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Bainton J, Trachtenberg F, McCrindle BW, Wang K, Boruta R, Brosig CL, Egerson D, Sood E, Calderon J, Doman T, Golub K, Graham A, Haas K, Hamstra M, Lindauer B, Sylvester D, Woodard F, Young-Borkowski L, Mussatto KA. Prevalence and associated factors of post-traumatic stress disorder in parents whose infants have single ventricle heart disease. Cardiol Young 2023; 33:2171-2180. [PMID: 36601959 DOI: 10.1017/s1047951122004012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Post-traumatic stress disorder occurs in parents of infants with CHD, contributing to psychological distress with detrimental effects on family functioning and well-being. We sought to determine the prevalence and factors associated with post-traumatic stress disorder symptoms in parents whose infants underwent staged palliation for single ventricle heart disease. MATERIALS AND METHODS A large longitudinal multi-centre cohort study evaluated 215 mothers and fathers for symptoms of post-traumatic stress disorder at three timepoints, including post-Norwood, post-Stage II, and a final study timepoint when the child reached approximately 16 months of age, using the self-report questionnaire Impact of Event Scale - Revised. RESULTS The prevalence of probable post-traumatic stress disorder post-Norwood surgery was 50% of mothers and 39% of fathers, decreasing to 27% of mothers and 24% of fathers by final follow-up. Intrusive symptoms such as flashbacks and nightmares and hyperarousal symptoms such as poor concentration, irritability, and sudden physical symptoms of racing heart and difficulty breathing were particularly elevated in parents. Higher levels of anxiety, reduced coping, and decreased satisfaction with parenting were significantly associated with symptoms of post-traumatic stress disorder in parents. Demographic and clinical variables such as parent education, pre-natal diagnosis, medical complications, and length of hospital stay(s) were not significantly associated with symptoms of post-traumatic stress disorder. DISCUSSION Parents whose infants underwent staged palliation for single ventricle heart disease often reported symptoms of post-traumatic stress disorder. Symptoms persisted over time and routine screening might help identify parents at-risk and prompt referral to appropriate supports.
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Affiliation(s)
- Jessica Bainton
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Brian W McCrindle
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ke Wang
- HealthCore, Watertown, MA, USA
| | | | - Cheryl L Brosig
- Herma Heart Institute, Children's Wisconsin, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Erica Sood
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | - Tammy Doman
- University of Michigan Health System, Ann Arbor, MI, USA
| | - Katrina Golub
- Columbia University Irving Medical Center, New York, NY, USA
| | | | - Karen Haas
- Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Michelle Hamstra
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | - Lisa Young-Borkowski
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Mussatto KA, Van Rompay MI, Trachtenberg FL, Pemberton V, Young-Borkowski L, Uzark K, Hollenbeck-Pringle D, Dunbar-Masterson C, Infinger P, Walter P, Sawin K. Family Function, Quality of Life, and Well-Being in Parents of Infants With Hypoplastic Left Heart Syndrome. J Fam Nurs 2021; 27:222-234. [PMID: 33535863 PMCID: PMC8594631 DOI: 10.1177/1074840720987309] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Survival for hypoplastic left heart syndrome (HLHS) has improved dramatically. Little is known about early family function, quality of life (QOL), or well-being/adjustment for parents of infants with HLHS. Parent/family outcomes over time, predictors, and differences in 143 mothers and 72 fathers were examined. Parents reported better family function compared with published norms, but 26% experienced family dysfunction. QOL and well-being were significantly lower than adult norms. QOL scores generally declined over time, whereas self-reported well-being improved. Responses from mothers and fathers showed different trends, with mothers having worse scores on most measures and at most time points. Being a single parent was a risk factor for poorer family function, but not for lower individual QOL or well-being. Family characteristics, stress, and coping skills were predictive of outcomes. Parents' psychosocial responses to the challenges of life with infants with HLHS change over time. Individually tailored psychosocial support is needed.
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Affiliation(s)
| | | | | | | | | | - Karen Uzark
- C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | | | | | | | | | - Kathleen Sawin
- Milwaukee School of Engineering, WI, USA
- Children's Hospital of Wisconsin, Milwaukee, USA
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3
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Sanz JH, Anixt J, Bear L, Basken A, Beca J, Marino BS, Mussatto KA, Nembhard WN, Sadhwani A, Sananes R, Shekerdemian LS, Sood E, Uzark K, Willen E, Ilardi D. Characterisation of neurodevelopmental and psychological outcomes in CHD: a research agenda and recommendations from the cardiac neurodevelopmental outcome collaborative. Cardiol Young 2021; 31:876-887. [PMID: 34082845 PMCID: PMC8429101 DOI: 10.1017/s1047951121002146] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The Neurodevelopmental and Psychological Outcomes Working Group of the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute with the goals of identifying knowledge gaps regarding the neurodevelopmental and psychological outcomes of individuals with CHD and investigations needed to advance science, policy, clinical care, and patient/family outcomes. Accurate characterisation of neurodevelopmental and psychological outcomes in children with CHD will drive improvements in patient and family outcomes through targeted intervention. Decades of research have produced a generalised perspective about neurodevelopmental and psychological outcomes in this heterogeneous population. Future investigations need to shift towards improving methods, measurement, and analyses of outcomes to better inform early identification, prevention, and intervention. Improved definition of underlying developmental, neuropsychological, and social-emotional constructs is needed, with an emphasis on symptom networks and dimensions. Identification of clinically meaningful outcomes that are most important to key stakeholders, including patients, families, schools and providers, is essential, specifically how and which neurodevelopmental differences across the developmental trajectory impact stakeholders. A better understanding of the discontinuity and patterns of neurodevelopment across the lifespan is critical as well, with some areas being more impactful at some ages than others. Finally, the field needs to account for the impact of race/ethnicity, socio-economic status, cultural and linguistic diversity on our measurement, interpretation of data, and approach to intervention and how to improve generalisability to the larger worldwide population of patients and families living with CHD.
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Affiliation(s)
- Jacqueline H. Sanz
- Division of Neuropsychology, Children’s National Hospital, Departments of Psychiatry and Behavioral Sciences & Pediatrics, George Washington University School of Medicine, Washington, DC, USA
| | - Julia Anixt
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Laurel Bear
- Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children’s Wisconsin, Milwaukee, Wisconsin, USA
| | | | - John Beca
- Department of Intensive Care, Starship Children’s Health, Auckland, New Zealand
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children’s Hospital, Cleveland, Ohio, USA
| | | | - Wendy N. Nembhard
- Department of Epidemiology and the Arkansas Birth Defects Center for Research and Prevention, Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Anjali Sadhwani
- Department of Psychiatry, Boston Children’s Hospital & Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Renee Sananes
- Division of Cardiology, Department of Psychology, The Hospital for Sick Children, Department of Pediatrics, The University of Toronto, Toronto, Canada
| | - Lara S. Shekerdemian
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Houston, TX, USA
| | - Erica Sood
- Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, DE & Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Karen Uzark
- Department of Pediatrics, Section of Pediatric Cardiology, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Elizabeth Willen
- Division of Developmental and Behavioral Sciences and the Ward Family Heart Center, Children’s Mercy, Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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4
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Sananes R, Goldberg CS, Newburger JW, Hu C, Trachtenberg F, Gaynor JW, Mahle WT, Miller T, Uzark K, Mussatto KA, Pizarro C, Jacobs JP, Cnota J, Atz AM, Lai WW, Burns KM, Milazzo A, Votava-Smith J, Brosig CL. Six-Year Neurodevelopmental Outcomes for Children With Single-Ventricle Physiology. Pediatrics 2021; 147:peds.2020-014589. [PMID: 33441486 PMCID: PMC7849196 DOI: 10.1542/peds.2020-014589] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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] [Accepted: 10/27/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine if neurodevelopmental deficits in children with single-ventricle physiology change with age and early developmental scores predict 6-year outcomes. METHODS In the Single Ventricle Reconstruction Trial, Bayley Scales of Infant Development, Second Edition, were administered at 14 months of age, and parents completed the Behavior Assessment System for Children, Second Edition (BASC-2) annually from the ages of 2 to 6 years. Scores were classified as average, at risk, or impaired. We calculated sensitivities, specificities, and positive and negative predictive values of earlier tests on 6-year outcomes. RESULTS Of 291 eligible participants, 244 (84%) completed the BASC-2 at 6 years; more Single Ventricle Reconstruction participants than expected on the basis of normative data scored at risk or impaired on the BASC-2 Adaptive Skills Index at that evaluation (28.7% vs 15.9%; P < .001). Children with Adaptive Skills Composite scores <2 SD below the mean at the age of 6 were more likely to have had delayed development at 14 months, particularly on the Psychomotor Development Index (sensitivity of 79%). However, the positive predictive value of the 14-month Mental Development Index and Psychomotor Development Index for 6-year BASC-2 Adaptive Scores was low (44% and 36%, respectively). Adaptive Skills Composite score impairments at the age of 6 were poorly predicted by using earlier BASC-2 assessments, with low sensitivities at the ages of 3 (37%), 4 (48%), and 5 years (55%). CONCLUSIONS Many children with hypoplastic left heart syndrome who have low adaptive skills at the age of 6 years will not be identified by screening at earlier ages. With our findings, we highlight the importance of serial evaluations for children with critical congenital heart disease throughout development.
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Affiliation(s)
- Renee Sananes
- Department of Pediatrics and Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada;
| | - Caren S. Goldberg
- Department of Pediatrics, Michigan Medicine, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Chenwei Hu
- New England Research Institutes, Watertown, Massachusetts
| | | | - J. William Gaynor
- Division of Pediatric Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William T. Mahle
- Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Thomas Miller
- Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;,Division of Pediatric Cardiology, Maine Medical Center, Portland, Maine
| | - Karen Uzark
- Department of Pediatrics, Michigan Medicine, Medical School, University of Michigan, Ann Arbor, Michigan
| | | | - Christian Pizarro
- Department of Surgery, Nemours Cardiac Center, Alfred I du Pont Hospital for Children, Wilmington, Delaware
| | | | - James Cnota
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Andrew M. Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Wyman W. Lai
- Children’s Heart Institute, Children’s Hospital of Orange County, Orange, California
| | | | - Angelo Milazzo
- Department of Pediatrics, School of Medicine, Duke University, Durham, North Carolina;,Department of Pediatrics, East Carolina University, Greenville, North Carolina;,Department of Pediatrics, Wake Forest University, Winston-Salem, North Carolina; and
| | - Jodie Votava-Smith
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
| | - Cheryl L. Brosig
- Pediatrics, Herma Heart Institute, Children’s Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
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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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6
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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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7
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Goldberg CS, Hu C, Brosig C, Gaynor JW, Mahle WT, Miller T, Mussatto KA, Sananes R, Uzark K, Trachtenberg F, Pizarro C, Pemberton VL, Lewis AB, Li JS, Jacobs JP, Cnota J, Atz AM, Lai WW, Bellinger D, Newburger JW. Behavior and Quality of Life at 6 Years for Children With Hypoplastic Left Heart Syndrome. Pediatrics 2019; 144:e20191010. [PMID: 31628208 PMCID: PMC6856798 DOI: 10.1542/peds.2019-1010] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We measured behavioral, quality of life (QoL), and functional status outcomes for 6-year-old children with hypoplastic left heart syndrome enrolled in the Single Ventricle Reconstruction Trial. We sought to compare these outcomes with those in the normative population and to analyze risk factors for worse outcomes within the single-ventricle group. METHODS Parent-response instruments included the Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) (primary outcome), Behavior Assessment System for Children 2, Pediatric Quality of Life Inventory 4.0, and other measures of QoL and functional status. We compared subjects with those in the normative sample using 1-sample Wilcoxon rank tests and assessed outcome predictors using multivariable regression. RESULTS Of 325 eligible patients, 250 (77%) participated. Compared with population norms, participants had lower scores on the Vineland-II motor skills domain (90 ± 17 vs 100 ± 15; P < .001), with 11% scoring >2 SDs below the normative mean. On nearly all major domains, more study subjects (3.3%-19.7%) scored outside the normal range than anticipated for the general population. Independent risk factors for lower Vineland-II scores included perioperative extracorporeal membrane oxygenation, male sex, use of regional cerebral perfusion, catheterization after stage 2 operation, visual problems, seizure history, and more complications after 2 years (R 2 = 0.32). Independent predictors of worse Behavior Assessment System for Children 2 (R 2 = 0.07-0.20) and Pediatric Quality of Life Inventory 4.0 (R 2 = 0.17-0.25) domain scores also included sociodemographic factors and measures of morbidity and/or greater course complexity. CONCLUSIONS At 6 years, children with hypoplastic left heart syndrome had difficulty in areas of adaptive behavior, behavioral symptoms, QoL, and functional status. Principal risks for adverse outcomes include sociodemographic factors and measures of greater course complexity. However, models reveal less than one-third of outcome variance.
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Affiliation(s)
- Caren S Goldberg
- Department of Pediatrics, Medical School, University of Michigan and Michigan Medicine, Ann Arbor, Michigan;
| | - Chenwei Hu
- New England Research Institutes, Watertown, Massachusetts
| | - Cheryl Brosig
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - J William Gaynor
- Pediatric Cardiothoracic Surgery, School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William T Mahle
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Thomas Miller
- Department of Pediatrics, and The University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Kathleen A Mussatto
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Renee Sananes
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Canada
| | - Karen Uzark
- Department of Pediatrics, Medical School, University of Michigan and Michigan Medicine, Ann Arbor, Michigan
| | | | - Christian Pizarro
- Department of Surgery, Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Victoria L Pemberton
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Alan B Lewis
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Jennifer S Li
- Department of Pediatrics, Duke University, Durham, North Carolina
- Department of Pediatrics, East Carolina University, Greenville, North Carolina
- Department of Pediatrics, Wake Forest University, Winston-Salem, North Carolina
| | | | - James Cnota
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Wyman W Lai
- Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - David Bellinger
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and
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Devlin PJ, Jegatheeswaran A, Williams WG, Blackstone EH, DeCampli WM, Lambert LM, Mussatto KA, Prospero CJ, Bondarenko I, McCrindle BW. Late Survival and Patient-Perceived Health Status of the Congenital Heart Surgeons' Society dextro-Transposition of the Great Arteries Cohort. Ann Thorac Surg 2019; 108:1447-1455. [PMID: 31348901 DOI: 10.1016/j.athoracsur.2019.05.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 02/05/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Improved survival for patients with dextro-transposition of the great arteries (d-TGA) has led to an increased focus on functional health status (FHS). We assessed late survival and patient-perceived FHS for repaired TGA patients. METHODS From 1985-1990, 830 neonates admitted to 24 Congenital Heart Surgeons' Society (CHSS) institutions with d-TGA underwent repair, including 516 arterial switch, 110 Mustard, 175 Senning, and 29 Rastelli operations. Median follow-up was 24.0 years (range, 0-32.7 years). We performed multiphase parametric hazard analysis for death after repair. Patients completed Pediatric Quality of Life Inventory (PedsQL) Core Scales and Cardiac Module Adult Forms. Patient and operative factors and CHSS General Questionnaire responses were analyzed for association with FHS using multiple linear regression. RESULTS Survival at 30 years after repair was arterial switch, 80% ± 2%; Mustard, 81% ± 5%; Senning, 70% ± 4%; and Rastelli, 86% ± 8%. The arterial switch had the lowest hazard for late death. TGA patients reported FHS similar to a healthy population in all domains except physical health (lower scores). Symptoms, including chest pain and fainting, and having a pacemaker were associated with lower, and being employed with higher, self-reported physical health. Arterial switch patients reported higher FHS than the atrial switch patients in all domains. CONCLUSIONS Arterial switch patients have a lower risk of premature death and better FHS than those with an atrial switch. Increased surveillance in atrial switch patients is warranted because of their increased risk of late death. Presence of symptoms, pacemaker, and lack of employment are associated with reduced FHS.
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Affiliation(s)
- Paul J Devlin
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - William G Williams
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eugene H Blackstone
- Division of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Linda M Lambert
- Department of Pediatrics, Primary Children's Hospital, Salt Lake City, Utah
| | - Kathleen A Mussatto
- Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Carol J Prospero
- Nemours Cardiac Center, Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Igor Bondarenko
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Michigan
| | - Brian W McCrindle
- Division of Pediatric Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
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9
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Handisides JC, Hollenbeck-Pringle D, Uzark K, Trachtenberg FL, Pemberton VL, Atz TW, Bradley TJ, Cappella E, De Nobele S, Groh GKT, Hamstra MS, Korsin R, Levine JC, Lindauer B, Liou A, Mac Neal MK, Markham LW, Morrison T, Mussatto KA, Olson AK, Pierpont MEM, Pyeritz RE, Radojewski EA, Roman MJ, Xu M, Lacro RV. Health-Related Quality of Life in Children and Young Adults with Marfan Syndrome. J Pediatr 2019; 204:250-255.e1. [PMID: 30270167 PMCID: PMC6800200 DOI: 10.1016/j.jpeds.2018.08.061] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 05/29/2018] [Revised: 07/25/2018] [Accepted: 08/21/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess health-related quality of life (HRQOL) in a large multicenter cohort of children and young adults with Marfan syndrome participating in the Pediatric Heart Network Marfan Trial. STUDY DESIGN The Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales were administered to 321 subjects with Marfan syndrome (5-25 years). PedsQL scores were compared with healthy population norms. The impact of treatment arm (atenolol vs losartan), severity of clinical features, and number of patient-reported symptoms on HRQOL was assessed by general linear models. RESULTS Mean PedsQL scores in children (5-18 years) with Marfan syndrome were lower than healthy population norms for physical (P ≤ .003) and psychosocial (P < .001) domains; mean psychosocial scores for adults (19-25 years) were greater than healthy norms (P < .001). HRQOL across multiple domains correlated inversely with frequency of patient-reported symptoms (r = 0.30-0.38, P < .0001). Those <18 years of age with neurodevelopmental disorders (mainly learning disability, attention-deficit/hyperactivity disorder) had lower mean PedsQL scores (5.5-7.4 lower, P < .04). A multivariable model found age, sex, patient-reported symptoms, and neurodevelopmental disorder to be independent predictors of HRQOL. There were no differences in HRQOL scores by treatment arm, aortic root z score, number of skeletal features, or presence of ectopia lentis. CONCLUSIONS Children and adolescents with Marfan syndrome were at high risk for impaired HRQOL. Patient-reported symptoms and neurodevelopmental disorder, but not treatment arm or severity of Marfan syndrome-related physical findings, were associated with lower HRQOL.
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Affiliation(s)
| | | | - Karen Uzark
- C. S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | | | | | - Teresa W. Atz
- Medical University of South Carolina, Charleston, SC
| | - Timothy J. Bradley
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | - Jami C. Levine
- Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Bergen Lindauer
- Primary Children’s Hospital, University of Utah, Salt Lake City, UT
| | | | | | - Larry W. Markham
- The Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | | | | | | | | | - Reed E. Pyeritz
- The Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Mingfen Xu
- Duke University School of Medicine, Durham, NC
| | - Ronald V. Lacro
- Boston Children’s Hospital, Harvard Medical School, Boston, MA
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10
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Brosig CL, Bear L, Allen S, Simpson P, Zhang L, Frommelt M, Mussatto KA. Neurodevelopmental outcomes at 2 and 4 years in children with congenital heart disease. CONGENIT HEART DIS 2018; 13:700-705. [PMID: 30191663 DOI: 10.1111/chd.12632] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/29/2018] [Accepted: 05/04/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Children with congenital heart disease (CHD) are at risk for neurodevelopmental (ND) delays. The purpose of this study is to compare the ND testing results of children with CHD at 2 and 4 years of age and determine if rates of ND delays change over time. METHODS Children with CHD completed the Bayley Scales of Infant Development-III (BSID-III) at 2 years of age, and standardized neuropsychological measures at 4 years. Scores were compared with test norms and were classified as: average (within one SD of test mean); at risk (1-2 SDs from the test mean); and delayed (>2 SD from test mean). Pearson correlations and McNemar's exact tests were performed to determine the relationship between test scores at the two times of assessment. RESULTS Sixty-four patients completed evaluations at 24 ± 3 months of age and 4 years of age. BSID-III cognitive and fine motor scores were correlated with preschool IQ and fine motor scores, r = .75 to .87, P < .0001. Agreement in score categories was 79% for cognitive and 61% for fine motor. More patients had at risk or delayed scores at age 4 vs age 2 (P ≤ .01). CONCLUSION(S) Despite significant correlations between 2- and 4-year-old test scores, many patients who scored in the average range at age 2 showed deficits at age 4. BSID-III scores at age 2 may underestimate delays. Therefore, longitudinal ND assessment is recommended.
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Affiliation(s)
- Cheryl L Brosig
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.,Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Laurel Bear
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.,Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Sydney Allen
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa Simpson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Liyun Zhang
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michele Frommelt
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.,Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Kathleen A Mussatto
- Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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11
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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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12
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Geddes GC, Stamm K, Mitchell M, Mussatto KA, Tomita-Mitchell A. Ciliopathy variant burden and developmental delay in children with hypoplastic left heart syndrome. Genet Med 2016; 19:711-714. [PMID: 27787502 DOI: 10.1038/gim.2016.167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 08/31/2016] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To test the hypothesis that patients with hypoplastic left heart syndrome (HLHS) and developmental delay will have a higher average summative C-score in ciliopathy genes than patients with HLHS without developmental delay. METHODS Ciliopathy gene variant burden was determined utilizing a summative C-score for 14 ciliopathy genes in children with HLHS (n = 24). Mean summative C-scores were compared between children with and without developmental delay. Genome-wide randomizing gene sets were evaluated as a scoring control. RESULTS Children with developmental delay had a mean summative C-score of 4.05 in ciliopathy genes as compared to a mean summative C-score of 2.02 for children without developmental delay. This difference in means was higher than 99.1% (empirical P value <0.01) of 2 million random lists of 14 genes. CONCLUSION Genetically complex disorders such as ciliopathies can be assessed to determine phenotypic risk with summative C-score in appropriately chosen gene sets. If these results are replicated in subsequent cohorts, a diagnostic gene panel could identify risk for developmental delay and other ciliopathy-related comorbidities in infants with congenital heart disease.Genet Med advance online publication 27 October 2016Genetics in Medicine (2016); doi:10.1038/gim.2016.167.
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Affiliation(s)
- Gabrielle C Geddes
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Karl Stamm
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael Mitchell
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kathleen A Mussatto
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aoy Tomita-Mitchell
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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13
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Mussatto KA, Hoffmann R, Hoffman G, Tweddell JS, Bear L, Cao Y, Tanem J, Brosig C. Risk Factors for Abnormal Developmental Trajectories in Young Children With Congenital Heart Disease. Circulation 2015; 132:755-61. [PMID: 26304667 DOI: 10.1161/circulationaha.114.014521] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [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] [Indexed: 01/09/2023]
Abstract
BACKGROUND Children with congenital heart disease are at risk for developmental delay. This study sought to identify early risk factors for abnormal developmental trajectories in children with congenital heart disease. METHODS AND RESULTS Children with congenital heart disease at high risk for developmental delay, without known genetic abnormality, and with ≥3 assessments by the use of the Bayley Scales of Infant and Toddler Development, Third Edition, were studied. Logistic regression was used to assess the impact of patient and clinical factors on cognitive, language, and motor score trajectories; classified as: average or improved if all scores were ≥85 (<1 standard deviation below the mean) or increased to ≥85 and never decreased; or abnormal if all scores were <85, fell to <85 and never improved, or fluctuated above and below 85. Data on 131 children with 527 Bayley Scales of Infant and Toddler Development, Third Edition assessments were analyzed. Subject age was 5.5 to 37.4 months. Overall, 56% had cognitive, language, and motor development in the average range. Delays occurred in single domains in 23%. Multiple domains were delayed in 21%. More cardiac surgeries, longer hospital stay, poorer linear growth, and tube feeding were associated with worse outcomes in all domains (P<0.05). In the multivariable model, the need for tube feeding was a risk factor for having an abnormal developmental trajectory (odds ratio, 5.1-7.9). Minority race and lack of private insurance had significant relationships with individual domains. CONCLUSIONS Longitudinal developmental surveillance identified early factors that can help quantify the risk of developmental delay over time. Strategies to improve modifiable factors and early therapeutic intervention can be targeted to children at highest risk.
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Affiliation(s)
- Kathleen A Mussatto
- From Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee (K.A.M., J.T.); and Departments of Pediatrics (R.H., L.B., Y.C., C.B.), Anesthesiology (G.H.), and Surgery (J.S.T.), Medical College of Wisconsin, Milwaukee.
| | - Raymond Hoffmann
- From Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee (K.A.M., J.T.); and Departments of Pediatrics (R.H., L.B., Y.C., C.B.), Anesthesiology (G.H.), and Surgery (J.S.T.), Medical College of Wisconsin, Milwaukee
| | - George Hoffman
- From Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee (K.A.M., J.T.); and Departments of Pediatrics (R.H., L.B., Y.C., C.B.), Anesthesiology (G.H.), and Surgery (J.S.T.), Medical College of Wisconsin, Milwaukee
| | - James S Tweddell
- From Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee (K.A.M., J.T.); and Departments of Pediatrics (R.H., L.B., Y.C., C.B.), Anesthesiology (G.H.), and Surgery (J.S.T.), Medical College of Wisconsin, Milwaukee
| | - Laurel Bear
- From Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee (K.A.M., J.T.); and Departments of Pediatrics (R.H., L.B., Y.C., C.B.), Anesthesiology (G.H.), and Surgery (J.S.T.), Medical College of Wisconsin, Milwaukee
| | - Yumei Cao
- From Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee (K.A.M., J.T.); and Departments of Pediatrics (R.H., L.B., Y.C., C.B.), Anesthesiology (G.H.), and Surgery (J.S.T.), Medical College of Wisconsin, Milwaukee
| | - Jena Tanem
- From Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee (K.A.M., J.T.); and Departments of Pediatrics (R.H., L.B., Y.C., C.B.), Anesthesiology (G.H.), and Surgery (J.S.T.), Medical College of Wisconsin, Milwaukee
| | - Cheryl Brosig
- From Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee (K.A.M., J.T.); and Departments of Pediatrics (R.H., L.B., Y.C., C.B.), Anesthesiology (G.H.), and Surgery (J.S.T.), Medical College of Wisconsin, Milwaukee
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Hoffman GM, Brosig CL, Bear LM, Tweddell JS, Mussatto KA. Effect of Intercurrent Operation and Cerebral Oxygenation on Developmental Trajectory in Congenital Heart Disease. Ann Thorac Surg 2015; 101:708-16. [PMID: 26542436 DOI: 10.1016/j.athoracsur.2015.08.059] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [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: 02/01/2015] [Revised: 07/13/2015] [Accepted: 08/21/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Children with congenital heart disease are at increased risk of abnormal neurodevelopment (ND). Demographic and perioperative physiologic factors have both been associated with developmental outcome. The acute physiologic effect of a surgical procedure, anesthesia, and hospitalization may offset any potential advantage gained from anatomic correction and circulatory palliation. The specific risk/benefit balance on ND outcome of the insult of the operation, offset by the benefit of improved anatomy and physiology, has not been addressed. We therefore sought to identify interval procedural and physiologic factors assessed at outpatient ND evaluation visits that were associated with outcome. METHODS The study included children with congenital heart disease at high risk for impaired ND performance with at least three ND assessments using the Bayley Scales of Infant Development-III during the first 3 years of life. The number of cardiac procedures, duration of hospitalization, feeding status, height, weight, and arterial, cerebral, and somatic oxygen saturations by near-infrared spectroscopy were recorded at each visit and used as predictors of language, motor, and cognitive composite scores and slopes (change over time) in general linear models. RESULTS Data on 178 children derived from 632 visits (median, 4 visits/child) were analyzed, with ages at first and last assessment of 7.7 and 30.2 months. Fifty-one had 1 ventricle (1V), 88 had 2 ventricles, and 39 had genetic syndrome conditions. Motor performance increased with age in all diagnostic categories. Cognitive and language performance increased with age in 1V patients but exhibited no significant change in 2-ventricle and genetic syndrome groups. At the first visit, 1V patients performed less well than 2-ventricle patients in the motor domain, but the rate of improvement was higher for 1V patients; by 24 months, there were no differences, and both groups were normal in all domains. Performance in genetic syndrome patients was below normal in all domains at the first visit and did not improve. Higher arterial saturation and narrower arterial-cerebral and arterial-somatic near-infrared spectroscopy saturation differences were associated with better or improving motor performance. Incremental cardiopulmonary bypass time, cumulative hospital length of stay, and tube feedings were risk factors in all domains. Total and incremental times for deep hypothermic circulatory arrest, extracorporeal membrane oxygenation, total open and total surgical procedures, and birth weight were not risk factors. CONCLUSIONS Patient physiologic status assessed by cerebral and somatic near-infrared spectroscopy is associated with ND performance. Incremental surgical procedures are not associated with ND performance when adjusted for cardiopulmonary bypass time and physiologic status. Treatment strategies that target improved physiologic status may also improve ND outcome.
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Affiliation(s)
- George M Hoffman
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Departments of Pediatric Anesthesiology, Pediatrics, and Pediatric Critical Care Medicine, Cardiology, and Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Cheryl L Brosig
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Departments of Pediatric Anesthesiology, Pediatrics, and Pediatric Critical Care Medicine, Cardiology, and Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laurel M Bear
- Departments of Pediatric Anesthesiology, Pediatrics, and Pediatric Critical Care Medicine, Cardiology, and Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James S Tweddell
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Departments of Pediatric Anesthesiology, Pediatrics, and Pediatric Critical Care Medicine, Cardiology, and Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Czosek RJ, Cassedy AE, Wray J, Wernovsky G, Newburger JW, Mussatto KA, Mahony L, Tanel RE, Cohen MI, Franklin RC, Brown KL, Rosenthal D, Drotar D, Marino BS. Quality of life in pediatric patients affected by electrophysiologic disease. Heart Rhythm 2015; 12:899-908. [PMID: 25602174 DOI: 10.1016/j.hrthm.2015.01.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Treatment of electrophysiologic (EP) disease in pediatric patients has improved; however, the effects on quality of life (QOL) are unknown. OBJECTIVE The purpose of this study was to compare QOL within EP disease groups and to other congenital heart diseases, to evaluate the effects of cardiac rhythm devices on QOL, and to identify drivers of QOL in EP disease. METHODS Cross-sectional study of patient/parent proxy-reported Pediatric Cardiac Quality of Life Inventory scores (Total, Disease Impact, Psychosocial Impact) in subjects aged 8 to 18 years from 11 centers with congenital complete heart block (CCHB), ventricular tachycardia (VT), supraventricular tachycardia (SVT), and long QT syndrome (LQTS). QOL was compared between EP disease groups and congenital heart disease groups [bicuspid aortic valve (BAV), tetralogy of Fallot (TOF), and Fontan]. General linear modeling was used to perform group comparisons and to identify predictors of QOL variation. RESULTS Among 288 patient-parent pairs, mean age was 12.8 ± 3.0 years. CCHB (μ = 83) showed higher patient Total QOL than other EP disease cohorts (P ≤ .02; LQTS μ = 73; SVT μ = 74). SVT (μ = 75) and LQTS (μ = 75) had lower patient Total scores than BAV (μ = 81; P ≤ .008). Patient/parent-proxy QOL scores for all EP disease groups were not different than TOF and higher than Fontan. The presence of a cardiac rhythm device was associated with lower QOL scores in LQTS (μ = 66 vs μ = 76; P < .01). Predictors of lower patient/parent-proxy QOL included EP disease type (P ≤ .03), increased medical care utilization (P ≤ .04), and no parental college degree (P ≤ .001). CONCLUSION Given the significant variation in QOL in EP disease type, stratification by EP disease type and increased medical care utilization may allow for targeted interventions to improve QOL.
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Affiliation(s)
- Richard J Czosek
- The Heart Institute, Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Amy E Cassedy
- Department of Biostatistics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jo Wray
- Critical Care and Cardiorespiratory Division, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | | | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Lynn Mahony
- Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, Texas
| | - Ronn E Tanel
- Division of Pediatric Cardiology, UCSF Benioff Children's Hospital, and Department of Pediatrics, UCSF School of Medicine, San Francisco, California
| | - Mitchell I Cohen
- Phoenix Children's Hospital and Arizona Pediatric Cardiology Consultants/Pediatrix, University of Arizona School of Medicine-Phoenix, Phoenix, Arizona
| | - Rodney C Franklin
- Department of Paediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Kate L Brown
- Critical Care and Cardiorespiratory Division, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - David Rosenthal
- Department of Pediatrics, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
| | - Dennis Drotar
- The Heart Institute, Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Bradley S Marino
- The Heart Institute, Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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16
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Goldberg CS, Lu M, Sleeper LA, Mahle WT, Gaynor JW, Williams IA, Mussatto KA, Ohye RG, Graham EM, Frank DU, Jacobs JP, Krawczeski C, Lambert L, Lewis A, Pemberton VL, Sananes R, Sood E, Wechsler SB, Bellinger DC, Newburger JW. Factors associated with neurodevelopment for children with single ventricle lesions. J Pediatr 2014; 165:490-496.e8. [PMID: 24952712 PMCID: PMC4356168 DOI: 10.1016/j.jpeds.2014.05.019] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 03/19/2014] [Accepted: 05/09/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To measure neurodevelopment at 3 years of age in children with single right-ventricle anomalies and to assess its relationship to Norwood shunt type, neurodevelopment at 14 months of age, and patient and medical factors. STUDY DESIGN All subjects in the Single Ventricle Reconstruction Trial who were alive without cardiac transplant were eligible for inclusion. The Ages and Stages Questionnaire (ASQ, n = 203) and other measures of behavior and quality of life were completed at age 3 years. Medical history, including measures of growth, feeding, and complications, was assessed through annual review of the records and phone interviews. The Bayley Scales of Infant Development, Second Edition (BSID-II) scores from age 14 months were also evaluated as predictors. RESULTS Scores on each ASQ domain were significantly lower than normal (P < .001). ASQ domain scores at 3 years of age varied nonlinearly with 14-month BSID-II. More complications, abnormal growth, and evidence of feeding, vision, or hearing problems were independently associated with lower ASQ scores, although models explained <30% of variation. Type of shunt was not associated with any ASQ domain score or with behavior or quality-of-life measures. CONCLUSION Children with single right-ventricle anomalies have impaired neurodevelopment at 3 years of age. Lower ASQ scores are associated with medical morbidity, and lower BSID-II scores but not with shunt type. Because only a modest percentage of variation in 3-year neurodevelopmental outcome could be predicted from early measures, however, all children with single right-ventricle anomalies should be followed longitudinally to improve recognition of delays.
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Affiliation(s)
- Caren S Goldberg
- University of Michigan Medical School and CS Mott Children's Hospital, Ann Arbor, MI.
| | - Minmin Lu
- New England Research Institute, Watertown, MA
| | | | - William T Mahle
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | | | - Ismee A Williams
- Columbia University and Morgan Stanley Children's Hospital, New York, NY
| | - Kathleen A Mussatto
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI
| | - Richard G Ohye
- University of Michigan Medical School and CS Mott Children's Hospital, Ann Arbor, MI
| | - Eric M Graham
- Medical University of South Carolina, Charleston, SC
| | - Deborah U Frank
- University of Utah Primary Children's Medical Center, Salt Lake City, UT
| | - Jeffrey P Jacobs
- All Children's Hospital, Johns Hopkins Medicine, St Petersburg, FL
| | | | - Linda Lambert
- University of Utah Primary Children's Medical Center, Salt Lake City, UT
| | - Alan Lewis
- Children's Hospital of Los Angeles, Los Angeles, CA
| | | | - Renee Sananes
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Erica Sood
- Alfred I. duPont Hospital for Children, Wilmington, DE
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Mussatto KA, Sawin KJ, Schiffman R, Leske J, Simpson P, Marino BS. The importance of self-perceptions to psychosocial adjustment in adolescents with heart disease. J Pediatr Health Care 2014; 28:251-61. [PMID: 23910944 PMCID: PMC4518862 DOI: 10.1016/j.pedhc.2013.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 04/16/2013] [Accepted: 05/29/2013] [Indexed: 11/15/2022]
Abstract
INTRODUCTION This study examined the importance of self-perceptions as determinants of psychosocial adjustment reported by adolescents with heart disease and compared adolescents with heart disease to healthy norms. METHODS Ninety-two adolescents with heart disease from a single Midwestern institution provided reports of self-perceptions (health, self-worth, competence, and importance), internalizing behavior problems (IPs; e.g., anxiety and depression) and externalizing behavior problems (EPs; e.g., attention problems and aggression), and health-related quality of life (HRQOL). Hierarchical linear regression was used to assess the impact of self-perceptions, as well as clinical factors (e.g., illness severity, time since last hospitalization, and medications) and demographic characteristics on outcomes. RESULTS Self-perceptions explained the most variance in behavioral and HRQOL outcomes (R(2)adj = 0.34 for IP, 0.24 for EP, and 0.33 for HRQOL, p < .001). Male gender and lower household income were associated with more behavior problems. Clinical variables were only related to HRQOL. Compared with healthy norms, IPs were significantly more common in male adolescents and HRQOL was lower (p < .001). DISCUSSION Adolescents with heart disease are at risk for internalizing behavior problems and reduced HRQOL; however, positive self-perceptions appear to be protective. Self-perceptions are critical and should be addressed by clinicians.
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Affiliation(s)
| | - Kathleen J. Sawin
- Children’s Hospital of Wisconsin, Milwaukee, WI
- University of Wisconsin – Milwaukee, Milwaukee, WI
| | | | - Jane Leske
- University of Wisconsin – Milwaukee, Milwaukee, WI
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Mussatto KA, Hoffmann RG, Hoffman GM, Tweddell JS, Bear L, Cao Y, Brosig C. Risk and prevalence of developmental delay in young children with congenital heart disease. Pediatrics 2014; 133:e570-7. [PMID: 24488746 PMCID: PMC3934337 DOI: 10.1542/peds.2013-2309] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Children with congenital heart disease (CHD) are at risk for developmental delay (DD). Changes in cognitive, language, and motor skills in early childhood have not been described. We report the results of a structured approach using longitudinal testing to identify problems and ensure early intervention in accordance with published guidelines. METHODS Bayley Scales of Infant Development, Third Edition, were used to assess cognitive, language, and motor skills in 99 children with CHD. Subjects were evaluated 3 to 6 times in the first 3 years of life. DD was defined as scores >1 SD below the population mean. RESULTS Cardiac anatomy was single ventricle (1V) in 34 subjects and 2 ventricles (2V) in 65. Medical comorbidities were present in 21% and genetic syndromes in 19%. Most subjects (75%) had DD in ≥1 area at ≥1 assessments. Subjects with 1V anatomy had equivalent outcomes to those with 2V. Cognitive and language scores declined in subjects with genetic syndromes but were stable and within the average range for subjects with 1V and 2V. Motor scores improved for subjects with 1V and 2V but remained low for those with genetic syndromes. In addition to age, need for supplemental tube feeding, longer cardiopulmonary bypass time, and shorter time since last hospitalization were significant predictors of developmental outcomes. CONCLUSIONS DDs in young children with CHD are both common and dynamic. Providers should encourage longitudinal surveillance for children with CHD because exposure to risk and prevalence of DD change over time.
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Affiliation(s)
- Kathleen A. Mussatto
- Herma Heart Center, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; and,Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - George M. Hoffman
- Herma Heart Center, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; and,Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James S. Tweddell
- Herma Heart Center, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; and,Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laurel Bear
- Herma Heart Center, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; and,Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yumei Cao
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cheryl Brosig
- Herma Heart Center, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; and,Medical College of Wisconsin, Milwaukee, Wisconsin
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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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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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Kunz JH, Greenley RN, Mussatto KA, Roth-Wojcicki B, Miller T, Freeman ME, Lerand S. Personal attitudes, perceived social norms, and health-risk behavior among female adolescents with chronic medical conditions. J Health Psychol 2013; 19:877-86. [PMID: 23524992 DOI: 10.1177/1359105313481077] [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: 11/15/2022] Open
Abstract
To examine whether perceived peer/parent norms or personal beliefs about adolescent substance use influence substance use among female adolescents with chronic medical conditions. Sixty-eight females reported on substance use, personal beliefs, and perceived peer/parent norms. Personal beliefs and perceived peer/parent norms were associated with adolescent's current and future substance use. Although perceived peer norms accounted for variance in current substance use, only personal beliefs accounted for variance in future alcohol use. Targeting perceived peer norms may be effective for intervention efforts among adolescents endorsing current substance use, whereas alcohol use prevention efforts should target personal beliefs.
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Hehir DA, Rudd N, Slicker J, Mussatto KA, Simpson P, Li SH, Frommelt MA, Tweddell JS, Ghanayem NS. Normal interstage growth after the norwood operation associated with interstage home monitoring. Pediatr Cardiol 2012; 33:1315-22. [PMID: 22526219 PMCID: PMC4787622 DOI: 10.1007/s00246-012-0320-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 03/31/2012] [Indexed: 02/07/2023]
Abstract
After stage 1 palliation (S1P) with a Norwood operation, infants commonly experience growth failure during the initial interstage period. Growth failure during this high-risk period is associated with worse outcomes. This study evaluated the growth patterns of patients enrolled in the authors' interstage home-monitoring program (HMP), which uses a multidisciplinary team approach to nutrition management. From 2000 to 2009, 148 infants were enrolled in the HMP after S1P. Families recorded daily weights during the interstage period and alerted the interstage monitoring team about protocol violations of nutritional goals. Interstage monitoring and inpatient data from the S1P hospitalization were reviewed to identify risk factors for poor growth. Growth outcomes were compared with published norms from the Centers for Disease Control. Interstage survival for patients in the HMP was 98 % (145/148). Growth velocity during the interstage period was 26 ± 8 g/day. The weight-for-age z-scores decreased from birth to discharge after S1P (-0.4 ± 0.9 to -1.3 ± 0.9; p < 0.001) but then increased during the interstage period to the time of S2P (-0.9 ± 1; p < 0.001). The factors associated with improved growth during the interstage period included male gender, greater birth weight, full oral feeding at S1P discharge, and a later birth era. After S1P, infants enrolled in an HMP experienced normal growth velocity during the interstage period. Daily observation of oxygen saturation, weight change, and enteral intake together with implementation of a multidisciplinary feeding protocol is associated with excellent interstage growth and survival.
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Affiliation(s)
- David A. Hehir
- Division of Pediatric Critical Care, Children’s Hospital of Wisconsin, Medical College of Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI 53201, USA,Division of Pediatric Cardiology, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
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Imielski BR, Woods RK, Mussatto KA, Cao Y, Simpson PM, Tweddell JS. Fontan fenestration closure and event-free survival. J Thorac Cardiovasc Surg 2012; 145:183-7. [PMID: 23062415 DOI: 10.1016/j.jtcvs.2012.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [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: 05/31/2012] [Revised: 08/15/2012] [Accepted: 09/12/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of the present study was to evaluate the association of open and closed Fontan fenestration status with event-free survival. METHODS All patients who underwent a fenestrated Fontan procedure at our institution from January 1994 through June 2007 were reviewed. Patient information was obtained from the medical records. The patients were assigned to 1 of 2 study groups, open or closed, according to their most recent fenestration status. Clinically relevant morbid events were tabulated, and Kaplan-Meier event analysis was used to create event-free probability curves with log-rank comparisons. RESULTS A total of 161 patients were classified as open and 51 as closed. The median interval to an event was 1.1 years (interquartile range, 0.1-3.3 years) after the Fontan procedure. The median interval to closure was 1.2 years (interquartile range, 0.7-3.3 years). The median interval to an event was 1.5 years (interquartile range, 0.1-4.6 years) in the closed group and 1.1 years (interquartile range, 0.1-3.3 years) in the open group. Event-free probability analysis revealed no significant difference between the 2 groups (P = .15). The median follow-up arterial oxygen saturation was greater in the closed group (96.0%; interquartile range, 94.0%-97.0%) than in the open group (91.0%; interquartile range, 86.0%-95.0%; P < .0001). CONCLUSIONS Fenestration closure was associated with greater arterial oxygen saturation but not greater event-free survival. The interval to an event was slightly less than the interval to fenestration closure, suggesting potential merit in the evaluation of earlier fenestration closure. Adoption of specific fenestration management guidelines might help improve the overall outcomes and enhance the quality of future studies.
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Affiliation(s)
- Bartlomiej R Imielski
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin and Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wis 53226, USA
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Marino BS, Lipkin PH, Newburger JW, Peacock G, Gerdes M, Gaynor JW, Mussatto KA, Uzark K, Goldberg CS, Johnson WH, Li J, Smith SE, Bellinger DC, Mahle WT. Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association. Circulation 2012; 126:1143-72. [PMID: 22851541 DOI: 10.1161/cir.0b013e318265ee8a] [Citation(s) in RCA: 1001] [Impact Index Per Article: 83.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The goal of this statement was to review the available literature on surveillance, screening, evaluation, and management strategies and put forward a scientific statement that would comprehensively review the literature and create recommendations to optimize neurodevelopmental outcome in the pediatric congenital heart disease (CHD) population. METHODS AND RESULTS A writing group appointed by the American Heart Association and American Academy of Pediatrics reviewed the available literature addressing developmental disorder and disability and developmental delay in the CHD population, with specific attention given to surveillance, screening, evaluation, and management strategies. MEDLINE and Google Scholar database searches from 1966 to 2011 were performed for English-language articles cross-referencing CHD with pertinent search terms. The reference lists of identified articles were also searched. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. A management algorithm was devised that stratified children with CHD on the basis of established risk factors. For those deemed to be at high risk for developmental disorder or disabilities or for developmental delay, formal, periodic developmental and medical evaluations are recommended. A CHD algorithm for surveillance, screening, evaluation, reevaluation, and management of developmental disorder or disability has been constructed to serve as a supplement to the 2006 American Academy of Pediatrics statement on developmental surveillance and screening. The proposed algorithm is designed to be carried out within the context of the medical home. This scientific statement is meant for medical providers within the medical home who care for patients with CHD. CONCLUSIONS Children with CHD are at increased risk of developmental disorder or disabilities or developmental delay. Periodic developmental surveillance, screening, evaluation, and reevaluation throughout childhood may enhance identification of significant deficits, allowing for appropriate therapies and education to enhance later academic, behavioral, psychosocial, and adaptive functioning.
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Newburger JW, Sleeper LA, Bellinger DC, Goldberg CS, Tabbutt S, Lu M, Mussatto KA, Williams IA, Gustafson KE, Mital S, Pike N, Sood E, Mahle WT, Cooper DS, Dunbar-Masterson C, Krawczeski CD, Lewis A, Menon SC, Pemberton VL, Ravishankar C, Atz TW, Ohye RG, Gaynor JW. Early developmental outcome in children with hypoplastic left heart syndrome and related anomalies: the single ventricle reconstruction trial. Circulation 2012; 125:2081-91. [PMID: 22456475 DOI: 10.1161/circulationaha.111.064113] [Citation(s) in RCA: 249] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Survivors of the Norwood procedure may experience neurodevelopmental impairment. Clinical trials to improve outcomes have focused primarily on methods of vital organ support during cardiopulmonary bypass. METHODS AND RESULTS In the Single Ventricle Reconstruction trial of the Norwood procedure with modified Blalock-Taussig shunt versus right-ventricle-to-pulmonary-artery shunt, 14-month neurodevelopmental outcome was assessed by use of the Psychomotor Development Index (PDI) and Mental Development Index (MDI) of the Bayley Scales of Infant Development-II. We used multivariable regression to identify risk factors for adverse outcome. Among 373 transplant-free survivors, 321 (86%) returned at age 14.3 ± 1.1 (mean ± SD) months. Mean PDI (74 ± 19) and MDI (89 ± 18) scores were lower than normative means (each P<0.001). Neither PDI nor MDI score was associated with type of Norwood shunt. Independent predictors of lower PDI score (R(2)=26%) were clinical center (P=0.003), birth weight <2.5 kg (P=0.023), longer Norwood hospitalization (P<0.001), and more complications between Norwood procedure discharge and age 12 months (P<0.001). Independent risk factors for lower MDI score (R(2)=34%) included center (P<0.001), birth weight <2.5 kg (P=0.04), genetic syndrome/anomalies (P=0.04), lower maternal education (P=0.04), longer mechanical ventilation after the Norwood procedure (P<0.001), and more complications after Norwood discharge to age 12 months (P<0.001). We found no significant relationship of PDI or MDI score to perfusion type, other aspects of vital organ support (eg, hematocrit, pH strategy), or cardiac anatomy. CONCLUSIONS Neurodevelopmental impairment in Norwood survivors is more highly associated with innate patient factors and overall morbidity in the first year than with intraoperative management strategies. Improved outcomes are likely to require interventions that occur outside the operating room. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00115934.
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Feinstein JA, Benson DW, Dubin AM, Cohen MS, Maxey DM, Mahle WT, Pahl E, Villafañe J, Bhatt AB, Peng LF, Johnson BA, Marsden AL, Daniels CJ, Rudd NA, Caldarone CA, Mussatto KA, Morales DL, Ivy DD, Gaynor JW, Tweddell JS, Deal BJ, Furck AK, Rosenthal GL, Ohye RG, Ghanayem NS, Cheatham JP, Tworetzky W, Martin GR. Hypoplastic left heart syndrome: current considerations and expectations. J Am Coll Cardiol 2012; 59:S1-42. [PMID: 22192720 PMCID: PMC6110391 DOI: 10.1016/j.jacc.2011.09.022] [Citation(s) in RCA: 339] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 09/06/2011] [Accepted: 09/20/2011] [Indexed: 01/25/2023]
Abstract
In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.
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Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
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Lamers LJ, Frommelt PC, Mussatto KA, Jaquiss RDB, Mitchell ME, Tweddell JS. Coarctectomy combined with an interdigitating arch reconstruction results in a lower incidence of recurrent arch obstruction after the Norwood procedure than coarctectomy alone. J Thorac Cardiovasc Surg 2011; 143:1098-102. [PMID: 22050986 DOI: 10.1016/j.jtcvs.2011.09.037] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 09/05/2011] [Accepted: 09/26/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Recurrent aortic arch obstruction after the Norwood procedure continues to be a source of morbidity. We sought to determine if a modified interdigitating technique for aortic arch reconstruction during the Norwood procedure decreased recurrent arch obstruction. METHODS A total of 142 consecutive infants undergoing the Norwood procedure were divided into groups according to surgical technique: Group 1 (n = 79, January 1999 to May 2003) underwent arch reconstruction with complete coarctectomy followed by anastomosis of the descending aorta to the transverse arch. Group 2 (n = 63, June 2003 to September 2006) underwent complete coarctectomy plus a modified interdigitating technique. Catheterization before stage 2 palliation was reviewed for hemodynamics and angiographic arch dimensions, and a coarctation index was calculated. RESULTS Reintervention for recurrent coarctation occurred in 28% (22/79) of group 1 patients compared with 2% (1/63) of group 2 patients (P = .001). Aortic pressures, gradients, dimensions, and coarctation index were consistently more favorable for group 2. CONCLUSIONS Coarctectomy plus an interdigitating arch anastomosis was superior to coarctectomy alone and resulted in a dramatically decreased incidence of recurrent arch obstruction.
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Affiliation(s)
- Luke J Lamers
- Section of Pediatric Cardiology, Department of Pediatrics, The Medical College of Wisconsin, Milwaukee, WI, USA
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Sawin KJ, Gralton KS, Harrison TM, Malin S, Balchunas MK, Brock LA, Cavegn B, Cisler-Cahill L, Graves SM, Mussatto KA, O'Brien ME, Sherburne EC, Schiffman RF. Nurse researchers in children's hospitals. J Pediatr Nurs 2010; 25:408-17. [PMID: 20816564 DOI: 10.1016/j.pedn.2009.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [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: 06/30/2008] [Revised: 07/06/2009] [Accepted: 07/08/2009] [Indexed: 10/20/2022]
Abstract
Little is known about the role of nurse researchers (NRs) and the structure of nursing research programs in children's hospitals in the United States. This descriptive study obtained survey data from 33 NRs. Data suggest that the NR role is emerging and has both commonalities and unique components when compared with the previous studies of NRs in adult hospitals. Most participants have been in their position for less than 4 years. Conducting research, having staff development related to research, and facilitating evidence-based practice or research were common responsibilities. The structure of nursing research programs impacts both the NRs and the program outcomes.
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Johnson BA, Hoffman GM, Tweddell JS, Cava JR, Basir M, Mitchell ME, Scanlon MC, Mussatto KA, Ghanayem NS. Near-infrared spectroscopy in neonates before palliation of hypoplastic left heart syndrome. Ann Thorac Surg 2009; 87:571-7; discussion 577-9. [PMID: 19161781 DOI: 10.1016/j.athoracsur.2008.10.043] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [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: 01/29/2008] [Revised: 10/13/2008] [Accepted: 10/14/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND Neonates with hypoplastic left heart syndrome have circulatory vulnerability that results in shock and high risk of mortality without intervention. High arterial saturation (SaO(2)) is often used as a proxy for inadequate systemic oxygen delivery and triggers the use of invasive therapies to restore circulatory balance. We hypothesized that preoperative use of near-infrared spectroscopy (NIRS) would reduce the need for invasive therapies, including controlled ventilation and inspired gas manipulation. METHODS A Human Research Review Board-approved retrospective review of patients who had stage 1 palliation from January 2000 to January 2006 was conducted. Preoperative patient characteristics, cardiorespiratory support, and monitored data were collected for all patients. Cerebral and somatic tissue oxyhemoglobin saturations were recorded for patients with preoperative NIRS monitoring. RESULTS The studied cohort included 92 patients, 47 without and 45 with preoperative NIRS. Patient characteristics were similar between groups. Differences were observed in preoperative respiratory support. Controlled ventilation was less common in the NIRS group (51% versus 79%, p = 0.005) as was the use of inspired nitrogen (16% versus 70%, p = 0.001). The NIRS patients had higher mean SaO(2) (92% versus 88%, p = 0.001). Age at surgery was similar between groups (5.7 +/- 3.2 versus 6.5 +/- 5.2 days, p = 0.3). Early survival was 96% in each group. CONCLUSIONS Near-infrared spectroscopy monitoring of patients with hypoplastic left heart syndrome awaiting palliation provides noninvasive assessment of oxygen delivery and simplified management, with reduced use of controlled ventilation and inspired gas. Higher SaO(2) in the NIRS group was not associated with impaired systemic oxygen delivery, and did not lead to earlier palliation or postoperative mortality.
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Affiliation(s)
- Beth Ann Johnson
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Tweddell JS, Ghanayem NS, Mussatto KA, Mitchell ME, Lamers LJ, Musa NL, Berger S, Litwin SB, Hoffman GM. Mixed venous oxygen saturation monitoring after stage 1 palliation for hypoplastic left heart syndrome. Ann Thorac Surg 2007; 84:1301-10; discussion 1310-1. [PMID: 17888987 DOI: 10.1016/j.athoracsur.2007.05.047] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 05/04/2007] [Accepted: 05/01/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Staged palliation for hypoplastic left heart syndrome has been marked by high early mortality due to the limited cardiac output of the postischemic single right ventricle combined with the inefficiency and volatility of parallel circulation. METHODS Since July 1996, we have performed stage 1 palliation (S1P) in 178 patients. Within this group is a consecutive cohort of 116 patients with true hypoplastic left heart syndrome that underwent S1P with a modified Blalock-Taussig shunt. A prospective database containing postoperative hemodynamic data was maintained on all patients. Studied were the incidence of organ failure, extracorporeal membrane oxygenation (ECMO), and mortality, as well as the relationship between these outcomes and postoperative hemodynamics. RESULTS Hospital survival for this cohort was 93% (108/116). Patients who died after S1P had a lower superior vena cava oxygen saturation (SVO2) level compared with survivors (53.1% +/-10.6% versus 59.3% +/-9.2%, p = 0.034). Renal failure developed in 2 (1.7%) of the 116 patients, necrotizing enterocolitis developed in 1 (0.9%), and 5 (4.3%) had clinical seizures. ECMO support was instituted in 12 patients (10.3%). The SVO2 level was lower in patients requiring ECMO (54.0% +/- 9.7% versus 59.9% +/- 9.2%, p = 0.031). CONCLUSIONS Goal-directed therapy with SVO2 as an indicator of systemic oxygen delivery is associated with excellent early survival and a low incidence of organ failure after S1P. Inability to optimize SVO2 in the early postoperative period is associated with an increased risk of organ failure, ECMO, and death.
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Affiliation(s)
- James S Tweddell
- Herma Heart Center and Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Brosig CL, Mussatto KA, Kuhn EM, Tweddell JS. Psychosocial outcomes for preschool children and families after surgery for complex congenital heart disease. Pediatr Cardiol 2007; 28:255-62. [PMID: 17486393 DOI: 10.1007/s00246-006-0013-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Accepted: 12/21/2006] [Indexed: 11/29/2022]
Abstract
The purpose of the current study was to assess the psychosocial outcomes of preschool-aged survivors (ages 3-6 years) of hypoplastic left heart syndrome (HLHS; n=13) and transposition of the great arteries (TGA; n=13). Parents completed the following measures: Pediatric Quality of Life Inventory, Impact on the Family Scale, Parenting Stress Index, Parent Behavior Checklist, and Child Behavior Checklist. Quality of life scores did not differ from those of healthy controls. Parents of children with HLHS reported more negative impact of the child's illness on the family and more parenting stress than parents of children with TGA. Parents of both groups of children were more permissive in their parenting style than parents of healthy controls. Children with HLHS had higher rates of attention and externalizing behavior problems than children with TGA. The results highlight the need for practitioners working with these children and families to ask about parental stress, family functioning, and behavioral expectations for the child in the context of routine medical/cardiac follow-up.
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Affiliation(s)
- C L Brosig
- Department of Pediatrics, Medical College of Wisconsin, and Children's Hospital of Wisconsin, Herma Heart Center, Milwaukee, WI 53226, USA.
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Brosig CL, Mussatto KA, Kuhn EM, Tweddell JS. Neurodevelopmental outcome in preschool survivors of complex congenital heart disease: implications for clinical practice. J Pediatr Health Care 2007; 21:3-12. [PMID: 17198894 DOI: 10.1016/j.pedhc.2006.03.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2006] [Revised: 03/22/2006] [Accepted: 03/23/2006] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The purpose of this study was to describe the neurodevelopmental outcome of preschool survivors of Hypoplastic Left Heart Syndrome (HLHS) and Transposition of the Great Arteries (TGA) in the modern surgical era. METHODS A cross-sectional design was used to evaluate 26 children (13 HLHS, 13 TGA), ages 3.5 to 6 years, at a Midwestern children's hospital. Measures included McCarthy Scales of Children's Abilities, Woodcock Johnson III Tests of Achievement, Developmental Test of Visual-Motor Integration, Receptive One-Word Vocabulary Test, Expressive One-Word Vocabulary Test, and Child Behavior Checklist. RESULTS Although intelligence quotient scores fell within the average range for both groups (TGA=110.5 vs. HLHS=97), the difference between groups was clinically meaningful (effect size= .79). The HLHS group showed more problems than did the TGA group with visual-motor skills, expressive language, attention, and externalizing behavior. DISCUSSION Results suggest that even in the modern surgical era, regular developmental screening for these patients is critical. Pediatric nurse practitioners play an important role in educating parents about the potential developmental risks to these children.
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Affiliation(s)
- Cheryl L Brosig
- Medical College of Wisconsin, Department of Pediatrics, Milwaukee,Wisconsin, USA
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Ghanayem NS, Jaquiss RDB, Cava JR, Frommelt PC, Mussatto KA, Hoffman GM, Tweddell JS. Right Ventricle–to–Pulmonary Artery Conduit Versus Blalock-Taussig Shunt: A Hemodynamic Comparison. Ann Thorac Surg 2006; 82:1603-9; discussion 1609-10. [PMID: 17062213 DOI: 10.1016/j.athoracsur.2006.05.103] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 05/18/2006] [Accepted: 05/22/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND A comprehensive assessment of 48 hour postoperative hemodynamics in neonates randomized to the right ventricle-to-pulmonary artery (RV-PA) conduit or modified Blalock-Taussig (BT) shunt for stage 1 palliation of hypoplastic left heart syndrome was performed to determine the potential benefits of the modified technique. METHODS Randomization to either RV-PA conduit or BT shunt was stratified by surgeon and the presence of aortic atresia. The designated procedure was performed by using hypothermic cardiopulmonary bypass with phenoxybenzamine, continuous cerebral perfusion, pH-stat blood gas management, and continuous postoperative venous oximetry. Differences between treatments were analyzed by time-series generalized least-squares regression, chi2 tests, two-way repeated measures analysis of variance, and the Levene variance ratio test for variability in parameters, as appropriate. RESULTS All patients underwent the procedure to which they were randomized. There were no differences in age, weight, deep hypothermic circulatory arrest, or cardiopulmonary bypass times between patients receiving the BT shunt (n = 8) or the RV-PA conduit (n = 9). There was one early and one late death in the RV-PA conduit group, and one interstage death in the BT shunt group. Other than diastolic blood pressure (39 mm Hg in BT shunt versus 46 mm Hg in RV-PA conduit, p < 0.001), there were no differences in the mean values of arterial saturation, venous oximetry, mean arterial blood pressure, pulmonary-to-systemic flow ratio (Qp/Qs), or any other physiologic or inotropic support variable between groups. The variability of physiologic values related to pulmonary blood flow was greater in the RV-PA group (Qp/Qs coefficient of variation, 0.91 versus 2.50, p < 0.001). CONCLUSIONS In this randomized prospective study, no hemodynamic benefits of the RV-PA modification for stage 1 palliation of hypoplastic left heart syndrome were found. Pulmonary blood flow was more variable, and the diastolic blood pressure was higher. These findings did not influence indicators of systemic oxygen delivery with our afterload reduction strategy.
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Affiliation(s)
- Nancy S Ghanayem
- Herma Heart Center at the Children's Hospital of Wisconsin, Milwaukee, Wisconsin 53201, USA.
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Zangwill SD, Ellis TM, Zlotocha J, Jaquiss RD, Tweddell JS, Mussatto KA, Berger S. The virtual crossmatch--a screening tool for sensitized pediatric heart transplant recipients. Pediatr Transplant 2006; 10:38-41. [PMID: 16499585 DOI: 10.1111/j.1399-3046.2005.00394.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [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: 11/29/2022]
Abstract
Heart transplantation in the setting of human leukocyte antigen (HLA) sensitization is challenging, as a time-consuming prospective crossmatch (XM) may be required, severely limiting the number of potential donors. We evaluated a 'virtual XM', defining a positive virtual XM as the presence of recipient pre-formed anti-HLA antibodies to the prospective donor HLA type, and compared the virtual XM to a standard direct XM. Bead-based flow cytometric analysis was used to identify anti-HLA antibody (Ab) present in a child listed for heart transplantation. Using recipient serum, direct-flow cytometric T- and B-cell XM were run for potential donors against whose HLA type the recipient had specific antibodies (group 1, n = 7) and for potential donors with predicted compatible HLA types by virtual XM (group 2, n = 7). Results were expressed as median channel difference (MCD) between the control and recipient serum. A positive T-cell XM was defined as MCD > 50, whereas MCD > 100 constituted a positive B-cell result. The rate of T-cell reactivity was significantly less in group 2 than in group 1 (29% vs. 100%, p = 0.02); similarly, B-cell reactivity was also less for group 2 (14% vs. 100%, p = 0.005). The virtual XM was 100% sensitive in detecting positive flow cytometric XM results for T and B cells. Although only 72% specific in predicting a negative T-cell XM, and 86% specific for negative B-cell XM, the false negatives were weakly positive and would probably have been clinically acceptable. Currently, potentially suitable donor organs are often declined for lack of a prospective XM; these organs may ultimately be allocated to more distant recipients or perhaps not used at all. While further studies are needed, virtual XM has the potential to improve availability of organs for sensitized patients and improve the overall allocation process.
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Affiliation(s)
- S D Zangwill
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
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Hoffman GM, Mussatto KA, Brosig CL, Ghanayem NS, Musa N, Fedderly RT, Jaquiss RDB, Tweddell JS. Systemic venous oxygen saturation after the Norwood procedure and childhood neurodevelopmental outcome. J Thorac Cardiovasc Surg 2005; 130:1094-100. [PMID: 16214525 DOI: 10.1016/j.jtcvs.2005.06.029] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [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: 05/12/2005] [Revised: 06/16/2005] [Accepted: 06/28/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Neonates with hypoplastic left heart syndrome have impaired systemic oxygen delivery and also have a high risk of hypoxic ischemic brain injury with resultant neurodevelopmental impairment. We hypothesized that decreased postoperative oxygen delivery, as measured on the basis of systemic venous oxyhemoglobin saturation, would be related to persistent neurodevelopmental abnormality assessed in childhood. METHODS Early perioperative hemodynamic data, prospectively acquired from neonates undergoing staged palliation of hypoplastic left heart syndrome by using deep hypothermic circulatory arrest with uniform perioperative management, were tested for relationship to later neurodevelopmental outcome assessed at age 4 years. RESULTS Complete hemodynamic and neurodevelopmental data were available in 13 patients aged 7 +/- 8 days at the time of the Norwood procedure and aged 4.5 +/- 0.7 years at follow-up assessment. The subjects scored significantly below the population mean for motor, visual-motor integration, and composite neurodevelopmental outcomes. The 5 (38%) patients with abnormal outcomes had significantly lower postoperative systemic venous oxygen saturation values than those with normal outcomes (46% +/- 8% vs 56% +/- 6%, P = .024). Standard hemodynamic parameters did not differentiate patient outcomes. The risk of abnormal outcome increased with increasing time at a systemic venous oxygen saturation of less than 40% (P < .001). A multivariate model of deep hypothermic circulatory arrest time, systemic venous oxygen saturation, blood pressure, and carbon dioxide tension accounted for 79% of the observed variance (P < .001). CONCLUSIONS Decreased systemic oxygen delivery in the neonatal postoperative period is associated with hypoxic-ischemic brain injury and childhood neurodevelopmental abnormality. Measures of systemic oxygen delivery should be used to guide perioperative strategies to reduce the risk of hypoxic-ischemic brain injury.
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Affiliation(s)
- George M Hoffman
- Department of Pediatric Anesthesiology, Medical College of Wisconsin, Milwaukee, Wis, USA.
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Tweddell JS, Pelech AN, Frommelt PC, Jaquiss RDB, Hoffman GM, Mussatto KA, Litwin SB. Complex aortic valve repair as a durable and effective alternative to valve replacement in children with aortic valve disease. J Thorac Cardiovasc Surg 2005; 129:551-8. [PMID: 15746738 DOI: 10.1016/j.jtcvs.2004.09.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [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: 10/25/2022]
Abstract
OBJECTIVE This study was undertaken to determine the utility of aortic valve repair in children. METHODS A retrospective analysis was conducted on aortic valve surgery from 1973 to 2004 at Children's Hospital of Wisconsin. RESULTS Procedures were classified as simple repairs (blunt valvotomy, commissurotomy with or without thinning, n = 147), repair of aortic insufficiency with ventricular septal defect (n = 22), complex repairs (any combination of additional procedures including suspension of prolapsed leaflets, leaflet extensions, repair of torn or perforated leaflets, annuloplasty, reduction of sinus of Valsalva plasty, and concomitant repair of supravalvular or subvalvular stenosis, n = 57), and replacements (n = 57, 20 mechanical, 2 porcine, and 35 human valves). Freedoms from reintervention for simple repairs and repair of aortic insufficiency with ventricular septal defect at 10 years were 86% +/- 5% and 93.3% +/- 6%, respectively. For complex valve repair, freedoms from reintervention at 1, 5, and 10 years were 94% +/- 3%, 85% +/- 6%, and 44% +/- 15%, versus 96% +/- 3%, 77% +/- 9%, and 77% +/- 9% for valve replacement ( P = .3). At intermediate follow-up, patients with complex valve repair had a residual gradient of 20 +/- 21 mm Hg, and 94% were free of severe aortic insufficiency. Residual aortic stenosis ( P < .05) but not the preoperative diagnosis of combined aortic stenosis and insufficiency predicted the need for reintervention. CONCLUSION Freedom from reintervention after complex valve repairs was not different from that after valve replacement, with acceptable residual aortic stenosis and insufficiency. Simple repairs and repair of aortic insufficiency with ventricular septal defect yielded excellent long-term freedom from reintervention.
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Affiliation(s)
- James S Tweddell
- Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee 53226, USA.
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38
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Abstract
Aortic valve replacement options are limited in children, and all of them have disadvantages. Aortic valve repair techniques have evolved slowly and have not gained wide acceptance; however, large series using a variety of techniques demonstrate that valve repair is possible with excellent early hemodynamics and satisfactory intermediate durability. The results of aortic valve repair at the Children's Hospital of Wisconsin are presented. Simple repairs (blunt valvotomy, commissurotomy, or commissurotomy with leaflet thinning) directed at congenital aortic stenosis resulted in 86% +/- 5% freedom from reintervention at 10 years. Repair of aortic insufficiency with ventricular septal defect (VSD) resulted in 93.3% +/- 6% freedom from reoperation at 10 years. Complex repairs included a combination of techniques and yielded 5-year freedom from reintervention of 83% +/- 7% compared with 73% +/- 11% for patients undergoing aortic valve replacement (P = .62). Aortic valve repair provides an alternative to aortic valve replacement in selected patients. The utility of aortic valve repair and aortic valve replacement must be measured not only in freedom from reintervention but also in regression of left ventricular mass and exercise testing. Improvement in outcome depends on better patient selection and suitable bioprosthetic materials.
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Affiliation(s)
- James S Tweddell
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee 53226, USA
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Affiliation(s)
- Deborah Soetenga
- Deborah Soetenga is the advance practice nurse for the pediatric intensive care unit and the cardiovascular surgery program at Children’s Hospital of Wisconsin, Milwaukee, Wis
| | - Kathleen A. Mussatto
- Kathleen A. Mussatto is the research manager for the Herma Heart Center at Children’s Hospital of Wisconsin
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Soetenga D, Mussatto KA. Management of infants With hypoplastic left heart syndrome integrating research in Nursing practice. Crit Care Nurse 2004; 24:46-8, 50, 52 passim. [PMID: 15646089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Deborah Soetenga
- Pediatric Intensive Care Unit, Cardiovascular Surgery Program at Children's Hospital of Wisconsin, Milwaukee, Wis, USA
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41
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Jaquiss RDB, Ghanayem NS, Hoffman GM, Fedderly RT, Cava JR, Mussatto KA, Tweddell JS. Early cavopulmonary anastomosis in very young infants after the Norwood procedure: impact on oxygenation, resource utilization, and mortality. J Thorac Cardiovasc Surg 2004; 127:982-9. [PMID: 15052194 DOI: 10.1016/j.jtcvs.2003.10.035] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The optimal timing of second-stage palliation after Norwood operations remains undefined. Advantages of early cavopulmonary anastomosis are early elimination of volume load and shortening the high-risk interstage period. Potential disadvantages include severe cyanosis, prolonged pleural drainage and hospitalization, and excess mortality. We reviewed our recent experience to evaluate the safety of early cavopulmonary anastomosis. METHODS Eighty-five consecutive patients undergoing post-Norwood operation cavopulmonary anastomosis were divided into group I (cavopulmonary anastomosis at <4 months; n = 33) and group II (cavopulmonary anastomosis at >4 months; n = 52). Groups were compared for age; size; early and late mortality; preoperative, initial postoperative, and discharge oxygen saturation; and duration of mechanical ventilation, intensive care unit stay, pleural drainage, and hospitalization. RESULTS Group I patients were younger than group II patients (94 +/- 21 days vs 165 +/- 44 days, respectively; P <.001) and smaller (4.8 +/- 0.8 kg vs 5.8 +/- 0.9 kg; P <.001). The preoperative oxygen saturation was not different (group I, 75% +/- 10%; group II, 78% +/- 8%; P =.142). The oxygen saturation was lower immediately after surgery in group I compared with group II (75% +/- 7% vs 81% +/- 7%, respectively; P <.001) but not by discharge (group I, 79% +/- 4%; group II, 80% +/- 4%). Younger patients were ventilated longer (62 +/- 86 hours vs 19 +/- 42 hours; P =.001), in the intensive care unit longer (130 +/- 111 hours vs 104 +/- 94 hours; P =.049), hospitalized longer (12.5 +/- 11.5 days vs 10.3 +/- 14.8 days; P =.012), and required longer pleural drainage (106 +/- 45 hours vs 104 +/- 93 hours; P =.046). Hospital survival was 100% in both groups. Actuarial survival to 12 months was 96% +/- 4% for group I and 96% +/- 3% for group II. CONCLUSIONS Early cavopulmonary anastomosis after the Norwood operation is safe. Younger patients are more cyanotic initially after surgery and have a longer duration of mechanical ventilation, pleural drainage, intensive care unit stay, and hospitalization.
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Affiliation(s)
- Robert D B Jaquiss
- Division of Pediatric Cardiothoracic Surgery Medical College of Wisconsin, and Children's Hospital of Wisconsin, Milwaukee, 53226, USA.
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42
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Ghanayem NS, Hoffman GM, Mussatto KA, Cava JR, Frommelt PC, Rudd NA, Steltzer MM, Bevandic SM, Frisbee SS, Jaquiss RDB, Litwin SB, Tweddell JS. Home surveillance program prevents interstage mortality after the Norwood procedure. J Thorac Cardiovasc Surg 2003; 126:1367-77. [PMID: 14666008 DOI: 10.1016/s0022-5223(03)00071-0] [Citation(s) in RCA: 271] [Impact Index Per Article: 12.9] [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
OBJECTIVE To determine whether early identification of physiologic variances associated with interstage death would reduce mortality, we developed a home surveillance program. METHODS Patients discharged before initiation of home surveillance (group A, n = 63) were compared with patients discharged with an infant scale and pulse oximeter (group B, n = 24). Parents maintained a daily log of weight and arterial oxygen saturation according to pulse oximetry and were instructed to contact their physician in case of an arterial oxygen saturation less than 70% according to pulse oximetry, an acute weight loss of more than 30 g in 24 hours, or failure to gain at least 20 g during a 3-day period. RESULTS Interstage mortality among infants surviving to discharge was 15.8% (n = 9/57) in group A and 0% (n = 0/24) in group B (P =.039). Surveillance criteria were breached for 13 of 24 group B patients: 12 patients with decreased arterial oxygen saturation according to pulse oximetry with or without poor weight gain and 1 patient with poor weight gain alone. These 13 patients underwent bidirectional superior cavopulmonary connection (stage 2 palliation) at an earlier age, 3.7 +/- 1.1 months of age versus 5.2 +/- 2.0 months for patients with an uncomplicated interstage course (P =.028). A growth curve was generated and showed reduced growth velocity between 4 and 5 months of age, with a plateau in growth beyond 5 months of age. CONCLUSION Daily home surveillance of arterial oxygen saturation according to pulse oximetry and weight selected patients at increased risk of interstage death, permitting timely intervention, primarily with early stage 2 palliation, and was associated with improved interstage survival. Diminished growth identified 4 to 5 months after the Norwood procedure brings into question the value of delaying stage 2 palliation beyond 5 months of age.
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Affiliation(s)
- N S Ghanayem
- Department of Pediatrics, and National Outcomes Center, Inc, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, 53226, USA.
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Huth MM, Broome ME, Mussatto KA, Morgan SW. A study of the effectiveness of a pain management education booklet for parents of children having cardiac surgery. Pain Manag Nurs 2003; 4:31-9. [PMID: 12707866 DOI: 10.1053/jpmn.2003.7] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Parents need education about pain so they can support their hospitalized child and manage their child's pain at home. The purpose of this study was to examine the effectiveness of a pain booklet on parental pain support to children experiencing postoperative pain. A randomized, repeated measures, experimental design using a pain education booklet and a standard care comparison group was used to study parents of 51 children (3 to 16 years of age) having cardiac surgery. Measurement techniques used to assess differences in parental pain management included: attitudes about pain medication, child and parent pain ratings (Oucher), opioids used, recovery, satisfaction, and comfort in communication. Results indicate that children do report moderate levels of pain postoperatively. Parents who were exposed to the pain assessment and management for parents education booklet preoperatively significantly increased their knowledge and attitudes toward pain medication scores from pre- to post-test, whereas those in the control group remained stable. Post-test scores were not significantly different between groups. Child and parent pain ratings were significantly and positively correlated. Practice implications include the use of an educational booklet about pain with parents before surgery to increase their knowledge about and attitudes toward pain management. Additionally, a parent may provide an alternative pain report when a child is unable to or unwilling to self-report their pain.
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Affiliation(s)
- Myra Martz Huth
- Jane B. Pettit Pain and Palliative Pain Center, Children's Hospital of Wisconsin, Milwaukee 53201-1997, USA
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Jaquiss RDB, Ghanayem NS, Zacharisen MC, Mussatto KA, Tweddell JS, Litwin SB. Safety of aprotinin use and re-use in pediatric cardiothoracic surgery. Circulation 2002; 106:I90-4. [PMID: 12354715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Hypersensitivity reactions to aprotinin have been reported in adult cardiac surgical patients undergoing initial and re-exposure to the medication. This study describes the incidence and impact of aprotinin hypersensitivity reactions in children undergoing cardiothoracic surgery. METHODS AND RESULTS In this retrospective review of our entire experience with aprotinin (n=865), 681 first exposures, 150 second exposures, and 34 third or higher exposures were examined. Reactions were classified as mild (generalized cutaneous erythema, Type A) or severe (unexplained cardiopulmonary instability after aprotinin exposure, Type B). Records of patients sustaining a reaction were reviewed to assess the impact of the reaction on outcome and to survey reaction management strategies. Reactions occurred in 7 of 681 first exposures (1.0%), of which 2 were Type A and 5 were Type B. In second exposures, there were reactions in 2 of 150 (1.3%), of which both were Type B. In 34 third or higher exposures, there was only 1 reaction (2.9%), which was Type B. Reactions were no more likely on second, third, or higher exposure than on initial exposure. Skin testing had a negative predictive value of 98.9% and a positive predictive value of 20%. Anti-aprotinin IgE was undetectable in 7 of 8 reactor cases tested. No adverse sequelae were attributed to aprotinin reaction. CONCLUSIONS The risk of hypersensitivity reactions to aprotinin is low in children undergoing cardiothoracic surgery, even with multiple exposures to the medication. Reactions are more likely with re-exposure, and risk increases with multiple exposures. Neither skin testing nor assays for IgE identified reactors.
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Affiliation(s)
- Robert D B Jaquiss
- Medical College of Wisconsin, and the Children's Hospital of Wisconsin, Milwaukee, Wisc, USA.
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Tweddell JS, Hoffman GM, Mussatto KA, Fedderly RT, Berger S, Jaquiss RDB, Ghanayem NS, Frisbee SJ, Litwin SB. Improved Survival of Patients Undergoing Palliation of Hypoplastic Left Heart Syndrome: Lessons Learned From 115 Consecutive Patients. Circulation 2002. [DOI: 10.1161/01.cir.0000032878.55215.bd] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [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] [Indexed: 11/16/2022]
Abstract
Background
Outcome of stage 1 palliation (S1P) for hypoplastic left heart syndrome (HLHS) has improved coincident with application of treatment strategies including continuous superior vena cava oximetry (SvO
2
), phenoxybenzamine (POB), strategies to minimize the duration of deep hypothermic circulatory arrest (DHCA) and efforts to ameliorate the inflammatory response to cardiopulmonary bypass (CPB) using aprotinin and modified ultrafiltration.
Methods and Results
Analysis of a consecutive series of 115 patients undergoing S1P was done to identify the risk factors for mortality and the impact of new treatment strategies. For the current era, July 1996 to October 2001, hospital survival was 93% (75/81) compared with 53% (18/34) for the time period, January 1992 to June 1996,
P
<0.001. Survival to stage 2 palliation (S2P) was also significantly improved in the current era, 81% (66/81) versus 44% (15/34),
P
<0.01. Anti-inflammatory treatment strategies demonstrated improved survival by univariate analysis (
P
<0.001). Multivariate analysis identified continuous SvO
2
monitoring as a factor favoring S1P survival (
P
=0.02) and use of POB as a factor favoring survival to S2P (
P
=0.003). In the current era shorter duration of DHCA was associated with improved survival to S2P (
P
=0.02).
Conclusions–Improved survival following S1P can be achieved with strategies that allow for early identification of decreased systemic output and the use of afterload reduction to stabilize systemic vascular resistance and therefore the pulmonary to systemic flow ratio. Strategies to ameliorate the inflammatory response to CPB may decrease the degree and duration of postoperative support. Strategies to minimize duration of DHCA may improve intermediate survival and merit additional studies.
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Affiliation(s)
- James S. Tweddell
- From the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis
| | - George M. Hoffman
- From the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis
| | - Kathleen A. Mussatto
- From the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis
| | - Raymond T. Fedderly
- From the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis
| | - Stuart Berger
- From the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis
| | - Robert D. B. Jaquiss
- From the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis
| | - Nancy S. Ghanayem
- From the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis
| | - Stephanie J. Frisbee
- From the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis
| | - S. Bert Litwin
- From the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis
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Tweddell JS, Hoffman GM, Mussatto KA, Fedderly RT, Berger S, Jaquiss RDB, Ghanayem NS, Frisbee SJ, Litwin SB. Improved survival of patients undergoing palliation of hypoplastic left heart syndrome: lessons learned from 115 consecutive patients. Circulation 2002; 106:I82-9. [PMID: 12354714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Outcome of stage 1 palliation (S1P) for hypoplastic left heart syndrome (HLHS) has improved coincident with application of treatment strategies including continuous superior vena cava oximetry (SvO2), phenoxybenzamine (POB), strategies to minimize the duration of deep hypothermic circulatory arrest (DHCA) and efforts to ameliorate the inflammatory response to cardiopulmonary bypass (CPB) using aprotinin and modified ultrafiltration. METHODS AND RESULTS Analysis of a consecutive series of 115 patients undergoing S1P was done to identify the risk factors for mortality and the impact of new treatment strategies. For the current era, July 1996 to October 2001, hospital survival was 93% (75/81) compared with 53% (18/34) for the time period, January 1992 to June 1996, P<0.001. Survival to stage 2 palliation (S2P) was also significantly improved in the current era, 81% (66/81) versus 44% (15/34), P<0.01. Anti-inflammatory treatment strategies demonstrated improved survival by univariate analysis (P<0.001). Multivariate analysis identified continuous SvO2 monitoring as a factor favoring S1P survival (P=0.02) and use of POB as a factor favoring survival to S2P (P=0.003). In the current era shorter duration of DHCA was associated with improved survival to S2P (P=0.02). CONCLUSIONS Improved survival following S1P can be achieved with strategies that allow for early identification of decreased systemic output and the use of afterload reduction to stabilize systemic vascular resistance and therefore the pulmonary to systemic flow ratio. Strategies to ameliorate the inflammatory response to CPB may decrease the degree and duration of postoperative support. Strategies to minimize duration of DHCA may improve intermediate survival and merit additional studies.
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Affiliation(s)
- James S Tweddell
- Cardiothoracic Surgery, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, Wis 53226, USA.
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Mussatto KA, Frisbee SJ, Sachdeva RC, Pelech AN, Litwin S, Tweddell JS. Subjects with surgically treated complex congenital heart disease report health related quality of life equal to healthy peers. J Am Coll Cardiol 2002. [DOI: 10.1016/s0735-1097(02)81856-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Tweddell JS, Pelech AN, Frommelt PC, Mussatto KA, Wyman JD, Fedderly RT, Berger S, Frommelt MA, Lewis DA, Friedberg DZ, Thomas JP, Sachdeva R, Litwin SB. Factors affecting longevity of homograft valves used in right ventricular outflow tract reconstruction for congenital heart disease. Circulation 2000; 102:III130-5. [PMID: 11082375 DOI: 10.1161/01.cir.102.suppl_3.iii-130] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Few studies have explored the long-term function of cryopreserved homograft valves used for reconstruction of the right ventricular tract (RVOT) in patients with congenital heart disease. METHODS AND RESULTS Among 205 patients receiving cryopreserved homografts for reconstruction of the RVOT between November 1985 and April 1999, the outcome of 220 homografts in 183 operative survivors was analyzed. There were 150 pulmonary and 70 aortic homografts used. Median age at implantation was 4.4 years (mean 6.9+/-7.6 years, range 3 days to 48 years). End points included (1) patient survival, (2) homograft failure (valve explant or late death), and (3) homograft dysfunction (homograft insufficiency or homograft stenosis). Survival was 88% at 10 years. Freedom from homograft failure was 74+/-4% at 5 years and 54+/-7% at 10 years. Univariable analysis identified younger age, longer donor warm ischemic time, valve Z: value <2, and previous procedure as risk factors for homograft failure and dysfunction. Aortic homograft type and extracardiac operative technique predicted homograft failure but not dysfunction. For patients </=1 year of age, valve type did not predict failure or dysfunction. Multivariable analysis identified younger age and longer donor warm ischemic time as risk factors for homograft failure and dysfunction, whereas, Z: value <2 and aortic valve type predicted homograft valve failure. CONCLUSIONS Homograft valves used for RVOT reconstruction provide effective intermediate palliation with excellent late survival. Factors that adversely affect graft longevity include younger age, longer donor warm ischemic time, smaller homograft size, use of aortic homograft in the older patient, and extracardiac operative technique.
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Affiliation(s)
- J S Tweddell
- Department of Surgery (Cardiothoracic Surgery), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Hoffman GM, Ghanayem NS, Kampine JM, Berger S, Mussatto KA, Litwin SB, Tweddell JS. Venous saturation and the anaerobic threshold in neonates after the Norwood procedure for hypoplastic left heart syndrome. Ann Thorac Surg 2000; 70:1515-20; discussion 1521. [PMID: 11093480 DOI: 10.1016/s0003-4975(00)01772-0] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.4] [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: 10/17/2022]
Abstract
BACKGROUND Reduction in oxygen delivery can lead to organ dysfunction and death by cellular hypoxia, detectable by progressive (mixed) venous oxyhemoglobin desaturation until extraction is limited at the anaerobic threshold. We sought to determine the critical level of venous oxygen saturation to maintain aerobic metabolism in neonates after the Norwood procedure (NP) for the hypoplastic left heart syndrome (HLHS). METHODS A prospective perioperative database was maintained for demographic, hemodynamic, and laboratory data. Invasive arterial and atrial pressures, arterial saturation, oximetric superior vena cava (SVC) saturation, and end-tidal CO2 were continuously recorded and logged hourly for the first 48 postoperative hours. Arterial and venous blood gases and cooximetry were obtained at clinically appropriate intervals. SVC saturation was used as an approximation of mixed venous saturation (SvO2). A standard base excess (BE) less than -4 mEq/L (BElo), or a change exceeding -2 mEq/L/h (deltaBElo), were used as indicators of anaerobic metabolism. The relationship between SvO2 and BE was tested by analysis of variance and covariance for repeated measures; the binomial risk of BElo or deltaBElo at SvO2 strata was tested by the likelihood ratio test and logistic regression, with cutoff at p < 0.05. RESULTS Complete data were available in 48 of 51 consecutive patients undergoing NP yielding 2,074 valid separate determinations. BE was strongly related to SvO2 (model R2 = 0.40, p < 0.0001) with minimal change after adjustment for physiologic covariates. The risk of anaerobic metabolism was 4.8% overall, but rose to 29% when SvO2 was 30% or below (p < 0.0001). Survival was 100% at 1 week and 94% at hospital discharge. CONCLUSIONS Analysis of acid-base changes revealed an apparent anaerobic threshold when SvO2 fell below 30%. Clinical management to maintain SvO2 above this threshold yielded low mortality.
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Affiliation(s)
- G M Hoffman
- Department of Anesthesiology, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee 53226, USA.
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50
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Tweddell JS, Hoffman GM, Fedderly RT, Ghanayem NS, Kampine JM, Berger S, Mussatto KA, Litwin SB. Patients at risk for low systemic oxygen delivery after the Norwood procedure. Ann Thorac Surg 2000; 69:1893-9. [PMID: 10892943 DOI: 10.1016/s0003-4975(00)01349-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.4] [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: 11/18/2022]
Abstract
BACKGROUND Identification of patients at risk for inadequate systemic oxygen delivery following the Norwood procedure could allow for application of more intensive monitoring, provide for earlier intervention of decreased cardiac output, and result in improved outcome. METHODS AND RESULTS Superior vena cava saturation (SvO2) and arteriovenous oxygen content difference were prospectively monitored as indicators of systemic oxygen delivery and recorded hourly for the first 48 hours in 29 of 33 consecutive patients following the Norwood procedure. Risk factors were evaluated using multiple linear regression to determine their impact on SvO2 and arteriovenous oxygen content difference. Age less than 8 days, weight less than 2.5 kg, aortic atresia, and prolonged cardiopulmonary bypass time were risk factors for low SvO2 and wide arteriovenous oxygen content difference (p < 0.05). Phenoxybenzamine and increasing time after operation were associated with higher SvO2 and narrower arteriovenous oxygen content difference (p < 0.05). Thirty-day survival was 97% and hospital survival was 94%. The earliest death occurred on postoperative day 20. Survival to bidirectional cavopulmonary shunt was 77%. Preoperative mechanical ventilation was the only risk factor identified for late death. CONCLUSIONS Aortic atresia, low weight, younger age, and prolonged cardiopulmonary bypass, previously identified risk factors for mortality, were associated with decreased SvO2 and narrower arteriovenous oxygen content difference in the early postoperative period. The impact of this hemodynamic vulnerability on mortality was minimized by continuous SvO2 monitoring.
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Affiliation(s)
- J S Tweddell
- Department of Surgery (Cardiothoracic Surgery), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee 53226, USA.
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