogr 2020; 33:641-644.e2. [PMID: 32139137 DOI: 10.1016/j.echo.2020.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Hannah H Nam
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christian Herz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andras Lasso
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, Ontario, Canada
| | - Simon Drouin
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adriana Posada
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian Morray
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Michael L O'Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Denise Joffe
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - Lindsay Rogers
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gabor Fichtinger
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, Ontario, Canada
| | - Matthew A Jolley
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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50
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Ghosh RM, Mascio CE, Silvestro E, O'Byrne ML, Whitehead KK. A road map for collaterals: Use of 3-dimensional techniques in tetralogy of Fallot pulmonary atresia with major aortopulmonary collateral arteries. JTCVS Tech 2020; 1:82-85. [PMID: 34317724 PMCID: PMC8288564 DOI: 10.1016/j.xjtc.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 11/23/2019] [Accepted: 01/03/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Reena M. Ghosh
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
- Address for reprints: Reena M. Ghosh, MD, Division of Cardiology, 34th and Civic Center Blvd, 8NW90 Cardiology Suite, Philadelphia, PA 19104.
| | - Christopher E. Mascio
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Elizabeth Silvestro
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Michael L. O'Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Kevin K. Whitehead
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
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