1
|
Bogle C, Colan SD, Miyamoto SD, Choudhry S, Baez-Hernandez N, Brickler MM, Feingold B, Lal AK, Lee TM, Canter CE, Lipshultz SE. Treatment Strategies for Cardiomyopathy in Children: A Scientific Statement From the American Heart Association. Circulation 2023; 148:174-195. [PMID: 37288568 DOI: 10.1161/cir.0000000000001151] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This scientific statement from the American Heart Association focuses on treatment strategies and modalities for cardiomyopathy (heart muscle disease) in children and serves as a companion scientific statement for the recent statement on the classification and diagnosis of cardiomyopathy in children. We propose that the foundation of treatment of pediatric cardiomyopathies is based on these principles applied as personalized therapy for children with cardiomyopathy: (1) identification of the specific cardiac pathophysiology; (2) determination of the root cause of the cardiomyopathy so that, if applicable, cause-specific treatment can occur (precision medicine); and (3) application of therapies based on the associated clinical milieu of the patient. These clinical milieus include patients at risk for developing cardiomyopathy (cardiomyopathy phenotype negative), asymptomatic patients with cardiomyopathy (phenotype positive), patients with symptomatic cardiomyopathy, and patients with end-stage cardiomyopathy. This scientific statement focuses primarily on the most frequent phenotypes, dilated and hypertrophic, that occur in children. Other less frequent cardiomyopathies, including left ventricular noncompaction, restrictive cardiomyopathy, and arrhythmogenic cardiomyopathy, are discussed in less detail. Suggestions are based on previous clinical and investigational experience, extrapolating therapies for cardiomyopathies in adults to children and noting the problems and challenges that have arisen in this experience. These likely underscore the increasingly apparent differences in pathogenesis and even pathophysiology in childhood cardiomyopathies compared with adult disease. These differences will likely affect the utility of some adult therapy strategies. Therefore, special emphasis has been placed on cause-specific therapies in children for prevention and attenuation of their cardiomyopathy in addition to symptomatic treatments. Current investigational strategies and treatments not in wide clinical practice, including future direction for investigational management strategies, trial designs, and collaborative networks, are also discussed because they have the potential to further refine and improve the health and outcomes of children with cardiomyopathy in the future.
Collapse
|
2
|
Hollander SA, Wujcik K, Schmidt J, Liu E, Lin A, Dykes J, Good J, Brown M, Rosenthal D. Home Milrinone in Pediatric Hospice Care of Children with Heart Failure. J Pain Symptom Manage 2023; 65:216-221. [PMID: 36417945 DOI: 10.1016/j.jpainsymman.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT The symptom profile of children dying from cardiac disease, especially heart failure, differs from those with cancer and other non-cardiac conditions. Treatment with vasoactive infusions at home may be a superior therapy for symptom control for these patients, rather than traditional pain and anxiety management with morphine and benzodiazepines. OBJECTIVES We report our experience using outpatient milrinone in children receiving hospice care for end-stage heart failure. METHODS Retrospective review of a contemporary cohort of all patients at Lucile Packard Children's Hospital, Stanford who were discharged on intravenous milrinone and hospice care between 2008 and 2021. Clinical data, including cardiac diagnosis, milrinone dose and route of administration, total milrinone days, symptoms reported, rehospitalization rates, concurrent therapies and complications were analyzed. RESULTS Among 8 patients, median duration of home milrinone infusion was 191 (33, 572) days with the longest support duration 1,054 days. All (100%) patients were also receiving diuretics at the time of death. Five (63%) were receiving no other pain control medications until the active phase of dying. From milrinone initiation to last outpatient assessment, a reduction in the number of patients reporting respiratory discomfort, abdominal pain, weight loss/lack of appetite, and fatigue was observed. Six (75%) died at home. CONCLUSION We used milrinone with oral diuretics effectively for symptom control in children with heart failure on palliative care. Our experience was that this combination can be used safely in the outpatient setting for long-term use without the addition of opiates, benzodiazepines, or supplemental oxygen in most cases.
Collapse
Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA.
| | - Kari Wujcik
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Julie Schmidt
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Esther Liu
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Aileen Lin
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - John Dykes
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Julie Good
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Michelle Brown
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - David Rosenthal
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| |
Collapse
|
3
|
Das BB. Therapeutic Approaches in Heart Failure with Preserved Ejection Fraction (HFpEF) in Children: Present and Future. Paediatr Drugs 2022; 24:235-246. [PMID: 35501560 DOI: 10.1007/s40272-022-00508-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 12/29/2022]
Abstract
For a long time, pediatric heart failure (HF) with preserved systolic function (HFpEF) has been noted in patients with cardiomyopathies and congenital heart disease. HFpEF is infrequently reported in children and instead of using the HFpEF terminology the HF symptoms are attributed to diastolic dysfunction. Identifying HFpEF in children is challenging because of heterogeneous etiologies and unknown pathophysiological mechanisms. Advances in echocardiography and cardiac magnetic resonance imaging techniques have further increased our understanding of HFpEF in children. However, the literature does not describe the incidence, etiology, clinical features, and treatment of HFpEF in children. At present, treatment of HFpEF in children is extrapolated from clinical trials in adults. There are significant differences between pediatric and adult HF with reduced ejection fraction, supported by a lack of adequate response to adult HF therapies. Evidence-based clinical trials in children are still not available because of the difficulty of conducting trials with a limited number of pediatric patients with HF. The treatment of HFpEF in children is based upon the clinician's experience, and the majority of children receive off-level medications. There are significant differences between pediatric and adult HFpEF pharmacotherapies in many areas, including side-effect profiles, underlying pathophysiologies, the β-receptor physiology, and pharmacokinetics and pharmacodynamics. This review describes the present and future treatments for children with HFpEF compared with adults. This review also highlights the need to urgently test new therapies in children with HFpEF to demonstrate the safety and efficacy of drugs and devices with proven benefits in adults.
Collapse
Affiliation(s)
- Bibhuti B Das
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 N State St., Jackson, MS, 39216, USA.
| |
Collapse
|
4
|
Woulfe KC, Jeffrey DA, Pires Da Silva J, Wilson CE, Mahaffey JH, Lau E, Slavov D, Hailu F, Karimpour-Fard A, Dockstader K, Bristow MR, Stauffer BL, Miyamoto SD, Sucharov CC. Serum response factor deletion 5 regulates phospholamban phosphorylation and calcium uptake. J Mol Cell Cardiol 2021; 159:28-37. [PMID: 34139234 PMCID: PMC8546760 DOI: 10.1016/j.yjmcc.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/25/2021] [Accepted: 06/13/2021] [Indexed: 11/25/2022]
Abstract
AIMS Pediatric dilated cardiomyopathy (pDCM) is characterized by unique age-dependent molecular mechanisms that include myocellular responses to therapy. We previously showed that pDCM, but not adult DCM patients respond to phosphodiesterase 3 inhibitors (PDE3i) by increasing levels of the second messenger cAMP and consequent phosphorylation of phospholamban (PLN). However, the molecular mechanisms involved in the differential pediatric and adult response to PDE3i are not clear. METHODS AND RESULTS Quantification of serum response factor (SRF) isoforms from the left ventricle of explanted hearts showed that PDE3i treatment affects expression of SRF isoforms in pDCM hearts. An SRF isoform lacking exon 5 (SRFdel5) was highly expressed in the hearts of pediatric, but not adult DCM patients treated with PDE3i. To determine the functional consequence of expression of SRFdel5, we overexpressed full length SRF or SRFdel5 in cultured cardiomyocytes with and without adrenergic stimulation. Compared to a control adenovirus, expression of SRFdel5 increased phosphorylation of PLN, negatively affected expression of the phosphatase that promotes dephosphorylation of PLN (PP2Cε), and promoted faster calcium reuptake, whereas expression of full length SRF attenuated calcium reuptake through blunted phosphorylation of PLN. CONCLUSIONS Taken together, these data indicate that expression of SRFdel5 in pDCM hearts in response to PDE3i contributes to improved function through regulating PLN phosphorylation and thereby calcium reuptake.
Collapse
Affiliation(s)
- Kathleen C Woulfe
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Danielle A Jeffrey
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Julie Pires Da Silva
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Cortney E Wilson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jennifer H Mahaffey
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Edward Lau
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Dobromir Slavov
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Frehiwet Hailu
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Anis Karimpour-Fard
- Department of Pharmacology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Karen Dockstader
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Michael R Bristow
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Brian L Stauffer
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Denver Health Medical Center, Denver, CO, United States
| | - Shelley D Miyamoto
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital of Colorado, Aurora, CO, United States
| | - Carmen C Sucharov
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
| |
Collapse
|
5
|
Abstract
Pediatric heart failure is a complex, heterogenous syndrome that occurs relatively rarely in children, but carries a high burden of morbidity and mortality. This article reflects on the current state of medical therapy for both acute and chronic pediatric heart failure, based on expert consensus guidelines, and the extrapolation of data from trials performed in adults. For the management of acute heart failure specifically, we rely on an initial assessment of the perfusion and volume status of a patient, to guide medical therapy. This paradigm was adapted from adult studies that demonstrated increased morbidity and mortality in heart failure patients whose hemodynamics or examination findings were consistent with a PCWP >18 mmHg and a CI ≤2.2 L/min/m2. The cornerstone of treatment in the acute setting therefore relies on achieving a euvolemic state with adequate cardiac output. In the chronic setting, patients are typically maintained on a regimen of an angiotensin converting enzyme inhibitor, a beta-blocker, and spironolactone. For those with refractory heart failure, intravenous milrinone therapy has become a mainstay of bridging children to cardiac transplantation. The pediatric-specific data driving these clinical practices are limited and often times, conflicting. The future of pediatric heart failure depends on collaboration, quality improvement, and a commitment to pediatric-specific indications for new medical and device therapies.
Collapse
Affiliation(s)
- Humera Ahmed
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina VanderPluym
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Abstract
PURPOSE OF REVIEW The goal of this paper is to provide an overview of contemporary knowledge specific to the causes, management, and outcome of heart failure in children. RECENT FINDINGS While recently there have been subtle improvements in heart failure outcomes in children, these improvements lag significantly behind that of adults. There is a growing body of literature suggesting that pediatric heart failure is a unique disease process with age- and disease-specific myocardial adaptations. In addition, the heterogenous etiologies of heart failure in children contribute to differential response to therapies and challenge the ability to obtain meaningful results from prospective clinical trials. Consideration of novel clinical trial designs with achievable but clinically relevant endpoints and focused study of the mechanisms underlying pediatric heart failure secondary to cardiomyopathies and structural heart disease are essential if we hope to advance care and identify targeted and effective therapies.
Collapse
Affiliation(s)
| | - Anastacia M Garcia
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Roni M Jacobsen
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Shelley D Miyamoto
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA.
| |
Collapse
|
7
|
Garcia AM, Beatty JT, Nakano SJ. Heart failure in single right ventricle congenital heart disease: physiological and molecular considerations. Am J Physiol Heart Circ Physiol 2020; 318:H947-H965. [PMID: 32108525 PMCID: PMC7191494 DOI: 10.1152/ajpheart.00518.2019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 12/27/2022]
Abstract
Because of remarkable surgical and medical advances over the past several decades, there are growing numbers of infants and children living with single ventricle congenital heart disease (SV), where there is only one functional cardiac pumping chamber. Nevertheless, cardiac dysfunction (and ultimately heart failure) is a common complication in the SV population, and pharmacological heart failure therapies have largely been ineffective in mitigating the need for heart transplantation. Given that there are several inherent risk factors for ventricular dysfunction in the setting of SV in addition to probable differences in molecular adaptations to heart failure between children and adults, it is perhaps not surprising that extrapolated adult heart failure medications have had limited benefit in children with SV heart failure. Further investigations into the molecular mechanisms involved in pediatric SV heart failure may assist with risk stratification as well as development of targeted, efficacious therapies specific to this patient population. In this review, we present a brief overview of SV anatomy and physiology, with a focus on patients with a single morphological right ventricle requiring staged surgical palliation. Additionally, we discuss outcomes in the current era, risk factors associated with the progression to heart failure, present state of knowledge regarding molecular alterations in end-stage SV heart failure, and current therapeutic interventions. Potential avenues for improving SV outcomes, including identification of biomarkers of heart failure progression, implications of personalized medicine and stem cell-derived therapies, and applications of novel models of SV disease, are proposed as future directions.
Collapse
Affiliation(s)
- Anastacia M Garcia
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
| | - Jonathan-Thomas Beatty
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Stephanie J Nakano
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
| |
Collapse
|
8
|
Sucharov CC, Nakano SJ, Slavov D, Schwisow JA, Rodriguez E, Nunley K, Medway A, Stafford N, Nelson P, McKinsey TA, Movsesian M, Minobe W, Carroll IA, Taylor MRG, Bristow MR. A PDE3A Promoter Polymorphism Regulates cAMP-Induced Transcriptional Activity in Failing Human Myocardium. J Am Coll Cardiol 2020; 73:1173-1184. [PMID: 30871701 DOI: 10.1016/j.jacc.2018.12.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The phosphodiesterase 3A (PDE3A) gene encodes a PDE that regulates cardiac myocyte cyclic adenosine monophosphate (cAMP) levels and myocardial contractile function. PDE3 inhibitors (PDE3i) are used for short-term treatment of refractory heart failure (HF), but do not produce uniform long-term benefit. OBJECTIVES The authors tested the hypothesis that drug target genetic variation could explain clinical response heterogeneity to PDE3i in HF. METHODS PDE3A promoter studies were performed in a cloned luciferase construct. In human left ventricular (LV) preparations, mRNA expression was measured by reverse transcription polymerase chain reaction, and PDE3 enzyme activity by cAMP-hydrolysis. RESULTS The authors identified a 29-nucleotide (nt) insertion (INS)/deletion (DEL) polymorphism in the human PDE3A gene promoter beginning 2,214 nt upstream from the PDE3A1 translation start site. Transcription factor ATF3 binds to the INS and represses cAMP-dependent promoter activity. In explanted failing LVs that were homozygous for PDE3A DEL and had been treated with PDE3i pre-cardiac transplantation, PDE3A1 mRNA abundance and microsomal PDE3 enzyme activity were increased by 1.7-fold to 1.8-fold (p < 0.05) compared with DEL homozygotes not receiving PDE3i. The basis for the selective up-regulation in PDE3A gene expression in DEL homozygotes treated with PDE3i was a cAMP response element enhancer 61 nt downstream from the INS, which was repressed by INS. The DEL homozygous genotype frequency was also enriched in patients with HF. CONCLUSIONS A 29-nt INS/DEL polymorphism in the PDE3A promoter regulates cAMP-induced PDE3A gene expression in patients treated with PDE3i. This molecular mechanism may explain response heterogeneity to this drug class, and may inform a pharmacogenetic strategy for a more effective use of PDE3i in HF.
Collapse
Affiliation(s)
- Carmen C Sucharov
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado.
| | - Stephanie J Nakano
- Department of Pediatrics, University of Colorado Denver, Children's Hospital Colorado, Aurora, Colorado
| | - Dobromir Slavov
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado
| | - Jessica A Schwisow
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado
| | - Erin Rodriguez
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado
| | - Karin Nunley
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado
| | - Allen Medway
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado
| | - Natalie Stafford
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado
| | - Penny Nelson
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado
| | - Timothy A McKinsey
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado; University of Colorado Anschutz Medical Campus Consortium for Fibrosis Research & Translation, Aurora, Colorado
| | - Matthew Movsesian
- Cardiology Section, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah; Department of Internal Medicine (Cardiovascular Medicine), University of Utah School of Medicine, Salt Lake City, Utah; Department of Pharmacology & Toxicology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Wayne Minobe
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado
| | | | - Matthew R G Taylor
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado
| | - Michael R Bristow
- Division of Cardiology and Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado; ARCA Biopharma, Westminster, Colorado
| |
Collapse
|
9
|
Nakano SJ, Walker JS, Walker LA, Li X, Du Y, Miyamoto SD, Sucharov CC, Garcia AM, Mitchell MB, Ambardekar AV, Stauffer BL. Increased myocyte calcium sensitivity in end-stage pediatric dilated cardiomyopathy. Am J Physiol Heart Circ Physiol 2019; 317:H1221-H1230. [PMID: 31625780 DOI: 10.1152/ajpheart.00409.2019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Dilated cardiomyopathy (DCM) is the most common cause of heart failure (HF) in children, resulting in high mortality and need for heart transplantation. The pathophysiology underlying pediatric DCM is largely unclear; however, there is emerging evidence that molecular adaptations and response to conventional HF medications differ between children and adults. To gain insight into alterations leading to systolic dysfunction in pediatric DCM, we measured cardiomyocyte contractile properties and sarcomeric protein phosphorylation in explanted pediatric DCM myocardium (N = 8 subjects) compared with nonfailing (NF) pediatric hearts (N = 8 subjects). Force-pCa curves were generated from skinned cardiomyocytes in the presence and absence of protein kinase A. Sarcomeric protein phosphorylation was quantified with Pro-Q Diamond staining after gel electrophoresis. Pediatric DCM cardiomyocytes demonstrate increased calcium sensitivity (pCa50 =5.70 ± 0.0291), with an associated decrease in troponin (Tn)I phosphorylation compared with NF pediatric cardiomyocytes (pCa50 =5.59 ± 0.0271, P = 0.0073). Myosin binding protein C and TnT phosphorylation are also lower in pediatric DCM, whereas desmin phosphorylation is increased. Pediatric DCM cardiomyocytes generate peak tension comparable to that of NF pediatric cardiomyocytes [DCM 29.7 mN/mm2, interquartile range (IQR) 21.5-49.2 vs. NF 32.8 mN/mm2, IQR 21.5-49.2 mN/mm2; P = 0.6125]. In addition, cooperativity is decreased in pediatric DCM compared with pediatric NF (Hill coefficient: DCM 1.56, IQR 1.31-1.94 vs. NF 1.94, IQR 1.36-2.86; P = 0.0425). Alterations in sarcomeric phosphorylation and cardiomyocyte contractile properties may represent an impaired compensatory response, contributing to the detrimental DCM phenotype in children.NEW & NOTEWORTHY Our study is the first to demonstrate that cardiomyocytes from infants and young children with dilated cardiomyopathy (DCM) exhibit increased calcium sensitivity (likely mediated by decreased troponin I phosphorylation) compared with nonfailing pediatric cardiomyocytes. Compared with published values in adult cardiomyocytes, pediatric cardiomyocytes have notably decreased cooperativity, with a further reduction in the setting of DCM. Distinct adaptations in cardiomyocyte contractile properties may contribute to a differential response to pharmacological therapies in the pediatric DCM population.
Collapse
Affiliation(s)
- Stephanie J Nakano
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
| | - John S Walker
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Lori A Walker
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Xiaotao Li
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Yanmei Du
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Shelley D Miyamoto
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
| | - Carmen C Sucharov
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Anastacia M Garcia
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
| | - Max B Mitchell
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Denver, Aurora, Colorado
| | - Amrut V Ambardekar
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Brian L Stauffer
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado.,Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado
| |
Collapse
|
10
|
West TM, Wang Q, Deng B, Zhang Y, Barbagallo F, Reddy GR, Chen D, Phan KS, Xu B, Isidori A, Xiang YK. Phosphodiesterase 5 Associates With β2 Adrenergic Receptor to Modulate Cardiac Function in Type 2 Diabetic Hearts. J Am Heart Assoc 2019; 8:e012273. [PMID: 31311394 PMCID: PMC6761630 DOI: 10.1161/jaha.119.012273] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background In murine heart failure models and in humans with diabetic‐related heart hypertrophy, inhibition of phosphodiesterase 5 (PDE5) by sildenafil improves cardiac outcomes. However, the mechanism by which sildenafil improves cardiac function is unclear. We have observed a relationship between PDE5 and β2 adrenergic receptor (β2AR), which is characterized here as a novel mechanistic axis by which sildenafil improves symptoms of diabetic cardiomyopathy. Methods and Results Wild‐type and β2AR knockout mice fed a high fat diet (HFD) were treated with sildenafil, and echocardiogram analysis was performed. Cardiomyocytes were isolated for excitation‐contraction (E‐C) coupling, fluorescence resonant energy transfer, and proximity ligation assays; while heart tissues were implemented for biochemical and histological analyses. PDE5 selectively associates with β2AR, but not β1 adrenergic receptor, and inhibition of PDE5 with sildenafil restores the impaired response to adrenergic stimulation in HFD mice and isolated ventriculomyocytes. Sildenafil enhances β adrenergic receptor (βAR)‐stimulated cGMP and cAMP signals in HFD myocytes. Consequently, inhibition of PDE5 leads to protein kinase G–, and to a lesser extent, calcium/calmodulin‐dependent kinase II–dependent improvements in adrenergically stimulated E‐C coupling. Deletion of β2AR abolishes sildenafil's effect. Although the PDE5‐β2AR association is not altered in HFD, phosphodiesterase 3 displays an increased association with the β2AR‐PDE5 complex in HFD myocytes. Conclusions This study elucidates mechanisms by which the β2AR‐PDE5 axis can be targeted for treating diabetic cardiomyopathy. Inhibition of PDE5 enhances β2AR stimulation of cGMP and cAMP signals, as well as protein kinase G–dependent E‐C coupling in HFD myocytes.
Collapse
Affiliation(s)
- Toni M West
- Department of Pharmacology University of California Davis School of Medicine Davis CA
| | - Qingtong Wang
- Department of Pharmacology University of California Davis School of Medicine Davis CA
| | - Bingqing Deng
- Department of Pharmacology University of California Davis School of Medicine Davis CA.,Sun-Yet Sen Memorial hospital Sun-Yet Sen University Guangzhou China
| | - Yu Zhang
- Department of Pharmacology University of California Davis School of Medicine Davis CA.,College of Pharmacy Guangzhou Medical University Guangzhou China
| | - Federica Barbagallo
- Department of Pharmacology University of California Davis School of Medicine Davis CA.,Department of Experimental Medicine Sapienza University of Rome Rome Italy
| | - Gopireddy R Reddy
- Department of Pharmacology University of California Davis School of Medicine Davis CA
| | - Dana Chen
- Department of Pharmacology University of California Davis School of Medicine Davis CA
| | - Kyle S Phan
- Department of Pharmacology University of California Davis School of Medicine Davis CA
| | - Bing Xu
- Department of Pharmacology University of California Davis School of Medicine Davis CA.,College of Pharmacy Guangzhou Medical University Guangzhou China
| | - Andres Isidori
- Department of Experimental Medicine Sapienza University of Rome Rome Italy
| | - Yang K Xiang
- Department of Pharmacology University of California Davis School of Medicine Davis CA.,VA Northern California Health Care System Mather CA
| |
Collapse
|
11
|
Guo Q, Liu J, Zhu P, Liu Y, Dong N, Shi J, Peng H. Evaluation of Drug-Related Receptors in Children With Dilated Cardiomyopathy. Front Pediatr 2019; 7:387. [PMID: 31632936 PMCID: PMC6779825 DOI: 10.3389/fped.2019.00387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/09/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Effective treatments for pediatric dilated cardiomyopathy (DCM) are limited. Currently, pediatric DCM therapy mainly includes supportive heart failure (HF) treatment. While the treatment for child DCM patients is generally the same as that for adult DCM patients, few randomized prospective studies on the clinical efficacy of treatments for pediatric DCM have been published. We explored the appropriate treatments for child patients. Methods: The ultrastructure of pediatric DCM and control hearts was analyzed by electron microscopy and HE staining. Left ventricular tissues from children in the DCM and control groups were subjected to quantitative RT-PCR (qRT-PCR) to study the mRNA expression of receptors related to various treatments, including drugs targeting the renin-angiotensin-aldosterone system (RAAS) system, digoxin, milrinone, and β-receptor blockers, in child patients in the clinic. Furthermore, the differences in drug receptors in heart tissues between children and adults with DCM were analyzed. Results: Compared with the control children, the children in the DCM group showed marked abnormalities in structure and organelles. The mRNA levels of angiotensin-converting enzyme (ACE), REN, prorenin receptor (PRR), NEP, ATP1A1, and phosphodiesterase3 (PDE3A) were higher in the pediatric DCM group than the control group. Interestingly, the mRNA expression of these treatment-related receptors was much higher in children than in adults. Conclusion: ACE inhibitors, PRR or REN receptor inhibitors, PDE3 inhibitors and LCZ696 may be effective in children with DCM. However, β-receptor blockers are not valid treatments for pediatric DCM. Moreover, high receptor expression was observed in children. These data will improve the selection of drugs for DCM patients, enhance treatment, and increase the survival rate.
Collapse
Affiliation(s)
- Qing Guo
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Liu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peng Zhu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yali Liu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiawei Shi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hua Peng
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
12
|
Apostolopoulou SC, Vagenakis GA, Tsoutsinos A, Kakava F, Rammos S. Ambulatory Intravenous Inotropic Support and or Levosimendan in Pediatric and Congenital Heart Failure: Safety, Survival, Improvement, or Transplantation. Pediatr Cardiol 2018; 39:1315-1322. [PMID: 29777282 DOI: 10.1007/s00246-018-1897-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 05/05/2018] [Indexed: 11/30/2022]
Abstract
End-stage heart failure (HF) frequently needs continuous inotropic support in hospital and has high morbidity and mortality in absence of heart transplantation. This study reports outcome, efficacy, and safety of continuous ambulatory inotropes (AI) and/or periodic levosimendan (LS) infusions in pediatric HF patients. The study included 27 patients, median age 9.4 (0.1-26.1) years, with severe HF (6 myocarditis, 13 dilated cardiomyopathy, 2 restrictive cardiomyopathy, 6 repaired congenital heart disease). Dobutamine and milrinone AI were administered in 21 patients through a permanent central catheter for median duration 1.0 (0.3-3.7) years. Additionally, 14 AI patients and the remaining 6 study patients received periodic LS infusions for median duration 1.1 (0.2-4.2) years. During median follow-up 2.1 (0.3-21.3) years, 4 patients died of worsening HF after 0.8-2.1 years AI, 6 patients underwent heart transplantation with only 3 survivors, while the rest remained stable out of the hospital with complications 4 line infections treated with antibiotics and 4 catheter reinsertions due to dislodgement. Severe pulmonary hypertension was reversed with AI in 2 patients, allowing successful heart-only transplantation. Therapy with AI was discontinued after 1.4-0.4 years in 6 improved myocarditis and 3 cardiomyopathy patients without deterioration. In conclusion, prolonged AI and/or LS infusions in HF are safe and beneficial even in small infants, allowing stabilization and reasonable social and family life out of the hospital. It may provide precious time for heart transplantation or myocardial remodeling, improvement, and possible discontinuation even after long periods of support.
Collapse
Affiliation(s)
- Sotiria C Apostolopoulou
- Department of Pediatric Cardiology & Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, 356 Syngrou Ave, 176 74, Athens, Greece.
| | - George A Vagenakis
- Department of Pediatric Cardiology & Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, 356 Syngrou Ave, 176 74, Athens, Greece
| | - Alexandros Tsoutsinos
- Department of Pediatric Cardiology & Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, 356 Syngrou Ave, 176 74, Athens, Greece
| | - Felicia Kakava
- Department of Pediatric Cardiology & Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, 356 Syngrou Ave, 176 74, Athens, Greece
| | - Spyridon Rammos
- Department of Pediatric Cardiology & Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, 356 Syngrou Ave, 176 74, Athens, Greece
| |
Collapse
|
13
|
Miyamoto SD, Sucharov CC, Woulfe KC. Differential Response to Heart Failure Medications in Children. PROGRESS IN PEDIATRIC CARDIOLOGY 2018; 49:27-30. [PMID: 29962825 DOI: 10.1016/j.ppedcard.2018.01.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There have been many advances in the treatment of heart failure over the past several years. While these advancements have resulted in improved outcomes in adults with heart failure, these same treatments do not seem to be as efficacious in children with heart failure. Investigations of the failing pediatric heart suggest that there are unique phenotypic, pathologic and molecular differences that could influence how children with heart failure response to adult-based therapies. In this review, several recent studies and the potential implications of their findings on informing the future of the management of pediatric heart failure are discussed.
Collapse
Affiliation(s)
- Shelley D Miyamoto
- Division of Pediatric Cardiology, Department of Pediatrics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, 12700 E 19 Ave, Aurora, CO USA, 80045
| | - Carmen C Sucharov
- Division of Cardiology, Department of Medicine, University of Colorado Denver School of Medicine, 12700 E 19 Ave, Aurora, CO USA 80045
| | - Kathleen C Woulfe
- Division of Cardiology, Department of Medicine, University of Colorado Denver School of Medicine, 12700 E 19 Ave, Aurora, CO USA 80045
| |
Collapse
|
14
|
Urmaliya V, Franchelli G. A multidimensional sight on cardiac failure: uncovered from structural to molecular level. Heart Fail Rev 2018; 22:357-370. [PMID: 28474325 DOI: 10.1007/s10741-017-9610-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Heart failure is one of the leading causes of death, with high mortality rate within 5 years after diagnosis. Treatment and prognosis options for heart failure primarily targeted on hemodynamic and neurohumoral components that drive progressive deterioration of the heart. However, given the multifactorial background that eventually leads to the "phenotype" named heart failure, better insight into the various components may lead to personalized treatment opportunities. Indeed, currently used criteria to diagnose and/or classify heart failure are possibly too focused on phenotypic improvement rather than the molecular driver of the disease and could therefore be further refined by integrating the leap of molecular and cellular knowledge. The ambiguity of the ejection fraction-based classification criteria became evident with development of advanced molecular techniques and the dawn of omics disciplines which introduced the idea that disease is caused by a myriad of cellular and molecular processes rather than a single event or pathway. The fact that different signaling pathways may underlie similar clinical manifestations calls for a more holistic study of heart failure. In this context, the systems biology approach can offer a better understanding of how different components of a system are altered during disease and how they interact with each other, potentially leading to improved diagnosis and classification of this condition. This review is aimed at addressing heart failure through a multilayer approach that covers individually some of the anatomical, morphological, functional, and tissue aspects, with focus on cellular and subcellular features as an alternative insight into new therapeutic opportunities.
Collapse
Affiliation(s)
- Vijay Urmaliya
- Discovery Sciences, Janssen Research & Development, Beerse, Belgium.
| | | |
Collapse
|
15
|
Abstract
Milrinone is a phosphodiesterase 3 inhibitor with both positive inotropic and vasodilator properties. Administered as a continuous infusion, milrinone is indicated for the short-term treatment of patients with acute decompensated heart failure. Despite limited data supporting long-term milrinone therapy in adults with congestive heart failure, children managed as outpatients may benefit from continuous milrinone as a treatment for cardiac dysfunction, as a destination therapy for cardiac transplant, or as palliative therapy for cardiomyopathy. The aim of this article is to review the medical literature and describe a home infusion company's experience with pediatric outpatient milrinone therapy.
Collapse
|
16
|
Abstract
Milrinone is an inotropic drug used in a variety of clinical settings in adults and children. The efficacy of milrinone in pediatric low-cardiac output syndrome after cardiac surgery is reported. Its primary route of removal from the body is through the kidney as unchanged drug in the urine. Milrinone is not known to be efficiently removed by extracorporeal dialytic therapies and thus has the potential to cause serious adverse effects and potentially worsens renal function in patients experiencing acute kidney injury (AKI). AKI is an important public health issue that is associated with increased morbidity, mortality, and cost. It is a known risk factor for the development of chronic kidney disease. There are no specific therapies to mitigate AKI once it has developed, and interventions are focused on supportive care and dose adjustment of medications. Estimating glomerular filtration rate based on height and serum creatinine is the most commonly used clinical method for assessing kidney function and modification of medication doses. The purpose of this review is to discuss our current understanding of milrinone pharmacokinetics and pharmacodynamics in children with AKI and to describe the potential use of urinary biomarkers to guide therapeutic decision making for milrinone dosing.
Collapse
|
17
|
Advanced practice nursing in pediatric heart failure- therapeutics and models of care. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
18
|
Xue A, Dersch-Mills D, Tsang C, Greenway SC. Pharmacy Support of a Pediatric Patient Receiving Milrinone at Home. Can J Hosp Pharm 2016; 69:415-419. [PMID: 27826160 DOI: 10.4212/cjhp.v69i5.1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Ariel Xue
- , BScH, BScPharm, ACPR, is with Pharmacy Services, Alberta Health Services, Calgary, Alberta
| | - Deonne Dersch-Mills
- , BScPharm, ACPR, PharmD, is with Pharmacy Services, Alberta Health Services, Calgary, Alberta
| | - Clara Tsang
- , BScPharm, is with Pharmacy Services, Alberta Health Services, Calgary, Alberta
| | - Steven C Greenway
- , MSc, MD, FRCPC, is with the Departments of Paediatrics, of Cardiac Sciences, and of Biochemistry and Molecular Biology, University of Calgary, and is also with Alberta Health Services, Calgary, Alberta
| |
Collapse
|
19
|
Holley CL. The Challenges of Bedside-to-Bench Research in Pediatric Cardiology. J Card Fail 2016; 23:81-82. [PMID: 27697503 DOI: 10.1016/j.cardfail.2016.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 09/29/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Christopher L Holley
- Duke University School of Medicine, 2301 Erwin Road, DUMC Box 2647, Durham, North Carolina 27710.
| |
Collapse
|
20
|
Nakano SJ, Sucharov J, van Dusen R, Cecil M, Nunley K, Wickers S, Karimpur-Fard A, Stauffer BL, Miyamoto SD, Sucharov CC. Cardiac Adenylyl Cyclase and Phosphodiesterase Expression Profiles Vary by Age, Disease, and Chronic Phosphodiesterase Inhibitor Treatment. J Card Fail 2016; 23:72-80. [PMID: 27427220 DOI: 10.1016/j.cardfail.2016.07.429] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 07/05/2016] [Accepted: 07/12/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pediatric heart failure (HF) patients have a suboptimal response to traditional HF medications, although phosphodiesterase-3 inhibition (PDE3i) has been used with greater success than in the adult HF population. We hypothesized that molecular alterations specific to children with HF and HF etiology may affect response to treatment. METHODS AND RESULTS Adenylyl cyclase (AC) and phosphodiesterase (PDE) isoforms were quantified by means of quantitative real-time polymerase chain reaction in explanted myocardium from adults with dilated cardiomyopathy (DCM), children with DCM, and children with single-ventricle congenital heart disease of right ventricular morphology (SRV). AC and PDE expression profiles were uniquely regulated in each subject group and demonstratde distinct changes in response to chronic PDE3i. There was unique up-regulation of AC5 in adult DCM with PDE3i (fold change 2.415; P = .043), AC2 in pediatric DCM (fold change 2.396; P = .0067), and PDE1C in pediatric SRV (fold change 1.836; P = .032). Remarkably, PDE5A expression was consistently increased across all age and disease groups. CONCLUSIONS Unique regulation of AC and PDE isoforms supports a differential molecular adaptation to HF in children compared with adults, and may help identify mechanisms specific to the pathogenesis of pediatric HF. Greater understanding of these differences will help optimize medical therapies based on age and disease process.
Collapse
Affiliation(s)
- Stephanie J Nakano
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver, Aurora, Colorado
| | | | | | | | - Karin Nunley
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | | | | | - Brian L Stauffer
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado; Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado
| | - Shelley D Miyamoto
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver, Aurora, Colorado
| | - Carmen C Sucharov
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado.
| |
Collapse
|
21
|
Myocardial Response to Milrinone in Single Right Ventricle Heart Disease. J Pediatr 2016; 174:199-203.e5. [PMID: 27181939 PMCID: PMC4925285 DOI: 10.1016/j.jpeds.2016.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/02/2016] [Accepted: 04/05/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Empiric treatment with milrinone, a phosphodiesterase (PDE) 3 inhibitor, has become increasingly common in patients with single ventricle heart disease of right ventricular (RV) morphology (SRV); our objective was to characterize the myocardial response to PDE3 inhibition (PDE3i) in the pediatric population with SRV. STUDY DESIGN Cyclic adenosine monophosphate levels, PDE activity, and phosphorylated phospholamban (PLN) were determined in explanted human ventricular myocardium from nonfailing pediatric donors (n = 10) and pediatric patients transplanted secondary to SRV. Subjects with SRV were further classified by PDE3i treatment (n = 13 with PDE3i and n = 12 without PDE3i). RESULTS In comparison with nonfailing RV myocardium (n = 8), cyclic adenosine monophosphate levels are lower in patients with SRV treated with PDE3i (n = 12, P = .021). Chronic PDE3i does not alter total PDE or PDE3 activity in SRV myocardium. Compared with nonfailing RV myocardium, SRV myocardium (both with and without PDE3i) demonstrates equivalent phosphorylated PLN at the protein kinase A phosphorylation site. CONCLUSIONS As evidenced by preserved phosphorylated PLN, the molecular adaptation associated with SRV differs significantly from that demonstrated in pediatric heart failure because of dilated cardiomyopathy. These alterations support a pathophysiologically distinct mechanism of heart failure in pediatric patients with SRV, which has direct implications regarding the presumed response to PDE3i treatment in this population.
Collapse
|
22
|
Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Chronic Heart Failure. Pediatr Crit Care Med 2016; 17:S20-34. [PMID: 26945326 DOI: 10.1097/pcc.0000000000000624] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Heart failure is a serious complication that can occur in patients with a variety of congenital and acquired disorders including congenital heart disease, cardiomyopathy, and myocarditis. Furthermore, heart failure patients comprise an increasing number of ICU admissions. Thus, it is important for those caring for patients with critical cardiovascular disease to have a thorough understanding of the medications used for the treatment of heart failure. The aim of this review is to provide an overview, rationale, indications, and adverse effects of medications used in the treatment of chronic heart failure. DATA SOURCES PubMed, Medline, Cochrane Database of Systemic Reviews. STUDY SELECTION Studies were selected on their relevance for pediatric heart failure. When limited data on pediatric heart failure were available, studies in adult patients were selected. DATA EXTRACTION Relevant findings from studies were selected by the authors. DATA SYNTHESIS The rationale for the efficacy of most heart failure medications used in pediatric patients is extrapolated from studies in adult heart failure. Commonly used medications for chronic heart failure include β-receptor antagonists (e.g., carvedilol and metoprolol), and medications aimed at blocking the renin-angiotensin-aldosterone system (e.g., angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone receptor antagonists). In addition, diuretics are useful for symptoms of fluid overload. For patients with impaired perfusion, inotropic agents are useful acutely, but may be associated with worse outcomes when used chronically. Newer medications that have been recently approved in adults (e.g., serelaxin, ivabradine, and neprilysin inhibitor [angiotensin receptor blocker]) may prove to be important in pediatric heart failure. CONCLUSIONS Heart failure patients are in an important population of critically ill children. The pharmacologic approach to these patients is aimed at treating symptoms of congestion and/or poor perfusion and improving long-term outcomes.
Collapse
|
23
|
Jean-St-Michel E, Chetan D, Schwartz SM, Van Arsdell GS, Floh AA, Honjo O, Conway J. Outcomes in Patients with Persistent Ventricular Dysfunction After Stage I Palliation for Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2016; 37:239-47. [PMID: 26396116 DOI: 10.1007/s00246-015-1268-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 09/09/2015] [Indexed: 10/23/2022]
Abstract
We sought to describe the clinical course for patients with hypoplastic left heart syndrome and persistent ventricular dysfunction and identify risk factors for death or transplantation before stage II palliation. 138 children undergoing stage I palliation from 2004 to 2011 were reviewed. Twenty-two (16 %) patients (seven Hybrid, 15 Norwood) with two consecutive echocardiograms reporting at least moderate dysfunction were included and compared to case-matched controls. Eleven of the 22 patients with dysfunction (50 %) underwent stage II, seven (32 %) were transplanted, and four (18 %) died prior to stage II. Of the patients who survived to hospital discharge (n = 17) following stage 1, 14 (82 %) required readmission for heart failure (HF) compared to only two (10 %) for controls (p < 0.001). Among patients with ventricular dysfunction, there was an increased use of ACE inhibitors or beta-blockers (82 vs. 25 %; p = 0.001), inotropes (71 vs. 15 %; p = 0.001), ventilation (58 vs. 10 %; p = 0.001), and ECMO (29 vs. 0 %; p = 0.014) for HF management post-discharge when compared to controls. There was a lower heart transplant-free survival at 7 months in patients with dysfunction compared to controls (50.6 vs. 90.9 %; p = 0.040). ECMO support (p = 0.001) and duration of inotropic support (p = 0.04) were significantly associated with death or transplantation before stage II palliation. Patients with ventricular dysfunction received more HF management and related admissions. Longer inotropic support should prompt discussion regarding alternative treatment strategies given its association with death or transplant.
Collapse
Affiliation(s)
- Emilie Jean-St-Michel
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
| | - Devin Chetan
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Steven M Schwartz
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Glen S Van Arsdell
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alejandro A Floh
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jennifer Conway
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
24
|
Silvetti S, Nieminen MS. Repeated or intermittent levosimendan treatment in advanced heart failure: An updated meta-analysis. Int J Cardiol 2016; 202:138-43. [DOI: 10.1016/j.ijcard.2015.08.188] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 08/21/2015] [Indexed: 11/29/2022]
|
25
|
Abstract
Acute heart failure is a common and serious complication of congenital and acquired heart disease, and it is associated with significant morbidity, mortality, and costs. When a patient is admitted to the hospital with acute heart failure, there are several important goals for the hospital admission, including maintaining adequate perfusion, establishing the underlying aetiology for the heart failure, patient and family education, and discharge from the hospital in a stable condition. The pathway to home discharge is variable and may include inotropic therapy, mechanical circulatory support, and/or heart transplantation. This review will cover the epidemiology, presentation, and management of acute heart failure in children.
Collapse
|
26
|
Birnbaum BF, Simpson KE, Boschert TA, Zheng J, Wallendorf MJ, Schechtman K, Canter CE. Intravenous home inotropic use is safe in pediatric patients awaiting transplantation. Circ Heart Fail 2014; 8:64-70. [PMID: 25472966 DOI: 10.1161/circheartfailure.114.001528] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Intravenous inotropic therapy can be used to support children awaiting heart transplantation. Although use of this therapy is discouraged in adults because of poor outcomes, its use in children, particularly outpatient, has had limited evaluation. We aimed to evaluate the safety and efficacy of this practice. METHODS AND RESULTS A retrospective analysis of an intent to treat protocol was completed on United Network for Organ Sharing status 1A patients discharged on inotropic therapy from 1999 until 2012. Intravenous inotropic therapy was initiated for cardiac symptoms not amenable to oral therapy. Patients who were not status 1A or required >1 inotrope were excluded. Efficacy was analyzed by time to first event: transplantation; readmission until transplantation; improvement leading to inotrope withdrawal; or death. Safety included analysis of infection rates, line malfunctions, temporary hospitalization, neurological events, and arrhythmias. One hundred six patients met inclusion criteria. The mean age was 10.1±6.4 years, 47% of patients had congenital heart disease, and 80% of these patients had single ventricle physiology. In patients without congenital heart disease, 53% had dilated cardiomyopathy, 91% of patients received milrinone, 85% of patients underwent transplantation, 8% of patients successfully weaned from support as outpatients, whereas 6% died. Fifty percent of patients were readmitted before transplantation or weaning from support, of which 64% required only 1 readmission. The majority of readmissions were for heart failure. CONCLUSIONS Outpatient intravenous inotropic therapy can be safely used as a bridge to transplantation in pediatric patients. A minority of patients can discontinue inotropic therapy because of clinical improvement.
Collapse
Affiliation(s)
- Brian F Birnbaum
- From the Washington University School of Medicine, Department of Pediatrics, Division of Cardiology, St. Louis, MO (B.F.B., K.E.S., C.E.C.); St. Louis Children's Hospital, MO (B.F.B., K.E.S., T.A.B., C.E.C.); and Washington University School of Medicine, Division of Biostatistics, St. Louis, MO (J.Z., M.J.W., K.S.).
| | - Kathleen E Simpson
- From the Washington University School of Medicine, Department of Pediatrics, Division of Cardiology, St. Louis, MO (B.F.B., K.E.S., C.E.C.); St. Louis Children's Hospital, MO (B.F.B., K.E.S., T.A.B., C.E.C.); and Washington University School of Medicine, Division of Biostatistics, St. Louis, MO (J.Z., M.J.W., K.S.)
| | - Traci A Boschert
- From the Washington University School of Medicine, Department of Pediatrics, Division of Cardiology, St. Louis, MO (B.F.B., K.E.S., C.E.C.); St. Louis Children's Hospital, MO (B.F.B., K.E.S., T.A.B., C.E.C.); and Washington University School of Medicine, Division of Biostatistics, St. Louis, MO (J.Z., M.J.W., K.S.)
| | - Jie Zheng
- From the Washington University School of Medicine, Department of Pediatrics, Division of Cardiology, St. Louis, MO (B.F.B., K.E.S., C.E.C.); St. Louis Children's Hospital, MO (B.F.B., K.E.S., T.A.B., C.E.C.); and Washington University School of Medicine, Division of Biostatistics, St. Louis, MO (J.Z., M.J.W., K.S.)
| | - Michael J Wallendorf
- From the Washington University School of Medicine, Department of Pediatrics, Division of Cardiology, St. Louis, MO (B.F.B., K.E.S., C.E.C.); St. Louis Children's Hospital, MO (B.F.B., K.E.S., T.A.B., C.E.C.); and Washington University School of Medicine, Division of Biostatistics, St. Louis, MO (J.Z., M.J.W., K.S.)
| | - Kenneth Schechtman
- From the Washington University School of Medicine, Department of Pediatrics, Division of Cardiology, St. Louis, MO (B.F.B., K.E.S., C.E.C.); St. Louis Children's Hospital, MO (B.F.B., K.E.S., T.A.B., C.E.C.); and Washington University School of Medicine, Division of Biostatistics, St. Louis, MO (J.Z., M.J.W., K.S.)
| | - Charles E Canter
- From the Washington University School of Medicine, Department of Pediatrics, Division of Cardiology, St. Louis, MO (B.F.B., K.E.S., C.E.C.); St. Louis Children's Hospital, MO (B.F.B., K.E.S., T.A.B., C.E.C.); and Washington University School of Medicine, Division of Biostatistics, St. Louis, MO (J.Z., M.J.W., K.S.)
| |
Collapse
|
27
|
Nakano SJ, Miyamoto SD, Movsesian M, Nelson P, Stauffer BL, Sucharov CC. Age-related differences in phosphodiesterase activity and effects of chronic phosphodiesterase inhibition in idiopathic dilated cardiomyopathy. Circ Heart Fail 2014; 8:57-63. [PMID: 25278000 DOI: 10.1161/circheartfailure.114.001218] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Despite the application of proven adult heart failure therapies to children with idiopathic dilated cardiomyopathy (IDC), prognosis remains poor. Clinical experience with phosphodiesterase 3 inhibitors (PDE3i) in pediatric patients with IDC, however, demonstrates improved heart failure symptoms without the increased incidence of sudden death seen in adults treated with PDE3i. We sought to determine age-related differences in PDE activity and associated intracellular signaling responsible for the efficacy and relative safety of chronic PDE3i in pediatric heart failure. METHODS AND RESULTS cAMP levels, PDE activity, and phospholamban phosphorylation (pPLB) were determined in explanted human left ventricular myocardium (pediatric n=41; adult n=88). Adults and children with IDC (not treated with PDE3i) had lower cAMP and pPLB compared with nonfailing controls. In contrast to their adult counterparts, pediatric IDC patients chronically treated with PDE3i had elevated cAMP (P=0.0403) and pPLB (P=0.0119). In addition, total PDE- and PDE3-specific activities were not altered in pediatric IDC patients on PDE3i, whereas adult IDC patients on PDE3i demonstrated higher total PDE-specific (74.6±13.8 pmol/mg per minute) and PDE3-specific (48.2±15.9 pmol/mg per minute) activities in comparison with those of nonfailing controls (59.5±14.4 and 35.5±12.8 pmol/mg per minute, respectively). CONCLUSIONS Elevated cAMP and higher pPLB may contribute to sustained hemodynamic benefits in pediatric IDC patients treated with PDE3i. In contrast, higher total PDE and PDE3 activities in adult IDC patients treated with PDE3i may perpetuate lower myocardial cAMP and pPLB levels, limiting the potential benefits of PDE3i therapy.
Collapse
Affiliation(s)
- Stephanie J Nakano
- From the Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora (S.J.N., S.D.M.); Cardiology Section, Veterans Affairs Salt Lake City Health Care System and the Departments of Internal Medicine (Cardiology) and Pharmacology, University of Utah School of Medicine (M.M.); Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (P.N., B.L.S., C.C.S.); and Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, CO (B.L.S.)
| | - Shelley D Miyamoto
- From the Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora (S.J.N., S.D.M.); Cardiology Section, Veterans Affairs Salt Lake City Health Care System and the Departments of Internal Medicine (Cardiology) and Pharmacology, University of Utah School of Medicine (M.M.); Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (P.N., B.L.S., C.C.S.); and Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, CO (B.L.S.)
| | - Matthew Movsesian
- From the Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora (S.J.N., S.D.M.); Cardiology Section, Veterans Affairs Salt Lake City Health Care System and the Departments of Internal Medicine (Cardiology) and Pharmacology, University of Utah School of Medicine (M.M.); Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (P.N., B.L.S., C.C.S.); and Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, CO (B.L.S.)
| | - Penny Nelson
- From the Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora (S.J.N., S.D.M.); Cardiology Section, Veterans Affairs Salt Lake City Health Care System and the Departments of Internal Medicine (Cardiology) and Pharmacology, University of Utah School of Medicine (M.M.); Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (P.N., B.L.S., C.C.S.); and Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, CO (B.L.S.)
| | - Brian L Stauffer
- From the Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora (S.J.N., S.D.M.); Cardiology Section, Veterans Affairs Salt Lake City Health Care System and the Departments of Internal Medicine (Cardiology) and Pharmacology, University of Utah School of Medicine (M.M.); Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (P.N., B.L.S., C.C.S.); and Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, CO (B.L.S.)
| | - Carmen C Sucharov
- From the Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora (S.J.N., S.D.M.); Cardiology Section, Veterans Affairs Salt Lake City Health Care System and the Departments of Internal Medicine (Cardiology) and Pharmacology, University of Utah School of Medicine (M.M.); Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (P.N., B.L.S., C.C.S.); and Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, CO (B.L.S.).
| |
Collapse
|
28
|
Lee J, Kim GB, Kwon HW, Kwon BS, Bae EJ, Noh CI, Lim HG, Kim WH, Lee JR, Kim YJ. Safety and efficacy of the off-label use of milrinone in pediatric patients with heart diseases. Korean Circ J 2014; 44:320-7. [PMID: 25278985 PMCID: PMC4180609 DOI: 10.4070/kcj.2014.44.5.320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/07/2014] [Accepted: 08/19/2014] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives Milrinone is often used in children to treat acute heart failure and prevent low cardiac output syndrome after cardiac surgery. Due to the lack of studies on the long-term milrinone use in children, the objective of this study was to assess the safety and efficacy of the current patterns of milrinone use for ≥3 days in infants and children with heart diseases. Subjects and Methods We retrospectively reviewed the medical records of patients aged <13 years who received milrinone for ≥3 days from January 2005 to December 2012. Patients' characteristics including age, sex, height, weight, and body surface area were recorded. The following parameters were analyzed to identify the clinical application of milrinone: initial infusion rate, maintenance continuous infusion rate, total duration of milrinone therapy, and concomitantly infused inotropes. The safety of milrinone was determined based on the occurrence of adverse events such as hypotension, arrhythmia, chest pain, headache, hypokalemia, and thrombocytopenia. Results We assessed 730 admissions (684 patients) during this period. Ventricular septal defects were the most common diagnosis (42.4%) in these patients. Milrinone was primarily used after cardiac surgery in 715 admissions (97.9%). The duration of milrinone treatment varied from 3 to 64.4 days (≥7 days in 149 admissions). Ejection fraction and fractional shortening of the left ventricle improved in patients receiving milrinone after cardiac surgery. Dose reduction of milrinone due to hypotension occurred in only 4 admissions (0.5%). Although diverse arrhythmias occurred in 75 admissions (10.3%), modification of milrinone infusion to manage arrhythmia occurred in only 3 admissions (0.4%). Multivariate analysis indicated that the development of arrhythmia was not influenced by the pattern of milrinone use. Conclusion Milrinone was generally administered for ≥3 days in children with heart diseases. The use of milrinone for ≥3 days was effective in preventing low cardiac output after cardiac surgery when combined with other inotropes, suggesting that milrinone could be safely employed in pediatric patients with heart diseases.
Collapse
Affiliation(s)
- Joowon Lee
- 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
| | - Hye Won Kwon
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, 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
| | - Hong Gook Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Woong Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Jeong Ryul Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Yong Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Korea
| |
Collapse
|
29
|
Al Kindi H, Paul A, You Z, Nepotchatykh O, Schwertani A, Prakash S, Shum-Tim D. Sustained release of milrinone delivered via microparticles in a rodent model of myocardial infarction. J Thorac Cardiovasc Surg 2014; 148:2316-23. [PMID: 25175952 DOI: 10.1016/j.jtcvs.2014.07.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 06/21/2014] [Accepted: 07/06/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of the present study was to construct a new drug delivery system for milrinone using microparticles. This novel technology enhances drug bioavailability and decreases toxicity, with future implications for the treatment of end-stage heart failure. METHODS Polylactic-co-glycolic acid microparticles (PLGA-MPs) loaded with milrinone were prepared using a double emulsion-solvent evaporation technique. In vitro release kinetics was evaluated at physiologic conditions. A total of 24 female Lewis rats underwent left coronary artery ligation. One week after ligation, all rats were randomized to 1 of 3 groups (n=8 per group). Group I received an intravenous injection of PLGA-MPs alone; group II, a bolus intravenous injection of milrinone; and group III an intravenous injection of milrinone-PLGA-MPs. All injections were administrated slowly by way of the tail vein over 10 minutes. Transthoracic echocardiography, noninvasive heart rate monitoring, and blood pressure measurements were performed at different predetermined intervals before and for 24 hours after the injection. All rats survived for 24 hours and were then killed by euthanasia. Serum plasma was taken for cytokine assays and determination of milrinone levels using high-performance liquid chromatography. RESULTS Group III had a significantly greater left ventricular ejection fraction at 90 minutes and 3, 6, and 12 hours after treatment compared with the other groups. The milrinone plasma level was significantly greater in group III than in the other groups (group I, 0 ng/mL; group II, 1.7±2.4 ng/mL; group III, 9.1±2.2 ng/mL; P<.05). The intercellular adhesion molecule and cytokine-induced neutrophil chemoattractant-1 levels were significantly lower in group III than in the other 2 groups (P<.05). CONCLUSIONS Drug encapsulation using microparticles can prolong the effects of milrinone. We propose a new strategy for future drug delivery in patients with end-stage heart failure.
Collapse
Affiliation(s)
- Hamood Al Kindi
- Division of Cardiothoracic Surgery and Surgical Research, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Arghya Paul
- Department of Chemical and Petroleum Engineering, University of Kansas, Lawrence, Kan
| | - Zhipeng You
- Division of Cardiology, Montreal General Hospital, Montreal, Quebec, Canada
| | - Oleg Nepotchatykh
- Department of Chemistry, McGill University, Montreal, Quebec, Canada
| | - Adel Schwertani
- Division of Cardiology, Montreal General Hospital, Montreal, Quebec, Canada
| | - Satya Prakash
- Biomedical Technology and Cell Therapy Research Laboratory, Department of Biomedical Engineering, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Dominique Shum-Tim
- Division of Cardiothoracic Surgery and Surgical Research, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada.
| |
Collapse
|
30
|
Nieminen M, Altenberger J, Ben-Gal T, Böhmer A, Comin-Colet J, Dickstein K, Édes I, Fedele F, Fonseca C, García-González M, Giannakoulas G, Iakobishvili Z, Jääskeläinen P, Karavidas A, Kettner J, Kivikko M, Lund L, Matskeplishvili S, Metra M, Morandi F, Oliva F, Parkhomenko A, Parissis J, Pollesello P, Pölzl G, Schwinger R, Segovia J, Seidel M, Vrtovec B, Wikström G. Repetitive use of levosimendan for treatment of chronic advanced heart failure: Clinical evidence, practical considerations, and perspectives: An expert panel consensus. Int J Cardiol 2014; 174:360-7. [DOI: 10.1016/j.ijcard.2014.04.111] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 03/14/2014] [Accepted: 04/09/2014] [Indexed: 01/19/2023]
|
31
|
Affiliation(s)
- Joseph W. Rossano
- From the Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA; and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Robert E. Shaddy
- From the Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA; and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
32
|
Stauffer BL, Russell G, Nunley K, Miyamoto SD, Sucharov CC. miRNA expression in pediatric failing human heart. J Mol Cell Cardiol 2013; 57:43-6. [PMID: 23333438 PMCID: PMC3694420 DOI: 10.1016/j.yjmcc.2013.01.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 01/04/2013] [Accepted: 01/09/2013] [Indexed: 12/16/2022]
Abstract
miRNAs are short regulatory RNAs that can regulate gene expression through interacting with the 3'UTR of target mRNAs. Although the role of miRNAs has been extensively studied in adult human and animal models of heart disease, nothing is known about their expression in pediatric heart failure patients. Different than adults with heart failure, pediatric patients respond well to phosphodiesterase inhibitor (PDEi) treatment, which is safe in the outpatient setting, results in fewer heart failure emergency department visits, fewer cardiac hospital admissions and improved NYHA classification. We have recently shown that pediatric heart failure patients display a unique molecular profile that is different from adults with heart failure. In this study we show for the first time that pediatric heart failure patients display a unique miRNA profile, and that expression of some miRNAs correlate with response to PDEi treatment. Moreover, we show that expression of Smad4, a potential target for PDEi-regulated miRNAs, is normalized in PDEi-treated patients. Since miRNAs may be used as therapy for human heart failure, our results underscore the importance of defining the molecular characteristics of pediatric heart failure patients, so age-appropriate therapy can be designed for this population.
Collapse
Affiliation(s)
- Brian L. Stauffer
- University of Colorado, Denver Department of Medicine/Division of Cardiology
- Division of Cardiology, Denver Health and Hospital Authority, Denver, Colorado
| | - Gloria Russell
- Pontificia Universidad Católica Madre y Maestra, Departamento de Medicina, Santiago, República Dominicana
| | - Karin Nunley
- University of Colorado, Denver Department of Medicine/Division of Cardiology
| | - Shelley D. Miyamoto
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Carmen C. Sucharov
- University of Colorado, Denver Department of Medicine/Division of Cardiology
| |
Collapse
|
33
|
|
34
|
|
35
|
Gazit AZ, Oren PP. Pharmaceutical management of decompensated heart failure syndrome in children: current state of the art and a new approach. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 11:403-9. [PMID: 19846039 DOI: 10.1007/s11936-009-0042-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Prompt initiation of appropriate and intensive treatment in children with decompensated heart failure is crucial to avoid irreversible end-organ dysfunction. Initial management of these children includes transfer to the pediatric cardiac intensive care unit, basic hemodynamic monitoring, and establishment of intravenous access. Inotropic support should be instituted peripherally before obtaining central venous and arterial access. The team should be prepared for emergent intubation and initiation of mechanical circulatory support. Two experienced physicians should work together to obtain vascular access and manage sedation, airway control, and cardiovascular support. Acute heart failure syndrome in children may be related to cardiomyopathy, myocarditis, congenital heart disease, and acute rejection post heart transplantation. Each of these causes requires a different approach. Fulminant myocarditis may lead to severe morbidity and requires intensive support, although its outcome is considered to be good. Acute heart failure related to newly diagnosed dilated cardiomyopathy may represent end-stage heart failure; therefore, long-term mechanical circulatory support and heart transplantation may be considered to avoid other end-organ dysfunction. Hypertrophic cardiomyopathy may lead to acute decompensation due to 1) left ventricular outflow obstruction, 2) restrictive physiology leading to pulmonary hypertension, or 3) myocardial ischemia associated with coronary artery bridging. Decompensated heart failure associated with congenital heart disease usually represents end-stage heart failure and requires thorough evaluation for heart transplantation. Children with single-ventricle physiology who develop decompensated heart failure after a Fontan procedure are not candidates for mechanical circulatory support and therefore may not survive to heart transplantation. Acute heart failure due to posttransplantation acute rejection requires aggressive antirejection treatment, which places these patients at significant risk for overwhelming opportunistic infections. In our opinion, mechanical circulatory support should be initiated early in children who present with end-stage heart failure associated with hemodynamic instability to avoid end-organ damage.
Collapse
Affiliation(s)
- Avihu Z Gazit
- Avihu Z. Gazit, MD Pediatric Critical Care, Washington University School of Medicine, St. Louis Children's Hospital, Campus Box 8116-NWT, St. Louis, MO 63110, USA.
| | | |
Collapse
|
36
|
Gazit AZ, Huddleston CB, Checchia PA, Fehr J, Pezzella AT. Care of the pediatric cardiac surgery patient--part 2. Curr Probl Surg 2010; 47:261-376. [PMID: 20207257 DOI: 10.1067/j.cpsurg.2009.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Avihu Z Gazit
- Pediatric Critical Care Medicine and Cardiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | | | | |
Collapse
|
37
|
McMahon CJ, Murchan H, Prendiville T, Burch M. Long-term support with milrinone prior to cardiac transplantation in a neonate with left ventricular noncompaction cardiomyopathy. Pediatr Cardiol 2007; 28:317-8. [PMID: 17551772 DOI: 10.1007/s00246-007-0020-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Accepted: 03/17/2007] [Indexed: 11/27/2022]
Abstract
A 2-week-old female infant presented with acute decompensated left ventricular failure. Echocardiography diagnosed left ventricular noncompaction cardiomyopathy with dilated phenotype and a left ventricular shortening fraction <10%. The infant was mechanically ventilated for 2 weeks and then successfully extubated. She was maintained on intravenous milrinone for 6 months until she underwent successful orthotopic heart transplantation. Young children can be supported with inotropes for prolonged periods while awaiting heart transplantation.
Collapse
Affiliation(s)
- C J McMahon
- Department of Paediatric Cardiology, Heart Failure Unit, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Ireland.
| | | | | | | |
Collapse
|
38
|
Berg AM, Snell L, Mahle WT. Home Inotropic Therapy in Children. J Heart Lung Transplant 2007; 26:453-7. [PMID: 17449413 DOI: 10.1016/j.healun.2007.02.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Revised: 01/30/2007] [Accepted: 02/03/2007] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Inotropic therapy is a well-established practice for children with advanced congestive heart failure (CHF). Traditionally, children have been maintained on inotropic therapy in the hospital under close, monitored supervision. Changes to UNOS listing criteria now allow patients awaiting heart transplantation to be discharged to home yet maintain 1B status. In adults, home inotropic therapy has been shown to be a safe and cost-effective bridge to transplantation. To date, there are limited data on the use of home inotropic therapy in children. METHODS We reviewed the safety and efficacy of continuous ambulatory home inotropic therapy in children. Data were obtained from a single institution from January 2000 to January 2007. RESULTS There were 14 pediatric patients with end-stage CHF, who received home intravenous inotropic therapy. The indications for home inotropic therapy included palliative care (n = 8) and awaiting heart transplantation (n = 6). Patients ranged in age from 6 to 18 years (median 14.5 years). The majority of subjects (n = 11) received milrinone at a dose of 0.5 to 1.0 mug/kg/min, 2 received dobutamine at 5 mug/kg/min, and 1 received both agents. Duration of therapy ranged from 14 to 476 days (median 68 days). There were 26 hospital re-admissions and 4 suspected catheter infections. No unexpected deaths or pump failures occurred. CONCLUSIONS Based on this initial review, continuous home inotropic therapy in children with CHF is safe with few complications. Home inotropic therapy may result in substantial cost-savings and improve family dynamics by avoiding prolonged hospitalization.
Collapse
Affiliation(s)
- Alexandria M Berg
- Sibley Heart Transplant Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia 30322, USA
| | | | | |
Collapse
|