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Ashfaq A, Lorts A, Rosenthal D, Adachi I, Rossano J, Davies R, Simpson KE, Maeda K, Wisotzkey B, Koehl D, Cantor RS, Jacobs JP, Peng D, Kirklin JK, Morales DLS. Predicting Stroke for Pediatric Patients Supported With Ventricular Assist Devices: A Pedimacs Report. Ann Thorac Surg 2024:S0003-4975(24)00386-2. [PMID: 38802036 DOI: 10.1016/j.athoracsur.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/03/2024] [Accepted: 05/06/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) provides detailed understanding on pediatric patients supported with ventricular assist devices (VADs). We sought to identify important variables affecting the incidence of stroke in pediatric VADs. METHODS Between 2012 and 2022, 1463 devices in 1219 patients were reported to Pedimacs from 40 centers in patients aged <19 years at their first VAD implantation. Multiphase parametric hazard modeling was used to identify risk factors for stroke among all device types. RESULTS Of the 1219 patients, the most common devices were implantable continuous (472 [39%]), followed by paracorporeal pulsatile (342 [28%]), and paracorporeal continuous (327 [27%]). Overall freedom from stroke at 6 months was higher in the recent era (2012-2016; 80.2% [95% CI, 77.1%-82.9%] vs 2017-2023; 87.9% [95% CI, 86.2%-89.4%], P = .009). Implantable continuous VADs had the highest freedom from stroke at 3 months (92.7%; 95% CI, 91.1%-93.9%) and 6 months (91.1%; 95% CI, 89.3%-92.6%), followed by paracorporeal pulsatile (87.0% [95% CI, 84.8%-88.9%] and 82.8% [95% CI, 79.8%-85.5%], respectively), and paracorporeal continuous (76.0% [95% CI, 71.8%-79.5%] and 69.5% [95% CI, 63.4%-74.8%], respectively) VADs. Parametric modeling identified risk factors for stoke early after implant and later. Overall, and particularly for paracorporeal pulsatile devices, early stroke risk has decreased in the most recent era (hazard ratio, 5.01). Among implantable continuous devices, cardiogenic shock was the major risk factor. For patients <10 kg, early hazard was only seen in the previous era. For congenital patients, early hazard was seen in nonimplantable device use and use of extracorporeal membrane oxygenation. CONCLUSIONS The overall stroke rate has decreased from 20% to 15% at 6 months, with particular improvement among paracorporeal pulsatile devices. Risk factor analyses offer insights for identification of higher stroke risk subsets and further management refinements.
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Affiliation(s)
- Awais Ashfaq
- Division of Cardiovascular Surgery, Department of Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Angela Lorts
- Division of Cardiovascular Surgery, Department of Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Salter Packard Children's Hospital, Palo Alto, California
| | - Iki Adachi
- Division of Cardiovascular Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Joseph Rossano
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ryan Davies
- Division of Cardiovascular Surgery, Department of Surgery, UT Southwestern, Dallas, Texas
| | - Kathleen E Simpson
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado
| | - Katsuhide Maeda
- Division of Cardiovascular Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bethany Wisotzkey
- Division of Pediatric Cardiology, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, Arizona
| | | | | | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Congenital Heart Center, Division of Cardiovascular Surgery, Department of Pediatrics, University of Florida, Gainesville, Florida
| | - David Peng
- Division of Pediatric Cardiology, Department of Pediatrics, Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | | | - David L S Morales
- Division of Cardiovascular Surgery, Department of Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Amdani S, Marino BS, Boyle G, Cassedy A, Lorts A, Morales D, Joong A, Burstein D, Bansal N, Sutcliffe DL. Impact of center volume on outcomes after ventricular assist device implantation in pediatric patients: An analysis of the STS-Pedimacs database. J Heart Lung Transplant 2024; 43:787-796. [PMID: 38199514 DOI: 10.1016/j.healun.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 12/01/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND To date, no pediatric studies have highlighted the impact of center's ventricular assist device (VAD) volumes on post implant outcomes. METHODS Children (age <19) enrolled in Pedimacs undergoing initial left ventricular assist device implantation from 2012 to 2020 were included. Center volume was analyzed as a continuous and categorical variable. For categorical analysis, center volumes were divided as: low volume (1-15 implants), medium volume (15-30 implants), and high volume (>30 implants) during our study period. Patient characteristics and outcomes were compared by center's VAD volumes. RESULTS Of 44 centers, 16 (36.4%) were low, 11 (25%) were medium, and 17 (38.6%) were high-volume centers. Children at high-volume centers were least likely intubated, sedated, or paralyzed, and most likely ambulating preimplant (p < 0.05 for all). Center's VAD volumes were not a significant risk factor for mortality post implant when treated as a continuous or a categorical variable (p > 0.05). Compared to low volume, children at high-volume centers had fewer early neurological events. Compared to medium volume, those at high-volume centers had fewer late bleeding events (p < 0.05 for all). There were no significant differences in survival after an adverse event by hospital volumes (p > 0.05). CONCLUSIONS Although hospital volume does not affect post-VAD implant mortality, pediatric centers with higher VAD volumes have fewer patients intubated, sedated, paralyzed pre implant, and have lower adverse events. Failure to rescue was not significantly different between low, medium, and high-volume VAD centers.
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Affiliation(s)
- Shahnawaz Amdani
- Division of Pediatric Cardiology, Department of Heart, Vascular & Thoracic, Children's Institute, Cleveland Clinic Children's, Cleveland, Ohio.
| | - Bradley S Marino
- Division of Pediatric Cardiology, Department of Heart, Vascular & Thoracic, Children's Institute, Cleveland Clinic Children's, Cleveland, Ohio
| | - Gerard Boyle
- Division of Pediatric Cardiology, Department of Heart, Vascular & Thoracic, Children's Institute, Cleveland Clinic Children's, Cleveland, Ohio
| | - Amy Cassedy
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Angela Lorts
- Department of Cardiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - David Morales
- Department of Cardiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Anna Joong
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Danielle Burstein
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Neha Bansal
- Division of Pediatric Cardiology, Mount Sinai School of Medicine, New York, New York
| | - David L Sutcliffe
- Division of Pediatric Cardiology, Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri
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Peng DM, Davies RR, Simpson KE, Shugh SB, Morales DLS, Jacobs JP, Butto A, Joong A, Conway J, Schindler K, Griffiths ER, Koehl D, Cantor RS, Kirklin JK, Rossano JW, Adachi I. Seventh Annual Society of Thoracic Surgeons Pedimacs Report. Ann Thorac Surg 2024; 117:690-703. [PMID: 38123046 DOI: 10.1016/j.athoracsur.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/01/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs), supported by The Society of Thoracic Surgeons, provides detailed information on pediatric patients supported with ventricular assist devices (VADs). METHODS From September 19, 2012, to December 31, 2022, 1463 devices in 1219 patients aged <19 years were reported to the registry from 40 North American hospitals. RESULTS Cardiomyopathy remains the most common underlying etiology (59%), followed by congenital heart disease (26%) and myocarditis (8%). Implantable continuous devices were most common (39%) type, followed by paracorporeal pulsatile (28%) and paracorporeal continuous (27%) devices. At 6 months after VAD implantation, a favorable outcome (transplant, recovery, or alive on device) was achieved in 85% of patients, which was greatest among those on implantable continuous VADs (92%) and least for paracorporeal continuous VADs (68%), although the patient population supported on these devices is different. CONCLUSIONS This Seventh Pedimacs Report demonstrates the continued importance of VADs in the treatment of children. With the complexity of cardiac physiologies and sizes of patients, multiple types of devices are used, including paracorporeal continuous, paracorporeal pulsatile, and implantable continuous devices. The preoperative risk factors and differences in patient populations may account for some of the differences in survival observed among these devices. This report, along with other collaborative work, continues to advance the care of this challenging and vulnerable population.
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Affiliation(s)
- David M Peng
- Department of Pediatrics, University of Michigan Medical School, Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical School, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kathleen E Simpson
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | | | - David L S Morales
- Department of Surgery, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey P Jacobs
- Department of Surgery, University of Florida College of Medicine, Congenital Heart Center, University of Florida, Gainesville, Florida; Department of Pediatrics, University of Florida College of Medicine, Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Arene Butto
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Anna Joong
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jennifer Conway
- Department of Pediatrics, University of Alberta Faculty of Medicine, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Kerry Schindler
- Morgan Stanley Children's Hospital of NewYork-Presbyterian, Columbia University Medical Center, New York, New York
| | - Eric R Griffiths
- Department of Surgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, Birmingham, Alabama
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, Birmingham, Alabama
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, Birmingham, Alabama
| | - Joseph W Rossano
- Department of Pediatrics, Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Iki Adachi
- Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Rasooli R, Holmstrom H, Giljarhus KET, Jolma IW, Vinningland JL, de Lange C, Brun H, Hiorth A. In vitro hemodynamic performance of a blood pump for self-powered venous assist in univentricular hearts. Sci Rep 2024; 14:6941. [PMID: 38521832 PMCID: PMC10960831 DOI: 10.1038/s41598-024-57269-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/15/2024] [Indexed: 03/25/2024] Open
Abstract
Univentricular heart anomalies represent a group of severe congenital heart defects necessitating early surgical intervention in infancy. The Fontan procedure, the final stage of single-ventricle palliation, establishes a serial connection between systemic and pulmonary circulation by channeling venous return to the lungs. The absence of the subpulmonary ventricle in this peculiar circulation progressively eventuates in failure, primarily due to chronic elevation in inferior vena cava (IVC) pressure. This study experimentally validates the effectiveness of an intracorporeally-powered venous ejector pump (VEP) in reducing IVC pressure in Fontan patients. The VEP exploits a fraction of aortic flow to create a jet-venturi effect for the IVC, negating the external power requirement and driveline infections. An invitro Fontan mock-up circulation loop is developed and the impact of VEP design parameters and physiological conditions is assessed using both idealized and patient-specific total cavopulmonary connection (TCPC) phantoms. The VEP performance in reducing IVC pressure exhibited an inverse relationship with the cardiac output and extra-cardiac conduit (ECC) size and a proportional relationship with the transpulmonary pressure gradient (TPG) and mean arterial pressure (MAP). The ideal VEP with fail-safe features provided an IVC pressure drop of 1.82 ± 0.49, 2.45 ± 0.54, and 3.12 ± 0.43 mm Hg for TPG values of 6, 8, and 10 mm Hg, respectively, averaged over all ECC sizes and cardiac outputs. Furthermore, the arterial oxygen saturation was consistently maintained above 85% during full-assist mode. These results emphasize the potential utility of the VEP to mitigate elevated venous pressure in Fontan patients.
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Affiliation(s)
- Reza Rasooli
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway.
| | - Henrik Holmstrom
- Department of Pediatric Cardiology, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Knut Erik Teigen Giljarhus
- Department of Mechanical and Structural Engineering and Materials Science, University of Stavanger, 4036, Stavanger, Norway
| | - Ingunn Westvik Jolma
- Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, 4036, Stavanger, Norway
| | | | - Charlotte de Lange
- Department of Pediatric Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Brun
- Department of Pediatric Cardiology, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Section for Medical Cybernetics and Image Processing, The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Aksel Hiorth
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway
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Esangbedo ID, Yu P, Choudhury TA, Tume SC, Lasa JJ. Ventricular Assist Device Training and Emergency Management Among Pediatric Cardiac Intensive Care Physicians - Multicenter Cross-Sectional Survey. World J Pediatr Congenit Heart Surg 2024; 15:202-208. [PMID: 38128949 DOI: 10.1177/21501351231205804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Background/Aim: Pediatric cardiac intensive care physicians practicing at centers that implant ventricular assist devices (VAD's) are exposed to increasing numbers of VAD patients, with a significant number of VAD-days. We aimed to delineate pediatric cardiac critical care practices surrounding routine and emergency management of VADs. Methodology: We administered a multicenter cross-sectional survey of pediatric cardiac intensive care unit (CICU) physicians in the United States and Canada. Survey distribution occurred between August 31st and October 26th 2021. Results: A total of 254 CICU physicians received a formal invitation to participate, with 108 returning completed surveys (42.5% response rate). Responses came from CICU attending physicians at 26 separate institutions. Respondents' level of experience was well distributed across junior, mid-level, and senior staff: less than 5 years (38%), 5-9 years (25%), and >/= 10 years (37%). Most respondents had received formal training in the management of VAD patients (n = 93, 86.1%), with training format including fellowship (61%), simulation (36%), and national/international conferences (26.5%). Dedicated advanced cardiac therapies teams were available at the institutions of 97.2% of respondents. A total of 78/108 (72.2%) described themselves as "comfortable" or "very comfortable" in pediatric VAD management. While 63% (68/108) of respondents reported that they had never performed (or overseen the performance of) chest compressions in a pediatric patient with a VAD, 37% (40/108) reported performing CPR at least once in a VAD patient. Conclusion: With no existing international guidelines for emergency cardiovascular care in the pediatric VAD population, our survey identifies an important gap in resuscitation recommendations.
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Affiliation(s)
- Ivie D Esangbedo
- Division of Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Priscilla Yu
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarif A Choudhury
- Division of Critical Care Medicine, Division of Cardiology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Sebastian C Tume
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Javier J Lasa
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Ullman A, Hyun A, Gibson V, Newall F, Takashima M. Device Related Thrombosis and Bleeding in Pediatric Health Care: A Meta-analysis. Hosp Pediatr 2024; 14:e25-e41. [PMID: 38161187 DOI: 10.1542/hpeds.2023-007345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
CONTEXT The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood. OBJECTIVES This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care. DATA SOURCES Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched. STUDY SELECTION Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included. DATA EXTRACTION Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used. MAIN OUTCOMES AND MEASURES Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor). RESULTS Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications. CONCLUSIONS This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.
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Affiliation(s)
- Amanda Ullman
- School of Nursing, Midwifery and Social Work, The University of Queensland, Queensland, Australia
- Centre for Children's Health Research, Children's Health Queensland Hospital and Health Service, Queensland, Australia
- NHMRC Centre for Research Excellence in Wiser Wound Care, Griffith University, Queensland, Australia
| | - Areum Hyun
- School of Nursing, Midwifery and Social Work, The University of Queensland, Queensland, Australia
| | - Victoria Gibson
- School of Nursing, Midwifery and Social Work, The University of Queensland, Queensland, Australia
- Centre for Children's Health Research, Children's Health Queensland Hospital and Health Service, Queensland, Australia
| | - Fiona Newall
- Royal Children's Hospital Melbourne, Victoria, Australia
- The University of Melbourne, Victoria, Australia
| | - Mari Takashima
- School of Nursing, Midwifery and Social Work, The University of Queensland, Queensland, Australia
- Centre for Children's Health Research, Children's Health Queensland Hospital and Health Service, Queensland, Australia
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Ashfaq A, Lorts A, Rosenthal D, Adachi I, Rossano J, Davies R, Simpson KE, Maeda K, Wisotzkey B, Koehl D, Cantor RS, Jacobs JP, Peng D, Kirklin JK, Morales DLS. Survival in Pediatric Patients With Ventricular Assist Devices: A Special Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report. Ann Thorac Surg 2023; 116:972-979. [PMID: 37573991 DOI: 10.1016/j.athoracsur.2023.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/05/2023] [Accepted: 07/11/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) provides detailed understanding on pediatric patients supported with ventricular assist devices (VADs). We sought to identify important variables affecting mortality in pediatric VADs. METHODS Patients aged <19 years, from 2012 to 2021, were included. Survival analyses were performed using Kaplan-Meier. Parametric hazard modeling was used to identify risk factors for death. RESULTS Of the 1109 patients, the most common devices were implantable continuous (IC, 448 [40%]), followed by paracorporeal pulsatile (PP, 306 [28%]), paracorporeal continuous (PC, 293 [26%]), and percutaneous (58 [5%]). Patients with percutaneous device, infants, congenital heart disease, biventricular support, and Interagency Registry for Mechanically Assisted Circulatory Support profile 1 had worse overall survival at 6 months. Positive outcome was 83% at 6 months. Consistent with their cohort composition, device type positive outcomes at 6 months were IC, 92%; PP, 84%; and PC, 69%. Parametric hazard modeling for overall survival showed an early hazard for death with biventricular support, congenital heart disease (CHD), intubation before implantation, PC device, and renal impairment, whereas a constant hazard was associated with ascites. For patients <10 kg, parametric modeling showed an early hazard for CHD, intubation, and renal impairment. Modeling in CHD patients showed an early hazard for biventricular support, renal impairment, and use of PC/PP devices. CONCLUSIONS This multivariable analysis of the complete Pedimacs database demonstrates that illness at VAD implantation, diagnosis, and strategy of support affect survival and differ by device type. We hope this is the first step in creating a predictive tool to help providers and families have informed expectations.
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Affiliation(s)
- Awais Ashfaq
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Angela Lorts
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Rosenthal
- Department of Pediatric Cardiology, Lucile Salter Packard Children's Hospital, Palo Alto, California
| | - Iki Adachi
- Department of Pediatric Cardiac Surgery, Texas Children's Hospital, Houston, Texas
| | - Joseph Rossano
- Department of Pediatric Cardiology and Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ryan Davies
- Department of Pediatric Cardiac Surgery, UT Southwestern, Dallas, Texas
| | - Kathleen E Simpson
- Department of Pediatric Cardiology, Children's Hospital of Colorado, Aurora, Colorado
| | - Katsuhide Maeda
- Department of Pediatric Cardiology and Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bethany Wisotzkey
- Department of Pediatric Cardiology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - David Peng
- Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - David L S Morales
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Kozik D, Alsoufi B. Pediatric mechanical circulatory support - a review. Indian J Thorac Cardiovasc Surg 2023; 39:80-90. [PMID: 37525715 PMCID: PMC10386992 DOI: 10.1007/s12055-023-01499-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
The history of mechanical circulatory support began in 1953, as the first heart-lung machine enabled surgeons to perform complex open heart surgery. Heart failure is more prevalent in adults than pediatric patients which has led to the development of devices for adults with end-stage heart failure at a faster pace. Pediatric mechanical circulatory support has been derived from adult durable devices and subsequently applied in the adolescent population. The application of adult devices in children is inherently problematic due to size mismatch, especially in smaller patients. There has been an increasing interest in developing durable pumps that are appropriate for children for several reasons, with the primary factor being the number of children with end-stage heart failure far exceeding the number of potential donors. Mechanical circulatory support (MCS) for children can be divided into short-term temporary support and long-term durable support. The goal of this review is to discuss the devices available for the pediatric population and review the options for support in complex patients including single-ventricle anatomy, biventricular support, and total artificial heart options. We will also briefly discuss the Pumps for Kids, Infants, and Neonates (PumpKIN) Trial and MCS registries, including the Advanced Cardiac Therapies Improving Outcomes Network (ACTION).
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Affiliation(s)
- Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
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Rasooli R, Giljarhus KET, Hiorth A, Jolma IW, Vinningland JL, de Lange C, Brun H, Holmstrom H. In Silico Evaluation of a Self-powered Venous Ejector Pump for Fontan Patients. Cardiovasc Eng Technol 2023; 14:428-446. [PMID: 36877450 PMCID: PMC10412470 DOI: 10.1007/s13239-023-00663-5] [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: 09/06/2022] [Accepted: 02/06/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE The Fontan circulation carries a dismal prognosis in the long term due to its peculiar physiology and lack of a subpulmonic ventricle. Although it is multifactorial, elevated IVC pressure is accepted to be the primary cause of Fontan's high mortality and morbidity. This study presents a self-powered venous ejector pump (VEP) that can be used to lower the high IVC venous pressure in single-ventricle patients. METHODS A self-powered venous assist device that exploits the high-energy aortic flow to lower IVC pressure is designed. The proposed design is clinically feasible, simple in structure, and is powered intracorporeally. The device's performance in reducing IVC pressure is assessed by conducting comprehensive computational fluid dynamics simulations in idealized total cavopulmonary connections with different offsets. The device was finally applied to complex 3D reconstructed patient-specific TCPC models to validate its performance. RESULTS The assist device provided a significant IVC pressure drop of more than 3.2 mm Hg in both idealized and patient-specific geometries, while maintaining a high systemic oxygen saturation of more than 90%. The simulations revealed no significant caval pressure rise (< 0.1 mm Hg) and sufficient systemic oxygen saturation (> 84%) in the event of device failure, demonstrating its fail-safe feature. CONCLUSIONS A self-powered venous assist with promising in silico performance in improving Fontan hemodynamics is proposed. Due to its passive nature, the device has the potential to provide palliation for the growing population of patients with failing Fontan.
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Affiliation(s)
- Reza Rasooli
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway.
| | - Knut Erik Teigen Giljarhus
- Department of Mechanical and Structural Engineering and Materials Science, University of Stavanger, 4036, Stavanger, Norway
| | - Aksel Hiorth
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway
| | - Ingunn Westvik Jolma
- Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, 4036, Stavanger, Norway
| | | | - Charlotte de Lange
- Department of Paediatric Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Henrik Brun
- Section for Medical Cybernetics and Image Processing, The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Department of Paediatric Cardiology, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Henrik Holmstrom
- Department of Paediatric Cardiology, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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10
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Greenberg JW, Bryant R, Villa C, Fields K, Fynn-Thompson F, Zafar F, Morales DLS. Racial disparity exists in the utilization and post-transplant survival benefit of ventricular assist device support in children. J Heart Lung Transplant 2023; 42:585-592. [PMID: 36710094 PMCID: PMC10121747 DOI: 10.1016/j.healun.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 12/04/2022] [Accepted: 12/18/2022] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Children of minority race and ethnicity experience inferior outcomes postheart transplantation (HTx). Studies have associated ventricular assist device (VAD) bridge-to-transplant (BTT) with similar-to-superior post-transplant-survival (PTS) compared to no mechanical circulatory support. It is unclear whether racial and ethnic discrepancies exist in VAD utilization and outcomes. METHODS The United Network for Organ Sharing (UNOS) database was used to identify 6,121 children (<18 years) listed for HTx between 2006 and 2021: black (B-22% of cohort), Hispanic (H-21%), and white (W-57%). VAD utilization, outcomes, and PTS were compared between race/ethnicity groups. Multivariable Cox proportional analyses were used to study the association of race and ethnicity on PTS with VAD BTT, using backward selection for covariates. RESULTS Black children were most ill at listing, with greater proportions of UNOS status 1A/1 (p < 0.001 vs H & W), severe functional limitation (p < 0.001 vs H & W), and greater inotrope requirements (p < 0.05 vs H). Non-white children had higher proportions of public insurance. VAD utilization at listing was: B-11%, H-8%, W-8% (p = 0.001 for B vs H & W). VAD at transplant was: B-24%, H-21%, W-19% (p = 0.001 for B vs H). At transplant, all VAD patients had comparable clinical status (functional limitation, renal/hepatic dysfunction, inotropes, mechanical ventilation; all p > 0.05 between groups). Following VAD, hospital outcomes and one-year PTS were equivalent but long-term PTS was significantly worse among non-whites-(p < 0.01 for W vs B & H). On multivariable analysis, black race independently predicted mortality (hazard ratio 1.67 [95% confidence interval 1.22-2.28]) while white race was protective (0.54 [0.40-0.74]). CONCLUSIONS Pediatric VAD use is, seemingly, equitable; the most ill patients receive the most VADs. Despite similar pretransplant and early post-transplant benefits, non-white children experience inferior overall PTS after VAD BTT.
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Affiliation(s)
- Jason W Greenberg
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Roosevelt Bryant
- Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Chet Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Katrina Fields
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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11
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Kwiatkowski DM, Shezad M, Barnes AP, Ploutz MS, Law SP, Zafar F, Morales DLS, O'Connor MJ. Impact of Weight on Ventricular Assist Device Outcomes in Dilated Cardiomyopathy Patients in Pediatric Centers: An ACTION Registry Study. ASAIO J 2023; 69:496-503. [PMID: 37071761 DOI: 10.1097/mat.0000000000001861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
Ventricular assist device (VAD) options vary for children in different weight groups. This study evaluates contemporary device usage and outcomes for children based on weight. Data from the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry were examined for patients with dilated cardiomyopathy (DCM) in 4 weight cohorts: <8 kg, 8-20 kg, 21-40 kg, and >40 kg, for devices implanted 3/2013-10/2020. Adverse event rates and ultimate outcome (deceased, alive on device, transplanted, or ventricular recovery) were analyzed. 222 DCM patients were identified with 24% in cohort 1, 23% in cohort 2, 15% in cohort 3, and 38% in cohort 4. Of 272 total implants, paracorporeal pulsatile devices were most common (95%) in cohorts 1 and 2 and intracorporeal continuous devices (81%) in cohorts 3 and 4. Stroke was noted in 17%, 12%, 6%, and 4% of cohorts, respectively (Cohort 1 vs. 4 and 2 vs. 4 - p = 0.01; other comparisons - not significant). Incidences of major bleeding, device malfunction, and infection was not different. All cohorts had >90% positive outcomes. Stroke incidence was higher in smaller cohorts, but other outcomes were similar. Positive outcomes were attained in over 90% across all weight groups, demonstrating excellent outcomes using current VADs in this DCM population.
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Affiliation(s)
- David M Kwiatkowski
- From the Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA
| | - Muhammad Shezad
- The Heart Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Aliessa P Barnes
- Division of Pediatric Cardiology, The Children's Mercy Hospital, Kansas City, MO
| | - Michelle S Ploutz
- Division of Pediatric Cardiology, University of Utah Health, Salt Lake City, UT
| | - Sabrina P Law
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, NY
| | - Farhan Zafar
- The Heart Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - David L S Morales
- The Heart Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Matthew J O'Connor
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
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12
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Benck KN, Khan FA, Munagala MR. Women in mechanical circulatory support: She persisted! Front Cardiovasc Med 2022; 9:961404. [PMID: 36312259 PMCID: PMC9606210 DOI: 10.3389/fcvm.2022.961404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
Many women physicians have blazed trails and played instrumental roles in advancing the field of Advanced Heart Failure (AHF), Mechanical Circulatory Support (MCS), and cardiac transplantation to its current recognition and glory. In contrast to other areas of cardiology, women have played an integral role in the evolution and emergence of this sub-specialty. Although the ceiling had been broken much later for women cardiothoracic (CT) surgeons in the field of AHF, the ingress of women into surgical fields particularly CT surgery was stonewalled due to pervasive stereotyping. The constancy, commitment, and contributions of women to the field of AHF and MCS cannot be minimized in bringing this field to the forefront of innovation both from technological aspect as well as in redesigning of healthcare delivery models. Integrated team-based approach is a necessity for the optimal care of MCS patients and forced institutions to develop this approach when patients with durable left ventricular assist devices (LVAD) began discharging from the hospitals to local communities. Women in various roles in this field played a pivotal role in developing and designing patient centered care and coordination of care in a multidisciplinary manner. While embracing the challenges and turning them to opportunities, establishing partnerships and finding solutions with expectations to egalitarianism, women in this field continue to push boundaries and subscribe to the continued evolution of the field of AHF and advanced cardiac therapies.
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Affiliation(s)
- Kelley N. Benck
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Fatima A. Khan
- Department of Cardiology, University of Texas Medical Branch, Galveston, TX, United States,*Correspondence: Fatima A. Khan,
| | - Mrudula R. Munagala
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, FL, United States,Mrudula R. Munagala, ;
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13
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Oscherwitz M, Nguyen HQ, Raza SS, Cleveland DC, Padilla LA, Sorabella RA, Ayares D, Maxwell K, Rhodes LA, Cooper DKC, Hara H. Will previous palliative surgery for congenital heart disease be detrimental to subsequent pig heart xenotransplantation? Transpl Immunol 2022; 74:101661. [PMID: 35787933 PMCID: PMC9762890 DOI: 10.1016/j.trim.2022.101661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pig heart xenotransplantation might act as a bridge in infants with complex congenital heart disease (CHD) until a deceased human donor heart becomes available. Infants develop antibodies to wild-type (WT, i.e., genetically-unmodified) pig cells, but rarely to cells in which expression of the 3 known carbohydrate xenoantigens has been deleted by genetic engineering (triple-knockout [TKO] pigs). Our objective was to test sera from children who had undergone palliative surgery for complex CHD (and who potentially might need a pig heart transplant) to determine whether they had serum cytotoxic antibodies against TKO pig cells. METHODS Sera were obtained from children with CHD undergoing Glenn or Fontan operation (n = 14) and healthy adults (n = 8, as controls). All of the children had complex CHD and had undergone some form of cardiac surgery. Seven had received human blood transfusions and 3 bovine pericardial patch grafts. IgM and IgG binding to WT and TKO pig red blood cells (RBCs) and peripheral blood mononuclear cells (PBMCs) were measured by flow cytometry, and killing of PBMCs by a complement-dependent cytotoxicity assay. RESULTS Almost all children and adults demonstrated relatively high IgM/IgG binding to WT RBCs, but minimal binding to TKO RBCs (p < 0.0001 vs WT), although IgG binding was greater in children than adults (p < 0.01). All sera showed IgM/IgG binding to WT PBMCs, but this was much lower to TKO PBMCs (p < 0.0001 vs WT) and was greater in children than in adults (p < 0.05). Binding to both WT and TKO PBMCs was greater than to RBCs. Mean serum cytotoxicity to WT PBMCs was 90% in both children and adults, whereas to TKO PBMCs it was only 20% and < 5%, respectively. The sera from 6/14 (43%) children were cytotoxic to TKO PBMCs, but no adult sera were cytotoxic. CONCLUSIONS Although no children had high levels of antibodies to TKO RBCs, 13/14 demonstrated antibodies to TKO PBMCs, in 6 of these showed mild cytotoxicity. As no adults had cytotoxic antibodies to TKO PBMCs, the higher incidence in children may possibly be associated with their exposure to previous cardiac surgery and biological products. However, the numbers were too small to determine the influence of such past exposures. Before considering pig heart xenotransplantation for children with CHD, testing for antibody binding may be warranted.
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Affiliation(s)
- Max Oscherwitz
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Huy Quoc Nguyen
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Syed Sikandar Raza
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David C Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert A Sorabella
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Kathryn Maxwell
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Leslie A Rhodes
- Department of Pediatric Cardiology, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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14
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Kaski JP. Paediatric cardiology - Not just small hearts in small bodies!: An editorial by the section editor of the new section on pediatric cardiology. Int J Cardiol 2022; 366:88-89. [PMID: 35809808 DOI: 10.1016/j.ijcard.2022.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 07/04/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Juan Pablo Kaski
- Centre for Paediatric Inherited and Rare Cardiovascular Disease, University College London Institute of Cardiovascular Science, London, UK; Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, UK.
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15
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Du Y, Duan C, Yang Y, Yuan G, Zhou Y, Zhu X, Wei N, Hu Y. Heart Transplantation: A Bibliometric Review From 1990-2021. Curr Probl Cardiol 2022; 47:101176. [PMID: 35341797 DOI: 10.1016/j.cpcardiol.2022.101176] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND As the rapidly aging population and the rising incidence of end-stage heart failure (HF), extensive research has been conducted on heart transplantation (HTx). Bibliometrics harbors the function for describing the relationships of knowledge structures in different research fields and predicting the growth trend . METHODS The publications were searched and filtered based on the WOS core database. The target literature was visualized and analyzed by CiteSpace or VOSviewer . RESULTS In total, 19,998 published papers were obtained. There is a wave-like growth in HTx development. Most advanced research results are concentrated in a few developed countries, while the interactions with developing countries are still in infancy. The United States occupies a strong dominant position among active countries on HTx. Early research hotpots mostly focused on primary disease, survival risk factors, and complications. In recent years, the research frontiers have shifted steadily to clinical evaluation of immunosuppressants and diagnosis of acute rejection, cardiac re-injury with COVID-19, innovations in ventricular assist devices(VAD), and donation allocation strategies. The research directions of HTx are gradually shifting from observational studies to intervention research.
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Affiliation(s)
- Yihang Du
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China
| | - Chenglin Duan
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China; Beijing University of Chinese Medicine, Beijing, China
| | - Yihan Yang
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China; Beijing University of Chinese Medicine, Beijing, China
| | - Guozhen Yuan
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China
| | - Yan Zhou
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China; Beijing University of Chinese Medicine, Beijing, China
| | - Xueping Zhu
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China
| | - Namin Wei
- Beijing University of Chinese Medicine, Beijing, China
| | - Yuanhui Hu
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China.
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16
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Horsley M, Pathak S, Morales D, Lorts A, Mouzaki M. Nutritional Outcomes of Patients with Pediatric and Congenital Heart Disease Requiring Ventricular Assist Device. JPEN J Parenter Enteral Nutr 2022; 46:1553-1558. [DOI: 10.1002/jpen.2351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/20/2022] [Accepted: 02/14/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - David Morales
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery
- Division of Cardiology
| | - Angela Lorts
- Department of Clinical Pediatrics
- Division of Cardiology
| | - Marialena Mouzaki
- Department of Clinical Pediatrics
- Division of Gastroenterology, Hepatology and Nutrition Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine
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17
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Auerbach SR, Cantor RS, Bradford TT, Bock MJ, Skipper ER, Koehl DA, Butler K, Alejos JC, Edens RE, Kirklin JK. The Effect of Infectious Complications During Ventricular Assist Device Use on Outcomes of Pediatric Heart Transplantation. ASAIO J 2022; 68:287-296. [PMID: 34264872 DOI: 10.1097/mat.0000000000001442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
To describe the impact of infectious adverse events (IAEs) during ventricular assist device (VAD) support on graft loss, infection, and rejection after pediatric heart transplant (HT). Pedimacs data were linked to Pediatric Heart Transplant Society (PHTS) data for patients receiving a VAD followed by HT between September 2012 and December 2016. Linked patients were categorized into IAE on VAD (group A) and no IAE on VAD (group B). Infectious adverse event locations included nondevice, device (external or internal), and sepsis. Post-HT outcomes for analysis were graft loss, infection, and rejection. Time-dependent analysis included Kaplan-Meier and multiphase parametric hazard function analysis. We linked 207 patients (age 9.4 ± 6.3 years). Post-HT follow-up was 19.4 patient-months (<8 days-4.1 years). Group A included 42 patients (20%) with 62 IAEs. Group B included 165 patients without an IAE. Group A patients were younger (7.4 ± 6.1 vs. 9.5 ± 6.3 years; p = 0.03), waited longer for HT (5.3 ± 4.1 vs. 2.9 ± 2.5 months; p = 0.0005), and were hospitalized longer post-HT (42 ± 59 vs. 23 ± 22 days; p = 0.05). VAD-related IAEs were rare (N = 11). Groups A and B had similar freedom from first post-HT infection, rejection, and graft loss (all p > 0.1). However, patients with VAD-related IAE were somewhat more likely to experience rejection (p = 0.03) and graft loss (p = 0.01). Children with an IAE on VAD who survive to HT are younger, wait longer for HT, and remain hospitalized longer than those without an IAE on VAD. Overall, IAE on VAD did not impact post-HT outcomes, but VAD-related IAE may be associated with graft loss and rejection.
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Affiliation(s)
- Scott R Auerbach
- From the Pediatrics, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tamara T Bradford
- Louisiana State University Health Sciences Center, Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Matthew J Bock
- Pediatrics, Division of Cardiology, Loma Linda University Children's Hospital, Loma Linda, California
| | - Eric R Skipper
- Department of Thoracic and Cardiovascular Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Devin A Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kathleen Butler
- Children's Hospital Colorado, Heart Institute, Aurora, Colorado
| | - Juan C Alejos
- Pediatrics, Division of Cardiology, UCLA, Mattel Children's Hospital, Los Angeles, California
| | - R Erik Edens
- Division of Pediatric Cardiology, The Children's Heart Clinic, Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
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18
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Conway J, Ravekes W, McConnell P, Cantor RS, Koehl D, Sun B, Daly RC, Hsu DT. Early Improvement in Clinical Status Following Ventricular Assist Device Implantation in Children: A Marker for Survival. ASAIO J 2022; 68:87-95. [PMID: 33852494 DOI: 10.1097/mat.0000000000001420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
While clinical status at the time of ventricular assist device (VAD) implant can negatively affect outcomes, it is unclear if early improvement after implant can have a positive effect. Therefore, the objectives of this study were to describe the clinical status of pediatric patients supported with a VAD and determine the impact of clinical status on the 1-month follow-up form on survival and ability to discharge. This was a retrospective analysis of data collected prospectively by the Pediatric Interagency Registry for Mechanical Circulatory Support Registry (Pedimacs) Registry. The Pedimacs database was queried for patients implanted between September 19, 2012, and September 30, 2019, who were alive on VAD support at 1-month postimplant on either a paracorporeal pulsatile or intracorporeal continuous device. Four factors on the 1-month follow-up were the focus of this study: mechanical ventilation, supplemental nutritional support, inotropic support, and ambulatory status. These factors were regarded as present if detected between 1-week and 1-month postimplant and were analyzed to determine their impact on survival following 1 month of VAD support and on successful discharge from hospital in patients with implantable continuous-flow devices. The eligible study cohort consisted of 414 patients with a mean age of 9.6 ± 6.2 years, weight of 40.8 ± 32.3 kg with the majority being male (56.7%) and having cardiomyopathy (68%). An isolated left ventricular assist device (LVAD) was the most common implant (85.5%). At implant, 40% were ventilated, 57% required nutritional support, 93% were on inotropes, and 58% were nonambulating. On the 1-month postimplant form, there were significant improvements in all four categories (14% ventilator support, 46% nutritional support, 53% on inotropes, and 25% nonambulating). However, there was no significant early change in the percentage of patients requiring supplemental nutrition in the paracorporeal pulsatile devices (88% vs. 82%; p = 0.2). Presence of these clinical parameters in early follow-up postimplant had a significant negative impact on survival and on the ability of patients with continuous-flow devices to be discharged. Presence of four specific clinical parameters early after VAD placement is associated with worse overall survival and an inability to discharge patients on VAD support. Ongoing work is needed for optimization of patients before implant and aggressive rehabilitation after implant to help improve long-term outcomes.
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Affiliation(s)
- Jennifer Conway
- From the Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes (KIRSO), The University of Alabama at Birmingham, Birmingham, Alabama
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes (KIRSO), The University of Alabama at Birmingham, Birmingham, Alabama
| | - Benjamin Sun
- Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Daphne T Hsu
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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19
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Valencia E, Nasr VG. Ventricular Assist Devices: Improving Lives of Children with Heart Failure. J Cardiothorac Vasc Anesth 2022; 36:1509-1510. [DOI: 10.1053/j.jvca.2022.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022]
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20
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Fifth Annual Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report. Ann Thorac Surg 2021; 112:1763-1774. [PMID: 34648810 DOI: 10.1016/j.athoracsur.2021.10.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) provides detailed information on pediatric patients supported with ventricular assist devices (VADs). METHODS From September 19, 2012, to December 31, 2020, 1229 devices in 1011 patients were reported to the registry from 47 North American Hospitals in patients aged younger than 19 years. RESULTS Cardiomyopathy was the most common underlying etiology (58%), followed by congenital heart disease (CHD; 25%) and myocarditis (10%). The most common devices implanted were implantable continuous (IC; 419 [41%]), followed by paracorporeal pulsatile (PP; 269 [27%]), paracorporeal continuous (PC; 263 [26%]), and percutaneous (53 [5%]). Overall, at 6 months after VAD implantation, 83% had a positive outcome (transplant, explant, or alive on device). The freedom from stroke at 3 months was highest in IC VADs (93%), compared with PP VADs (84%) and with PC VADs (75%). There were differences in survival by device type, with patients on IC VADs having the best overall survival and those on PC having the lowest overall survival, though the patient populations being supported by each VAD type differed significantly from each other. CONCLUSIONS This Fifth Pedimacs Report demonstrates the continued robust growth of VADs in the pediatric community, now with more than 1000 patients reported to the registry. The multiple available device types (PC, PP, IC) serve different populations with different pre-VAD risk profiles, which may account for differences in survival and adverse events between device types.
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21
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Tompkins LH, Gellman BN, Morello GF, Prina SR, Roussel T, Kopechek JA, Petit PC, Slaughter MS, Koenig SC, Dasse KA. Design and Computational Evaluation of a Pediatric MagLev Rotary Blood Pump. ASAIO J 2021; 67:1026-1035. [PMID: 33315663 PMCID: PMC8187468 DOI: 10.1097/mat.0000000000001323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Pediatric heart failure (HF) patients have been a historically underserved population for mechanical circulatory support (MCS) therapy. To address this clinical need, we are developing a low cost, universal magnetically levitated extracorporeal system with interchangeable pump heads for pediatric support. Two impeller and pump designs (pump V1 and V2) for the pediatric pump were developed using dimensional analysis techniques and classic pump theory based on defined performance criteria (generated flow, pressure, and impeller diameter). The designs were virtually constructed using computer-aided design (CAD) software and 3D flow and pressure features were analyzed using computational fluid dynamics (CFD) analysis. Simulated pump designs (V1, V2) were operated at higher rotational speeds (~5,000 revolutions per minute [RPM]) than initially estimated (4,255 RPM) to achieve the desired operational point (3.5 L/min flow at 150 mm Hg). Pump V2 outperformed V1 by generating approximately 30% higher pressures at all simulated rotational speeds and at 5% lower priming volume. Simulated hydrodynamic performance (achieved flow and pressure, hydraulic efficiency) of our pediatric pump design, featuring reduced impeller size and priming volume, compares favorably to current commercially available MCS devices.
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Affiliation(s)
- Landon H. Tompkins
- Department of Bioengineering, University of Louisville, Louisville, KY 40202
| | | | | | | | - Thomas Roussel
- Department of Bioengineering, University of Louisville, Louisville, KY 40202
| | | | | | - Mark S. Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY 40202
| | - Steven C. Koenig
- Department of Bioengineering, University of Louisville, Louisville, KY 40202
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY 40202
| | - Kurt A. Dasse
- Department of Bioengineering, University of Louisville, Louisville, KY 40202
- Inspired Therapeutics LLC, Merritt Island, FL 32925
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY 40202
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22
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Romlin B, Dahlin A, Hallhagen S, Björk K, Wåhlander H, Söderlund F. Clinical course and outcome after treatment with ventricular assist devices in paediatric patients: A single-centre experience. Acta Anaesthesiol Scand 2021; 65:785-791. [PMID: 33616235 DOI: 10.1111/aas.13804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Heart failure is a rare condition in the paediatric population, associated with high morbidity and mortality. When medical therapy is no longer sufficient, mechanical circulatory support such as a ventricular assist device can be used to bridge these children to transplant or recovery. Coagulation-related complications such as thrombi, embolism and bleeding events represent the greatest challenge in paediatric patients on mechanical support. We aimed to describe the outcomes and coagulation-related complications in this patient population at our institution. METHODS A total of 20 patients with either Berlin Heart EXCOR® or HeartWare® implantation were reviewed in this retrospective study. Study endpoints were survival to heart transplant, weaning due to recovery or death. Thrombotic events were defined as thrombus formation in the device or in the patient, or cardioembolic strokes. Bleeding events were defined as events requiring interventional surgery or transfusion of red blood cells. RESULTS The aetiology of heart failure included cardiomyopathy (n = 12), end-stage congenital heart disease (n = 6) and myocarditis (n = 2). Of the 20 patients, 12 were bridged to transplant, 7 recovered and could be weaned and 1 died. The median duration of mechanical support was 84 days (range: 20-524 days). At least one major or minor bleeding event occurred in 45% of the patients. Thrombotic events occurred 21 times in 10 patients. Four of the patients (20%) had no bleeding or thromboembolic event. CONCLUSION In all, 95% of the patients were successfully bridged to transplant or recovery. Bleeding events and thrombotic events were common.
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Affiliation(s)
- Birgitta Romlin
- Department of Paediatric Anaesthesiology and Intensive Care Queen Silvia Children's Hospital Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Anna Dahlin
- Department of Paediatric Anaesthesiology and Intensive Care Queen Silvia Children's Hospital Gothenburg Sweden
| | - Stefan Hallhagen
- Department of Cardiothoracic Surgery Sahlgrenska University Hospital Gothenburg Sweden
| | - Kerstin Björk
- Department of Cardiothoracic Surgery Sahlgrenska University Hospital Gothenburg Sweden
| | - Håkan Wåhlander
- Paediatric Heart Centre Queen Silvia Children's Hospital Gothenburg Sweden
- Department of Paediatrics Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Fredrik Söderlund
- Department of Paediatric Anaesthesiology and Intensive Care Queen Silvia Children's Hospital Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
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Auerbach SR, Simpson KE. HVAD Usage and Outcomes in the Current Pediatric Ventricular Assist Device Field: An Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Analysis. ASAIO J 2021; 67:675-680. [PMID: 33587465 DOI: 10.1097/mat.0000000000001373] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Advanced Cardiac Therapies Improving Outcomes Network (ACTION) is the first pediatric ventricular assist device (VAD) quality improvement network (46 centers). We aimed to describe outcomes with the HeartWare HVAD from ACTION centers. Patients with an HVAD implant in the ACTION registry (April 2018-April 2020) were analyzed. Baseline characteristics, adverse events, and survival were described. There were 50 patients implanted with a HVAD during the study period [36 cardiomyopathy, 8 congenital heart disease (CHD), and 6 other] and 21 (42%) had a prior sternotomy. Median age (range) was 12.9 years (3.4-19.1), body surface area was 1.3 m2 (0.56-2.62), and weight was 41.8 kg (12.8-135.3). Most were INTERMACS profile 2 (n = 26, 52%). Mechanical ventilation and ECMO were used pre-HVAD in 13 (26%) and 6 (12%), respectively. Median time on VAD was 71 (5-602) days. Survival was 96% at 1 year; 3 deaths were recorded, all of whom had CHD (p = 0.001). Neither ECMO nor mechanical ventilation were associated with death (p > 0.29). Most frequent AEs were bleeding (n = 7, 14%) and infection (n = 7, 14%). Stroke was rare (n = 2, 4%). ACTION Network HVAD outcomes were excellent, with 96% survival at 1 year and only 4% occurrence of stroke. Major bleeding and infection were the most common adverse events.
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Affiliation(s)
- Scott R Auerbach
- From the Children's Hospital of Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
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Lorts A, Conway J, Schweiger M, Adachi I, Amdani S, Auerbach SR, Barr C, Bleiweis MS, Blume ED, Burstein DS, Cedars A, Chen S, Cousino-Hood MK, Daly KP, Danziger-Isakov LA, Dubyk N, Eastaugh L, Friedland-Little J, Gajarski R, Hasan A, Hawkins B, Jeewa A, Kindel SJ, Kogaki S, Lantz J, Law SP, Maeda K, Mathew J, May LJ, Miera O, Murray J, Niebler RA, O'Connor MJ, Özbaran M, Peng DM, Philip J, Reardon LC, Rosenthal DN, Rossano J, Salazar L, Schumacher KR, Simpson KE, Stiller B, Sutcliffe DL, Tunuguntla H, VanderPluym C, Villa C, Wearden PD, Zafar F, Zimpfer D, Zinn MD, Morales IRD, Cowger J, Buchholz H, Amodeo A. ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association. J Heart Lung Transplant 2021; 40:709-732. [PMID: 34193359 DOI: 10.1016/j.healun.2021.04.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Angela Lorts
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio.
| | | | - Martin Schweiger
- Universitäts-Kinderspitals Zürich - Herzchirurgie, Zurich, Switzerland
| | - Iki Adachi
- Texas Children's Hospital, Houston, Texas
| | | | - Scott R Auerbach
- Anschutz Medical Campus, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado
| | - Charlotte Barr
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | - Mark S Bleiweis
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | | | - Ari Cedars
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sharon Chen
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Kevin P Daly
- Boston Children's Hospital, Boston, Massachusetts
| | - Lara A Danziger-Isakov
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Nicole Dubyk
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lucas Eastaugh
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Asif Hasan
- Freeman Hospital, Newcastle upon Tyne, UK
| | - Beth Hawkins
- Boston Children's Hospital, Boston, Massachusetts
| | - Aamir Jeewa
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Steven J Kindel
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | - Jodie Lantz
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sabrina P Law
- Morgan Stanley Children's Hospital of New York Presbyterian, New York, New York
| | - Katsuhide Maeda
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Jacob Mathew
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Jenna Murray
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Robert A Niebler
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | | | - David M Peng
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joseph Philip
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | - David N Rosenthal
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Joseph Rossano
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Kurt R Schumacher
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | | | - David L Sutcliffe
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Chet Villa
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Matthew D Zinn
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Recent Era Outcomes of Mechanical Circulatory Support in Children With Congenital Heart Disease as a Bridge to Heart Transplantation. ASAIO J 2021; 68:432-439. [DOI: 10.1097/mat.0000000000001468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Lichtenstein KM, Tunuguntla HP, Peng DM, Buchholz H, Conway J. Pediatric ventricular assist device registries: update and perspectives in the era of miniaturized continuous-flow pumps. Ann Cardiothorac Surg 2021; 10:329-338. [PMID: 34159114 DOI: 10.21037/acs-2020-cfmcs-18] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The success of ventricular assist devices (VADs) in the treatment of end-stage heart failure in the adult population has led to industrial innovation in VAD design, focusing on miniaturization and the reduction of complications. A byproduct of these innovations was that newer generation devices could have clinical applications in the pediatric population. Over the last decade, VAD usage in the pediatric population has increased dramatically, and the newer generation continuous flow (CF) devices have begun to supplant the older, pulsatile flow (PF) devices, formerly the sole option for ventricular assist in the pediatric population. However, despite the increase in VAD implants in the pediatric population, patient numbers remain low, and the need to share data between pediatric VAD centers has become that much more important for the continued growth of VAD programs worldwide. The creation of pediatric VAD registries, such as the Pediatric Registry for Mechanical Circulatory Support (PediMACS), the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) and the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) has enabled the collection of aggregate data from VAD centers worldwide, and provides a valuable resource for clinicians and programs, as more and more pediatric heart failure patients are considered candidates for VAD therapy.
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Affiliation(s)
- Kevin M Lichtenstein
- Department of Cardiothoracic Surgery, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Hari P Tunuguntla
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - David M Peng
- Department of Pediatrics, Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Holger Buchholz
- Department of Cardiothoracic Surgery, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Conway
- Division of Pediatric Cardiology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
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Das BB, Moskowitz WB, Butler J. Current and Future Drug and Device Therapies for Pediatric Heart Failure Patients: Potential Lessons from Adult Trials. CHILDREN-BASEL 2021; 8:children8050322. [PMID: 33922085 PMCID: PMC8143500 DOI: 10.3390/children8050322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 12/11/2022]
Abstract
This review discusses the potential drug and device therapies for pediatric heart failure (HF) due to reduced systolic function. It is important to realize that most drugs that are used in pediatric HF are extrapolated from adult cardiology practices or consensus guidelines based on expert opinion rather than on evidence from controlled clinical trials. It is difficult to conclude whether the drugs that are well established in adult HF trials are also beneficial for children because of tremendous heterogeneity in the mechanism of HF in children and variations in the pharmacokinetics and pharmacodynamics of drugs from birth to adolescence. The lessons learned from adult trials can guide pediatric cardiologists to design clinical trials of the newer drugs that are in the pipeline to study their efficacy and safety in children with HF. This paper's focus is that the reader should specifically think through the pathophysiological mechanism of HF and the mode of action of drugs for the selection of appropriate pharmacotherapy. We review the drug and device trials in adults with HF to highlight the knowledge gap that exists in the pediatric HF population.
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Affiliation(s)
- Bibhuti B. Das
- Heart Center, Department of Pediatrics, Mississippi Children’s Hospital, University of Mississippi Medical Center, Jackson, MS 39212, USA;
- Correspondence: ; Tel.: +601-984-5250; Fax: +601-984-5283
| | - William B. Moskowitz
- Heart Center, Department of Pediatrics, Mississippi Children’s Hospital, University of Mississippi Medical Center, Jackson, MS 39212, USA;
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39212, USA;
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28
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Checchia PA, Brown KL, Wernovsky G, Penny DJ, Bronicki RA. The Evolution of Pediatric Cardiac Critical Care. Crit Care Med 2021; 49:545-557. [PMID: 33591011 DOI: 10.1097/ccm.0000000000004832] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Paul A Checchia
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Katherine L Brown
- Heart and Lung Division and Biomedical Research Centre, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Gil Wernovsky
- Cardiac Critical Care and Pediatric Cardiology, Children's National Medical Center and George Washington University School of Medicine and Health Sciences, Washington DC
| | - Daniel J Penny
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston TX
| | - Ronald A Bronicki
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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29
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Newington DFT, De Rita F, McCheyne A, Barker CL. Pediatric Ventricular Assist Device Implantation: An Anesthesia Perspective. Semin Cardiothorac Vasc Anesth 2021; 25:229-238. [DOI: 10.1177/1089253221998546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Ventricular assist devices (VADs) are increasingly being implanted in children, yet there is little literature to guide anesthetic management for these procedures. Aims To describe the pediatric population presenting for VAD implantation and the anesthetic management these patients receive. To compare (a) children under and over 12 months of age and (b) children with and without congenital heart disease. Methods Retrospective review of patients aged 0 to 17 years who underwent VAD implantation at a single center between 2014 and 2019. Results Seventy-seven VADs were implanted in 68 patients (46 left VADs, 24 biventricular VADs, 6 right VADs, and 1 univentricular VAD). One procedure was abandoned. Preoperatively, 20 (26%) patients were supported with extracorporeal membrane oxygenation and 57 (73%) patients were ventilated. Intraoperative donor blood products were required in 74 (95%) cases. Postimplantation inotropic support was required in 66 (85%) cases overall and 46 (100%) patients receiving a left VAD. Infants under 12 months were more likely to require preoperative extracorporeal membrane oxygenation (42% vs 19%), have femoral venous access (54% vs 28%), receive an intraoperative vasoconstrictor (42% vs 24%), and have delayed sternal closure (63 vs 22%). Mortality was higher in patients under 12 months (25% vs 19%) and in patients with congenital heart disease (25% vs 20%). Conclusions Children undergoing VAD implantation require high levels of preoperative organ support, high-dose intraoperative inotropic support, and high-volume blood transfusion. Children under 12 months and those with congenital heart disease are particularly challenging for anesthesiologists and have worse overall outcomes.
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30
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Nieto-Moral C, Polo-López L, Sánchez-Pérez R, Rey-Lois J, González-Rocafort Á, Aroca-Peinado Á. Asistencia ventricular izquierda y reparación de drenaje venoso pulmonar anómalo parcial, como puente al trasplante cardiaco. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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31
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Ragusa R, Di Molfetta A, Amodeo A, Trivella MG, Caselli C. Pathophysiology and molecular signalling in pediatric heart failure and VAD therapy. Clin Chim Acta 2020; 510:751-759. [PMID: 32949569 DOI: 10.1016/j.cca.2020.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
Heart Failure (HF) is a progressive clinical syndrome characterized by molecular and structural abnormalities that result in impaired ventricular filling and a reduced blood ejection. In pediatric patients, HF represents an important cause of morbidity and mortality, but underlying cause, presentation and disease course remains unclear in many cases. It is evident that a child is not a "small adult" and findings are not comparable. The adoption of a standardized clinical and surgical tools as well as increased biomolecular research and therapeutic trials targeting pediatric patients with HF would greatly improve the management of this special class of patients. This review examines the most current information about the pathophysiology and molecular mechanisms related to HF in children to identify gaps in our knowledge base to further improve clinical care and outcomes.
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Affiliation(s)
- Rosetta Ragusa
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Institute of Clinical Physiology, CNR, Pisa, Italy
| | - Arianna Di Molfetta
- Department of Cardiothoracic Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Antonio Amodeo
- Department of Cardiothoracic Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy
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Prada-Ruiz AC, Baker-Smith C, Beaty C, Matoq A, Pelletier G, Pizarro C, Tikare-Fakoya K, Tsuda T, Dadlani G. Echocardiographic assessment of mechanical circulatory support and heart transplant. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101272] [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: 10/23/2022]
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Fahnhorst SE, Beasley G, Goldberg JF, Martinez HR, Ryan KA, Towbin JA, Boston U, Absi M. Novel use of cangrelor in pediatrics: A pilot cohort study demonstrating use in ventricular assist devices. Artif Organs 2020; 45:38-45. [PMID: 33180355 DOI: 10.1111/aor.13782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/19/2020] [Accepted: 07/14/2020] [Indexed: 01/02/2023]
Abstract
Thromboembolic events and bleeding are major sources of morbidity among pediatric patients supported on a ventricular assist device (VAD). Pharmacokinetics and pharmacodynamics of enteral antiplatelet agents are affected and variable due to erratic enteral absorption in end-stage heart failure and VAD circulation. Additionally, 20%-40% of the population are poor metabolizers of clopidogrel, a prodrug, making cangrelor an alternative when antiplatelet therapy is crucial. Cangrelor has been used effectively and safely for short durations in adults during percutaneous coronary interventions, but the use of cangrelor is still under investigation in pediatrics. This case series utilized cangrelor, a novel short-acting, reversible, intravenous P2Y12 platelet inhibitor in managing pediatric patients supported with a VAD. We performed a retrospective, single-center review of patients admitted to a tertiary medical center with end-stage heart failure requiring mechanical circulatory support and concomitant cangrelor administration between January 2019 and March 2020. Platelet function testing, cangrelor dose, bleeding complications, thromboembolic events, and frequency of circuit interventions during the use of cangrelor were recorded. Optimal platelet reactivity, defined as P2Y12 < 180 platelet reaction units (PRU), was measured with serial point-of-care testing (VerifyNow). Seven patients, median age of 4.9 years, met the above criteria. Three patients had a diagnosis of complex congenital heart disease. Four patients had dilated or restrictive cardiomyopathy. All patients were on continuous flow VADs. The median VAD duration was 84.5 days (IQR 61.5-103). The median duration on cangrelor was 43 days (IQR 8-70). The median cangrelor dose to reach the therapeutic threshold was 0.75 μg/kg/min with the mean P2Y12 , while on cangrelor of 164.75 PRU. Bleeding complications included mild gastrointestinal bleeding and hematuria. There was one patient with pump thrombosis requiring intervention. There were no cerebrovascular events while on cangrelor. We report the first successful long-term use of cangrelor in pediatric patients. The reversibility and short half-life of cangrelor make it a feasible antiplatelet agent in selected patients. This data supports the use of cangrelor in children as a viable antiplatelet option; with minimal bleeding complications and no cerebrovascular events demonstrated in this cohort.
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Affiliation(s)
- Sarah E Fahnhorst
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Gary Beasley
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Jason F Goldberg
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Hugo R Martinez
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Kaitlin A Ryan
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Jeffrey A Towbin
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Umar Boston
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mohammed Absi
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
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VanderPluym CJ, Cantor RS, Machado D, Boyle G, May L, Griffiths E, Niebler RA, Lorts A, Rossano J, Sutcliffe DL, Lytrivi ID, Buchholz H, Fynn-Thompson F, Hawkins B, Conway J. Utilization and Outcomes of Children Treated with Direct Thrombin Inhibitors on Paracorporeal Ventricular Assist Device Support. ASAIO J 2020; 66:939-945. [PMID: 32740356 DOI: 10.1097/mat.0000000000001093] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Thrombotic and bleeding complications have historically been major causes of morbidity and mortality in pediatric ventricular assist device (VAD) support. Standard anticoagulation with unfractionated heparin is fraught with problems related to its heterogeneous biochemical composition and unpredictable pharmacokinetics. We sought to describe the utilization and outcomes in children with paracorporeal VAD support who are treated with direct thrombin inhibitors (DTIs) antithrombosis therapy. Retrospective multicenter review of all pediatric patients (aged <19 years) treated with a DTI (bivalirudin or argatroban) on paracorporeal VAD support, examining bleeding and thrombotic adverse events. From May 2012 to 2018, 43 children (21 females) at 10 centers in North America, median age 9.5 months (0.1-215 months) weighing 8.6 kg (2.8-150 kg), were implanted with paracorporeal VADs and treated with a DTI. Diagnoses included cardiomyopathy 40% (n = 17), congenital heart disease 37% (n = 16; single ventricle n = 5), graft vasculopathy 9% (n = 4), and other 14% (n = 6). First device implanted included Berlin Heart EXCOR 49% (n = 21), paracorporeal continuous flow device 44% (n = 19), and combination of devices in 7% (n = 3). Adverse events on DTI therapy included; major bleeding in 16% (n = 7) (2.6 events per 1,000 patient days of support on DTI), and stroke 12% (n = 5) (1.7 events per 1,000 patient days of support on DTI). Overall survival to transplantation (n = 30) or explantation (n = 8) was 88%. This is the largest multicenter experience of DTI use for anticoagulation therapy in pediatric VAD support. Outcomes are encouraging with lower major bleeding and stroke event rate than that reported in literature using other anticoagulation agents in pediatric VAD support.
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Affiliation(s)
- Christina J VanderPluym
- From the Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Desiree Machado
- Department of Pediatrics and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Gerald Boyle
- Center for Pediatric and Congenital Heart Disease, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lindsay May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Division of Cardiothoracic Surgery, University of Utah Health Care, Salt Lake City, Utah
| | - Robert A Niebler
- Department of Pediatrics, Section of Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joseph Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David L Sutcliffe
- Division of Cardiology, Children's Health Dallas, UT Southwestern Medical Center, Dallas, Texas
| | - Irene D Lytrivi
- From the Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Holger Buchholz
- Department of Cardiovascular Surgery, University of Alberta, Edmonton, Alberta
| | - Francis Fynn-Thompson
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Beth Hawkins
- From the Department of Cardiology, Boston Children's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Jennifer Conway
- Division of Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta
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Butto A, Teele SA, Sleeper LA, Thrush PT, Philip J, Lu M, Cantor RS, Rossano JW. The impact of pre-implant illness severity on the outcomes of pediatric patients undergoing durable ventricular assist device. J Heart Lung Transplant 2020; 39:666-674. [DOI: 10.1016/j.healun.2020.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/16/2020] [Accepted: 02/14/2020] [Indexed: 12/17/2022] Open
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Abstract
The total artificial heart (TAH) is a device that replaces the failing ventricles. There have been numerous TAHs designed over the last few decades, but the one with the largest patient experience is the SynCardia temporary TAH. The 50-mL and 70-mL sizes have been approved in the United States, Europe, and Canada as a bridge to transplantation. It is indicated in patients with severe biventricular failure or structural heart issues that preclude the use of a left ventricular assist device. The majority of the patients implanted are Interagency Registry for Mechanically Assisted Circulatory Support profile 1 or 2. The 1-year survival in experienced centers that have implanted over 10 TAHs is 73%. The risk factors for death include older age, need for preimplantation dialysis, and malnutrition. The most common causes of death are multiple organ failure, usually the result of physiologic deterioration before implantation, and neurologic dysfunction. The device allows the patient to be discharged home and managed as an outpatient. Proper patient selection, the timing of intervention, patient care, and device management are essential for a suitable outcome. In addition, the CARMAT TAH is another device that will soon be studied in a clinical trial in the United States. The BiVACOR TAH is a revolutionary design utilizing electromagnetic levitation that is expected to enter a clinical trial in the next few years.
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Houska NM, Schwartz LI. The Year in Review: Anesthesia for Congenital Heart Disease 2019. Semin Cardiothorac Vasc Anesth 2020; 24:175-186. [DOI: 10.1177/1089253220920476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review focuses on the literature published from January 2019 to February 2020 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Five themes are addressed during this time period, and 59 peer-reviewed articles are discussed.
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Affiliation(s)
- Nicholas M. Houska
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
| | - Lawrence I. Schwartz
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
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Lasa JJ, Gaies M, Bush L, Zhang W, Banerjee M, Alten JA, Butts RJ, Cabrera AG, Checchia PA, Elhoff J, Lorts A, Rossano JW, Schumacher K, Shekerdemian LS, Price JF. Epidemiology and Outcomes of Acute Decompensated Heart Failure in Children. Circ Heart Fail 2020; 13:e006101. [PMID: 32301336 DOI: 10.1161/circheartfailure.119.006101] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute decompensated heart failure (ADHF) is a highly morbid condition among adults. Little is known about outcomes in children with ADHF. We analyzed the Pediatric Cardiac Critical Care Consortium registry to determine the epidemiology, contemporary treatments, and predictors of mortality in critically ill children with ADHF. METHODS Cardiac intensive care unit (CICU) patients ≤18 years of age meeting Pediatric Cardiac Critical Care Consortium criteria for ADHF were included. ADHF was defined as systolic or diastolic dysfunction requiring continuous vasoactive or diuretic infusion, respiratory support, or mechanical circulatory support. Demographics, diagnosis, therapies, complications, and mortality are described for the cohort. Predictors of CICU mortality were identified using logistic regression. RESULTS Among 26 294 consecutive admissions (23 centers), 1494 (6%) met criteria for analysis. Median age was 0.93 years (interquartile range, 0.1-9.3 years). Patients with congenital heart disease (CHD) comprised 57% of the cohort. Common therapies included the following: vasoactive infusions (88%), central venous catheters (86%), mechanical ventilation (59%), and high flow nasal cannula (46%). Common complications were arrhythmias (19%), cardiac arrest (10%), sepsis (7%), and acute renal failure requiring dialysis (3%). Median length of CICU stay was 7.9 days (interquartile range, 3-18 days) and the CICU readmission rate was 22%. Overall, CICU mortality was 15% although higher for patients with CHD versus non-CHD (19% versus 11%; P<0.001). Independent risk factors associated with CICU mortality included age <30 days, CHD, vasoactive infusions, ventricular tachycardia, mechanical ventilation, sepsis, pulmonary hypertension, extracorporeal membrane oxygenation, and cardiac arrest. CONCLUSIONS ADHF in children is characterized by comorbidities, high mortality rates, and frequent readmission, especially among patients with CHD. Opportunities exist to determine best practices around appropriate use of mechanical support, cardiac arrest prevention, and optimal heart transplantation candidacy to improve outcomes for these patients.
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Affiliation(s)
- Javier J Lasa
- Division of Critical Care Medicine (J.J.L., P.A.C., J.E., L.S.S.), Texas Children's Hospital, Baylor College of Medicine, Houston.,Division of Cardiology (J.J.L., A.G.C., J.F.P.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor (M.G., K.S.)
| | - Lauren Bush
- PC Data Coordinating Center, Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan, Ann Arbor (L.B., W.Z.)
| | - Wenying Zhang
- PC Data Coordinating Center, Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan, Ann Arbor (L.B., W.Z.)
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor (M.B.)
| | - Jeffrey A Alten
- Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, OH (J.A.A., A.L.)
| | - Ryan J Butts
- UT Southwestern Department of Pediatrics, Division of Cardiology, UT Southwestern Medical Center, Dallas, TX (R.J.B.)
| | - Antonio G Cabrera
- Division of Cardiology (J.J.L., A.G.C., J.F.P.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Paul A Checchia
- Division of Critical Care Medicine (J.J.L., P.A.C., J.E., L.S.S.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Justin Elhoff
- Division of Critical Care Medicine (J.J.L., P.A.C., J.E., L.S.S.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Angela Lorts
- Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, OH (J.A.A., A.L.)
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (J.W.R.)
| | - Kurt Schumacher
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor (M.G., K.S.)
| | - Lara S Shekerdemian
- Division of Critical Care Medicine (J.J.L., P.A.C., J.E., L.S.S.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Jack F Price
- Division of Cardiology (J.J.L., A.G.C., J.F.P.), Texas Children's Hospital, Baylor College of Medicine, Houston
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Shin JH, Park HK, Jung SY, Kim AY, Jung JW, Shin YR. The First Pediatric Heart Transplantation Bridged by a Durable Left Ventricular Assist Device in Korea. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:79-81. [PMID: 32309207 PMCID: PMC7155184 DOI: 10.5090/kjtcs.2020.53.2.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 11/01/2019] [Accepted: 11/04/2019] [Indexed: 11/24/2022]
Abstract
Treatment options for children with end-stage heart failure are limited. We report the first case of a successful pediatric heart transplantation bridged with a durable left ventricular assist device in Korea. A 10-month-old female infant with dilated cardiomyopathy and left ventricular non-compaction was listed for heart transplantation. During the waiting period, the patient’s status deteriorated. Therefore, we decided to provide support with a durable left ventricular assist device as a bridge to transplantation. The patient was successfully bridged to heart transplantation with effective support and without any major adverse events.
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Affiliation(s)
- Jung Hoon Shin
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Han Ki Park
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Se Yong Jung
- Division of Pediatric Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Ah Young Kim
- Division of Pediatric Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Jo Won Jung
- Division of Pediatric Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Yu Rim Shin
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
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Variations of circulating miRNA in paediatric patients with Heart Failure supported with Ventricular Assist Device: a pilot study. Sci Rep 2020; 10:5905. [PMID: 32246041 PMCID: PMC7125126 DOI: 10.1038/s41598-020-62757-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/18/2020] [Indexed: 01/13/2023] Open
Abstract
Circulating miRNAs (c-miRNAs) are promising biomarkers for HF diagnosis and prognosis. There are no studies on HF pediatric patients undergoing VAD-implantation. Aims of this study were: to examine the c-miRNAs profile in HF children; to evaluate the effects of VAD on c-miRNAs levels; to in vitro validate putative c-miRNA targets. c-miRNA profile was determined in serum of HF children by NGS before and one month after VAD-implant. The c-miRNA differentially expressed were analyzed by real time-PCR, before and at 4 hrs,1,3,7,14,30 days after VAD-implant. A miRNA mimic transfection study in HepG2 cells was performed to validate putative miRNA targets selected through miRWalk database. Thirteen c-miRNAs were modified at 30 days after VAD-implant compared to pre-VAD at NSG, and, among them, six c-miRNAs were confirmed by Real-TimePCR. Putative targets of the validated c-miRNAs are involved in the hemostatic process. The in vitro study confirmed a down-regulatory effect of hsa-miR-409-3p towards coagulation factor 7 (F7) and F2. Of note, all patients had thrombotic events requiring pump change. In conclusion, in HF children, the level of six c-miRNAs involved in the regulation of hemostatic events changed after 30 days of VAD-treatment. In particular, the lowering of c-miR-409-3p regulating both F7 and F2 could reflect a pro-thrombotic state after VAD-implant.
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41
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Blood trauma potential of the HeartWare Ventricular Assist Device in pediatric patients. J Thorac Cardiovasc Surg 2020; 159:1519-1527.e1. [DOI: 10.1016/j.jtcvs.2019.06.084] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 01/19/2023]
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The Creation of a Pediatric Health Care Learning Network: The ACTION Quality Improvement Collaborative. ASAIO J 2020; 66:441-446. [DOI: 10.1097/mat.0000000000001133] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Right heart failure with left ventricular assist device implantation in children: An analysis of the Pedimacs registry database. J Heart Lung Transplant 2020; 39:231-240. [DOI: 10.1016/j.healun.2019.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 11/23/2022] Open
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44
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Baez Hernandez N, Kirk R, Sutcliffe D, Davies R, Jaquiss R, Gao A, Zhang S, Butts RJ. Utilization and outcomes in biventricular assist device support in pediatrics. J Thorac Cardiovasc Surg 2019; 160:1301-1308.e2. [PMID: 31948738 DOI: 10.1016/j.jtcvs.2019.11.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Patients with biventricular assist devices (BiVADs) have worse outcomes than those with left ventricular assist devices (LVADs). It is unclear whether these outcomes are due to device selection or patient factors. We used propensity score matching to reduce patient heterogeneity and compare outcomes in pediatric patients supported with BiVADs with a similar LVAD cohort. METHODS The Pedimacs registry was queried for patients who were supported with BiVAD or LVAD. Patients were analyzed by BiVAD or LVAD at primary implant and the 2 groups were compared before and after using propensity score matching. RESULTS Of 363 patients who met inclusion criteria, 63 (17%) underwent primary BiVAD support. After propensity score matching, differences between cohorts were reduced. Six months after implant, in the BiVAD cohort (LVAD cohort) 52.5% (42.5%) had been transplanted; 32.5% (40%) were alive with device, and 15% (10%) had died. Survival was similar between cohorts (P = .31, log-rank), but patients with BiVADs were more likely to experience a major adverse event in the form of bleeding (P = .04, log-rank). At 1 week and 1 and 3 months' postimplant, the percentage of patients on mechanical ventilation, on dialysis, or with elevated bilirubin was similar between the 2 groups. CONCLUSIONS When propensity scores were used to reduce differences in patient characteristics, there were no differences in survival but more major adverse events in the patients with BiVADs, particularly bleeding. Differences in unmatched patient outcomes between LVAD and BiVAD cohorts likely represent differences in severity of illness rather than mode of support.
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Affiliation(s)
| | - Richard Kirk
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David Sutcliffe
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Ryan Davies
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Robert Jaquiss
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Ang Gao
- Department of Clinical Science, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Song Zhang
- Department of Clinical Science, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Ryan J Butts
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Tex
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Shah M, Lin KY. Failure (at any stage) and the role of mechanical circulatory support in hypoplastic left heart syndrome. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.101134] [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: 10/26/2022]
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46
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Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian AM, Haskell SE, Kilgannon JH, Lasa JJ, Hazinski MF. Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e194-e233. [DOI: 10.1161/cir.0000000000000697] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.
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Ventricular Assist Devices in Pediatric Patients-Stasis or Progress? Pediatr Crit Care Med 2019; 20:784-785. [PMID: 31397813 DOI: 10.1097/pcc.0000000000001994] [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: 11/26/2022]
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48
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Hollander SA, Cantor RS, Sutherland SM, Koehl DA, Pruitt E, McDonald N, Kirklin JK, Ravekes WJ, Ameduri R, Chrisant M, Hoffman TM, Lytrivi ID, Conway J. Renal injury and recovery in pediatric patients after ventricular assist device implantation and cardiac transplant. Pediatr Transplant 2019; 23:e13477. [PMID: 31124590 DOI: 10.1111/petr.13477] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/05/2019] [Accepted: 04/18/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The use of ventricular assist devices (VADs) in children with heart failure may be of particular benefit to those with accompanying renal failure, as improved renal function is seen in some, but not all recipients. We hypothesized that persistent renal dysfunction at 7 days and/or 1 month after VAD implantation would predict chronic kidney disease (CKD) 1 year after heart transplantation (HT). METHODS Linkage analysis of all VAD patients enrolled in both the PEDIMACS and PHTS registries between 2012 and 2016. Persistent acute kidney injury (P-AKI), defined as a serum creatinine ≥1.5× baseline, was assessed at post-implant day 7. Estimated glomerular filtration rate (eGFR) was determined at implant, 30 days thereafter, and 12 months post-HT. Pre-implant eGFR, eGFR normalization (to ≥90 mL/min/1.73 m2 ), and P-AKI were used to predict post-HT CKD (eGFR <90 mL/min/1.73 m2 ). RESULTS The mean implant eGFR was 85.4 ± 46.5 mL/min/1.73 m2 . P-AKI was present in 19/188 (10%). Mean eGFR at 1 month post-VAD implant was 131.1 ± 62.1 mL/min/1.73 m2 , significantly increased above baseline (P < 0.001). At 1 year post-HT (n = 133), 60 (45%) had CKD. Lower pre-implant eGFR was associated with post-HT CKD (OR 0.99, CI: 0.97-0.99, P = 0.005); P-AKI was not (OR 0.96, CI: 0.3-3.0, P = 0.9). Failure to normalize renal function 30 days after implant was highly associated with CKD at 1 year post-transplant (OR 12.5, CI 2.8-55, P = 0.003). CONCLUSIONS Renal function improves after VAD implantation. Lower pre-implant eGFR and failure to normalize renal function during the support period are risk factors for CKD development after HT.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Scott M Sutherland
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Palo Alto, California
| | - Devin A Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth Pruitt
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nancy McDonald
- Solid Organ Transplant Services, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Rebecca Ameduri
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Characteristics and Outcomes of Pediatric Patients Supported With Ventricular Assist Device-A Multi-Institutional Analysis. Pediatr Crit Care Med 2019; 20:744-752. [PMID: 31162368 DOI: 10.1097/pcc.0000000000001966] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The use of ventricular assist devices for pediatric patients with heart failure is increasing, but is associated with significant morbidity and mortality. Our objectives were to describe the admission outcomes and resource utilization of pediatric patients supported with ventricular assist devices, utilizing a multicenter database. DATA SOURCES Pediatric Health Information System database (comprising 49 nonprofit children's hospitals). STUDY SELECTION Retrospective cohort analysis of the database from January 2006 to September 2015 for all admissions less than or equal to 21 years old with ventricular assist device implantation. DATA EXTRACTION The primary outcome was hospital mortality. The secondary outcomes were hospital length of stay and adjusted cost. DATA SYNTHESIS We analyzed 744 ventricular assist device implantations (740 patients), 422 (57%) males, and 363 (49%) non-Hispanic white. Median age at admission was 5.9 years (interquartile range, 0.9-13.5 yr), and median length of stay was 69 days (interquartile range, 36-122 d). The overall hospital mortality was 188 (25%), whereas 395 (53%) were transplanted and 141 (19%) were discharged on ventricular assist device. Extracorporeal membrane oxygenation was used, in addition to ventricular assist device, in 340 (46%). The majority of ventricular assist device implantations (453, 61%) were from 2011 to 2015 (compared to 2006-2010). More patients discharged on ventricular assist device from 2011 to 2015 (23% vs 13% in 2006-2010; p = 0.001). There was no difference in median age, mortality, length of stay, or adjusted costs between these time periods. On multivariable analysis, underlying congenital heart disease, renal failure, liver congestion, sepsis, cerebrovascular accident, and extracorporeal membrane oxygenation were associated with hospital mortality. Sepsis and ventricular assist device replacement/repair were associated with higher adjusted cost and longer length of stay. CONCLUSIONS The pediatric ventricular assist device experience continues to grow, with a significant increase in the number of patients undergoing ventricular assist device implantation and a higher proportion being discharged from hospital on ventricular assist device support in recent years. Underlying congenital heart disease, renal failure, sepsis, cerebrovascular accident, and extracorporeal membrane oxygenation are significantly associated with hospital mortality.
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