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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.
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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.
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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
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Medical Therapies for Heart Failure in Hypoplastic Left Heart Syndrome. J Cardiovasc Dev Dis 2022; 9:jcdd9050152. [PMID: 35621863 PMCID: PMC9143150 DOI: 10.3390/jcdd9050152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 02/05/2023] Open
Abstract
Significant surgical and medical advances over the past several decades have resulted in a growing number of infants and children surviving with hypoplastic left heart syndrome (HLHS) and other congenital heart defects associated with a single systemic right ventricle (RV). However, cardiac dysfunction and ultimately heart failure (HF) remain the most common cause of death and indication for transplantation in this population. Moreover, while early recognition and treatment of single ventricle-related complications are essential to improving outcomes, there are no proven therapeutic strategies for single systemic RV HF in the pediatric population. Importantly, prototypical adult HF therapies have been relatively ineffective in mitigating the need for cardiac transplantation in HLHS, likely due to several unique attributes of the failing HLHS myocardium. Here, we discuss the most commonly used medical therapies for the treatment of HF symptoms in HLHS and other single systemic RV patients. Additionally, we provide an overview of potential novel therapies for systemic ventricular failure in the HLHS and related populations based on fundamental science, pre-clinical, clinical, and observational studies in the current literature.
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Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
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Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
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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.
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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.
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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.
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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
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DiFusco LA, Saylor JL, Schell KA. Maternal experiences of caring for a child with a ventricular assist device. Pediatr Transplant 2020; 24:e13620. [PMID: 31815350 DOI: 10.1111/petr.13620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 10/19/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Abstract
The purpose of this study was to gain a deeper understanding of maternal experiences of caring for their child with a VAD at home as a bridge to transplant. A descriptive, qualitative study was conducted via telephone-recorded guided interviews. Participants were caring for or had a child with a VAD between 4 and 16 years old. Data collection occurred over a 12-month period. Using the snowball sampling technique, a purposeful sample of mothers (n = 6) was consented and completed the interview. The data were analyzed using an iterative process of thematic analysis. Five themes emerged: physical modifications, the loss of independence, the emotional rollercoaster, support from others, and transitions on and off the device. We introduced new evidence about sleep, contraception, and heart transplantation, and how VAD therapy impacts childhood development. The mean duration of VAD support was 263 ± 170 days. Five children had heart transplants by the time of interview. To the best of our knowledge, this is the first qualitative study in the US that explores maternal experiences of caring for a child who is living at home with a VAD. VAD therapy is a novel approach to managing advanced heart failure among children and presents unique challenges when caring for them at home. Results provide insight into the education, physical environment, and support needed by parents.
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Affiliation(s)
- Leigh Ann DiFusco
- The University of Delaware School of Nursing, Newark, DE, USA.,The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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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.
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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
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Risk-Taking Behaviors in Adolescents With Chronic Cardiac Conditions: A Scoping Review. J Pediatr Nurs 2019; 48:98-105. [PMID: 31369964 DOI: 10.1016/j.pedn.2019.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/17/2019] [Accepted: 07/19/2019] [Indexed: 12/28/2022]
Abstract
PROBLEM Advances in treatment and therapy for children with chronic cardiac conditions have extended their life expectancy. Risk-taking behavior among adolescents requires further exploration. Researchers conducted a scoping review to address a literature gap specific to risk-taking behavior among adolescents with chronic cardiac conditions. ELIGIBILITY CRITERIA Sources were limited to (1) human subjects, (2) English language or translatable to English, (3) adolescents without age restrictions, (4) all research designs and (5) presence of a chronic cardiac condition. SAMPLE Searches of six electronic databases (CINAHL Plus Full Text, PubMed, Web of Knowledge, Scopus, ProQuest and Grey Literature Report) were conducted to verify the empirical literature between 1975 and 2018. Seventeen sources were included in this review. RESULTS Among the 17 sources, 12 sources examined risk-taking behavior by self-report among adolescents with chronic cardiac conditions. Tobacco, alcohol and/or other drug use and physical inactivity were the most prevalent risk-taking behaviors identified through this review. CONCLUSIONS Findings from this scoping review describe the types of risk-taking behaviors that adolescents with chronic cardiac conditions are engaging in, highlight similarities when compared to other types of chronic conditions, and serve as a foundation for future research among this population. IMPLICATIONS Discussion of risk-taking behaviors should be integrated into each healthcare encounter beginning in early adolescence and continuing through transition to adulthood and adult health care. Qualitative research studies may serve as an effective method by which to explore risk-taking behavior among adolescents with chronic cardiac conditions in greater detail.
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10
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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.
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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
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11
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Implementation of Smart Pump Technology With Home Infusion Providers: An Assessment of Clinician Workflow and Patient Satisfaction. JOURNAL OF INFUSION NURSING 2019; 41:344-349. [PMID: 30399070 PMCID: PMC6237252 DOI: 10.1097/nan.0000000000000302] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
While hospitals have adopted smart pump technology (SPT) featuring drug libraries and medication safety software, most home infusion providers (HIPs) continue to use traditional infusion pumps that don't offer drug libraries or medication safety software. As infusion delivery is moving from the hospital to the home, the purpose of this study was to determine whether SPT was a feasible alternative at both a hospital-based and a rural HIP. HIP personnel were trained on an ambulatory infusion pump. Patients requiring home infusion used the pump and recorded daily pump interactions for 5 to 7 days. After the creation of a drug library, clinicians felt comfortable programming pumps after 7 uses. Patients reported 100% overall satisfaction, and the majority of alarms were resolved without contacting the HIP. Ambulatory SPT can be implemented successfully by HIPs and can be used effectively by patients.
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12
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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: 6] [Impact Index Per Article: 1.0] [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.
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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
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13
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Nanayakkara S, Mak V, Crannitch K, Byrne M, Kaye DM. Extended Release Oral Milrinone, CRD-102, for Advanced Heart Failure. Am J Cardiol 2018; 122:1017-1020. [PMID: 30064857 DOI: 10.1016/j.amjcard.2018.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/29/2018] [Accepted: 06/01/2018] [Indexed: 10/28/2022]
Abstract
Although heart transplantation and mechanical circulatory support are effective therapies for patients with advanced heart failure (HF), many patients are ineligible due to co-morbidities. Continuous home intravenous with positive inotropes such as milrinone are used in these patients to improve quality of life. We hypothesized that, unlike previous studies with oral milrinone, a slow-release formulation that provides stable lower plasma levels may be better tolerated and provide symptomatic benefit. Accordingly, we developed an extended release milrinone formulation (CRD-102) and evaluated its effects in 26 patients with no-option Stage D HF. One month after open-label therapy there were significant improvements in NYHA class, Minnesota Living with Heart Failure score and 6-minute walk distance. There was no evidence of hypotension or increased arrhythmic burden. In conclusion, the present study demonstrates evidence of beneficial actions of extended release milrinone in advanced HF. Longer-term randomized clinical trial data are required.
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14
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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.
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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
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15
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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.
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16
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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.
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17
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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]
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18
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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
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19
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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.
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20
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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.
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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.
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21
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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.
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22
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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.
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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
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23
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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.
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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.)
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24
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Wittlieb-Weber CA, Lin KY, Zaoutis TE, O'Connor MJ, Gerald K, Paridon SM, Shaddy RE, Rossano JW. Pediatric versus adult cardiomyopathy and heart failure-related hospitalizations: a value-based analysis. J Card Fail 2014; 21:76-82. [PMID: 25451708 DOI: 10.1016/j.cardfail.2014.10.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 10/14/2014] [Accepted: 10/15/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Value-based health care is a proposed driver for reimbursement under the Affordable Care Act, with value broadly defined as outcomes divided by cost. Data on value-based health care in pediatric heart failure are scarce. METHODS AND RESULTS A retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database and Nationwide Inpatient Sample was performed for pediatric and adult cardiomyopathy and heart failure-related hospitalizations. The study included 5,689 pediatric and 473,416 adult hospitalizations. Pediatric cardiomyopathy and heart failure hospitalizations were significantly longer than adult hospitalizations (mean ± SE 16.2 ± 0.7 days vs 6.8 ± 0.1 days; P < .001). Overall mortality was greater for pediatric hospitalizations (7.7% vs 5.6%; P < .001), although it decreased over time for both pediatric and adult hospitalizations. Charges were greater for pediatric hospitalizations, both overall ($116,483 ± $5,735 vs $40,662 ± $1,419; P < .001) and for all years evaluated. CONCLUSIONS In a value-based model, pediatric cardiomyopathy and heart failure-related hospitalizations are associated with worse outcomes and greater charges than adult hospitalizations. More research is needed to understand the cost effectiveness of pediatric heart failure treatment and to reduce the burden on the health care system.
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Affiliation(s)
| | - Kimberly Y Lin
- Department of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Theoklis E Zaoutis
- Department of Pediatric Infectious Disease, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J O'Connor
- Department of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Stephen M Paridon
- Department of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert E Shaddy
- Department of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph W Rossano
- Department of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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25
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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.
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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.).
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The International Society for Heart and Lung Transplantation Guidelines for the management of pediatric heart failure: Executive summary. J Heart Lung Transplant 2014; 33:888-909. [DOI: 10.1016/j.healun.2014.06.002] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 06/04/2014] [Indexed: 01/11/2023] Open
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Abstract
There are many ways to add to children's quality of life within the hospital environment. Inpatient settings offer both opportunities and challenges with respect to providing care to children with life-threatening illnesses. The barriers to pediatric palliative care (PPC) on hospital wards, as with those in other settings, frequently stem from misconceptions. However, some barriers are intensified by characteristics of acute inpatient centers. Yet some characteristics of the inpatient setting, including the availability of human resources and unique interventions, offer creative ways to ease distress and improve quality of life for children and their families.
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Affiliation(s)
- Adam Rapoport
- Paediatric Advanced Care Team (PACT), The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Kevin Weingarten
- Paediatric Advanced Care Team (PACT), The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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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
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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.
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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.
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Abstract
The management of heart failure in children is becoming a specialized discipline within pediatric cardiology. Unlike the treatment of heart failure in adults, for which an extensive body of literature supports current treatment regimens, management of heart failure in children is largely guided by extrapolation from adult studies and expert opinion. This review focuses on the current state-of-the-art with respect to the outpatient management of heart failure in children.
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Abstract
OBJECTIVE To describe the clinical course of a group of patients who received a rotating inotrope regimen, including levosimendan, for decompensated congestive heart failure. DESIGN Case series. SETTING Pediatric intensive care unit in a tertiary care children's hospital. PATIENTS Nine pediatric patients with severe, decompensated heart failure. INTERVENTION The study patients received a rotating inotrope regimen, including levosimendan, dobutamine, and, in some cases, milrinone. MEASUREMENTS AND MAIN RESULTS Six patients were weaned from positive-pressure ventilation. Eight patients were discharged from the intensive care unit, and seven survived to hospital discharge. Two patients were successfully bridged to orthotopic cardiac transplantation. The therapies were generally well tolerated. CONCLUSIONS Rotating inotropes were safe and seemed to be effective in this heterogeneous population of infants and children with decompensated heart failure. This therapeutic regimen warrants prospective comparative analysis.
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Masotti P, McColl MA, Green M. Adverse events experienced by homecare patients: a scoping review of the literature. Int J Qual Health Care 2010; 22:115-25. [PMID: 20147333 DOI: 10.1093/intqhc/mzq003] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The paper summarizes the results of a scoping review that focused on the occurrence of adverse events experienced by homecare patients. DATA SOURCES The literature search covered published and grey literature between 1998 and 2007. Databases searched included: MEDLINE, EMBASE, CINAHL and EBM REVIEWS including the Cochrane Library, AGELINE, the National Patient Safety Foundation Bibliography, Agency for Healthcare Research and Quality and the Patient Safety Net bibliography. STUDY SELECTION Papers included research studies, review articles, policy papers, opinion articles and legal briefs. Inclusion criteria were: (i) homecare directed services provided in the home by healthcare professionals or caregivers; (ii) addressed a characteristic relevant to patient experienced adverse events (e.g. occurrences, rates, definitions, prevention or outcomes); and (iii) were in English. Data extraction A pool of 1007 articles was reduced to 168 after analysis. Data were charted according to six categories: definitions, rates, causes, consequences, interventions and policy. RESULTS Eight categories emerged: adverse drug events, line-related, technology-related, infections and urinary catheters, wounds, falls, studies reporting multiple rates and other. Reported overall rates of adverse events ranged from 3.5 to 15.1% with higher rates for specific types. Few intervention studies were found. Adverse events were commonly associated with communication problems. Policy suggestions included the need to improve assessments, monitoring, education, coordination and communication. CONCLUSION A standardized definition of adverse events in the homecare setting is needed. Prospective cohort studies are needed to improve estimates and intervention studies should be undertaken to reduce the risk that homecare patients will experience adverse events.
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Affiliation(s)
- Paul Masotti
- Centre for Health Services and Policy Research, Queen's University, Kingston, ONT, Canada.
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Mahle WT, Ianucci G, Vincent RN, Kanter KR. Costs Associated With Ventricular Assist Device Use in Children. Ann Thorac Surg 2008; 86:1592-7. [DOI: 10.1016/j.athoracsur.2008.07.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 07/07/2008] [Accepted: 07/08/2008] [Indexed: 10/21/2022]
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