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Mbabazi N, Aliku T, Namuyonga J, Tumwebaze H, Ndagire E, Obongonyinge B, Khainza RE, Akech MT, Angelline K, Nakato A, Ssendagire C, Ssemogerere L, Oketcho M, Omagino J, Lwabi P, Lubega S. Congenital heart disease cardiac catheterization at Uganda Heart Institute, a 12-year retrospective study of immediate outcomes. BMC Cardiovasc Disord 2024; 24:463. [PMID: 39210275 PMCID: PMC11360719 DOI: 10.1186/s12872-024-04085-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Cardiac catheterization is an invasive diagnostic and treatment tool for congenital heart disease (CHD) with potential complications. OBJECTIVE To describe the immediate outcomes of patients who underwent cardiac catheterization for CHD at the Uganda Heart Institute (UHI). METHODS The study was a retrospective chart review of 857 patients who underwent cardiac catheterization for CHD at UHI from 1st February 2012 to 30th June 2023. Precardiac catheterization clinical data, procedure details, and post-procedure data were recorded. The statistical software SPSS was used for data analysis. RESULTS We studied 857 patients who underwent cardiac catheterization for CHD at UHI. Females comprised 62.8% (n = 528). The age range was 3 days to 64 years, with a mean of 5.1 years (SD 7.4). Advanced heart failure was present in 24(2.8%) of the study participants. The most common procedures were patent ductus arteriosus device closure (n = 500, 58.3%), diagnostic catheterization (n = 194, 22.5%), and balloon pulmonary valvuloplasty (n = 114, 13.0%). PDA device closure had 89.4% optimal results while BPV had 75.9% optimal performance outcome. Adverse events occurred in 52 out of 857 study participants (6.1%). Clinically meaningful adverse events (CMAES) occurred in 3.9%, (n = 33), high severity adverse events in 2.9% (n = 25) and mortality in 1.5% (n = 13). Advanced heart failure at the time of cardiac catheterization, was significantly associated with clinically meaningful adverse events (OR 52 p-value < 0.001) and mortality (OR 564, p value < 0.001). CONCLUSION Many patients with CHD have benefited from the cardiac catheterization program at UHI with high optimal procedure outcome results. Patients with advanced heart failure at the time of cardiac catheterization have less favorable outcomes emphasizing the need for early detection and early intervention.
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Affiliation(s)
- Nestor Mbabazi
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda.
- Mulago National Referral Hospital, Kampala, Uganda.
| | - Twalib Aliku
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
- Uganda Christian University School of Medicine, Mukono, Uganda
| | - Judith Namuyonga
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Emma Ndagire
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
| | | | - Rebecca Esther Khainza
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
- Mulago National Referral Hospital, Kampala, Uganda
| | | | - Killen Angelline
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
- John. Fitzgerald Kennedy Hospital, 22nd Street Sinkor, Monrovia, Liberia
| | - Aisha Nakato
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
- Bombo General Military Hospital, Bombo, Uganda
| | - Cornelius Ssendagire
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Lameck Ssemogerere
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - John Omagino
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
| | - Peter Lwabi
- Uganda Heart Institute, P.O. Box 3792, Kampala, Uganda
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Morell E, Colglazier E, Becerra J, Stevens L, Steurer MA, Sharma A, Nguyen H, Kathiriya IS, Weston S, Teitel D, Keller R, Amin EK, Nawaytou H, Fineman JR. A single institution anesthetic experience with catheterization of pediatric pulmonary hypertension patients. Pulm Circ 2024; 14:e12360. [PMID: 38618291 PMCID: PMC11010955 DOI: 10.1002/pul2.12360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/04/2024] [Accepted: 03/18/2024] [Indexed: 04/16/2024] Open
Abstract
Cardiac catheterization remains the gold standard for the diagnosis and management of pediatric pulmonary hypertension (PH). There is lack of consensus regarding optimal anesthetic and airway regimen. This retrospective study describes the anesthetic/airway experience of our single center cohort of pediatric PH patients undergoing catheterization, in which obtaining hemodynamic data during spontaneous breathing is preferential. A total of 448 catheterizations were performed in 232 patients. Of the 379 cases that began with a natural airway, 274 (72%) completed the procedure without an invasive airway, 90 (24%) received a planned invasive airway, and 15 (4%) required an unplanned invasive airway. Median age was 3.4 years (interquartile range [IQR] 0.7-9.7); the majority were either Nice Classification Group 1 (48%) or Group 3 (42%). Vasoactive medications and cardiopulmonary resuscitation were required in 14 (3.7%) and eight (2.1%) cases, respectively; there was one death. Characteristics associated with use of an invasive airway included age <1 year, Group 3, congenital heart disease, trisomy 21, prematurity, bronchopulmonary dysplasia, WHO functional class III/IV, no PH therapy at time of case, preoperative respiratory support, and having had an intervention (p < 0.05). A composite predictor of age <1 year, Group 3, prematurity, and any preoperative respiratory support was significantly associated with unplanned airway escalation (26.7% vs. 6.9%, odds ratio: 4.9, confidence interval: 1.4-17.0). This approach appears safe, with serious adverse event rates similar to previous reports despite the predominant use of natural airways. However, research is needed to further investigate the optimal anesthetic regimen and respiratory support for pediatric PH patients undergoing cardiac catheterization.
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Affiliation(s)
- Emily Morell
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Elizabeth Colglazier
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Jasmine Becerra
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Leah Stevens
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Martina A. Steurer
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Anshuman Sharma
- Department of Anesthesia and Preoperative CareUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Hung Nguyen
- Department of Anesthesia and Preoperative CareUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Irfan S. Kathiriya
- Department of Anesthesia and Preoperative CareUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Stephen Weston
- Department of Anesthesia and Preoperative CareUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - David Teitel
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Roberta Keller
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Elena K. Amin
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Hythem Nawaytou
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Jeffrey R. Fineman
- Department of Pediatrics, UCSF Benioff Children's HospitalUniversity of California San FranciscoSan FranciscoCaliforniaUSA
- Cardiovascular Research InstituteUniversity of California San FranciscoSan FranciscoCaliforniaUSA
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Dawes TJW, Woodham V, Sharkey E, McEwan A, Derrick G, Muthurangu V, Moledina S, Hepburn L. Predicting Peri-Operative Cardiorespiratory Adverse Events in Children with Idiopathic Pulmonary Arterial Hypertension Undergoing Cardiac Catheterization Using Echocardiography: A Cohort Study. Pediatr Cardiol 2024:10.1007/s00246-024-03447-3. [PMID: 38512488 DOI: 10.1007/s00246-024-03447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/07/2024] [Indexed: 03/23/2024]
Abstract
General anesthesia in children with idiopathic pulmonary arterial hypertension (PAH) carries an increased risk of peri-operative cardiorespiratory complications though risk stratifying individual children pre-operatively remains difficult. We report the incidence and echocardiographic risk factors for adverse events in children with PAH undergoing general anesthesia for cardiac catheterization. Echocardiographic, hemodynamic, and adverse event data from consecutive PAH patients are reported. A multivariable predictive model was developed from echocardiographic variables identified by Bayesian univariable logistic regression. Model performance was reported by area under the curve for receiver operating characteristics (AUCroc) and precision/recall (AUCpr) and a pre-operative scoring system derived (0-100). Ninety-three children underwent 158 cardiac catheterizations with mean age 8.8 ± 4.6 years. Adverse events (n = 42) occurred in 15 patients (16%) during 16 catheterizations (10%) including cardiopulmonary resuscitation (n = 5, 3%), electrocardiographic changes (n = 3, 2%), significant hypotension (n = 2, 1%), stridor (n = 1, 1%), and death (n = 2, 1%). A multivariable model (age, right ventricular dysfunction, and dilatation, pulmonary and tricuspid regurgitation severity, and maximal velocity) was highly predictive of adverse events (AUCroc 0.86, 95% CI 0.75 to 1.00; AUCpr 0.68, 95% CI 0.50 to 0.91; baseline AUCpr 0.10). Pre-operative risk scores were higher in those who had a subsequent adverse event (median 47, IQR 43 to 53) than in those who did not (median 23, IQR 15 to 33). Pre-operative echocardiography informs the risk of peri-operative adverse events and may therefore be useful both for consent and multi-disciplinary care planning.
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Affiliation(s)
- Timothy J W Dawes
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK.
- UCL Institute of Cardiovascular Science, University College London, London, UK.
| | - Valentine Woodham
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK
| | - Emma Sharkey
- Department of Anaesthesia, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Angus McEwan
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK
| | - Graham Derrick
- UCL Institute of Cardiovascular Science, University College London, London, UK
- Department of Paediatric Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Vivek Muthurangu
- UCL Institute of Cardiovascular Science, University College London, London, UK
| | - Shahin Moledina
- UCL Institute of Cardiovascular Science, University College London, London, UK
- National Paediatric Pulmonary Hypertension Service UK, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lucy Hepburn
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK
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Mocumbi A, Humbert M, Saxena A, Jing ZC, Sliwa K, Thienemann F, Archer SL, Stewart S. Pulmonary hypertension. Nat Rev Dis Primers 2024; 10:1. [PMID: 38177157 DOI: 10.1038/s41572-023-00486-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/06/2024]
Abstract
Pulmonary hypertension encompasses a range of conditions directly or indirectly leading to elevated pressures within the pulmonary arteries. Five main groups of pulmonary hypertension are recognized, all defined by a mean pulmonary artery pressure of >20 mmHg: pulmonary arterial hypertension (rare), pulmonary hypertension associated with left-sided heart disease (very common), pulmonary hypertension associated with lung disease (common), pulmonary hypertension associated with pulmonary artery obstructions, usually related to thromboembolic disease (rare), and pulmonary hypertension with unclear and/or multifactorial mechanisms (rare). At least 1% of the world's population is affected, with a greater burden more likely in low-income and middle-income countries. Across all its forms, pulmonary hypertension is associated with adverse vascular remodelling with obstruction, stiffening and vasoconstriction of the pulmonary vasculature. Without proactive management this leads to hypertrophy and ultimately failure of the right ventricle, the main cause of death. In older individuals, dyspnoea is the most common symptom. Stepwise investigation precedes definitive diagnosis with right heart catheterization. Medical and surgical treatments are approved for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. There are emerging treatments for other forms of pulmonary hypertension; but current therapy primarily targets the underlying cause. There are still major gaps in basic, clinical and translational knowledge; thus, further research, with a focus on vulnerable populations, is needed to better characterize, detect and effectively treat all forms of pulmonary hypertension.
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Affiliation(s)
- Ana Mocumbi
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Moçambique.
- Instituto Nacional de Saúde, EN 1, Marracuene, Moçambique.
| | - Marc Humbert
- Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris), Université Paris-Saclay, INSERM UMR_S 999, Paris, France
- ERN-LUNG, Le Kremlin Bicêtre, Paris, France
| | - Anita Saxena
- Sharma University of Health Sciences, Haryana, New Delhi, India
| | - Zhi-Cheng Jing
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Karen Sliwa
- Cape Heart Institute, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Friedrich Thienemann
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Simon Stewart
- Institute of Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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Maisat W, Yuki K. Predictive factors for postoperative ICU admission and mechanical ventilation following cardiac catheterization for pediatric pulmonary vein stenosis. J Cardiothorac Vasc Anesth 2022; 36:2500-2508. [DOI: 10.1053/j.jvca.2022.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/31/2022] [Accepted: 02/18/2022] [Indexed: 11/11/2022]
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Cardiac Catheterization and Hemodynamics in a Multicenter Cohort of Children with Pulmonary Hypertension. Ann Am Thorac Soc 2022; 19:1000-1012. [PMID: 35049414 DOI: 10.1513/annalsats.202108-998oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Hemodynamic assessments direct care among children with pulmonary hypertension (PH), yet the use of cardiac catheterization is highly variable, which could impact patient care and research. Objective We analyzed hemodynamic findings from right (RHC) and left heart catheterization (LHC), acute vasodilator testing (AVT) and the safety of catheterization in children with World Symposium on Pulmonary Hypertension(WSPH) Group 1 and 3 subtypes in a large multicenter North American cohort. METHODS Of 1475 children enrolled in the Pediatric PH Network registry (2014 -2020), there were 1383 Group 1 and 3 patients, of whom 671 (48.5%) had a RHC performed at diagnosis and were included for analysis. RESULTS Compared to those without a diagnostic RHC, these children were older, less likely to be an infant or preterm, more often female, treated with targeted PH medications at diagnosis and had advanced WHO functional class. Catheterization was performed without a difference in complication rates between WSPH Groups. PCWP was well-correlated with LVEDP and left atrial pressures. AVT using 3 different methods were comparable; positive AVT was observed in 8.0-11.8% of subjects and did not differ between WSPH Groups 1 and 3 or associated with freedom from the composite endpoint of lung transplantation or death during follow-up. CONCLUSIONS In a large pediatric PH cohort, diagnostic RHC + LHC in WSPH Group 1 and 3 patients were performed safely at experienced pediatric PH Centers. Hemodynamic differences were noted between Group 1 and 3 subjects. Higher mean PAP and PAPm:SAPm ratio were associated with a higher risk of death/transplantation. Findings suggest overall safety and potential value of RHC as a standard diagnostic approach to guide PH management in children.
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Stein ML, Staffa SJ, O'Brien Charles A, Callahan R, DiNardo JA, Nasr VG, Brown ML. Anesthesia in Children With Pulmonary Hypertension: Clinically Significant Serious Adverse Events Associated With Cardiac Catheterization and Noncardiac Procedures. J Cardiothorac Vasc Anesth 2022; 36:1606-1616. [PMID: 35181233 DOI: 10.1053/j.jvca.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the incidence of clinically significant serious adverse events in a contemporary population of pediatric patients with pulmonary hypertension who require anesthesia and identify factors associated with adverse outcomes. DESIGN A retrospective, cross-sectional study. SETTING A single-center quaternary-care freestanding children's hospital in the northeastern United States. PARTICIPANTS Pediatric patients with pulmonary hypertension based on hemodynamic criteria on cardiac catheterization during a 3-year period from 2015 to 2018. INTERVENTIONS Anesthesia care for cardiac catheterization, noncardiac surgery, and diagnostic imaging. MEASUREMENTS AND MAIN RESULTS Two hundred forty-nine children underwent 862 procedures, 592 for cardiac catheterization and 278 for noncardiac surgery and diagnostic imaging. The median age was 1.6 years, and the weight was 9.5 lbs. On index catheterization, median pulmonary artery pressure was 36 mmHg, and the pulmonary vascular resistance was 5.1 indexed Wood units. Ten percent of anesthetics were performed with a natural airway, and 80% used volatile anesthetics. Serious adverse events occurred in 26% of procedures (confidence interval [CI], 22%-30%). The rate of periprocedural cardiac arrest was 8 per 1,000 anesthetic administrations. In multivariate analysis, younger age (adjusted odds ratio [aOR], 1.4 per year; CI, 1.1-1.9; p = 0.01), location in the catheterization laboratory (aOR, 5.1; CI, 1.7-16; p = 0.004), and longer procedure duration (aOR, 1.3 per 30 minutes; CI, 1.1-1.4; p = 0.001) were associated with serious adverse events. Patients with a tracheostomy in place were less likely to experience an adverse event (aOR, 0.1; CI, 0.04-0.5; p = 0.001). The primary anesthetic technique was not associated with adverse events. Interventional cardiac catheterization was associated with an increased incidence of adverse events compared with diagnostic catheterization (42% v 21%; OR, 2.23; CI, 1.5-3.3; p < 0.001). CONCLUSIONS Serious adverse events were common in this cohort. Careful planning to minimize anesthesia time in young children with pulmonary hypertension should be undertaken, and these factors considered in designing risk mitigation strategies.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Amy O'Brien Charles
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Muneuchi J, Ezaki H, Sugitani Y, Watanabe M. Comprehensive assessments of pulmonary circulation in children with pulmonary hypertension associated with congenital heart disease. Front Pediatr 2022; 10:1011631. [PMID: 36313863 PMCID: PMC9614099 DOI: 10.3389/fped.2022.1011631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Pulmonary hypertension associated with congenital heart disease (CHD-PH) encompasses different conditions confounded by the left-to-right shunt, left heart obstruction, ventricular dysfunction, hypoxia due to airway obstruction, dysplasia/hypoplasia of the pulmonary vasculature, pulmonary vascular obstructive disease, and genetic variations of vasoactive mediators. Pulmonary input impedance consists of the pulmonary vascular resistance (Rp) and capacitance (Cp). Rp is calculated as the transpulmonary pressure divided by the pulmonary cardiac output, whereas Cp is calculated as the pulmonary stroke volume divided by the pulmonary arterial pulse pressure. The plots of Rp and Cp demonstrate a unique hyperbolic relationship, namely, the resistor-capacitor coupling curve, which represents the pulmonary vascular condition. The product of Rp and Cp is the exponential pressure decay, which refers to the time constant. Alterations in Cp are more considerable in CHD patients at an early stage of developing pulmonary hypertension or with excessive pulmonary blood flow due to a left-to-right shunt. The importance of Cp has gained attention because recent reports have shown that low Cp potentially reflects poor prognosis in patients with CHD-PH and idiopathic pulmonary hypertension. It is also known that Cp levels decrease in specific populations, such as preterm infants and trisomy 21. Therefore, both Rp and Cp should be individually evaluated in the management of children with CHD-PH who have different disease conditions.
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Affiliation(s)
- Jun Muneuchi
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization
| | - Hiroki Ezaki
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization
| | - Yuichiro Sugitani
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization
| | - Mamie Watanabe
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization
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Mukherjee D, Konduri GG. Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment. Compr Physiol 2021; 11:2135-2190. [PMID: 34190343 PMCID: PMC8289457 DOI: 10.1002/cphy.c200023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.
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Affiliation(s)
- Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
| | - Girija G. Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
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Vaiyani D, Kelleman M, Downey LA, Kanaan U, Petit CJ, Bauser-Heaton H. Risk Factors for Adverse Events in Children with Pulmonary Hypertension Undergoing Cardiac Catheterization. Pediatr Cardiol 2021; 42:736-742. [PMID: 33512547 DOI: 10.1007/s00246-020-02535-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/23/2020] [Indexed: 11/25/2022]
Abstract
Pulmonary hypertension (PH) can lead to progressive heart failure with high morbidity and mortality. Cardiac catheterization (CC) is the gold standard for diagnosis and response to vasodilatory medications. The invasive nature of CC and associated anesthesia predispose this patient population to adverse events including death. Catheterization records were queried from 1/1/2011 to 10/31/2016. Patients with PH, defined as pulmonary vascular resistance (PVR) greater than 3 WU m2, pulmonary artery pressure above 20 mmHg, and pulmonary wedge pressure less than or equal to 15 mmHg, who underwent hemodynamic CC were included in this retrospective study. Both patients with and without congenital heart disease were included. There were 198 CC in 191 patients. Adverse events (n = 28, 14.1%) included cardiac arrest, increased respiratory support requiring ICU care, PH crisis, bradycardia/hypotension requiring intervention, and arrhythmias. Odds of an adverse event increased by 22% for every 15-min increase in procedure times (OR 1.22, CI 1.01-1.39, p = 0.002) and were significantly increased for procedures longer than 80 min (OR 3.75, CI 1.56-9.00, p = 0.007) (Fig. 1). Patients with an adverse event had higher mean pulmonary artery pressures while breathing oxygen (43 [35-58] versus 34 [27-44] mmHg, p = 0.017) and oxygen with inhaled nitric oxide (37 [32-56] versus 32 [25-40] mmHg, p = 0.026). Females carried more risk than males (OR 3.88, CI 1.44-10.40, p = 0.007). Younger age, medication regimens, prematurity, and genetic disease did not carry an increased risk. Adverse events are common in pediatric patients with PH undergoing CC. The risk of adverse events correlates with greater procedure times and higher mean pulmonary artery pressure. Minimizing procedure time may improve patient outcomes.
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Affiliation(s)
- Danish Vaiyani
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Laura A Downey
- Division of Cardiac Anesthesia, Emory University, Atlanta, GA, USA
| | - Usama Kanaan
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Division of Pediatrics, Emory University, Atlanta, GA, USA
| | - Christopher J Petit
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Division of Pediatrics, Emory University, Atlanta, GA, USA
| | - Holly Bauser-Heaton
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA.
- Division of Pediatrics, Emory University, Atlanta, GA, USA.
- Sibley Heart Center, 2835 Brandywine Rd Suite 300, Atlanta, GA, 30341, USA.
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12
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Wadia RS, Bernier ML, Diaz-Rodriguez NM, Goswami DK, Nyhan SM, Steppan J. Update on Perioperative Pediatric Pulmonary Hypertension Management. J Cardiothorac Vasc Anesth 2021; 36:667-676. [PMID: 33781669 DOI: 10.1053/j.jvca.2021.02.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 12/25/2022]
Abstract
Pediatric pulmonary hypertension is a disease that has many etiologies and can present anytime during childhood. Its newly revised hemodynamic definition follows that of adult pulmonary hypertension: a mean pulmonary artery pressure >20 mmHg. However, the pediatric definition stipulates that the elevated pressure must be present after the age of three months. The definition encompasses many different etiologies, and diagnosis often involves a combination of noninvasive and invasive testing. Treatment often is extrapolated from adult studies or based on expert opinion. Moreover, although general anesthesia may be required for pediatric patients with pulmonary hypertension, it poses certain risks. A thoughtful, multidisciplinary approach is needed to deliver excellent perioperative care.
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Affiliation(s)
- Rajeev S Wadia
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Meghan L Bernier
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Natalia M Diaz-Rodriguez
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dheeraj K Goswami
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sinead M Nyhan
- Department of Anesthesiology and Critical Care Medicine, Division of Adult Cardiothoracic Anesthesia, Division of Adult Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Division of Adult Cardiothoracic Anesthesia, Division of Adult Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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13
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Evers PD, Critser PJ, Cash M, Magness M, Hirsch R. Prognostic Value of Change in Cardiac Index After Prostacyclin Initiation in Pediatric Pulmonary Hypertension. Pediatr Cardiol 2021; 42:116-122. [PMID: 32974724 DOI: 10.1007/s00246-020-02460-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
Invasive hemodynamic assessment remains the gold standard for the diagnosis of pediatric pulmonary hypertension and for longitudinal assessment of response to therapy. This analysis sought to describe the changes in hemodynamic variables after initiation of prostacyclin therapy and determine which changes bear predictive power of adverse clinical outcomes. A retrospective chart review of established patients at Cincinnati Children's Hospital with pulmonary arterial hypertension (PAH) who required prostacyclin therapy between 2004 and 2018 was performed. The baseline hemodynamic parameters at diagnosis as well as change in those parameters between initial catheterization and post-prostacyclin initiation catheterization were independent variables. Cox proportional hazard regression and recursive partitioning analysis were used to characterize which hemodynamic factors predicted the composite adverse outcome (CAO) defined as death, lung transplantation, or reverse Pott's shunt surgery. During the study period, 29 patients met inclusion criteria in which there were 7 CAOs: 4 deaths, 3 lung transplants, and 2 reverse Pott's shunts. Median time between catheterizations was 86 days and between the initiation of prostacyclin therapy and the second catheterization was 54 days. Cox regression revealed that only baseline pulmonary artery pressure (> 51 mmHg) and a failure to increase cardiac index illustrated statistically significant hazard for occurrence of the CAO (p < 0.01). These criteria significantly dichotomized the population in a Kaplan-Meier analysis into likelihoods of experiencing the CAO. While controlling for other hemodynamic variables, the absence of augmentation of cardiac index after the initiation of prostacyclin therapy is a valuable prognostic indicator of adverse PAH outcomes in pediatrics.
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Affiliation(s)
- Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Sciences University, 707 SW Gaines St. CDRC-P, Portland, OR, 97239, USA.
| | - Paul J Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michelle Cash
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Melissa Magness
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Russel Hirsch
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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14
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Kheyfets VO, Lammers SR, Wagner J, Bartels K, Piccoli J, Smith BJ. PEEP/ FIO2 ARDSNet Scale Grouping of a Single Ventilator for Two Patients: Modeling Tidal Volume Response. Respir Care 2020; 65:1094-1103. [PMID: 32712582 DOI: 10.4187/respcare.07931] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The COVID-19 pandemic is creating ventilator shortages in many countries that is sparking a conversation about placing multiple patients on a single ventilator. However, on March 26, 2020, six leading medical organizations released a joint statement warning clinicians that attempting this technique could lead to poor outcomes and high mortality. Nevertheless, hospitals around the United States and abroad are considering this technique out of desperation (eg, New York), but there is little data to guide their approach. The overall objective of this study is to utilize a computational model of mechanically ventilated lungs to assess how patient-specific lung mechanics and ventilator settings impact lung tidal volume (VT). METHODS We developed a lumped-parameter computational model of multiple patients connected to a shared ventilator and validated it against a similar experimental study. We used this model to evaluate how patient-specific lung compliance and resistance would impact VT under 4 ventilator settings of pressure control level, PEEP, breathing frequency, and inspiratory:expiratory ratio. RESULTS Our computational model predicts VT within 10% of experimental measurements. Using this model to perform a parametric study, we provide proof-of-concept for an algorithm to better match patients in different hypothetical scenarios of a single ventilator shared by > 1 patient. CONCLUSIONS Assigning patients to preset ventilators based on their required level of support on the lower PEEP/higher [Formula: see text] scale of the National Institute of Health's National Heart, Lung, and Blood Institute ARDS Clinical Network (ARDSNet), secondary to lung mechanics, could be used to overcome some of the legitimate concerns of placing multiple patients on a single ventilator. We emphasize that our results are currently based on a computational model that has not been validated against any preclinical or clinical data. Therefore, clinicians considering this approach should not look to our study as an exact estimate of predicted patient VT values.
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Affiliation(s)
- Vitaly O Kheyfets
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado.
| | - Steven R Lammers
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Jennifer Wagner
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Karsten Bartels
- Department of Anesthesiology, Psychiatry, Medicine, and Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Jerome Piccoli
- University of Colorado School of Medicine, Aurora, Colorado
| | - Bradford J Smith
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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15
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Perioperative Considerations in Pediatric Patients With Pulmonary Hypertension. Int Anesthesiol Clin 2019; 57:25-41. [PMID: 31503094 DOI: 10.1097/aia.0000000000000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Active right atrial emptying fraction predicts reduced survival and increased adverse events in childhood pulmonary arterial hypertension. Int J Cardiol 2018; 271:306-311. [DOI: 10.1016/j.ijcard.2018.04.125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/12/2018] [Accepted: 04/26/2018] [Indexed: 12/16/2022]
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17
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Jassal A, Cavus O, Bradley EA. Pediatric and Adolescent Pulmonary Hypertension: What Is the Risk of Undergoing Invasive Hemodynamic Testing? J Am Heart Assoc 2018; 7:JAHA.118.008625. [PMID: 29490974 PMCID: PMC5866344 DOI: 10.1161/jaha.118.008625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Anudeep Jassal
- Department of Pediatrics, The Heart Center Nationwide Children's Hospital, Columbus, OH
| | - Omer Cavus
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute The Ohio State University, Columbus, OH
| | - Elisa A Bradley
- Department of Pediatrics, The Heart Center Nationwide Children's Hospital, Columbus, OH .,Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute The Ohio State University, Columbus, OH.,Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
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18
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O'Byrne ML, Kennedy KF, Kanter JP, Berger JT, Glatz AC. Risk Factors for Major Early Adverse Events Related to Cardiac Catheterization in Children and Young Adults With Pulmonary Hypertension: An Analysis of Data From the IMPACT (Improving Adult and Congenital Treatment) Registry. J Am Heart Assoc 2018; 7:e008142. [PMID: 29490973 PMCID: PMC5866335 DOI: 10.1161/jaha.117.008142] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac catheterization is the gold standard for assessment and follow-up of patients with pulmonary hypertension (PH). To date, there are limited data about the factors that influence the risk of catastrophic adverse events after catheterization in this population. METHODS AND RESULTS A retrospective multicenter cohort study was performed to measure risk of catastrophic adverse outcomes after catheterization in children and young adults with PH and identify risk factors for these outcomes. All catheterizations in children and young adults, aged 0 to 21 years, with PH at hospitals submitting data to the IMPACT (Improving Adult and Congenital Treatment) registry between January 1, 2011, and December 31, 2015, were studied. Using mixed-effects multivariable regression, we assessed the association between prespecified subject-, procedure-, and center-level covariates and the risk of death, cardiac arrest, or mechanical circulatory support during or after cardiac catheterization. A total of 8111 procedures performed in 7729 subjects at 77 centers were studied. The observed risk of the composite outcome was 1.4%, and the risk of death before discharge was 5.2%. Catheterization in prematurely born neonates and nonpremature infants was associated with increased risk of catastrophic adverse event, as was precatheterization treatment with inotropes and lower systemic arterial saturation. Secondary analyses demonstrated the following: (1) increasing volumes of catheterization in patients with PH were associated with reduced risk of composite outcome (odds ratio, 0.8 per 10 procedures; P=0.002) and (2) increasing pulmonary vascular resistance and pulmonary artery pressures were associated with increased risk (P<0.0001 for both). CONCLUSIONS Young patients with PH are a high-risk population for diagnostic and interventional cardiac catheterization. Hospital experience with PH is associated with reduced risk, independent of total catheterization case volume.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute at the University of Pennsylvania, Philadelphia, PA
| | - Kevin F Kennedy
- Mid America Heart Institute, St Luke's Health System, Kansas City, MO
| | - Joshua P Kanter
- Division of Cardiology, Children's National Health System, Washington, DC
- Department of Pediatrics, George Washington University School of Health Sciences, Washington, DC
| | - John T Berger
- Division of Cardiology, Children's National Health System, Washington, DC
- Department of Pediatrics, George Washington University School of Health Sciences, Washington, DC
| | - Andrew C Glatz
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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19
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Kloesel B, Belani K. Pulmonary Hypertension. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Hyperoxia Reduces Oxygen Consumption in Children with Pulmonary Hypertension. Pediatr Cardiol 2017; 38:959-964. [PMID: 28315943 DOI: 10.1007/s00246-017-1602-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 03/11/2017] [Indexed: 10/19/2022]
Abstract
High inspired oxygen concentration (FiO2 > 0.85) is administered to test pulmonary vascular reactivity in children with pulmonary hypertension (PH). It is difficult to measure oxygen consumption (VO2) if the subject is breathing a hyperoxic gas mixture so the assumption is made that baseline VO2 does not change. We hypothesized that hyperoxia changes VO2. We sought to compare the VO2 measured by a thermodilution catheter in room air and hyperoxia. A retrospective review of the hemodynamic data obtained in children with PH who underwent cardiac catheterization was conducted between 2009 and 2014. Cardiac index (CI) was measured by a thermodilution catheter in room air and hyperoxia. VO2 was calculated using the equation CI = VO2/arterial-venous oxygen content difference. Data were available in 24 subjects (males = 10), with median age 8.3 years (0.8-17.6 years), weight 23.3 kg (7.5-95 kg), and body surface area 0.9 m2 (0.4-2.0 m2). In hyperoxia compared with room air, we measured decreased VO2 (154 ± 38 to 136 ± 34 ml/min/m2, p = 0.007), heart rate (91 [Formula: see text] 20 to 83 [Formula: see text] 21 beats/minute, p=0.005), mean pulmonary artery pressure (41 [Formula: see text] 16 to 35 [Formula: see text] 14 mmHg, p=0.024), CI (3.6 [Formula: see text] 0.8 to 3.3 [Formula: see text] 0.9 L/min/m2, p = 0.03), pulmonary vascular resistance (9 [Formula: see text] 6 to 7 [Formula: see text] 3 WU m2, p = 0.029), increased mean aortic (61 [Formula: see text] 11 to 67 [Formula: see text] 11 mmHg, p = 0.005), pulmonary artery wedge pressures (11 [Formula: see text] 8 to 13 [Formula: see text] 9 mmHg, p = 0.006), and systemic vascular resistance (12 [Formula: see text] 6 to 20 [Formula: see text] 7 WU m2, p=0.001). Hyperoxia decreased VO2 and CI and caused pulmonary vasodilation and systemic vasoconstriction in children with PH. The assumption that VO2 remains unchanged in hyperoxia may be incorrect and, if the Fick equation is used, may lead to an overestimation of pulmonary blood flow and underestimation of PVRI.
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21
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Koestenberger M, Hansmann G, Apitz C, Latus H, Lammers A. Diagnostics in Children and Adolescents with Suspected or Confirmed Pulmonary Hypertension. Paediatr Respir Rev 2017; 23:3-15. [PMID: 27964948 DOI: 10.1016/j.prrv.2016.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/20/2016] [Indexed: 12/13/2022]
Abstract
We provide a practical approach on the initial assessment and diagnostic work-up of children and adolescents with pulmonary hypertension (PH). Transthoracic echocardiography (TTE) often serves as initial study tool before invasive cardiac catheterization. Misinterpretation of TTE variables may lead to missed or delayed diagnosis with devastating consequences, or unnecessary invasive diagnostics that have inherited risks. In addition to clinical and biochemical markers, serial examination of patients with PH using a standardized TTE approach, determining conventional and novel echocardiographic variables, may allow early diagnosis and treatment in paediatric PH. Cardiac magnetic resonance imaging and computed tomography represent important non-invasive imaging modalities, that together with TTE may enable comprehensive assessment of ventricular function and pulmonary hemodynamics. Invasive assessment of haemodynamics (ventricular, pulmonary) and testing of acute vasoreactivity in the catheterization laboratory is still the gold standard for the diagnosis of PH and pulmonary hypertensive vascular disease (PHVD) in children and for the initiation of specific PH therapy. We suggest the regular assessment of prognostic TTE variables as part of a standardized approach for initial diagnosis of children with PH. Overreliance on any single TTE variable should be avoided as it detracts from the overall diagnostic potential of a standardized TTE examination for PH.
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Affiliation(s)
- Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Austria.
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Germany
| | - Christian Apitz
- Department of Pediatric Cardiology, University Children's Hospital Ulm, Germany
| | - Heiner Latus
- Pediatric Heart Centre, Justus-Liebig-University, Giessen, Germany
| | - Astrid Lammers
- Department of Paediatric Cardiology, University of Münster, Germany
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22
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Kaddoura T, Vadlamudi K, Kumar S, Bobhate P, Guo L, Jain S, Elgendi M, Coe JY, Kim D, Taylor D, Tymchak W, Schuurmans D, Zemp RJ, Adatia I. Acoustic diagnosis of pulmonary hypertension: automated speech- recognition-inspired classification algorithm outperforms physicians. Sci Rep 2016; 6:33182. [PMID: 27609672 PMCID: PMC5016849 DOI: 10.1038/srep33182] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/19/2016] [Indexed: 12/14/2022] Open
Abstract
We hypothesized that an automated speech- recognition-inspired classification algorithm could differentiate between the heart sounds in subjects with and without pulmonary hypertension (PH) and outperform physicians. Heart sounds, electrocardiograms, and mean pulmonary artery pressures (mPAp) were recorded simultaneously. Heart sound recordings were digitized to train and test speech-recognition-inspired classification algorithms. We used mel-frequency cepstral coefficients to extract features from the heart sounds. Gaussian-mixture models classified the features as PH (mPAp ≥ 25 mmHg) or normal (mPAp < 25 mmHg). Physicians blinded to patient data listened to the same heart sound recordings and attempted a diagnosis. We studied 164 subjects: 86 with mPAp ≥ 25 mmHg (mPAp 41 ± 12 mmHg) and 78 with mPAp < 25 mmHg (mPAp 17 ± 5 mmHg) (p < 0.005). The correct diagnostic rate of the automated speech-recognition-inspired algorithm was 74% compared to 56% by physicians (p = 0.005). The false positive rate for the algorithm was 34% versus 50% (p = 0.04) for clinicians. The false negative rate for the algorithm was 23% and 68% (p = 0.0002) for physicians. We developed an automated speech-recognition-inspired classification algorithm for the acoustic diagnosis of PH that outperforms physicians that could be used to screen for PH and encourage earlier specialist referral.
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Affiliation(s)
- Tarek Kaddoura
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, Canada
| | - Karunakar Vadlamudi
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Shine Kumar
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Prashant Bobhate
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Long Guo
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Shreepal Jain
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Mohamed Elgendi
- Department Computing Science, University of Alberta, Edmonton, Canada
| | - James Y Coe
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Daniel Kim
- Department of Medicine, Division of Cardiology, Cardiac Catheterization Laboratories, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - Dylan Taylor
- Department of Medicine, Division of Cardiology, Cardiac Catheterization Laboratories, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - Wayne Tymchak
- Department of Medicine, Division of Cardiology, Cardiac Catheterization Laboratories, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - Dale Schuurmans
- Department Computing Science, University of Alberta, Edmonton, Canada
| | - Roger J Zemp
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, Canada
| | - Ian Adatia
- Pediatric Pulmonary Hypertension Service, Pediatric Cardiac Critical Care Unit, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
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Apitz C, Hansmann G, Schranz D. Hemodynamic assessment and acute pulmonary vasoreactivity testing in the evaluation of children with pulmonary vascular disease. Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK. Heart 2016; 102 Suppl 2:ii23-9. [PMID: 27053694 DOI: 10.1136/heartjnl-2014-307340] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/13/2015] [Indexed: 11/04/2022] Open
Abstract
Invasive assessment of haemodynamics (ventricular, pulmonary) and testing of acute vasoreactivity in the catheterisation laboratory remain the gold standard for the diagnosis of pulmonary hypertension (PH) and pulmonary hypertensive vascular disease. However, these measurements and the interpretation thereof are challenging due to the heterogeneous aetiology of PH in childhood and potentially confounding factors in the catheterisation laboratory. Patients with pulmonary arterial hypertension (PAH) associated with congenital heart disease who have a cardiovascular shunt need to undergo a completely different catheterisation approach than those with idiopathic PAH lacking an anatomical cardiovascular defect. Diagnostic cardiac catheterisation of children with suspected PH usually includes right and left heart catheterisation, particularly for the initial assessment (ie, at the time of diagnosis), and should be performed in experienced centres only. Here, we present graded consensus recommendations for the invasive evaluation of children with PH including those with pulmonary hypertensive vascular disease and/or ventricular dysfunction. Based on the limited published studies and our own experience we suggest a structured catheterisation protocol and two separate definitions of positive acute vasoreactivity testing (AVT): (1) AVT to assess prognosis and indication for specific PH therapy, and (2) AVT to assess operability of PAH associated with congenital heart disease. The protocol and the latter definitions may help in the systematic assessment of these patients and the interpretation of the obtained data. Beyond an accurate diagnosis in the individual patient, such a structured approach may allow systematic decision making for the initiation of a specific treatment and may assist in estimating disease progression and individual prognosis.
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Affiliation(s)
- Christian Apitz
- Division of Pediatric Cardiology, University Children's Hospital, Ulm, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Dietmar Schranz
- Pediatric Heart Centre, Justus-Liebig-University, Giessen, Germany
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24
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Park KM, Hwang JK, Chun KJ, Park SJ, On YK, Kim JS, Park SW, Kang IS, Song J, Huh J. Prediction of early-onset atrial tachyarrhythmia after successful trans-catheter device closure of atrial septal defect. Medicine (Baltimore) 2016; 95:e4706. [PMID: 27583905 PMCID: PMC5008589 DOI: 10.1097/md.0000000000004706] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Atrial tachyarrhythmia is a well-known long-term complication of atrial septal defect (ASD) in adults, even after successful trans-catheter closure. However, the risk factors for early-onset atrial tachyarrhythmia after trans-catheter closure remain unclear. This retrospective study enrolled adults with secundum ASD undergoing trans-catheter closure from January 2000 to March 2014. We analyzed the clinical characteristics of patients and assessed risk factors for new-onset atrial tachyarrhythmia defined as a composite of atrial fibrillation or flutter (AF/AFL) after ASD closure. We enrolled a total of 427 patients; 123 were male (28.8%) and the median age was 37.0 (interquartile range [IQR]: 18.3-49.0). Nineteen (4.4%) patients had documented atrial tachyarrhythmia during the follow-up period (median: 11.4 months [IQR: 5.4-24]). Patients with transient AF/AFL during closure showed a greater incidence of new-onset atrial tachyarrhythmia during the follow-up period than patients with consistent sinus rhythm during closure (27.3% vs 3.8%; P = 0.01). Most new-onset atrial tachyarrhythmias were documented within 6 months (median: 2.6 [IQR: 1.2-4.1] months) of closure. In the multivariate analysis, the risk for new-onset atrial tachyarrhythmia was significant in patients with AF/AFL during closure (hazard ratio [HR]: 9.90, 95% confidence interval [CI]: 2.86-34.20; P < 0.001), deficient posteroinferior rim (HR: 5.48, 95% CI: 1.15-25.72; P = 0.04), and age of closure over 48 years (HR: 3.30, 95% CI: 1.30-8.38; P = 0.01). In conclusion, transient AF/AFL during trans-catheter closure of ASD as well as deficient posteroinferior rim and age of closure over 48 years may be useful for predicting early new-onset atrial tachyarrhythmia after device closure.
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Affiliation(s)
| | | | | | | | | | | | | | - I-Seok Kang
- Grown-Up Congenital Heart Disease Clinic, Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinyoung Song
- Grown-Up Congenital Heart Disease Clinic, Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Huh
- Grown-Up Congenital Heart Disease Clinic, Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence: June Huh, Grown-Up Congenital Heart Disease Clinic, Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea (e-mail: ; ; )
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Abstract
OBJECTIVES To review the clinical classification, diagnosis, and pathophysiology of pulmonary hypertension in children, emphasizing the role of right ventricular function, ventricular interaction, and congenital heart disease in the evolution and progression of disease, as well as management strategies and therapeutic options. DATA SOURCE MEDLINE, PubMed. CONCLUSIONS Critically ill children with pulmonary hypertension associated with congenital heart disease are a high-risk population. Congenital cardiac defects resulting in either increased pulmonary blood flow or impaired pulmonary venous drainage predispose patients to developing structural and functional aberrations of the pulmonary vasculature. Mortality from pulmonary hypertension is most directly related to right ventricular failure.
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26
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Beghetti M, Berger RMF, Ivy DD, Bonnet D, Humpl T. To "Cath" or Not in Pediatric Pulmonary Hypertension? J Am Coll Cardiol 2016; 67:1010-1011. [PMID: 26916495 DOI: 10.1016/j.jacc.2015.11.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 11/12/2015] [Indexed: 11/29/2022]
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Del Cerro MJ, Moledina S, Haworth SG, Ivy D, Al Dabbagh M, Banjar H, Diaz G, Heath-Freudenthal A, Galal AN, Humpl T, Kulkarni S, Lopes A, Mocumbi AO, Puri GD, Rossouw B, Harikrishnan S, Saxena A, Udo P, Caicedo L, Tamimi O, Adatia I. Cardiac catheterization in children with pulmonary hypertensive vascular disease: consensus statement from the Pulmonary Vascular Research Institute, Pediatric and Congenital Heart Disease Task Forces. Pulm Circ 2016; 6:118-25. [PMID: 27076908 PMCID: PMC4809667 DOI: 10.1086/685102] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Cardiac catheterization is important in the diagnosis and risk stratification of pulmonary hypertensive vascular disease (PHVD) in children. Acute vasoreactivity testing provides key information about management, prognosis, therapeutic strategies, and efficacy. Data obtained at cardiac catheterization continue to play an important role in determining the surgical options for children with congenital heart disease and clinical evidence of increased pulmonary vascular resistance. The Pediatric and Congenital Heart Disease Task Forces of the Pulmonary Vascular Research Institute met to develop a consensus statement regarding indications for, conduct of, acute vasoreactivity testing with, and pitfalls and risks of cardiac catheterization in children with PHVD. This document contains the essentials of those discussions to provide a rationale for the hemodynamic assessment by cardiac catheterization of children with PHVD.
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Affiliation(s)
| | | | | | - Dunbar Ivy
- Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Hanaa Banjar
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Gabriel Diaz
- Universidad Nacional de Colombia, Bogota, Colombia
| | | | | | - Tilman Humpl
- University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Snehal Kulkarni
- Kokilaben Dhirubai Ambani Hospital and Medical Research Institute, Mumbai, India
| | | | | | - G D Puri
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - S Harikrishnan
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Anita Saxena
- All-India Institute of Medical Sciences, New Delhi, India
| | | | | | - Omar Tamimi
- King Saud bin Abdulaziz University, Riyadh, Saudi Arabia
| | - Ian Adatia
- Stollery Children's Hospital, Edmonton, Alberta, Canada; on behalf of the PVRI Pediatric Task Force members Steven Abman, Vera Aiello, Rolf Berger, Patricia Cortez, Jeffrey Fineman, Marilyne Lévy, Marlene Rabinovitch, J. Usha Raj, Irwin Reiss, Julio Sandoval, Kurt Stenmark, and Rao Sureshi
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Lee KE, Seo YJ, Kim GB, An HS, Song YH, Kwon BS, Bae EJ, Noh CI. Complications of Cardiac Catheterization in Structural Heart Disease. Korean Circ J 2016; 46:246-55. [PMID: 27014356 PMCID: PMC4805570 DOI: 10.4070/kcj.2016.46.2.246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 08/25/2015] [Accepted: 09/22/2015] [Indexed: 01/15/2023] Open
Abstract
Background and Objectives Cardiac catheterization is used to diagnose structural heart disease (SHD) and perform transcatheter treatment. This study aimed to evaluate complications of cardiac catheterization and the associated risk factors in a tertiary center over 10 years. Subjects and Methods Total 2071 cardiac catheterizations performed at the Seoul National University Children's Hospital from January 2004 to December 2013 were included in this retrospective study. Results The overall complication, severe complication, and mortality rates were 16.2%, 1.15%, and 0.19%, respectively. The factors that significantly increased the risk of overall and severe complications were anticoagulant use before procedure (odds ratio [OR] 1.83, p=0.012 and OR 6.45, p<0.001, respectively), prothrombin time (OR 2.30, p<0.001 and OR 5.99, p<0.001, respectively), general anesthesia use during procedure (OR 1.84, p=0.014 and OR 5.31, p=0.015, respectively), and total procedure time (OR 1.01, p<0.001 and OR 1.02, p<0.001, respectively). Low body weight (OR 0.99, p=0.003), severe SHD (OR 1.37, p=0.012), repetitive procedures (OR 1.7, p=0.009), and total fluoroscopy time (OR 1.01, p=0.005) significantly increased the overall complication risk. High activated partial thromboplastin time (OR 1.04, p=0.001), intensive care unit admission state (OR 14.03, p<0.001), and concomitant electrophysiological study during procedure (OR 3.41, p=0.016) significantly increased severe complication risk. Conclusion Currently, the use of cardiac catheterization in SHD is increasing and becoming more complex; this could cause complications despite the preventive efforts. Careful patient selection for therapeutic catheterization and improved technique and management during the peri-procedural period are required to reduce complications.
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Affiliation(s)
- Ko Eun Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Yeon Jeong Seo
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyo Soon An
- Department of Pediatrics, Seoul National University Boramae Hospital, Seoul, Korea
| | - Young Hwan Song
- Department of Pediatrics, Bundang Seoul National University Hospital, Seongnam, Korea
| | - Bo Sang Kwon
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Eun Jung Bae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Chung Il Noh
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
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O'Byrne ML, Rome JJ, Kawut SJ. Reply: The Need for Comprehensive Cardiac Catheterization in Children With Pulmonary Hypertension: To "Cath" or Not in Pediatric Pulmonary Hypertension? J Am Coll Cardiol 2016; 67:1011-1012. [PMID: 26916496 DOI: 10.1016/j.jacc.2015.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 12/01/2015] [Indexed: 11/24/2022]
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Abstract
Pulmonary hypertension in the perinatal period can present acutely (persistent pulmonary hypertension of the newborn) or chronically. Clinical and echocardiographic diagnosis of acute pulmonary hypertension is well accepted but there are no broadly validated criteria for echocardiographic diagnosis of pulmonary hypertension later in the clinical course, although there are significant populations of infants with lung disease at risk for this diagnosis. Contributing cardiovascular comorbidities are common in infants with pulmonary hypertension and lung disease. It is not clear who should be treated without confirmation of pulmonary vascular disease by cardiac catheterization, with concurrent evaluation of any contributing cardiovascular comorbidities.
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Affiliation(s)
- Roberta L Keller
- Neonatology, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, Box 0734, 550 16th Street, 5th Floor, San Francisco, CA 94143, USA.
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Hopper RK, Abman SH, Ivy DD. Persistent Challenges in Pediatric Pulmonary Hypertension. Chest 2016; 150:226-36. [PMID: 26836930 DOI: 10.1016/j.chest.2016.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/31/2015] [Accepted: 01/09/2016] [Indexed: 01/18/2023] Open
Abstract
Pulmonary hypertension and related pulmonary vascular diseases cause significant morbidities and high mortality and present many unique challenges toward improving outcomes in neonates, infants, and children. Differences between pediatric and adult disease are reflected in controversies regarding etiologies, classification, epidemiology, diagnostic evaluations, and therapeutic interventions. This brief review highlights several key topics reflecting recent advances in the field and identifies persistent gaps in our understanding of clinical pediatric pulmonary hypertension.
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Affiliation(s)
- Rachel K Hopper
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - D Dunbar Ivy
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
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Abstract
This article is a review of the literature published during the 12 months of 2015, which is of interest to the congenital cardiac anesthesiologist. While the review is not exhaustive, it identifies 7 themes in the literature for 2015 and cites 78 peer-reviewed publications.
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Affiliation(s)
- Mark Twite
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard J. Ing
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
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Kreutzer J. Catastrophic Adverse Events During Cardiac Catheterization in Pediatric Pulmonary Hypertension May Not Be So Rare. J Am Coll Cardiol 2015; 66:1270-1272. [PMID: 26361159 DOI: 10.1016/j.jacc.2015.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Jacqueline Kreutzer
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Elgendi M, Kumar S, Guo L, Rutledge J, Coe JY, Zemp R, Schuurmans D, Adatia I. Detection of Heart Sounds in Children with and without Pulmonary Arterial Hypertension--Daubechies Wavelets Approach. PLoS One 2015; 10:e0143146. [PMID: 26629704 PMCID: PMC4668061 DOI: 10.1371/journal.pone.0143146] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 10/30/2015] [Indexed: 11/18/2022] Open
Abstract
Background Automatic detection of the 1st (S1) and 2nd (S2) heart sounds is difficult, and existing algorithms are imprecise. We sought to develop a wavelet-based algorithm for the detection of S1 and S2 in children with and without pulmonary arterial hypertension (PAH). Method Heart sounds were recorded at the second left intercostal space and the cardiac apex with a digital stethoscope simultaneously with pulmonary arterial pressure (PAP). We developed a Daubechies wavelet algorithm for the automatic detection of S1 and S2 using the wavelet coefficient ‘D6’ based on power spectral analysis. We compared our algorithm with four other Daubechies wavelet-based algorithms published by Liang, Kumar, Wang, and Zhong. We annotated S1 and S2 from an audiovisual examination of the phonocardiographic tracing by two trained cardiologists and the observation that in all subjects systole was shorter than diastole. Results We studied 22 subjects (9 males and 13 females, median age 6 years, range 0.25–19). Eleven subjects had a mean PAP < 25 mmHg. Eleven subjects had PAH with a mean PAP ≥ 25 mmHg. All subjects had a pulmonary artery wedge pressure ≤ 15 mmHg. The sensitivity (SE) and positive predictivity (+P) of our algorithm were 70% and 68%, respectively. In comparison, the SE and +P of Liang were 59% and 42%, Kumar 19% and 12%, Wang 50% and 45%, and Zhong 43% and 53%, respectively. Our algorithm demonstrated robustness and outperformed the other methods up to a signal-to-noise ratio (SNR) of 10 dB. For all algorithms, detection errors arose from low-amplitude peaks, fast heart rates, low signal-to-noise ratio, and fixed thresholds. Conclusion Our algorithm for the detection of S1 and S2 improves the performance of existing Daubechies-based algorithms and justifies the use of the wavelet coefficient ‘D6’ through power spectral analysis. Also, the robustness despite ambient noise may improve real world clinical performance.
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Affiliation(s)
- Mohamed Elgendi
- Department of Mathematics and Computing Science, University of Alberta, Edmonton, Canada
| | - Shine Kumar
- Pediatric Pulmonary Hypertension Service and Cardiac Critical Care, Stollery children’s Hospital, Mazankowski Heart Institute, University of Alberta, Edmonton, Canada
| | - Long Guo
- Pediatric Pulmonary Hypertension Service and Cardiac Critical Care, Stollery children’s Hospital, Mazankowski Heart Institute, University of Alberta, Edmonton, Canada
| | - Jennifer Rutledge
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Canada
| | - James Y. Coe
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Canada
| | - Roger Zemp
- Department of Biomedical Electrical and Computer Engineering, University of Alberta, Edmonton, Canada
| | - Dale Schuurmans
- Department of Mathematics and Computing Science, University of Alberta, Edmonton, Canada
| | - Ian Adatia
- Pediatric Pulmonary Hypertension Service and Cardiac Critical Care, Stollery children’s Hospital, Mazankowski Heart Institute, University of Alberta, Edmonton, Canada
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Canada
- * E-mail:
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Beghetti M, Schulze-Neick I, Berger RMF, Ivy DD, Bonnet D, Weintraub RG, Saji T, Yung D, Mallory GB, Geiger R, Berger JT, Barst RJ, Humpl T. Haemodynamic characterisation and heart catheterisation complications in children with pulmonary hypertension: Insights from the Global TOPP Registry (tracking outcomes and practice in paediatric pulmonary hypertension). Int J Cardiol 2015; 203:325-30. [PMID: 26583838 DOI: 10.1016/j.ijcard.2015.10.087] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/04/2015] [Accepted: 10/12/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND The TOPP Registry has been designed to provide epidemiologic, diagnostic, clinical, and outcome data on children with pulmonary hypertension (PH) confirmed by heart catheterisation (HC). This study aims to identify important characteristics of the haemodynamic profile at diagnosis and HC complications of paediatric patients presenting with PH. METHODS AND RESULTS HC data sets underwent a blinded review for confirmation of PH (defined as mean pulmonary arterial pressure ≥ 25 mmHg, pulmonary capillary wedge pressure ≤ 12 mmHg and pulmonary vascular resistance index [PVRI] of >3 WU × m(2)). Of 568 patients enrolled, 472 who fulfilled the inclusion criteria and had sufficient data from HC were analysed. A total of 908 diagnostic and follow-up HCs were performed and complications occurred in 5.9% of all HCs including five (0.6%) deaths. General anaesthesia (GA) was used in 53%, and conscious sedation in 47%. Complications at diagnosis were more likely to occur if GA was used (p=0.04) and with higher functional class (p=0.02). Mean cardiac index (CI) was within normal limits at diagnosis when analysed for the entire group (3.7 L/min/m(2); 95% confidence interval 3.4-4.1), as was right atrial pressure despite a severely increased PVRI (16.6 WU × m(2,) 95% confidence interval 15.6-17.76). However, 24% of the patients had a CI of <2.5L/min/m(2) at diagnosis. A progressive increase in PVRI and decrease in CI was observed with age (p<0.001). CONCLUSION In TOPP, haemodynamic assessment was remarkable for preserved CI in the majority of patients despite severely elevated PVRI. HC-related complication incidence was 5.9%, and was associated with GA and higher functional class.
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Affiliation(s)
- M Beghetti
- Pediatric Cardiology, Department of the Child and Adolescents, Hôpital des Enfants, University of Geneva, Switzerland.
| | - I Schulze-Neick
- Cardiac Unit, Great Ormond Street Hospital for Children, London, UK
| | - R M F Berger
- Center for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Netherlands
| | - D D Ivy
- Pediatrics, University of Colorado School of Medicine, Aurora, USA
| | - D Bonnet
- M3C-Paediatric Cardiology, Université Paris Descartes, Necker Enfants Malades, AP-HP, Paris, France
| | - R G Weintraub
- Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Australia
| | - T Saji
- Toho University Medical Center Omori Hospital, Tokyo, Japan
| | - D Yung
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, USA
| | - G B Mallory
- Texas Children's Hospital, Baylor College of Medicine, Houston, USA
| | - R Geiger
- Innsbruck Medical University, Pediatric Cardiology, Innsbruck, Austria
| | - J T Berger
- Children's National Medical Center, Pediatric Critical Care and Cardiology, WA, USA
| | - R J Barst
- Pediatrics, Columbia University, New York, USA
| | - T Humpl
- Cardiology and Critical Care, University of Toronto, Toronto, ON, Canada
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Chau DF, Gangadharan M, Hartke LP, Twite MD. The Post-Anesthetic Care of Pediatric Patients With Pulmonary Hypertension. Semin Cardiothorac Vasc Anesth 2015; 20:63-73. [PMID: 26134177 DOI: 10.1177/1089253215593179] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Few conditions make even the most experienced pediatric anesthesiologists take pause. Pulmonary hypertension is one such condition due to the associated high perioperative morbidity and mortality. Much is written about the intraoperative management of pediatric pulmonary hypertension. This article will instead focus on postoperative care and review the evidence in support of a risk stratification approach for the post-anesthetic disposition of these patients. The total risk for post-anesthetic adverse events includes the patient's baseline risk factors and the incremental risks imposed by the procedure and anesthetic. A proposal with recommendations to guide practitioners and a table summarizing relevant factors are provided. Last, the readers' attention is drawn to the heterogeneity of pulmonary hypertensive disease. Pulmonary arterial hypertension (precapillary) differs significantly from pulmonary venous hypertension (postcapillary); the anesthetic management for one may be relatively contraindicated in the other. Their dissimilarities justify the need to distinguish them for study and research endeavors.
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Affiliation(s)
- Destiny F Chau
- Eastern Virginia Medical School, Norfolk, VA, USA Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | - Meera Gangadharan
- University of Texas Medical Branch at Galveston, TX, USA Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - Lopa P Hartke
- Eastern Virginia Medical School, Norfolk, VA, USA Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | - Mark D Twite
- Children's Hospital Colorado, Aurora, CO, USA University of Colorado, Denver, Aurora, CO, USA
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