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Asif H, McNeer JL, Ghanayem NS, Cursio JF, Kane JM. First-Line Respiratory Support for Children With Hematologic Malignancy and Acute Respiratory Failure. Crit Care Explor 2024; 6:e1076. [PMID: 38601458 PMCID: PMC11005899 DOI: 10.1097/cce.0000000000001076] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVES To characterize trends in noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) use over time in children with hematologic malignancy admitted to the PICU with acute respiratory failure (ARF), and to identify risk factors associated with NIV failure requiring transition to IMV. DESIGN Retrospective cohort analysis using the Virtual Pediatric Systems (VPS, LLC) between January 1, 2010 and December 31, 2019. SETTING One hundred thirteen North American PICUs participating in VPS. PATIENTS Two thousand four hundred eighty children 0-21 years old with hematologic malignancy admitted to participating PICUs for ARF requiring respiratory support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 3013 total encounters, of which 868 (28.8%) received first-line NIV alone (NIV only), 1544 (51.2%) received first-line IMV (IMV only), and 601 (19.9%) required IMV after a failed NIV trial (NIV failure). From 2010 to 2019, the NIV only group increased from 9.6% to 43.1% and the IMV only group decreased from 80.1% to 34.2% (p < 0.001). The NIV failure group had the highest mortality compared with NIV only and IMV only (36.6% vs. 8.1%, vs. 30.5%, p < 0.001). However, risk-of-mortality (ROM) was highest in the IMV only group compared with NIV only and NIV failure (median Pediatric Risk of Mortality III ROM 8.1% vs. 2.8% vs. 5.5%, p < 0.001). NIV failure patients also had the longest median PICU length of stay compared with the other two study groups (15.2 d vs. 6.1 and 9.0 d, p < 0.001). Higher age was associated with significantly decreased odds of NIV failure, and diagnosis of non-Hodgkin lymphoma was associated with significantly increased odds of NIV failure compared with acute lymphoid leukemia. CONCLUSIONS For children with hematologic malignancy admitted to the PICU with ARF, NIV has replaced IMV as the most common initial therapy. NIV failure rate remains high with high-observed mortality despite lower PICU admission ROM.
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Affiliation(s)
- Hassaan Asif
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Jennifer L McNeer
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Nancy S Ghanayem
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, University of Chicago, Comer Children's Hospital, Chicago, IL
| | - John F Cursio
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | - Jason M Kane
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, University of Chicago, Comer Children's Hospital, Chicago, IL
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Schmithorst V, Ceschin R, Lee V, Wallace J, Sahel A, Chenevert TL, Parmar H, Berman JI, Vossough A, Qiu D, Kadom N, Grant PE, Gagoski B, LaViolette PS, Maheshwari M, Sleeper LA, Bellinger DC, Ilardi D, O’Neil S, Miller TA, Detterich J, Hill KD, Atz AM, Richmond ME, Cnota J, Mahle WT, Ghanayem NS, Gaynor JW, Goldberg CS, Newburger JW, Panigrahy A. Single Ventricle Reconstruction III: Brain Connectome and Neurodevelopmental Outcomes: Design, Recruitment, and Technical Challenges of a Multicenter, Observational Neuroimaging Study. Diagnostics (Basel) 2023; 13:1604. [PMID: 37174995 PMCID: PMC10178603 DOI: 10.3390/diagnostics13091604] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
Patients with hypoplastic left heart syndrome who have been palliated with the Fontan procedure are at risk for adverse neurodevelopmental outcomes, lower quality of life, and reduced employability. We describe the methods (including quality assurance and quality control protocols) and challenges of a multi-center observational ancillary study, SVRIII (Single Ventricle Reconstruction Trial) Brain Connectome. Our original goal was to obtain advanced neuroimaging (Diffusion Tensor Imaging and Resting-BOLD) in 140 SVR III participants and 100 healthy controls for brain connectome analyses. Linear regression and mediation statistical methods will be used to analyze associations of brain connectome measures with neurocognitive measures and clinical risk factors. Initial recruitment challenges occurred that were related to difficulties with: (1) coordinating brain MRI for participants already undergoing extensive testing in the parent study, and (2) recruiting healthy control subjects. The COVID-19 pandemic negatively affected enrollment late in the study. Enrollment challenges were addressed by: (1) adding additional study sites, (2) increasing the frequency of meetings with site coordinators, and (3) developing additional healthy control recruitment strategies, including using research registries and advertising the study to community-based groups. Technical challenges that emerged early in the study were related to the acquisition, harmonization, and transfer of neuroimages. These hurdles were successfully overcome with protocol modifications and frequent site visits that involved human and synthetic phantoms.
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Affiliation(s)
- Vanessa Schmithorst
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Rafael Ceschin
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
- Department of Biomedical Informatics, University of Pittsburgh School, 5607 Baum Blvd., Pittsburgh, PA 15206, USA
| | - Vincent Lee
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Julia Wallace
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Aurelia Sahel
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Thomas L. Chenevert
- Michigan Medicine Department of Radiology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Hemant Parmar
- Michigan Medicine Department of Radiology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Jeffrey I. Berman
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Arastoo Vossough
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Deqiang Qiu
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322, USA
| | - Patricia Ellen Grant
- Children’s Hospital Boston, Fetal-Neonatal Neuroimaging and Developmental Science Center (FNNDSC), 300 Longwood Avenue, Boston, MA 02115, USA
| | - Borjan Gagoski
- Department of Radiology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Peter S. LaViolette
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Mohit Maheshwari
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - David C. Bellinger
- Cardiac Neurodevelopmental Program, Department of Neurology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA 30329, USA
| | - Sharon O’Neil
- Children’s Hospital Los Angeles, Neuropsychology Core of the Saban Research Institute, 4661 Sunset Blvd., Los Angeles, CA 90027, USA
| | - Thomas A. Miller
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Jon Detterich
- Division of Pediatric Cardiology, Children’s Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027, USA
| | - Kevin D. Hill
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 7506 Hospital North, DUMC Box 3090, Durham, NC 27710, USA
| | - Andrew M. Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, 96 Jonathan Lucas St. Ste. 601, MSC 617, Charleston, SC 29425, USA
| | - Marc E. Richmond
- Program for Pediatric Cardiomyopathy, Heart Failure, and Transplantation, New York-Presbyterian Morgan Stanley Children’s Hospital, 3959 Broadway MSCH North, 2nd Floor, New York, NY 10032, USA
| | - James Cnota
- Fetal Heart Program, Cincinnati Children’s, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - William T. Mahle
- Division of Pediatric Cardiology, Children’s Healthcare of Atlanta, 1400 Tullie Rd NE Suite 630, Atlanta, GA 30329, USA
| | - Nancy S. Ghanayem
- Section of Pediatric Critical Care, Department of Pediatrics, Comer Children’s Hospital, University of Chicago Medicine, 5721 S. Maryland Avenue, Chicago, IL 60637, USA
- Department of Pediatrics, Medical College of Wisconsin Section of Pediatric Critical Care, 9000 W. Wisconsin Avenue MS 681, Milwaukee, WI 53226, USA
| | - J. William Gaynor
- Heart Failure and Transplant Program, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Caren S. Goldberg
- Department of Pediatrics, Division of Cardiology, C.S. Mott Children’s Hospital, 1540 E Hospital Dr #4204, Ann Arbor, MI 48109, USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
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Handler SS, Chan T, Ghanayem NS, Rudd N, Wright G, Visotcky A, Sparapani R, Mitchell ME, Hoffman GM, Frommelt MA. Impact of Reintervention During Stage 1 Palliation Hospitalization: A National, Multicenter Study. Ann Thorac Surg 2023; 115:975-981. [PMID: 36306859 DOI: 10.1016/j.athoracsur.2022.10.014] [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: 06/23/2022] [Revised: 09/28/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Stage 1 palliation (S1P) for hypoplastic left heart syndrome remains associated with high morbidity and mortality. Previous studies on burden of reinterventions did not include patients who remain hospitalized before stage 2 palliation (S2P). This study described the rate of reintervention during S1P hospitalization and sought to determine the impact of reintervention on outcomes. METHODS All participants enrolled in phase II of the National Pediatric Cardiology Quality Improvement Collaborative after S1P were included in this study. The primary outcome was the rate of reintervention during hospitalization after S1P and before hospital discharge or S2P. Reintervention was defined as 1 or more unplanned interventional cardiac catheterizations or surgical reoperations. RESULTS Between March 1, 2016 and October 1, 2019, 1367 participants underwent S1P and 339 (24.8%) had a reintervention; most commonly to address the source of pulmonary blood flow. Gestational age, weight at S1P, atrioventricular septal defect, heterotaxy, preoperative pulmonary artery bands, hybrid S1P, and an additional bypass run or early extracorporeal membrane oxygenation were significantly associated with reintervention. Participants in the reintervention group experienced higher rates of nearly all postoperative complications, were less likely to be discharged before S2P (57.1% vs 86%; P < .001), and more likely to experience in-hospital mortality (17% vs 5%; P < .001). CONCLUSIONS Unplanned reintervention during hospitalization after S1P palliation occurred in 25% of participants in a large, registry-based national cohort. Participants who underwent reintervention were more likely to remain as inpatient and were less likely to survive to S2P. Reintervention was associated with a multitude of postoperative complications that affect survival and long-term outcome.
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Affiliation(s)
- Stephanie S Handler
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Titus Chan
- Division of Critical Care Medicine and Cardiology, Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, University of Chicago and Advocate Children's Hospital, Chicago, Illinois
| | - Nancy Rudd
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gail Wright
- Department of Pediatrics, Santa Clara Valley Health and Hospital System, San Jose, California
| | - Alexis Visotcky
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rodney Sparapani
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - George M Hoffman
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michele A Frommelt
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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Silva-Gburek J, Marroquín A, Flores S, Roddy J, Ghanayem NS, Shekerdemian LS, Coss-Bu JA. Perioperative Nutritional Status and Organ Dysfunction Following Surgery for Congenital Heart Disease. Pediatr Cardiol 2023:10.1007/s00246-023-03111-2. [PMID: 36745225 DOI: 10.1007/s00246-023-03111-2] [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: 12/26/2022] [Accepted: 01/23/2023] [Indexed: 02/07/2023]
Abstract
Children with congenital heart disease (CHD) are at risk of malnutrition; however, there is limited information regarding the impact of nutritional status on organ dysfunction and outcomes after surgery for CHD. The study aim was to assess the association between malnutrition, organ dysfunction, and outcomes after surgery for CHD. Retrospective cohort study of patients aged 30 days to 18 years admitted to the cardiac intensive care unit (CICU) following cardiac surgery. Nutritional status (malnutrition defined as weight for age z-score < - 2) and validated organ dysfunction scores (pSOFA and PELOD-2) on CICU days 1 and 3 were collected. The cohort included 967 patients with a median age of 2.8 years (IQR 0.46, 7.12) and hospital survival of 98.86%. The prevalence of malnutrition was 18.5% (n = 179). By multivariable logistic regression analysis including age, malnutrition, cardiopulmonary bypass time, and duration of mechanical ventilation; High STAT category (OR 7.51 [1.03-54], p = 0.0462) and PSOFA score > 5 day 1 (OR 1.84 [1.25-2.72], p = 0.0021) were associated with mortality; in a similar model including the same variables; High STAT category (OR 9.12 [1.33-62], p = 0.0243) and PELOD-2 score > 5 day 1 (OR 1.75 [1.10-2.77], p = 0.0175) were associated with mortality. Malnutrition was associated with persistent or worsening organ dysfunction by pSOFA (p < 0.05) and PELOD-2 (p < 0.01) on day 3. Malnutrition was present in infants and children undergoing surgery for congenital heart disease. Organ dysfunction and high surgical risk were associated with mortality. Malnutrition was not associated with mortality but was associated with postoperative organ dysfunction.
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Affiliation(s)
- Jaime Silva-Gburek
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Andrea Marroquín
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Saul Flores
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.,Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Jeramy Roddy
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Nancy S Ghanayem
- Division of Critical Care Medicine, Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Lara S Shekerdemian
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.,Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Jorge A Coss-Bu
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
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5
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Backes ER, Afonso NS, Guffey D, Tweddell JS, Tabbutt S, Rudd NA, O'Harrow G, Molossi S, Hoffman GM, Hill G, Heinle JS, Bhat P, Anderson JB, Ghanayem NS. Cumulative comorbid conditions influence mortality risk after staged palliation for hypoplastic left heart syndrome and variants. J Thorac Cardiovasc Surg 2023; 165:287-298.e4. [PMID: 35599210 DOI: 10.1016/j.jtcvs.2022.01.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/29/2021] [Accepted: 01/27/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Prematurity, low birth weight, genetic syndromes, extracardiac conditions, and secondary cardiac lesions are considered high-risk conditions associated with mortality after stage 1 palliation. We report the impact of these conditions on outcomes from a prospective multicenter improvement collaborative. METHODS The National Pediatric Cardiology Quality Improvement Collaborative Phase II registry was queried. Comorbid conditions were categorized and quantified to determine the cumulative burden of high-risk diagnoses on survival to the first birthday. Logistic regression was applied to evaluate factors associated with mortality. RESULTS Of the 1421 participants, 40% (575) had at least 1 high-risk condition. The aggregate high-risk group had lower survival to the first birthday compared with standard risk (76.2% vs 88.1%, P < .001). Presence of a single high-risk diagnosis was not associated with reduced survival to the first birthday (odds ratio, 0.71; confidence interval, 0.49-1.02, P = .066). Incremental increases in high-risk diagnoses were associated with reduced survival to first birthday (odds ratio, 0.23; confidence interval, 0.15-0.36, P < .001) for 2 and 0.17 (confidence interval, 0.10-0.30, P < .001) for 3 to 5 high-risk diagnoses. Additional analysis that included prestage 1 palliation characteristics and stage 1 palliation perioperative variables identified multiple high-risk diagnoses, poststage 1 palliation extracorporeal membrane oxygenation support (odds ratio, 0.14; confidence interval, 0.10-0.22, P < .001), and cardiac reoperation (odds ratio, 0.66; confidence interval, 0.45-0.98, P = .037) to be associated with reduced survival odds to the first birthday. CONCLUSIONS The presence of 1 high-risk diagnostic category was not associated with decreased survival at 1 year. Cumulative diagnoses across multiple high-risk diagnostic categories were associated with decreased odds of survival. Further patient accrual is needed to evaluate the impact of specific comorbid conditions within the broader high-risk categories.
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Affiliation(s)
- Emily R Backes
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex.
| | - Natasha S Afonso
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Danielle Guffey
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - James S Tweddell
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sarah Tabbutt
- Divisions of Critical Care and Cardiology, Department of Pediatrics, University of California San Francisco and Benioff Children's Hospital, San Francisco, Calif
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Ginny O'Harrow
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill
| | - Silvana Molossi
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - George M Hoffman
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Garick Hill
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey S Heinle
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Priya Bhat
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Jeffrey B Anderson
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill; Advocate Children's Hospital, Oak Lawn, Ill
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Achuff BJ, Lemming K, Causey JC, Sembera KA, Checchia PA, Heinle JS, Ghanayem NS. Opioid Weaning Protocol Using Morphine Compared With Nonprotocolized Methadone Associated With Decreased Dose and Duration of Opioid After Norwood Procedure. Pediatr Crit Care Med 2022; 23:361-370. [PMID: 34982761 DOI: 10.1097/pcc.0000000000002885] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Opioids are used to manage pain, comfort, maintain devices, and decrease oxygen consumption around Norwood palliation (NP), but in high dose and prolonged exposure, they increase risk of tolerance and iatrogenic withdrawal syndrome (IAWS). Variability in practice for IAWS prevention potentially increases opioid dose and duration. We hypothesize that protocolized weaning with morphine (MOR) versus nonprotocolized methadone (MTD) is associated with reduction in opioid exposure. DESIGN A before-versus-after study of outcomes of patients weaned with protocolized MOR versus nonprotocolized MTD including subset analysis for those patients with complications postoperatively. Primary endpoints include daily, wean phase, and total morphine milligram equivalent (MMEq) dose, duration, and, secondarily, length of stay (LOS). SETTING Quaternary-care pediatric cardiac ICU. PATIENTS Neonates undergoing single-ventricle palliation. INTERVENTIONS Introduction of IAWS prevention protocol. MEASUREMENTS AND MAIN RESULTS Analysis included 54 patients who underwent the NP in 2017-2018 including the subset analysis of 34 who had a complicated postoperative course. The total and wean phase opioid doses for the MTD group were significantly higher than that for the MOR group: 258 versus 22 and 115 versus 6 MMEq/kg; p < 0.001. Duration of opioid exposure was 63 days in the MTD group and 12 days in MOR group (p < 0.001). Subanalysis of the complicated subset also identifies higher total and wean dose for MTD group (293 vs 41 and 116 vs 7 MMEq/kg; p < 0.001) with a longer duration (65 vs 22 days; p = 0.001). Within the subset, LOS was 55% longer in the MTD group than that in the MOR group (150 vs 67 d; p = 0.01) and not different in the uncomplicated group. CONCLUSIONS After complex NP, a protocolized opioid weaning using MOR versus MTD is associated with 65% shorter opioid duration, 10-fold decreased dose, and shortened LOS.
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Affiliation(s)
| | | | - Jamie C Causey
- Pediatric Critical Care, Baylor College of Medicine, Houston, TX
| | | | - Paul A Checchia
- Pediatric Critical Care, Baylor College of Medicine, Houston, TX
| | - Jeffrey S Heinle
- Pediatric Critical Care, Baylor College of Medicine, Houston, TX
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Headrick AT, Qureshi AM, Ghanayem NS, Heinle J, Anders M. In-hospital Morbidity and Mortality Following Modified Blalock-Taussig-Thomas Shunts. Ann Thorac Surg 2021; 114:168-175. [PMID: 34838515 DOI: 10.1016/j.athoracsur.2021.11.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/20/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The modified Blalock-Taussig-Thomas shunt (mBTTs) is a critically important palliation for patients with insufficient pulmonary blood flow associated with congenital heart disease. Following creation of a mBTTs, patients experience high rates of early postoperative morbidity and mortality. METHODS This is a single-institution retrospective cohort study. A query of the Society of Thoracic Surgeons database identified relevant patients whose health records were manually queried for echocardiography and operative reports. Patients with ductal-dependent systemic circulation were excluded. Primary outcomes were early serious adverse events and in-hospital mortality. Secondary outcomes were time to primary outcomes and postoperative lengths of stay. We investigated the correlation of demographics, presence of competitive pulmonary blood flow, and surgical and anatomic factors on outcomes. RESULTS After exclusions, our cohort resulted in 155 patients. 33 (21.3%) patients experienced an early serious adverse event, ten (6.5%) early shunt malfunction, and 11 (7.1%) in-hospital mortality. Smaller shunt size, smaller shunted pulmonary artery size, surgical approach, and site of proximal shunt anastomosis were independently associated with morbidity and mortality. CONCLUSIONS Anatomical elements imparting increased resistance along the mBTTs predispose to increased morbidity and mortality, particularly in the early postoperative period. Despite the significant heterogeneity of patients receiving such shunts, similar risk profiles are observed regardless of lesion or presence of competitive flow. Surgical approach via thoracotomy with shunt anastomosis to the subclavian artery, where feasible, results in the subclavian artery as the point of natural resistance allowing for placement of larger shunts, yielding lower morbidity and mortality.
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Affiliation(s)
- Andrew T Headrick
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
| | - Athar M Qureshi
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Nancy S Ghanayem
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Section of Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Jeffrey Heinle
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas
| | - Marc Anders
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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8
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Ahmed H, Anderson JB, Bates KE, Natarajan S, Ghanayem NS, Lannon CM, Brown DW. Characteristics of Interstage Death After Discharge from Stage I Palliation. Pediatr Cardiol 2021; 42:1372-1378. [PMID: 33948710 DOI: 10.1007/s00246-021-02621-1] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Interstage mortality (IM) remains high for patients with single-ventricle congenital heart disease (SVCHD) in the period between Stage 1 Palliation (S1P) and Glenn operation. We sought to characterize IM. METHODS This was a descriptive analysis of 2184 patients with SVCHD discharged home after S1P from 60 National Pediatric Cardiology Quality Improvement Collaborative sites between 2008 and 2015. Patients underwent S1P with right ventricle-pulmonary artery conduit (RVPAC), modified Blalock-Taussig-Thomas shunt (BTT), or Hybrid; transplants were excluded. RESULTS IM occurred in 153 (7%) patients (median gestational age 38 weeks, 54% male, 77% white), at 88 (IQR 60,136) days of life, and 39 (IQR 17,84) days after hospital discharge; 13 (8.6%) occurred ≤ 30 days after S1P. The mortality rate for RVPAC was lower (5.2%; 59/1138) than BTT (9.1%; 65/712) and Hybrid (20.1%; 27/134). More than half of deaths occurred at home (20%) or in the emergency department (33%). The remainder occurred while inpatient at center of S1P (cardiac intensive care unit 36%, inpatient ward 5%) or at a different center (5%). Fussiness and breathing problems were most often cited as harbingers of death; distance to surgical center was the biggest barrier cited to seeking care. Cause of death was unknown in 44% of cases overall; in the subset of patients who underwent post-mortem autopsy, the cause of death remained unknown in 30% of patients, with the most common diagnosis being low cardiac output. CONCLUSIONS Most IM occurred in the outpatient setting, with non-specific preceding symptoms and unknown cause of death. These data indicate the need for research to identify occult causes of death, including arrhythmia.
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Affiliation(s)
- Humera Ahmed
- Departments of Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | | | - Katherine E Bates
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | | | - Nancy S Ghanayem
- Cardiology, Advocate Children's Heart Institute, Oak Lawn, IL, USA
| | - Carole M Lannon
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David W Brown
- Division of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
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9
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Niebler RA, Amdani S, Blume B, Cantor RS, Deng L, Kirklin JK, Lorts A, Morales DL, Rosenthal DN, Ghanayem NS. Stroke in pediatric ventricular assist device patients-a pedimacs registry analysis. J Heart Lung Transplant 2021; 40:662-670. [PMID: 33824064 DOI: 10.1016/j.healun.2021.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 02/19/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Cerebralvascular accidents (CVA) are common complications of pediatric ventricular assist devices (VADs). We employed the Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) to investigate rates, risk factors, and outcomes of CVA in pediatric patients supported on VAD. METHODS Analysis of Pedimacs (September 2012-June 2019) data to determine rates of all neurologic events and specifically CVA. Risk factors were determined by a multiphase parametric hazard model. Outcomes of patients with CVA were compared with patients without CVA. RESULTS We included 662 patients in our analysis. In total, 87 CVA events occurred in 71 patients (10.7%). The proportion of patients with CVA was highest in the paracorporeal pulsatile group (16.9%) followed by the paracorporeal continuous group (10.4%). However, the rate of CVA was lower in the paracorporeal pulsatile group compared to the paracorporeal continuous group (6.4 vs 11.1 events/100 patient months), which reflects differences in support duration. Ascites, higher patient profile groups, and implants within small volume centers were associated with the occurrence of CVA. Our analysis found that the recent era (i.e., June 2017), and intracorporeal continuous implants were protective. Mortality was higher in patients following a CVA diagnosis compared to those without a CVA diagnosis. CONCLUSIONS CVA continues to be a problem in pediatric VAD support, though the overall percent is now <11%. Data from the most recent era are encouraging, but CVA is still significantly associated with mortality. Future efforts should focus on pre-implant and early support periods.
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Affiliation(s)
- Robert A Niebler
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
| | - Shahnawaz Amdani
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Betsy Blume
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Ryan S Cantor
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Luqin Deng
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David N Rosenthal
- Department of Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Nancy S Ghanayem
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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10
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Savorgnan F, Elhoff JJ, Guffey D, Axelrod D, Buckley JR, Gaies M, Ghanayem NS, Lasa JJ, Shekerdemian L, Tweddell JS, Werho DK, Yeh J, Steurer MA. Relationship Between Gestational Age and Outcomes After Congenital Heart Surgery. Ann Thorac Surg 2020; 112:1509-1516. [PMID: 33080235 DOI: 10.1016/j.athoracsur.2020.08.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 08/11/2020] [Accepted: 08/17/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Previous studies suggest that birth before 39 weeks' gestational age (GA) is associated with higher perioperative mortality and morbidity after congenital heart surgery. The optimal approach to timing of cardiac operation in premature infants remains unclear. We investigated the impact of GA at birth and corrected GA at surgery on postoperative outcomes using the Pediatric Cardiac Critical Care Consortium (PC4) database. METHODS Infants undergoing selected index cardiac operations before the end of the neonatal period were included (n = 2298). GA at birth and corrected GA at the time of the index cardiac operation were used as categorical predictors and fitted as a cubic spline to assess nonlinear relationships. The primary outcome was hospital mortality. Multivariable logistic regression models assessed the association between predictors and outcomes while adjusting for confounders. RESULTS Late-preterm (34-36 weeks) birth was associated with increased odds of mortality compared with full-term (39-40 weeks) birth, while early-term (37-38 weeks) birth was not associated with increased mortality. Corrected GA at surgery of 34 to 37 weeks compared with 40 to 44 weeks was associated with increased mortality. When analyzing corrected GA at surgery as a continuous predictor of outcome, odds of survival improve as patients approach 39 weeks corrected GA. CONCLUSIONS Contrary to previous literature, we did not find an association between early-term birth and hospital mortality at PC4 hospitals. Our analysis of the relationship between corrected GA and mortality suggests that operating closer to full-term corrected GA may improve survival.
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Affiliation(s)
- Fabio Savorgnan
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Justin J Elhoff
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
| | - Danielle Guffey
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - David Axelrod
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Jason R Buckley
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Michael Gaies
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nancy S Ghanayem
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Javier J Lasa
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Lara Shekerdemian
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - James S Tweddell
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - David K Werho
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Justin Yeh
- Department of Pediatrics, University of California-San Diego, San Diego, California
| | - Martina A Steurer
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Pediatrics, University of California, San Francisco, California
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11
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Rudd NA, Ghanayem NS, Hill GD, Lambert LM, Mussatto KA, Nieves JA, Robinson S, Shirali G, Steltzer MM, Uzark K, Pike NA. Interstage Home Monitoring for Infants With Single Ventricle Heart Disease: Education and Management: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2020; 9:e014548. [PMID: 32777961 PMCID: PMC7660817 DOI: 10.1161/jaha.119.014548] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This scientific statement summarizes the current state of knowledge related to interstage home monitoring for infants with shunt‐dependent single ventricle heart disease. Historically, the interstage period has been defined as the time of discharge from the initial palliative procedure to the time of second stage palliation. High mortality rates during the interstage period led to the implementation of in‐home surveillance strategies to detect physiologic changes that may precede hemodynamic decompensation in interstage infants with single ventricle heart disease. Adoption of interstage home monitoring practices has been associated with significantly improved morbidity and mortality. This statement will review in‐hospital readiness for discharge, caregiver support and education, healthcare teams and resources, surveillance strategies and practices, national quality improvement efforts, interstage outcomes, and future areas for research. The statement is directed toward pediatric cardiologists, primary care providers, subspecialists, advanced practice providers, nurses, and those caring for infants undergoing staged surgical palliation for single ventricle heart disease.
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12
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Dhillon GS, Ghanayem NS, Broda CR, Lalani SR, Mery CM, Shekerdemian LS, Staffa SJ, Morris SA. An Analysis of Hospital Mortality After Cardiac Operations in Children With Down Syndrome. Semin Thorac Cardiovasc Surg 2020; 32:947-957. [PMID: 32621963 DOI: 10.1053/j.semtcvs.2020.06.037] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/27/2020] [Indexed: 11/11/2022]
Abstract
Children with Down syndrome (DS) have lower mortality compared to nonsyndromic (NS) children after atrioventricular septal defect (AVSD) repair. Limited data exist regarding hospital mortality and utilization after other congenital heart disease (CHD) operations in DS. We compared hospital mortality and utilization after CHD operations in both populations and hypothesized that the survival benefit in children with DS is not consistent across CHD lesions. The Texas Inpatient Public Use Datafile was queried for all patients <18 years old undergoing operations for CHD between 1999 and 2016. Hospital mortality, length-of-stay and charges were compared between DS and NS groups, stratified by CHD operation using mixed-effects multivariable analyses and propensity score matching analyses adjusting for prematurity, low birth weight, age, and sex. Over the 18-year period, 2841 cases with DS underwent CHD operations compared to 25,063 NS cases. The most common types of interventions performed in DS were AVSD repair, isolated ventricular septal defect (VSD) repair and tetralogy of Fallot (TOF) repair. By multivariable analyses, DS was associated with lower mortality after isolated AVSD repair (RR 0.40 [IQR 0.20-0.79]), and higher hospital mortality after bidirectional Glenn anastomosis (BDG) (RR 5.17 [IQR 2.10-12.77]) and TOF/pulmonary atresia repair (RR 9.71 [IQR 2.16-43.68]) compared to NS children. Similar results were noted using propensity score matching. Children with DS had lower mortality after AVSD repair than NS children, but higher mortality after operations for BDG and TOF/pulmonary atresia. Further study is needed to determine if the presence of pulmonary hypertension in DS modifies the association between DS and mortality depending on cardiac lesion.
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Affiliation(s)
- Gurpreet S Dhillon
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.
| | - Nancy S Ghanayem
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Christopher R Broda
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Seema R Lalani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School and Dell Children's Medical Center, Austin, Texas
| | - Lara S Shekerdemian
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Shaine A Morris
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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13
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Morris SA, Ghanayem NS. Patient With Poor Prognosis, Family Wishes to Pursue All Options, Care Team Cannot Reach Consensus. Ann Thorac Surg 2020; 108:1284-1286. [PMID: 31653290 DOI: 10.1016/j.athoracsur.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/05/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Shaine A Morris
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6651 Main St, Ste E1910, Houston, TX 77030.
| | - Nancy S Ghanayem
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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14
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Hoffman GM, Scott JP, Ghanayem NS, Stuth EA, Mitchell ME, Woods RK, Hraska V, Niebler RA, Bertrandt RA, Mussatto KA, Tweddell JS. Identification of Time-Dependent Risks of Hemodynamic States After Stage 1 Norwood Palliation. Ann Thorac Surg 2020; 109:155-162. [DOI: 10.1016/j.athoracsur.2019.06.063] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/05/2019] [Accepted: 06/17/2019] [Indexed: 11/25/2022]
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15
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Ahmed H, Anderson JB, Bates KE, Fleishman CE, Natarajan S, Ghanayem NS, Sleeper LA, Lannon CM, Brown DW. Development of a validated risk score for interstage death or transplant after stage I palliation for single-ventricle heart disease. J Thorac Cardiovasc Surg 2019; 160:1021-1030. [PMID: 31924360 DOI: 10.1016/j.jtcvs.2019.11.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 10/26/2019] [Accepted: 11/02/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To develop a risk score to predict mortality or transplant in the interstage period. BACKGROUND The "interstage" period between the stage 1 and stage 2 palliation is a time of high morbidity and mortality for infants with single-ventricle congenital heart disease. METHODS This was an analysis of patients with single-ventricle congenital heart disease requiring arch reconstruction who were enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from 2008 to 2015. The primary composite endpoint was interstage mortality or transplant. Multivariable logistic regression and classification and regression tree analysis were performed on two-thirds of the patients ("learning cohort") to build a risk score for the composite endpoint, that was validated in the remaining patients ("validation cohort"). RESULTS In the 2128 patients analyzed in the registry, the overall event rate was 9% (153 [7%] deaths, 42 [2%] transplants). In the learning cohort, factors independently associated with the composite endpoint were (1) type of Norwood; (2) postoperative ECMO; (3) discharge with Opiates; (4) No Digoxin at discharge; (5) postoperative Arch obstruction, (6) moderate-to-severe Tricuspid regurgitation without an oxygen requirement, and (7) Extra Oxygen required at discharge in patients with moderate-to-severe tricuspid regurgitation. This model was used to create a weighted risk score ("NEONATE" score; 0-76 points), with >75% accuracy in the learning and validation cohorts. In the validation cohort, the event rate in patients with a score >17 was nearly three times those with a score ≤17. CONCLUSIONS We introduce a risk score that can be used post-stage 1 palliation to predict freedom from interstage mortality or transplant.
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Affiliation(s)
- Humera Ahmed
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | | | - Katherine E Bates
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Mich
| | | | | | - Nancy S Ghanayem
- Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Carole M Lannon
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, Mass.
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16
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Gellings JA, Johnson WK, Ghanayem NS, Mitchell M, Tweddell J, Hoffman G, Hraska V, Kuhn EM, Woods RK. Norwood Procedure-Difficulty in Weaning From Cardiopulmonary Bypass and Implications for Outcomes. Semin Thorac Cardiovasc Surg 2019; 32:119-125. [PMID: 31404609 DOI: 10.1053/j.semtcvs.2019.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 11/11/2022]
Abstract
Difficulty weaning from cardiopulmonary bypass (CPB) or the need to return to CPB (collectively D-CPB) may occur after the Norwood procedure. We sought to evaluate the relationship between D-CBP and survival. This was a retrospective chart review of all patients undergoing a Norwood procedure at our institution during the interval 2005-2017. Primary outcome was survival for the Norwood procedure. Secondary outcomes included various measures of morbidity. Successful wean from CBP (S-CPB) was defined as no need to return to full-flow CPB during the initial definitive wean or after separation from CPB; otherwise, the classification was difficulty with wean (D-CBP). Successful rescue in the D-CPB group was defined as not requiring extracorporeal life support either in the operating room or within the first 3 postoperative days. Of the 196 patients in the cohort, 49 were D-CPB. Survival for S-CPB was 92.5% (136/147) vs 71.4% (35/49) for D-CPB (P = 0.001). Major morbidity occurred in 29.9% (44/147) in S-CPB vs 69.4% (34/49) in D-CPB (P < 0.001). With multivariable analysis, D-CPB was significantly associated with mortality (odds ratio = 8.09; confidence interval 2.72-24.05; P < 0.001). Successful rescue occurred in 30 of 49 patients in the D-CPB group and demonstrated survival similar to the S-CPB group. In the Norwood patient, D-CPB is an important intraoperative event and prognostic factor for mortality and morbidity. Successful rescue appears to ameliorate the impact of D-CPB on survival.
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Affiliation(s)
- Jaclyn A Gellings
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of WI, Milwaukee, Wisconsin
| | - William K Johnson
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of WI, Milwaukee, Wisconsin
| | - Nancy S Ghanayem
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Michael Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of WI, Milwaukee, Wisconsin
| | - James Tweddell
- Department of Cardiothoracic Surgery, University of Cincinnati, Heart Institute, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - George Hoffman
- Division of Critical Care, Department of Anesthesiology, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of WI, Milwaukee, Wisconsin
| | - Viktor Hraska
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of WI, Milwaukee, Wisconsin
| | - Evelyn M Kuhn
- Department of Analytics, Business Intelligence & Data Warehousing, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of WI, Milwaukee, Wisconsin.
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17
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Holst LM, Serrano F, Shekerdemian L, Ravn HB, Guffey D, Ghanayem NS, Monteiro S. Impact of feeding mode on neurodevelopmental outcome in infants and children with congenital heart disease. CONGENIT HEART DIS 2019; 14:1207-1213. [PMID: 31373176 DOI: 10.1111/chd.12827] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/14/2019] [Accepted: 07/11/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the impact of feeding mode on neurodevelopmental outcomes in children with congenital heart defects. DESIGN A retrospective cohort study of 208 children with congenital heart disease (CHD), who had surgery from 1 January 2013 until 31 December 2016 at Texas Children's Hospital, Houston, TX, US. SETTINGS University Hospital, Developmental Outcome Clinic. OUTCOMES MEASURES Standardized cognitive scores were assessed with Capute Scales and motor development with Revised Gesell Developmental Schedules. We analyzed anthropometrics, mode of feeding, surgical complexity, syndrome, and gender as predictors of developmental outcomes at four time points: hospital discharge, and 6, 12, and 24 months of age. RESULTS Mode of feeding is associated with neurodevelopmental outcome in children with CHD. Children on enteral feeding tubes had significantly lower developmental quotient (DQ) scores in cognition, communication, and motor function at 12 and 24 months compared to orally fed children. There were greater proportions of developmental delays (DQ < 70) in enteral tube fed children at the 6, 12, and 24 months visits. Further, there was a strong association between presence of enteral feeding tube, syndrome, and developmental outcome. Greater surgical complexity, weight gain and ethnicity were not associated with the developmental outcomes. CONCLUSIONS Our findings suggest that the presence of an enteral feeding tube following corrective congenital heart surgery are at increased risk of neurodevelopmental delays at 12 and 24 months.
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Affiliation(s)
- Line Marie Holst
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Faridis Serrano
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Lara Shekerdemian
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research Houston, Baylor College of Medicine, Houston, Texas
| | - Nancy S Ghanayem
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Sonia Monteiro
- Section of Developmental Pediatrics, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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18
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Miller TA, Ghanayem NS, Newburger JW, McCrindle BW, Hu C, DeWitt AG, Cnota JF, Tractenberg FL, Pemberton VL, Wolf MJ, Votava-Smith JK, Fifer CG, Lambert LM, Shah A, Graham EM, Pizarro C, Jacobs JP, Miller SG, Minich LL. Gestational Age, Birth Weight, and Outcomes Six Years After the Norwood Procedure. Pediatrics 2019; 143:peds.2018-2577. [PMID: 30979811 PMCID: PMC6564065 DOI: 10.1542/peds.2018-2577] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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] [Accepted: 01/29/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Preterm delivery and low birth weight (LBW) are generally associated with worse outcomes in hypoplastic left heart syndrome (HLHS), but an individual preterm or small neonate may do well. We sought to explore the interactions between gestational age, birth weight, and birth weight for gestational age with intermediate outcomes in HLHS. METHODS We analyzed survival, growth, neurodevelopment, length of stay, and complications to age 6 years in subjects with HLHS from the Single Ventricle Reconstruction trial. Univariate and multivariable survival and regression analyses examined the effects and interactions of LBW (<2500 g), weight for gestational age, and gestational age category. RESULTS Early-term delivery (n = 234) was more common than term (n = 219) delivery. Small for gestational age (SGA) was present in 41% of subjects, but only 14% had LBW. Preterm, compared with term, delivery was associated with an increased risk of death or transplant at age 6 years (all: hazard ratio = 2.58, confidence interval = 1.43-4.67; Norwood survivors: hazard ratio = 1.96, confidence interval = 1.10-3.49) independent of LBW and weight for gestational age. Preterm delivery, early-term delivery, LBW, and SGA were each associated with lower weight at 6 years. Neurodevelopmental outcomes were worst in the LBW cohort. CONCLUSIONS Preterm delivery in HLHS was associated with worse survival, even beyond Norwood hospitalization. LBW, SGA, and early-term delivery were associated with worse growth but not survival. LBW was associated with worse neurodevelopment, despite similar length of stay and complications. These data suggest that preterm birth and LBW (although often concomitant) are not equivalent, impacting clinical outcomes through mechanisms independent of perioperative course complexity.
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Affiliation(s)
- Thomas A. Miller
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Nancy S. Ghanayem
- Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Brian W. McCrindle
- Department of Pediatrics, University of Toronto and Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada
| | - Chenwei Hu
- New England Research Institute, Watertown, Massachusetts
| | - Aaron G. DeWitt
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - James F. Cnota
- Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | | | - Victoria L. Pemberton
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Michael J. Wolf
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Jodie K. Votava-Smith
- Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Carlen G. Fifer
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Linda M. Lambert
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Amee Shah
- Department of Pediatrics, Columbia University, New York, New York
| | - Eric M. Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Christian Pizarro
- Departments of Surgery and Pediatrics, Thomas Jefferson University, Wilmington, Delaware
| | - Jeffrey P. Jacobs
- The Congenital Heart Institute of Florida, St. Petersburg, Florida; and
| | - Stephen G. Miller
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - L. LuAnn Minich
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
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19
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Bertrandt RA, Saudek DM, Scott JP, Madrzak M, Miranda MB, Ghanayem NS, Woods RK. Chest tube removal algorithm is associated with decreased chest tube duration in pediatric cardiac surgical patients. J Thorac Cardiovasc Surg 2019; 158:1209-1217. [PMID: 31147165 DOI: 10.1016/j.jtcvs.2019.03.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/15/2019] [Accepted: 03/30/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Management of chest tubes in adult and pediatric patients is highly variable. There are no published guidelines for pediatric cardiac surgical patients. Our center undertook a quality improvement project aimed at reducing chest tube duration and length of stay in postsurgical pediatric cardiac patients. METHODS A work group identified 2 opportunities for reducing chest tube duration: standardizing removal criteria and increasing frequency of assessment for removal. An algorithm was created, and chest tube assessments were increased to twice daily. All postsurgical cardiac patients were managed according to the algorithm. Outcome measure reporting was limited to patients age 1 month to 18 years with a biventricular surgical procedure. Outcome measures included chest tube duration, cardiac intensive care unit and hospital length of stay, and cost of hospitalization. Process measure was documentation of chest tube assessments. The balancing measure was chest tube reinsertions. RESULTS Between April 2016 and July 2018, 126 patients aged 1 month to 18 years underwent a biventricular surgical procedure. Mean chest tube duration decreased from 61 to 47 hours. Cardiac intensive care unit length of stay decreased from 141 hours to 89 hours, hospital length of stay decreased from 266 to 156 hours, and average hospitalization cost decreased from $75,881 to $48,118. There was no increase in chest tube reinsertions. CONCLUSIONS Implementation of a chest tube removal algorithm for pediatric cardiac surgery patients resulted in decreased chest tube duration and was associated with decreased length of stay and costs without an increase in reinsertions. More significant impact may be attainable with more aggressive approach to removal.
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Affiliation(s)
- Rebecca A Bertrandt
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.
| | - David M Saudek
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - John P Scott
- Division of Anesthesiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Michael Madrzak
- Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Mary Beth Miranda
- Department of Quality and Patient Safety, Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, Tex
| | - Ronald K Woods
- Division of Cardiothoracic Surgery, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
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20
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Goldstone AB, Baiocchi M, Wypij D, Stopp C, Andropoulos DB, Atallah J, Atz AM, Beca J, Donofrio MT, Duncan K, Ghanayem NS, Goldberg CS, Hövels-Gürich H, Ichida F, Jacobs JP, Justo R, Latal B, Li JS, Mahle WT, McQuillen PS, Menon SC, Pike NA, Pizarro C, Shekerdemian LS, Synnes A, Williams IA, Bellinger DC, Newburger J, Gaynor JW. The Bayley-III scale may underestimate neurodevelopmental disability after cardiac surgery in infants. Eur J Cardiothorac Surg 2019; 57:63-71. [DOI: 10.1093/ejcts/ezz123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/17/2019] [Accepted: 03/20/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Neurodevelopmental disability is the most common complication among congenital heart surgery survivors. The Bayley scales are standardized instruments to assess neurodevelopment. The most recent edition (Bayley Scales of Infant and Toddler Development 3rd Edition, Bayley-III) yields better-than-expected scores in typically developing and high-risk infants than the second edition (Bayley Scales of Infant Development 2nd Edition, BSID-II). We compared BSID-II and Bayley-III scores in infants undergoing cardiac surgery.
METHODS
We evaluated 2198 infants who underwent operations with cardiopulmonary bypass between 1996 and 2009 at 26 institutions. We used propensity score matching to limit confounding by indication in a subset of patients (n = 705).
RESULTS
Overall, unadjusted Bayley-III motor scores were higher than BSID-II Psychomotor Development Index scores (90.7 ± 17.2 vs 77.6 ± 18.8, P < 0.001), and unadjusted Bayley-III composite cognitive and language scores were higher than BSID-II Mental Development Index scores (92.0 ± 15.4 vs 88.2 ± 16.7, P < 0.001). In the propensity-matched analysis, Bayley-III motor scores were higher than BSID-II Psychomotor Development Index scores [absolute difference 14.1, 95% confidence interval (CI) 11.7–17.6; P < 0.001] and the Bayley-III classified fewer children as having severe [odds ratio (OR) 0.24; 95% CI 0.14–0.42] or mild-to-moderate impairment (OR 0.21; 95% CI 0.14–0.32). The composite of Bayley-III cognitive and language scores was higher than BSID-II Mental Development Index scores (absolute difference 4.0, 95% CI 1.4–6.7; P = 0.003), but there was no difference between Bayley editions in the proportion of children classified as having severe cognitive and language impairment.
CONCLUSIONS
The Bayley-III yielded higher scores than the BSID-II and classified fewer children as severely impaired. The systematic bias towards higher scores with the Bayley-III precludes valid comparisons between early and contemporary cardiac surgery cohorts.
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Affiliation(s)
- Andrew B Goldstone
- Department of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | | | | | - Joseph Atallah
- Stollery Children’s Hospital, Western Canadian Complex Pediatric Therapies Follow-up Program, Edmonton, AB, Canada
| | - Andrew M Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - John Beca
- Starship Children’s Hospital, Auckland, New Zealand
| | | | - Kim Duncan
- Children’s Hospital and Medical Center, Omaha, NE, USA
| | - Nancy S Ghanayem
- Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | | | | | | | - Jeffrey P Jacobs
- Johns Hopkins All Children’s Heart Institute, St. Petersburg, FL, USA
| | | | - Beatrice Latal
- University Children’s Hospital Zurich, Zurich, Switzerland
| | | | | | | | - Shaji C Menon
- Primary Children’s Medical Center, Salt Lake City, UT, USA
| | - Nancy A Pike
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | | | | | - Anne Synnes
- University of British Columbia, Vancouver, BC, Canada
| | - Ismée A Williams
- New York-Presbyterian Morgan Stanley Children’s Hospital of New York, New York, NY, USA
| | | | | | - J William Gaynor
- Department of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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21
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Hill GD, Ghanayem NS, Hraska V, Jacobsen RM, Mitchell ME, Woods RK, Ginde S. Variation in the use of Fontan fenestration in the current surgical era. Progress in Pediatric Cardiology 2019. [DOI: 10.1016/j.ppedcard.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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22
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Ghanayem NS, Arca MJ. Gastrostomy Tubes in Post-Norwood Patients: Why, When and How are as Important as the Who. Semin Thorac Cardiovasc Surg 2018; 30:448-449. [PMID: 30048697 DOI: 10.1053/j.semtcvs.2018.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Nancy S Ghanayem
- Department of Pediatrics, Baylor College of Medicine, Houston, TX.
| | - Marjorie J Arca
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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23
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Newburger JW, Sleeper LA, Gaynor JW, Hollenbeck-Pringle D, Frommelt PC, Li JS, Mahle WT, Williams IA, Atz AM, Burns KM, Chen S, Cnota J, Dunbar-Masterson C, Ghanayem NS, Goldberg CS, Jacobs JP, Lewis AB, Mital S, Pizarro C, Eckhauser A, Stark P, Ohye RG. Transplant-Free Survival and Interventions at 6 Years in the SVR Trial. Circulation 2018; 137:2246-2253. [PMID: 29437119 DOI: 10.1161/circulationaha.117.029375] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [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: 05/15/2017] [Accepted: 01/16/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the SVR trial (Single Ventricle Reconstruction), 1-year transplant-free survival was better for the Norwood procedure with right ventricle-to-pulmonary artery shunt (RVPAS) compared with a modified Blalock-Taussig shunt in patients with hypoplastic left heart and related syndromes. At 6 years, we compared transplant-free survival and other outcomes between the groups. METHODS Medical history was collected annually using medical record review, telephone interviews, and the death index. The cohort included 549 patients randomized and treated in the SVR trial. RESULTS Transplant-free survival for the RVPAS versus modified Blalock-Taussig shunt groups did not differ at 6 years (64% versus 59%, P=0.25) or with all available follow-up of 7.1±1.6 years (log-rank P=0.13). The RVPAS versus modified Blalock-Taussig shunt treatment effect had nonproportional hazards (P=0.009); the hazard ratio (HR) for death or transplant favored the RVPAS before stage II surgery (HR, 0.66; 95% confidence interval, 0.48-0.92). The effect of shunt type on death or transplant was not statistically significant between stage II to Fontan surgery (HR, 1.36; 95% confidence interval, 0.86-2.17; P=0.17) or after the Fontan procedure (HR, 0.76; 95% confidence interval, 0.33-1.74; P=0.52). By 6 years, patients with RVPAS had a higher incidence of catheter interventions (0.38 versus 0.23/patient-year, P<0.001), primarily because of more interventions between the stage II and Fontan procedures (HR, 1.72; 95% confidence interval, 1.00-3.03). Complications did not differ by shunt type; by 6 years, 1 in 5 patients had had a thrombotic event, and 1 in 6 had had seizures. CONCLUSIONS By 6 years, the hazards of death or transplant and catheter interventions were not different between the RVPAS versus modified Blalock-Taussig shunt groups. Children assigned to the RVPAS group had 5% higher transplant-free survival, but the difference did not reach statistical significance, and they required more catheter interventions. Both treatment groups have accrued important complications. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00115934.
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Affiliation(s)
- Jane W Newburger
- Boston Children's Hospital and Harvard Medical School, MA (J.W.N., L.A.S., C.D.-M.).
| | - Lynn A Sleeper
- Boston Children's Hospital and Harvard Medical School, MA (J.W.N., L.A.S., C.D.-M.)
| | - J William Gaynor
- Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | | | - Peter C Frommelt
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F., N.S.G.)
| | - Jennifer S Li
- North Carolina Consortium, Duke University, Durham (J.S.L.).,East Carolina University, Greenville, NC (J.S.L.).,Wake Forest University, Winston-Salem, NC (J.S.L.)
| | - William T Mahle
- Children's Healthcare of Atlanta and Emory University, GA (W.T.M.)
| | - Ismee A Williams
- Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia College of Physicians and Surgeons, NY (I.A.W.)
| | - Andrew M Atz
- Medical University of South Carolina, Charleston (A.M.A.)
| | - Kristin M Burns
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (KM.B.)
| | - Shan Chen
- New England Research Institutes, Watertown, MA (D.H.-P., S.C., P.S.)
| | - James Cnota
- Cincinnati Children's Medical Center, OH (J.C.)
| | | | - Nancy S Ghanayem
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F., N.S.G.)
| | - Caren S Goldberg
- University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.)
| | | | | | - Seema Mital
- Hospital for Sick Children, Toronto, Ontario, Canada (S.M.)
| | | | - Aaron Eckhauser
- Primary Children's Hospital and the University of Utah, Salt Lake City (A.E.)
| | - Paul Stark
- New England Research Institutes, Watertown, MA (D.H.-P., S.C., P.S.)
| | - Richard G Ohye
- University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.)
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24
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Sachdeva S, Jacobsen RM, Woods RK, Mitchell ME, Cava JR, Ghanayem NS, Frommelt PC, Bartz PJ, Tweddell JS. Anatomic Repair of Congenitally Corrected Transposition of the Great Arteries: Single-Center Intermediate-Term Experience. Pediatr Cardiol 2017; 38:1696-1702. [PMID: 28918529 DOI: 10.1007/s00246-017-1715-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/31/2017] [Indexed: 01/15/2023]
Abstract
We present our experience for patients who have undergone an anatomic repair (AR) for congenitally corrected transposition of the great arteries (CCTGA) at the Children's Hospital of Wisconsin. A retrospective chart review of patients who underwent AR for CCTGA from 2001 to 2015 was performed. The cohort consisted of 15 patients (74% male). Median age of anatomic repair was 15 months (range 4.5-45.6 months). Four patients had a bidirectional Glenn (BDG) prior to AR. At the time of AR,-9 (60%) underwent Senning/Rastelli procedure, 4 (26.6%) had double switch operation, and 2 (13.3%) underwent only Senning with VSD closure. Median duration of follow-up was 5.5 years (0.05-14 years). Reoperations prior to discharge included BDG, revision of pulmonary venous baffle, closure of residual VSD, and pacemaker placement. Late reoperations included left ventricular outflow tract obstruction repair, conduit replacement, melody valve placement, and pacemaker implantation. At their most recent follow-up, no patient had heart failure symptoms and only 1 had severely diminished function that improved with cardiac resynchronization therapy. Moderate mitral regurgitation was noted in 15% (2/13), and severe in 7% (1/13). Moderate tricuspid regurgitation was noted in 15% (2/13). One patient, 7% (1/13), developed moderate aortic insufficiency. There was a 100% survival at the time of the most recent follow-up. Patients with CCTGA who have undergone AR have excellent functional status and mid-term survival but reinterventions are common. Longer term studies are needed to determine both the extent and spectrum of reinterventions as well as long term survival.
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Affiliation(s)
| | | | | | | | - Joseph R Cava
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | | | | | - Peter J Bartz
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - James S Tweddell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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25
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Gaies M, Werho DK, Zhang W, Donohue JE, Tabbutt S, Ghanayem NS, Scheurer MA, Costello JM, Gaynor JW, Pasquali SK, Dimick JB, Banerjee M, Schwartz SM. Duration of Postoperative Mechanical Ventilation as a Quality Metric for Pediatric Cardiac Surgical Programs. Ann Thorac Surg 2017; 105:615-621. [PMID: 28987397 DOI: 10.1016/j.athoracsur.2017.06.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/30/2017] [Accepted: 06/06/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Few metrics exist to assess quality of care at pediatric cardiac surgical programs, limiting opportunities for benchmarking and quality improvement. Postoperative duration of mechanical ventilation (POMV) may be an important quality metric because of its association with complications and resource utilization. In this study we modelled case-mix-adjusted POMV duration and explored hospital performance across POMV metrics. METHODS This study used the Pediatric Cardiac Critical Care Consortium clinical registry to analyze 4,739 hospitalizations from 15 hospitals (October 2013 to August 2015). All patients admitted to pediatric cardiac intensive care units after an index cardiac operation were included. We fitted a model to predict duration of POMV accounting for patient characteristics. Robust estimates of SEs were obtained using bootstrap resampling. We created performance metrics based on observed-to-expected (O/E) POMV to compare hospitals. RESULTS Overall, 3,108 patients (65.6%) received POMV; the remainder were extubated intraoperatively. Our model was well calibrated across groups; neonatal age had the largest effect on predicted POMV. These comparisons suggested clinically and statistically important variation in POMV duration across centers with a threefold difference observed in O/E ratios (0.6 to 1.7). We identified 1 hospital with better-than-expected and 3 hospitals with worse-than-expected performance (p < 0.05) based on the O/E ratio. CONCLUSIONS We developed a novel case-mix-adjusted model to predict POMV duration after congenital heart operations. We report variation across hospitals on metrics of O/E duration of POMV that may be suitable for benchmarking quality of care. Identifying high-performing centers and practices that safely limit the duration of POMV could stimulate quality improvement efforts.
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Affiliation(s)
- Michael Gaies
- Division of Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan.
| | - David K Werho
- Division of Critical Care Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Wenying Zhang
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Janet E Donohue
- Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan, Ann Arbor, Michigan
| | - Sarah Tabbutt
- Division of Critical Care Medicine, Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Nancy S Ghanayem
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Mark A Scheurer
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - John M Costello
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J William Gaynor
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sara K Pasquali
- Division of Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Justin B Dimick
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Steven M Schwartz
- Departments of Critical Care Medicine and Paediatrics, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Ontario, Canada
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26
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Woods RK, Ghanayem NS, Mitchell ME, Kindel S, Niebler RA. Mechanical Circulatory Support of the Fontan Patient. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2017; 20:20-27. [PMID: 28007060 DOI: 10.1053/j.pcsu.2016.09.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 12/30/2022]
Abstract
Because of the inadequacies inherent to a circulation supported by a single ventricle, many Fontan patients will experience failure of their circulation. To date, there is no medical regimen that reliably and consistently restores circulatory function in these patients. Because of the shortage of donor organs and the fact that many of these patients present with features that either preclude or render heart transplantation a high risk, there is an intense need to better understand how mechanical circulatory support (MCS) may benefit these patients. In this report, we share our experience of successful MCS and transplantation of three patients. Our experience and that of others is very encouraging, but also preliminary. In general, a systemic ventricular assist device, with or without a Fontan fenestration, is a reasonable consideration for a patient presenting with predominantly systolic dysfunction. A pulmonary/systemic venous assist device may be sufficient for the patient with preserved systolic function and failure of the systemic venous/lymphatic system; however, this remains speculative. The more comprehensive approach of a total artificial heart or bilateral support is attractive in theory, but beset by the need for a more complex operation. In all scenarios, early referral, before organ failure, is paramount to successful MCS.
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Affiliation(s)
- Ronald K Woods
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI.
| | - Nancy S Ghanayem
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, WI
| | - Michael E Mitchell
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Steven Kindel
- Department of Pediatrics, Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Robert A Niebler
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, WI; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI
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27
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Ragalie WS, Chun RH, Martin T, Ghanayem NS, Berens RJ, Beste DJ, Mitchell ME. Side-to-Side Tracheobronchoplasty to Reconstruct Complex Congenital Tracheobronchial Stenosis. Ann Thorac Surg 2017; 104:666-673. [DOI: 10.1016/j.athoracsur.2017.01.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 10/30/2016] [Accepted: 01/03/2017] [Indexed: 11/24/2022]
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28
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Hoffman GM, Ghanayem NS, Scott JP, Tweddell JS, Mitchell ME, Mussatto KA. Postoperative Cerebral and Somatic Near-Infrared Spectroscopy Saturations and Outcome in Hypoplastic Left Heart Syndrome. Ann Thorac Surg 2017; 103:1527-1535. [DOI: 10.1016/j.athoracsur.2016.09.100] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 09/09/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
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29
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Hill GD, Rudd NA, Ghanayem NS, Hehir DA, Bartz PJ. Center Variability in Timing of Stage 2 Palliation and Association with Interstage Mortality: A Report from the National Pediatric Cardiology Quality Improvement Collaborative. Pediatr Cardiol 2016; 37:1516-1524. [PMID: 27558553 DOI: 10.1007/s00246-016-1465-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/16/2016] [Indexed: 11/27/2022]
Abstract
For infants with single-ventricle lesions with aortic arch hypoplasia, the interstage period from discharge following stage 1 palliation (S1P) until stage 2 palliation (S2P) remains high risk. Significant variability among institutions exists around the timing of S2P. We sought to describe institutional variation in timing of S2P, determine the association between timing of S2P and interstage mortality, and determine the impact of earlier S2P on hospital morbidity and mortality. The National Pediatric Cardiology Quality Improvement Collaborative registry was queried. Centers were divided based on median age at S2P into early (n = 15) and late (n = 16) centers using a cutoff of 153 days. Groups were compared using Chi-squared or Wilcoxon rank-sum test. Multivariable logistic regression was used to determine risk factors for interstage mortality. The final cohort included 789 patients from 31 centers. There was intra- and inter-center variability in timing of S2P, with the median age by center ranging from 109 to 214 days. Late centers had a higher mortality (9.9 vs. 5.7 %, p = 0.03) than early centers. However, the event rate (late: 8.2 vs. early: 5.8 deaths per 10,000 interstage days) was not different by group (p = 0.26). Survival to hospital discharge and hospital length of stay following S2P were similar between groups. In conclusion, in a large multi-institution collaborative, the median age at S2P varies among centers. Although optimal timing of S2P remains unclear, centers performing early S2P did not experience worse S2P outcomes and experienced less interstage mortality.
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Affiliation(s)
- Garick D Hill
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA.
| | - Nancy A Rudd
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David A Hehir
- Division of Cardiac Critical Care, Department of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Peter J Bartz
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA
- Division of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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30
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Ghanayem NS, Woods RK. Turnstyle gridlock: Passenger (corpuscular) overload or slow-moving train? J Thorac Cardiovasc Surg 2016; 153:956. [PMID: 28065432 DOI: 10.1016/j.jtcvs.2016.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 11/10/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Nancy S Ghanayem
- Division of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, Wis.
| | - Ronald K Woods
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis
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31
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Anand V, Kwiatkowski DM, Ghanayem NS, Axelrod DM, DiNardo J, Klugman D, Krishnamurthy G, Siehr S, Stromberg D, Yates AR, Roth SJ, Cooper DS. Training Pathways in Pediatric Cardiac Intensive Care: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society. World J Pediatr Congenit Heart Surg 2016; 7:81-8. [PMID: 26714998 DOI: 10.1177/2150135115614576] [Citation(s) in RCA: 12] [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] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The increase in pediatric cardiac surgical procedures and establishment of the practice of pediatric cardiac intensive care has created the need for physicians with advanced and specialized knowledge and training. Current training pathways to become a pediatric cardiac intensivist have a great deal of variability and have unique strengths and weaknesses with influences from critical care, cardiology, neonatology, anesthesiology, and cardiac surgery. Such variability has created much confusion among trainees looking to pursue a career in our specialized field. This is a report with perspectives from the most common advanced fellowship training pathways taken to become a pediatric cardiac intensivist as well as various related topics including scholarship, qualifications, and credentialing.
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Affiliation(s)
- Vijay Anand
- Department of Critical Care, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - David M Kwiatkowski
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Nancy S Ghanayem
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - David M Axelrod
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - James DiNardo
- Department of Anesthesia, Boston Children's Hospital, Boston, MA, USA
| | - Darren Klugman
- Department of Cardiology, Children's National Health System, Washington, DC, USA
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Stephanie Siehr
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Daniel Stromberg
- Department of Pediatrics and Critical Care Medicine, Medical City Children's Hospital, Dallas, TX, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Stephen J Roth
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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Rosenthal DN, Almond CS, Jaquiss RD, Peyton CE, Auerbach SR, Morales DR, Epstein DJ, Cantor RS, Kormos RL, Naftel DC, Butts RJ, Ghanayem NS, Kirklin JK, Blume ED. Adverse events in children implanted with ventricular assist devices in the United States: Data from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS). J Heart Lung Transplant 2016; 35:569-77. [PMID: 27197775 DOI: 10.1016/j.healun.2016.03.005] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 02/25/2016] [Accepted: 03/11/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Ventricular assist devices (VADs) have been used in children on an increasing basis in recent years. One-year survival rates are now >80% in multiple reports. In this report we describe adverse events experienced by children with durable ventricular assist devices, using a national-level registry (PediMACS, a component of INTERMACS) METHODS: PediMACS is a national registry that contains clinical data on patients who are <19 years of age at the time of VAD implantation. Data collection concludes at the time of VAD explantation. All FDA-approved devices are included. PediMACS was launched on September 1, 2012, and this report includes all data from launch until August 2014. Adverse events were coded with a uniform, pre-specified set of definitions. RESULTS This report comprises data from 200 patients with a median age of 11 years (range 11 days to 18 years), and total follow-up of 783 patient-months. The diagnoses were cardiomyopathy (n = 146, 73%), myocarditis (n = 17, 9%), congenital heart disease (n = 35, 18%) and other (n = 2, 1%). Pulsatile-flow devices were used in 91 patients (45%) and continuous-flow devices in 109 patients (55%). Actuarial survival was 81% at 6 months. There were 418 adverse events reported. The most frequent events were device malfunction (n = 79), infection (n = 78), neurologic dysfunction (n = 52) and bleeding (n = 68). Together, these accounted for 277 events, 66% of the total. Although 38% of patients had no reported adverse event and 16% of patients had ≥5 adverse events. Adverse events occurred at all time-points after implantation, but were most likely to occur in the first 30 days. For continuous-flow devices, there were broad similarities in adverse event rates between this cohort and historic rates from the INTERMACS population. CONCLUSIONS In this study cohort, the overall rate of early adverse events (within 90 days of implantation) was 86.3 events per 100 patient-months, and of late adverse events it was 20.4 events per 100 patient-months. The most common adverse events in recipients of pulsatile VADs were device malfunction, neurologic dysfunction, bleeding and infection. For continuous-flow VADs, the most common adverse events were infection, bleeding, cardiac arrhythmia, neurologic dysfunction and respiratory failure. Compared with an adult INTERMACS cohort, the overall rate and distribution of adverse events appears similar.
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Affiliation(s)
- David N Rosenthal
- Department of Pediatric (Cardiology), Stanford University, Palo Alto, California, USA.
| | - Christopher S Almond
- Department of Pediatric (Cardiology), Stanford University, Palo Alto, California, USA
| | - Robert D Jaquiss
- Department of Pediatric Cardiac Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christine E Peyton
- Children's Hospital Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Scott R Auerbach
- Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - David R Morales
- Department of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Deirdre J Epstein
- Department of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan S Cantor
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Robert L Kormos
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David C Naftel
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryan J Butts
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nancy S Ghanayem
- Department of Pediatrics (Critical Care Section), Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - James K Kirklin
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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Niebler RA, Woods KJ, Murkowski K, Ghanayem NS, Hoffman G, Mitchell ME, Punzalan RC, Scott JP, Simpson P, Tweddell JS. A Pilot Study of Antithrombin Replacement Prior to Cardiopulmonary Bypass in Neonates. Artif Organs 2015; 40:80-5. [PMID: 26620919 DOI: 10.1111/aor.12642] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Neonates have low levels of antithrombin. Inadequate anticoagulation during cardiopulmonary bypass (CPB) due to low antithrombin activity may result in a poor preservation of the coagulation system during bypass. We hypothesize that antithrombin replacement to neonates prior to CPB will preserve the hemostatic system and result in less postoperative bleeding. A randomized, double-blinded, placebo-controlled pilot study of antithrombin replacement to neonates prior to CPB was conducted. Preoperative antithrombin levels determined the dose of recombinant antithrombin or placebo to be given. Antithrombin levels were measured following the dosing of the antithrombin/placebo, after initiation of bypass, near the completion of bypass, and upon intensive care unit admission. Eight subjects were enrolled. No subject had safety concerns. Mediastinal exploration occurred in two antithrombin subjects and one placebo subject. Antithrombin activity levels were significantly higher in the treated group following drug administration; levels continued to be higher than preoperatively but not different from the placebo group at all other time points. Total heparin administration was less in the antithrombin group; measurements of blood loss were similar in both groups. A single dose of recombinant antithrombin did not maintain 100% activity levels throughout the entire operation. Although no safety concerns were identified in this pilot study, a larger trial is necessary to determine clinical efficacy.
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Affiliation(s)
- Robert A Niebler
- Section of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Katherine J Woods
- Section of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathleen Murkowski
- Section of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nancy S Ghanayem
- Section of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - George Hoffman
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Michael E Mitchell
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Rowena C Punzalan
- Section of Hematology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Paul Scott
- Section of Hematology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Pippa Simpson
- Section of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - James S Tweddell
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Niebler RA, Shah TK, Mitchell ME, Woods RK, Zangwill SD, Tweddell JS, Berger S, Ghanayem NS. Ventricular Assist Device in Single-Ventricle Heart Disease and a Superior Cavopulmonary Anastomosis. Artif Organs 2015; 40:180-4. [DOI: 10.1111/aor.12531] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Robert A. Niebler
- Department of Pediatrics; Section of Critical Care; Medical College of Wisconsin; Milwaukee WI USA
- Department of Cardiothoracic Surgery; Medical College of Wisconsin; Milwaukee WI USA
| | - Tejas K. Shah
- Department of Cardiothoracic Surgery; Medical College of Wisconsin; Milwaukee WI USA
- Section of Cardiology; Medical College of Wisconsin; Milwaukee WI USA
| | - Michael E. Mitchell
- Department of Cardiothoracic Surgery; Medical College of Wisconsin; Milwaukee WI USA
- Herma Heart Center; Children's Hospital of Wisconsin; Milwaukee WI USA
| | - Ronald K. Woods
- Department of Cardiothoracic Surgery; Medical College of Wisconsin; Milwaukee WI USA
- Herma Heart Center; Children's Hospital of Wisconsin; Milwaukee WI USA
| | - Steven D. Zangwill
- Department of Cardiothoracic Surgery; Medical College of Wisconsin; Milwaukee WI USA
- Section of Cardiology; Medical College of Wisconsin; Milwaukee WI USA
| | - James S. Tweddell
- Department of Cardiothoracic Surgery; Medical College of Wisconsin; Milwaukee WI USA
- Herma Heart Center; Children's Hospital of Wisconsin; Milwaukee WI USA
| | - Stuart Berger
- Department of Pediatrics; Section of Cardiology; University of California-Davis; Davis CA USA
| | - Nancy S. Ghanayem
- Department of Pediatrics; Section of Critical Care; Medical College of Wisconsin; Milwaukee WI USA
- Department of Cardiothoracic Surgery; Medical College of Wisconsin; Milwaukee WI USA
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Gaynor JW, Stopp C, Wypij D, Andropoulos DB, Atallah J, Atz AM, Beca J, Donofrio MT, Duncan K, Ghanayem NS, Goldberg CS, Hövels-Gürich H, Ichida F, Jacobs JP, Justo R, Latal B, Li JS, Mahle WT, McQuillen PS, Menon SC, Pemberton VL, Pike NA, Pizarro C, Shekerdemian LS, Synnes A, Williams I, Bellinger DC, Newburger JW. Neurodevelopmental outcomes after cardiac surgery in infancy. Pediatrics 2015; 135:816-25. [PMID: 25917996 PMCID: PMC4533222 DOI: 10.1542/peds.2014-3825] [Citation(s) in RCA: 336] [Impact Index Per Article: 37.3] [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] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Neurodevelopmental disability is the most common complication for survivors of surgery for congenital heart disease (CHD). METHODS We analyzed individual participant data from studies of children evaluated with the Bayley Scales of Infant Development, second edition, after cardiac surgery between 1996 and 2009. The primary outcome was Psychomotor Development Index (PDI), and the secondary outcome was Mental Development Index (MDI). RESULTS Among 1770 subjects from 22 institutions, assessed at age 14.5 ± 3.7 months, PDIs and MDIs (77.6 ± 18.8 and 88.2 ± 16.7, respectively) were lower than normative means (each P < .001). Later calendar year of birth was associated with an increased proportion of high-risk infants (complexity of CHD and prevalence of genetic/extracardiac anomalies). After adjustment for center and type of CHD, later year of birth was not significantly associated with better PDI or MDI. Risk factors for lower PDI were lower birth weight, white race, and presence of a genetic/extracardiac anomaly (all P ≤ .01). After adjustment for these factors, PDIs improved over time (0.39 points/year, 95% confidence interval 0.01 to 0.78; P = .045). Risk factors for lower MDI were lower birth weight, male gender, less maternal education, and presence of a genetic/extracardiac anomaly (all P < .001). After adjustment for these factors, MDIs improved over time (0.38 points/year, 95% confidence interval 0.05 to 0.71; P = .02). CONCLUSIONS Early neurodevelopmental outcomes for survivors of cardiac surgery in infancy have improved modestly over time, but only after adjustment for innate patient risk factors. As more high-risk CHD infants undergo cardiac surgery and survive, a growing population will require significant societal resources.
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Affiliation(s)
| | | | - David Wypij
- Boston Children’s Hospital, Boston, Massachusetts
| | | | - Joseph Atallah
- Stollery Children’s Hospital and the Western Canadian Complex Pediatric Therapies Follow-up Program, Edmonton, Alberta, Canada
| | - Andrew M. Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - John Beca
- Starship Children’s Hospital, Auckland, New Zealand
| | - Mary T. Donofrio
- Children’s National Medical Center, Washington, District of Columbia
| | - Kim Duncan
- Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Nancy S. Ghanayem
- Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | - Jeffrey P. Jacobs
- Johns Hopkins All Children’s Heart Institute, St. Petersburg, Florida
| | | | - Beatrice Latal
- University Children’s Hospital Zurich, Zurich, Switzerland
| | | | | | | | | | | | - Nancy A. Pike
- Children’s Hospital Los Angeles, Los Angeles, California
| | | | | | - Anne Synnes
- University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Ismee Williams
- New York-Presbyterian Morgan Stanley Children’s Hospital of New York, New York, New York
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Cain MT, Cao Y, Ghanayem NS, Simpson PM, Trapp K, Mitchell ME, Tweddell JS, Woods RK. Transposition of the great arteries--outcomes and time interval of early neonatal repair. World J Pediatr Congenit Heart Surg 2015; 5:241-7. [PMID: 24668972 DOI: 10.1177/2150135113520559] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND This study evaluates the relationship of morbidity and resource utilization with the timing of early neonatal repair of transposition of the great arteries and intact ventricular septum (d-TGA/IVS). METHODS All patients with d-TGA/IVS who underwent arterial switch in the first 14 days of life, between January 2000 and May 2011, were reviewed. Patients undergoing repair at ≤ 4 days of age were categorized as group I, 5 to 7 days as group II, and 8 to 14 days as group III. Outcomes included mortality, morbidity, and resource utilization. RESULTS Hospital survival was 69 (98.6%) of 70. The length of stay (LOS) and total charges were lowest in group I--15.5 days compared to group II--18.0 days and group III--23.5 days (P = .005); group I--US$128,219 compared to group II--US$141,729 and group III--US$217,427 (P = .0006). Using regression analysis to account for potentially confounding effects of multiple variables and treating time as a continuous variable demonstrated that age at surgery was significantly associated with total LOS (P = .029), hospital charges (P = .029) and intensive care unit charges (P = .002). Younger age at repair was not associated with worse outcomes for any measure of morbidity. CONCLUSIONS Earlier repair of d-TGA/IVS was associated with decreased resource utilization and no detriment to clinical outcomes. Further analysis based on a larger cohort of patients is needed to verify these results that have important implications for improving the value of care.
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Abstract
The goal of perioperative monitoring is to aid the clinician in optimizing care to achieve the best possible survival with the lowest possible morbidity. Ideally, we would like to have monitoring that can rapidly and accurately identify perturbations in circulatory well-being that would permit timely intervention and allow for restoration before the patient is damaged. The evidence to support the use of our standard monitoring strategies (continuous electrocardiography, blood pressure, central venous pressure, oxygen saturation and capnography) is based on expert opinion, case series, or at best observational studies. While these monitoring parameters will identify life-threatening events, they provide no direct information concerning the oxygen economy of the patient. Nevertheless, they are mandated by professional societies representing specialists in cardiac disease, critical care, and anesthesiology. Additional non-routine monitoring strategies that provide data concerning the body's oxygen economy, such as venous saturation monitoring and near infrared spectroscopy, have shown promise in prospective observational studies in managing these complex groups of patients. Ideally, high-level evidence would be required before adopting these newer strategies, but in the absence of new funding sources and the challenges of the wide variation in practice patterns between centers, this seems unlikely. The evidence supporting the current standard perioperative monitoring strategies will be reviewed. In addition, evidence supporting non-routine monitoring strategies will be reviewed and their potential for added benefit assessed.
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Affiliation(s)
- James S Tweddell
- Herma Heart Center, Milwaukee, WI; Children's Hospital of Wisconsin, Milwaukee, WI; Department of Surgery, Division of Cardiothoracic Surgery, Milwaukee, WI.
| | - Nancy S Ghanayem
- Herma Heart Center, Milwaukee, WI; Children's Hospital of Wisconsin, Milwaukee, WI; Department of Pediatrics, Section of Critical Care, Milwaukee, WI
| | - George M Hoffman
- Herma Heart Center, Milwaukee, WI; Children's Hospital of Wisconsin, Milwaukee, WI; Department of Anesthesiology, The Medical College of Wisconsin, Milwaukee, WI
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38
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Nichols BG, Jabbour J, Hehir DA, Ghanayem NS, Beste D, Martin T, Woods R, Robey T. Recovery of vocal fold immobility following isolated patent ductus arteriosus ligation. Int J Pediatr Otorhinolaryngol 2014; 78:1316-9. [PMID: 24882459 DOI: 10.1016/j.ijporl.2014.05.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [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: 12/14/2013] [Revised: 05/13/2014] [Accepted: 05/14/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Identify laryngoscopic and functional outcomes of infants with vocal fold immobility (VFI) following patent ductus arteriosus (PDA) ligation and identify predictors of recovery. METHODS Retrospective review of patients with VFI following PDA ligation from 2001 to 2012 at a single institution. Inclusion criteria were: (1) PDA ligation as only cardiac surgical procedure; (2) left VFI documented by laryngoscopy; (3) minimum follow up 120 days, with at least 2 laryngoscopies performed. Resolution of VFI was determined at follow-up laryngoscopy. Univariate logistic regression models were used to identify variables associated with VFI recovery. RESULTS 66 subjects were included with median follow up of 3.0 (± 2.1) years. The mean gestational age was 24.5 ± 1.4 weeks, mean birth weight 673 ± 167 g, and mean age at procedure was 18.6 ± 14.3 days. Patients presented with respiratory symptoms (39%), dysphonia (78%) and dysphagia (55%). Resolution of VFI was observed in 2/66 (3%) patients. Recovery was documented at 20 days and 11 months respectively. Respiratory symptoms, dysphagia, and dysphonia persisted at last follow up in 11%, 47%, and 20% of patients. CONCLUSIONS VFI associated with ligation of the ductus arteriosus has a low rate of recovery. Clinical symptoms frequently persist, and as such regular follow-up by otolaryngologists to mitigate morbidity is indicated.
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Affiliation(s)
- Brent G Nichols
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jad Jabbour
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David A Hehir
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nancy S Ghanayem
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David Beste
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Timothy Martin
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ronald Woods
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas Robey
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA.
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Gaynor JW, Kim DS, Arrington CB, Atz AM, Bellinger DC, Burt AA, Ghanayem NS, Jacobs JP, Lee TM, Lewis AB, Mahle WT, Marino BS, Miller SG, Newburger JW, Pizarro C, Ravishankar C, Santani AB, Wilder NS, Jarvik GP, Mital S, Russell MW. Validation of association of the apolipoprotein E ε2 allele with neurodevelopmental dysfunction after cardiac surgery in neonates and infants. J Thorac Cardiovasc Surg 2014; 148:2560-6. [PMID: 25282659 DOI: 10.1016/j.jtcvs.2014.07.052] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [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: 04/07/2014] [Revised: 06/27/2014] [Accepted: 07/12/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Apolipoprotein E (APOE) genotype is a determinant of neurologic recovery after brain ischemia and traumatic brain injury. The APOE ε2 allele has been associated with worse neurodevelopmental (ND) outcome after repair of congenital heart defects (CHD) in infancy. Replication of this finding in an independent cohort is essential to validate the observed genotype-phenotype association. METHODS The association of APOE genotype with ND outcomes was assessed in a combined cohort of patients with single-ventricle CHD enrolled in the Single Ventricle Reconstruction and Infant Single Ventricle trials. ND outcome was assessed at 14 months using the Psychomotor Development Index (PDI) and Mental Development Index (MDI) of the Bayley Scales of Infant Development-II. Stepwise multivariable regression was performed to develop predictive models for PDI and MDI scores. RESULTS Complete data were available for 298 of 435 patients. After adjustment for preoperative and postoperative covariates, the APOE ε2 allele was associated with a lower PDI score (P = .038). Patients with the ε2 allele had a PDI score approximately 6 points lower than those without the risk allele, explaining 1.04% of overall PDI variance, because the ε2 allele was present in only 11% of the patients. There was a marginal effect of the ε2 allele on MDI scores (P = .058). CONCLUSIONS These data validate the association of the APOE ε2 allele with adverse early ND outcomes after cardiac surgery in infants, independent of patient and operative factors. Genetic variants that decrease neuroresilience and impair neuronal repair after brain injury are important risk factors for ND dysfunction after surgery for CHD.
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Affiliation(s)
- J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Daniel Seung Kim
- Departments of Medicine (Division of Medical Genetics) and Genome Sciences, University of Washington School of Medicine, Seattle, Wash
| | | | - Andrew M Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Boston, Mass, and Department of Neurology, Harvard Medical School, Boston, Mass
| | - Amber A Burt
- Division of Medical Genetics, Department of Medicine, University of Washington School of Medicine, Seattle, Wash
| | - Nancy S Ghanayem
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Jeffery P Jacobs
- Johns Hopkins Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, St Petersburg, Fla
| | - Teresa M Lee
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Alan B Lewis
- Children's Hospital Los Angeles, Los Angeles, Calif
| | | | - Bradley S Marino
- Ann and Robert F. Lurie Children's Hospital of Chicago, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen G Miller
- Division of Pediatric Oncology, Duke University Medical Center, Durham, NC
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Christian Pizarro
- Nemours Cardiac Center, Alfred I. Dupont Hospital for Children, Wilmington, Del
| | - Chitra Ravishankar
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Avni B Santani
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Nicole S Wilder
- Department of Anesthesia, University of Michigan Medical School, Ann Arbor, Mich
| | - Gail P Jarvik
- Departments of Medicine (Division of Medical Genetics) and Genome Sciences, University of Washington School of Medicine, Seattle, Wash
| | - Seema Mital
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mark W Russell
- Department of Pediatrics and Communicable Diseases (Division of Pediatric Cardiology), University of Michigan Medical School, Ann Arbor, Mich
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Niebler RA, Ghanayem NS, Shah TK, De La Rosa Bobke A, Zangwill S, Brosig C, Frommelt MA, Mitchell ME, Tweddell JS, Woods RK. Use of a HeartWare ventricular assist device in a patient with failed Fontan circulation. Ann Thorac Surg 2014; 97:e115-6. [PMID: 24694452 DOI: 10.1016/j.athoracsur.2013.11.075] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 11/27/2022]
Abstract
We present a successful case of the use of a HeartWare ventricular assist device as a bridge to transplantation in an 11-year-old with a hypoplastic left heart and failed Fontan circulation.
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Affiliation(s)
- Robert A Niebler
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Section of Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Nancy S Ghanayem
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Section of Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tejas K Shah
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Section of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrea De La Rosa Bobke
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Section of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steven Zangwill
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Section of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cheryl Brosig
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Section of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michelle A Frommelt
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Section of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James S Tweddell
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Newburger JW, Sleeper LA, Frommelt PC, Pearson GD, Mahle WT, Chen S, Dunbar-Masterson C, Mital S, Williams IA, Ghanayem NS, Goldberg CS, Jacobs JP, Krawczeski CD, Lewis AB, Pasquali SK, Pizarro C, Gruber PJ, Atz AM, Khaikin S, Gaynor JW, Ohye RG. Transplantation-free survival and interventions at 3 years in the single ventricle reconstruction trial. Circulation 2014; 129:2013-20. [PMID: 24705119 DOI: 10.1161/circulationaha.113.006191] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the Single Ventricle Reconstruction (SVR) trial, 1-year transplantation-free survival was better for the Norwood procedure with right ventricle-to-pulmonary artery shunt (RVPAS) compared with a modified Blalock-Taussig shunt (MBTS). At 3 years, we compared transplantation-free survival, echocardiographic right ventricular ejection fraction, and unplanned interventions in the treatment groups. METHODS AND RESULTS Vital status and medical history were ascertained from annual medical records, death indexes, and phone interviews. The cohort included 549 patients randomized and treated in the SVR trial. Transplantation-free survival for the RVPAS versus MBTS groups did not differ at 3 years (67% versus 61%; P=0.15) or with all available follow-up of 4.8±1.1 years (log-rank P=0.14). Pre-Fontan right ventricular ejection fraction was lower in the RVPAS group than in the MBTS group (41.7±5.1% versus 44.7±6.0%; P=0.007), and right ventricular ejection fraction deteriorated in RVPAS (P=0.004) but not MBTS (P=0.40) subjects (pre-Fontan minus 14-month mean, -3.25±8.24% versus 0.99±8.80%; P=0.009). The RVPAS versus MBTS treatment effect had nonproportional hazards (P=0.004); the hazard ratio favored the RVPAS before 5 months (hazard ratio=0.63; 95% confidence interval, 0.45-0.88) but the MBTS beyond 1 year (hazard ratio=2.22; 95% confidence interval, 1.07-4.62). By 3 years, RVPAS subjects had a higher incidence of catheter interventions (P<0.001) with an increasing HR over time (P=0.005): <5 months, 1.14 (95% confidence interval, 0.81-1.60); from 5 months to 1 year, 1.94 (95% confidence interval, 1.02-3.69); and >1 year, 2.48 (95% confidence interval, 1.28-4.80). CONCLUSIONS By 3 years, the Norwood procedure with RVPAS compared with MBTS was no longer associated with superior transplantation-free survival. Moreover, RVPAS subjects had slightly worse right ventricular ejection fraction and underwent more catheter interventions with increasing hazard ratio over time. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00115934.
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Affiliation(s)
- Jane W Newburger
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.).
| | - Lynn A Sleeper
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Peter C Frommelt
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Gail D Pearson
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - William T Mahle
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Shan Chen
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Carolyn Dunbar-Masterson
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Seema Mital
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Ismee A Williams
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Nancy S Ghanayem
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Caren S Goldberg
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Jeffrey P Jacobs
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Catherine D Krawczeski
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Alan B Lewis
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Sara K Pasquali
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Christian Pizarro
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Peter J Gruber
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Andrew M Atz
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Svetlana Khaikin
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - J William Gaynor
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | - Richard G Ohye
- From the Boston Children's Hospital and Harvard Medical School, Boston, MA (J.W.N., C.D.-M.); New England Research Institutes, Watertown, MA (L.A.S., S.C.); Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P.); Emory University, Atlanta, GA (W.T.M.); Hospital for Sick Children, Toronto, ON, Canada (S.M., S.K.); Morgan Stanley Children's Hospital of New York-Presbyterian, New York (I.A.W.); University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.); The Congenital Heart Institute of Florida, St. Petersburg (J.P.J.); Cincinnati Children's Medical Center, Cincinnati, OH (C.D.K.); Children's Hospital Los Angeles, Los Angeles, CA (A.B.L.); North Carolina Consortium: Duke University, Durham; East Carolina University, Greenville; Wake Forest University, Winston-Salem (S.K.P.); Nemours Cardiac Center, Wilmington, DE (C.P.); Primary Children's Medical Center and University of Utah, Salt Lake City (P.J.G.); Medical University of South Carolina, Charleston (A.M.A.); and Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
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Hehir DA, Scott JP, Regner K, Buelow M, Shillingford AJ, Simpson P, Cao Y, Dall AT, Horn B, Mitchell M, Tweddell J, Ghanayem NS, Hoffman G. ACUTE KIDNEY INJURY FOLLOWING SURGERY FOR CONGENITAL HEART DISEASE: ROLE OF URINE BIOMARKERS, RENAL PERFUSION PRESSURE, AND SOMATIC OXYGEN SATURATION. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60589-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rudd NA, Frommelt MA, Tweddell JS, Hehir DA, Mussatto KA, Frontier KD, Slicker JA, Bartz PJ, Ghanayem NS. Improving interstage survival after Norwood operation: outcomes from 10 years of home monitoring. J Thorac Cardiovasc Surg 2014; 148:1540-7. [PMID: 24667026 DOI: 10.1016/j.jtcvs.2014.02.038] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [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: 11/20/2013] [Revised: 02/04/2014] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Infants who undergo Norwood stage 1 palliation (S1P) continue with high-risk circulation until stage 2 palliation (S2P). Routine care during the interstage period is associated with 10% to 20% mortality. This report illustrates the sustained reduction of interstage mortality over 10 years associated with use of home monitoring. METHODS Daily monitoring of oxygen saturation and weight was done for all patients discharged to home after S1P. Notification of the care team occurred for oxygen saturation<75% or >90%, weight gain<20 g over 3 days, weight loss>30 g, or intake<100 cc/kg/d. Breach of these criteria marked an interstage event. Interstage outcomes are reported. Patient characteristics and perioperative variables were compared between patients with and without interstage events. RESULTS Over 10 years, 157 patients were discharged after S1P with home monitoring. Interstage survival was 98%. Breach of home criteria occurred in 59% (93 out of 157), with violation of oxygen saturation<75% the most common event. Patient characteristics, operative data, and early postoperative morbidity did not differ between patients with and without events. CONCLUSIONS Home monitoring after S1P is associated with excellent interstage survival. Although a breach of monitoring criteria occurred in more than half of patients, our analysis failed to identify independent predictors of interstage events. Analysis of variables predicting mortality could not be assessed due to the low frequency of death in this cohort. Failure to identify specific variables for interstage events suggests that home monitoring, as part of an interstage surveillance program, should be applied to all S1P hospital survivors.
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Affiliation(s)
- Nancy A Rudd
- Section of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wis.
| | - Michele A Frommelt
- Section of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wis
| | - James S Tweddell
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wis
| | - David A Hehir
- Section of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Section of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wis
| | | | | | - Julie A Slicker
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Peter J Bartz
- Section of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Nancy S Ghanayem
- Section of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wis
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Hill GD, Hehir DA, Bartz PJ, Rudd NA, Frommelt MA, Slicker J, Tanem J, Frontier K, Xiang Q, Wang T, Tweddell JS, Ghanayem NS. Effect of feeding modality on interstage growth after stage I palliation: a report from the National Pediatric Cardiology Quality Improvement Collaborative. J Thorac Cardiovasc Surg 2014; 148:1534-9. [PMID: 24607373 DOI: 10.1016/j.jtcvs.2014.02.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [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: 09/24/2013] [Revised: 12/30/2013] [Accepted: 02/03/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Achieving adequate growth after stage 1 palliation for children with single-ventricle heart defects often requires supplemental nutrition through enteral tubes. Significant practice variability exists between centers in the choice of feeding tube. The impact of feeding modality on the growth of patients with a single ventricle after stage 1 palliation was examined using the multiinstitutional National Pediatric Cardiology Quality Improvement Collaborative data registry. METHODS Characteristics of patients were compared by feeding modality, defined as oral only, nasogastric tube only, oral and nasogastric tube, gastrostomy tube only, and oral and gastrostomy tube. The impact of feeding modality on change in weight for age z-score during the interstage period, from stage 1 palliation discharge to stage 2 palliation, was evaluated by multivariable linear regression, adjusting for important patient characteristics and postoperative morbidities. RESULTS In this cohort of 465 patients, all groups demonstrated improved weight for age z-score during the interstage period with a mean increase of 0.3±0.8. In multivariable analysis, feeding modality was not associated with differences in the change in weight for age z-score during the interstage period (P=.72). Risk factors for poor growth were a diagnosis of hypoplastic left heart syndrome (P=.003), vocal cord injury (P=.007), and lower target caloric goal at discharge (P=.001). CONCLUSIONS In this large multicenter cohort, interstage growth improved for all groups and did not differ by feeding modality. With appropriate caloric goals and interstage monitoring, adequate growth may be achieved regardless of feeding modality and therefore local comfort and complication risk should dictate feeding modality.
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Affiliation(s)
- Garick D Hill
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.
| | - David A Hehir
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Peter J Bartz
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wis
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Michele A Frommelt
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Julie Slicker
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Jena Tanem
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Katherine Frontier
- Division of Speech and Audiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Qun Xiang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wis
| | - Tao Wang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wis
| | - James S Tweddell
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
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Russell RA, Ghanayem NS, Kuhn EM, Jeffries HE, Scanlon MC, Rice TB. Relationship between risk-adjustment tools and the pediatric logistic organ dysfunction score. World J Pediatr Congenit Heart Surg 2014; 5:16-21. [PMID: 24403350 DOI: 10.1177/2150135113510008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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
BACKGROUND The Risk-Adjusted Classification for Congenital Heart Surgery (RACHS-1) method and Aristotle Basic Complexity (ABC) scores correlate with mortality. However, low mortality rates in congenital heart disease (CHD) make use of mortality as the primary outcome measure insufficient. Demonstrating correlation between risk-adjustment tools and the Pediatric Logistic Organ Dysfunction (PELOD) score might allow for risk-adjusted comparison of an outcome measure other than mortality. METHODS Data were obtained from the Virtual PICU Systems database. Patients with postoperative CHD between 2009 and 2010 were included. Correlation between RACHS-1 category and PELOD score and between ABC level and PELOD score was examined using Spearman rank correlation. Consistency of PELOD scores across institutions for given levels of case complexity was examined using Kruskal-Wallis nonparametric analysis of variance. RESULTS A total of 1,981 patient visits among 12 institutions met inclusion criteria. Positive correlations between PELOD score and RACHS-1 category (r s = .353, P < .0001) as well as between PELOD score and ABC level (r s = .328, P < .0001) were demonstrated. Variability in PELOD scores across individual centers for given levels of case complexity was observed (P < .04). CONCLUSIONS Risk-Adjusted Classification for Congenital Heart Surgery categories and ABC levels correlate with postoperative organ dysfunction as measured by PELOD. However, the correlation was weak, potentially due to limitations of the PELOD score itself. Identification of a more accurate metric of morbidity for the congenital heart disease population is needed.
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Affiliation(s)
- Rebecca A Russell
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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Niebler RA, Lew SM, Zangwill SD, Woods RK, Mitchell ME, Tweddell JS, Ghanayem NS. Incidence and outcome of pediatric patients with intracranial hemorrhage while supported on ventricular assist devices. Artif Organs 2013; 38:73-8. [PMID: 24256117 DOI: 10.1111/aor.12209] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pediatric patients supported on ventricular assist devices (VADs) require systemic anticoagulation and are at risk for intracranial hemorrhage (ICH). Little is known about the incidence or outcomes of pediatric patients with ICH while supported on a VAD. A retrospective chart review of all patients receiving VAD support was completed. Patients diagnosed with ICH while supported on a VAD were identified. Significant factors prior to diagnosis of ICH, medical/surgical treatment of ICH, and patient outcomes were assessed. Five of 30 (17%) patients supported on a VAD from January 2000 to November 2012 were diagnosed with an ICH. Four patients had an identified cerebral thromboembolic injury prior to the ICH. Four patients required interruption in their anticoagulation regimen due to other bleeding concerns prior to ICH. Neurosurgical intervention consisted of evacuation of hemorrhage in one, whereas two others required management of hydrocephalus with external ventricular drainage. Three of the five patients died on VAD support. Two deaths were directly related to ICH, whereas the third was unrelated. Two patients were successfully transplanted; one remains with a significant neurological impairment, and the other has recovered with minimal residual impairment following neurosurgical evacuation of a large subdural hematoma. ICH is a devastating complication of VAD support. Prior ischemic infarcts and interruptions to anticoagulation may put a patient at risk for ICH. Prompt neurosurgical evaluation/intervention can result in positive outcomes.
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Affiliation(s)
- Robert A Niebler
- Department of Pediatrics, Section of Critical Care, The Medical College of Wisconsin, Milwaukee, WI, USA; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Myers JW, Ghanayem NS, Cao Y, Simpson P, Trapp K, Mitchell ME, Tweddell JS, Woods RK. Outcomes of systemic to pulmonary artery shunts in patients weighing less than 3 kg: analysis of shunt type, size, and surgical approach. J Thorac Cardiovasc Surg 2013; 147:672-7. [PMID: 24252942 DOI: 10.1016/j.jtcvs.2013.09.055] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [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: 06/28/2013] [Revised: 08/22/2013] [Accepted: 09/23/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate outcomes of systemic to pulmonary artery shunts (SPS) in patients weighing less than 3 kg with regard to shunt type, shunt size, and surgical approach. METHODS Patients weighing less than 3 kg who underwent modified Blalock-Taussig or central shunts with polytetrafluoroethylene grafts at our institution from January 1, 2000, to May 31, 2011, were reviewed. Patients who had undergone other major concomitant procedures were excluded from the analysis. Primary outcomes included mortality (discharge mortality and mortality before next planned palliative procedure or definitive repair), cardiac arrest and/or extracorporeal membrane oxygenation (ECMO), and shunt reintervention. RESULTS In this cohort of 80 patients, discharge survival was 96% (77/80). Postoperative cardiac arrest or ECMO occurred in 6/80 (7.5%), and shunt reintervention was required in 14/80 (17%). On univariate analysis, shunt reintervention was more common in patients with 3-mm shunts (11/30, 37%) compared with 3.5-mm (2/36, 6%) or 4-mm shunts (1/14, 7%) (P < .003). There were no statistically significant associations between shunt type, shunt size, or surgical approach and cardiac arrest/ECMO or mortality. Multiple logistic regression demonstrated that a shunt size of 3 mm (P = .019) and extracardiac anomaly (P = .047) were associated with shunt reintervention, whereas no variable was associated with cardiac arrest/ECMO or mortality. CONCLUSIONS In this high-risk group of neonates weighing less than 3 kg at the time of SPS, survival to discharge and the next planned surgical procedure was high. Outcomes were good with the 3.5- and 4-mm shunts; however, shunt reintervention was common with 3-mm shunts.
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Affiliation(s)
- John W Myers
- Medical College of Wisconsin and the Herma Heart Center at the Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Nancy S Ghanayem
- Medical College of Wisconsin and the Herma Heart Center at the Children's Hospital of Wisconsin, Milwaukee, Wis; Division of Critical Care in the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Yumei Cao
- Medical College of Wisconsin and the Herma Heart Center at the Children's Hospital of Wisconsin, Milwaukee, Wis; Division of Quantitative Health Sciences in the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Cardiothoracic Surgery in the Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Pippa Simpson
- Medical College of Wisconsin and the Herma Heart Center at the Children's Hospital of Wisconsin, Milwaukee, Wis; Division of Quantitative Health Sciences in the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Department of Pediatrics, Medical College of Wisconsin, Medical College of Wisconsin, Milwaukee, Wis
| | - Katie Trapp
- Medical College of Wisconsin and the Herma Heart Center at the Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Michael E Mitchell
- Medical College of Wisconsin and the Herma Heart Center at the Children's Hospital of Wisconsin, Milwaukee, Wis; Division of Cardiothoracic Surgery in the Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - James S Tweddell
- Medical College of Wisconsin and the Herma Heart Center at the Children's Hospital of Wisconsin, Milwaukee, Wis; Division of Cardiothoracic Surgery in the Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Ronald K Woods
- Medical College of Wisconsin and the Herma Heart Center at the Children's Hospital of Wisconsin, Milwaukee, Wis; Division of Cardiothoracic Surgery in the Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis.
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Hoffman GM, Brosig CL, Mussatto KA, Tweddell JS, Ghanayem NS. Perioperative cerebral oxygen saturation in neonates with hypoplastic left heart syndrome and childhood neurodevelopmental outcome. J Thorac Cardiovasc Surg 2013; 146:1153-64. [DOI: 10.1016/j.jtcvs.2012.12.060] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 11/23/2012] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
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Russell RA, Ghanayem NS, Mitchell ME, Woods RK, Tweddell JS. Bilateral pulmonary artery banding as rescue intervention in high-risk neonates. Ann Thorac Surg 2013; 96:885-90. [PMID: 23916808 DOI: 10.1016/j.athoracsur.2013.05.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [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: 01/30/2013] [Revised: 05/15/2013] [Accepted: 05/17/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Presentation in shock and preoperative infection remain risk factors for neonatal cardiac surgery. This report describes bilateral pulmonary artery banding (bPAB) in ductal-dependent lesions with systemic outflow obstruction as rescue intervention before surgery with cardiopulmonary bypass in these high-risk neonates. METHODS A retrospective chart review was conducted for 10 patients who underwent bPAB before conventional surgery with cardiopulmonary bypass. Patient characteristics including birth weight, gestational age, cardiac and noncardiac diagnoses, preoperative and postoperative markers of organ function, and outcome measures were examined. RESULTS The majority of patients (8 of 10) were considered high-risk owing to multiorgan dysfunction syndrome. The median age at bPAB was 12 days (range, 5 to 26 days), and the median interval between bPAB and second surgery was 10.5 days (range, 5 to 79 days). Organ function improved after admission and continued to improve after bPAB in 9 of 10 patients. No patient experienced new complications between bPAB and subsequent operation. Of 8 patients who had stage I palliation, 5 have undergone or are awaiting completion Fontan, 1 underwent Kawashima procedure, 1 underwent orthotopic heart transplant, and 1 with hypoplastic left heart syndrome and intact atrial septum died at 44 days old. Both patients who underwent biventricular repair are alive and well. Median follow-up for survivors was 2.9 years (range, 0.25 to 6.25 years). CONCLUSIONS Bilateral pulmonary artery banding is safe in ductal-dependent lesions with systemic outflow obstruction. High-risk patients with preoperative organ dysfunction or infection can recover within a short period and become lower risk candidates for complex congenital heart surgery using cardiopulmonary bypass.
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Affiliation(s)
- Rebecca A Russell
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin and Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, Wisconsin 53201, USA.
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Hehir DA, Niebler RA, Brabant CC, Tweddell JS, Ghanayem NS. Intensive care of the pediatric ventricular assist device patient. World J Pediatr Congenit Heart Surg 2013; 3:58-66. [PMID: 23804685 DOI: 10.1177/2150135111420888] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Utilization of ventricular assist devices (VADs) in children is increasing, as is the complexity of patients supported. We review the intensive care management of pediatric patients with VAD in the perioperative and rehabilitation phases, highlighting the technical aspects and physiology of VADs which impact care. Indications for VAD placement and the preoperative assessment of risk are discussed. Specific aspects of postoperative and long-term care including device troubleshooting, hemostasis and anticoagulation, support of the right ventricle, incidence and prevention of neurologic injury, and other complications are reviewed.
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Affiliation(s)
- David A Hehir
- Division of Pediatric Critical Care, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
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