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Shalhoub K, Heydarian HC, Hanke SP, Cnota JF, Stein LH, Tepe B, Hill GD. Achieving an Optimal Outcome After Stage 1 Palliation for Hypoplastic Left Heart Syndrome and Variants: Frequency, Associated Factors, and Subsequent Outcomes. J Am Heart Assoc 2024; 13:e032055. [PMID: 38860404 PMCID: PMC11255728 DOI: 10.1161/jaha.123.032055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 04/18/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND We sought to measure frequency of achieving an optimal outcome after stage 1 palliation (S1P) for hypoplastic left heart syndrome and variants, determine factors associated with optimal outcomes, and compare outcomes after stage 2 palliation (S2P) using the National Pediatric Cardiology Quality Improvement Collaborative database (2008-2016). METHODS AND RESULTS This is a retrospective cohort study with optimal outcome defined a priori as meeting all of the following: (1) discharge after S1P in <19 days (top quartile), (2) no red flag or major event readmissions before S2P, and (3) performing S2P between 90 and 240 days of age. Optimal outcome was achieved in 256 of 2182 patients (11.7%). Frequency varied among centers from 0% to 25%. Factors independently associated with an optimal outcome after S1P were higher gestational age (odds ratio [OR], 1.1 per week [95% CI, 1.0-1.2]; P=0.02); absence of a genetic syndrome (OR, 2.5 [95% CI, 1.2-5]; P=0.02); not requiring a post-S1P catheterization (OR, 2.7 [95% CI, 1.5-4.8]; P=0.01), intervention (OR, 1.5 [95% CI, 1.1-2]; P=0.006), or a procedure (OR, 4.5 [95% CI, 2.8-7.1]; P<0.001) before discharge; and not having a post-S1P complication (OR, 2.7 [95% CI, 1.9-3.7]; P<0.001). Those with an optimal outcome after S1P had improved S2P outcomes including shorter length of stay, less ventilator days, shorter bypass time, and fewer postoperative complications. CONCLUSIONS Identifying patients at lowest risk for poor outcomes during the home interstage period could shift necessary resources to those at higher risk, alter S2P postoperative expectations, and improve quality of life for families at lower risk.
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Affiliation(s)
- Khayri Shalhoub
- Department of PediatricsBaylor College of MedicineHoustonTXUSA
- Section of Critical Care Medicine & CardiologyTexas Children’s HospitalHoustonTXUSA
| | - Haleh C. Heydarian
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Samuel P. Hanke
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - James F. Cnota
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Laurel H. Stein
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Brooke Tepe
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Garick D. Hill
- Division of CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
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2
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Ahmed H, Anderson JB, Bates KE, Lannon CM, Brown DW. The NEONATE score predicts freedom from interstage mortality or transplant in a modern cohort. Cardiol Young 2024; 34:981-988. [PMID: 38014532 DOI: 10.1017/s1047951123003542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Derived from the National Pediatric Cardiology Quality Improvement Collaborative registry, the NEONATE risk score predicted freedom from interstage mortality or heart transplant for patients with single ventricle CHD and aortic arch hypoplasia discharged home following Stage 1 palliation. OBJECTIVES We sought to validate the score in an external, modern cohort. METHODS This was a retrospective cohort analysis of single ventricle CHD and aortic arch hypoplasia patients enrolled in the National Pediatric Cardiology Quality Improvement Collaborative Phase II registry from 2016 to 2020, who were discharged home after Stage 1 palliation. Points were allocated per the NEONATE score (Norwood type-Norwood/Blalock-Taussig shunt: 3, Hybrid: 12; extracorporeal membrane oxygenation post-op: 9, Opiates at discharge: 6, No Digoxin at discharge: 9, Arch Obstruction on discharge echo: 9, Tricuspid regurgitation ≥ moderate on discharge echo: 12; Extra oxygen plus ≥ moderate tricuspid regurgitation: 28). The composite primary endpoint was interstage mortality or heart transplant. RESULTS In total, 1026 patients met inclusion criteria; 61 (6%) met the primary outcome. Interstage mortality occurred in 44 (4.3%) patients at a median of 129 (IQR 62,195) days, and 17 (1.7%) were referred for heart transplant at a 167 (114,199) days of life. The median NEONATE score was 0(0,9) in those who survived to Stage 2 palliation compared to 9(0,15) in those who experienced interstage mortality or heart transplant (p < 0.001). Applying a NEONATE score cut-off of 17 points that separated patients into low- and high-risk groups in the learning cohort provided 91% specificity, negative predictive value of 95%, and overall accuracy of 87% (85.4-89.5%). CONCLUSION In a modern cohort of patients with single ventricle CHD and aortic arch hypoplasia, the NEONATE score remains useful at discharge post-Stage 1 palliation to predict freedom from interstage mortality or heart transplant.
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Affiliation(s)
- Humera Ahmed
- Departments of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Katherine E Bates
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Carole M Lannon
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Avasarala V, Aitharaju V, Encisco EM, Rymeski B, Ponsky TA, Huntington JT. Enteral access and reflux management in neonates with severe univentricular congenital heart disease: literature review and proposed algorithm. Eur J Pediatr 2023; 182:3375-3383. [PMID: 37191690 DOI: 10.1007/s00431-023-04992-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023]
Abstract
Neonates with severe congenital heart disease undergoing surgical repair may face various complications, including failure to thrive. Feeding tube placement and fundoplication are often performed to combat poor growth in neonates. With the variety of feeding tubes available and controversy surrounding when fundoplication is appropriate, there is no current protocol to determine which intervention is necessary for this patient population. We aim to provide an evidence-based feeding algorithm for this patient population. Initial searches for relevant publications yielded 696 publications; after review of these studies and inclusion of additional studies through external searches, a total of 38 studies were included for qualitative synthesis. Many of the studies utilized did not directly compare the different feeding modalities. Of the 38 studies included, five studies were randomized control trials, three studies were literature reviews, one study was an online survey, and the remaining twenty-nine studies were observational. There is no current evidence to suggest that this specific patient population should be treated differently regarding enteral feeding. We propose an algorithm to assist optimal feeding for neonates with congenital heart disease. Conclusion: Nutrition remains a vital component of the care of neonates with congenital heart disease; determining the optimal feeding strategy for these patients can be approached like other neonates.
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Affiliation(s)
- Vardhan Avasarala
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Varun Aitharaju
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Ellen M Encisco
- Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH, 44308, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Rymeski
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Todd A Ponsky
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
- Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH, 44308, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Justin T Huntington
- Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH, 44308, USA.
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Sunthankar SD, Zhao J, Wei WQ, Hill GD, Parra DA, Kohl K, McCoy A, Jayaram NM, Godown J. Machine Learning to Predict Interstage Mortality Following Single Ventricle Palliation: A NPC-QIC Database Analysis. Pediatr Cardiol 2023; 44:1242-1250. [PMID: 36820914 PMCID: PMC10627450 DOI: 10.1007/s00246-023-03130-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
There is high risk of mortality between stage I and stage II palliation of single ventricle heart disease. This study aimed to leverage advanced machine learning algorithms to optimize risk-prediction models and identify features most predictive of interstage mortality. This study utilized retrospective data from the National Pediatric Cardiology Quality Improvement Collaborative and included all patients who underwent stage I palliation and survived to hospital discharge (2008-2019). Multiple machine learning models were evaluated, including logistic regression, random forest, gradient boosting trees, extreme gradient boost trees, and light gradient boosting machines. A total of 3267 patients were included with 208 (6.4%) interstage deaths. Machine learning models were trained on 180 clinical features. Digoxin use at discharge was the most influential factor resulting in a lower risk of interstage mortality (p < 0.0001). Stage I surgery with Blalock-Taussig-Thomas shunt portended higher risk than Sano conduit (7.8% vs 4.4%, p = 0.0002). Non-modifiable risk factors identified with increased risk of interstage mortality included female sex, lower gestational age, and lower birth weight. Post-operative risk factors included the requirement of unplanned catheterization and more severe atrioventricular valve insufficiency at discharge. Light gradient boosting machines demonstrated the best performance with an area under the receiver operative characteristic curve of 0.642. Advanced machine learning algorithms highlight a number of modifiable and non-modifiable risk factors for interstage mortality following stage I palliation. However, model performance remains modest, suggesting the presence of unmeasured confounders that contribute to interstage risk.
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Affiliation(s)
- Sudeep D Sunthankar
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
- Thomas P. Graham Jr Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, 2220 Children's Way, Suite 5230, Nashville, TN, 37232, USA.
| | - Juan Zhao
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Garick D Hill
- Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David A Parra
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Karen Kohl
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Allison McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Natalie M Jayaram
- Division of Pediatric Cardiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Justin Godown
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
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Payne E, Garden F, d'Udekem Y, Weintraub R, McCallum Z, Wightman H, Zentner D, Cordina R, Wilson TG, Ayer J. Prolonged Enteral Tube Feeding in Infants With a Functional Single Ventricle Is Associated With Adverse Outcomes After Fontan Completion. J Pediatr 2023:S0022-3476(23)00042-2. [PMID: 36708874 DOI: 10.1016/j.jpeds.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To define the baseline characteristics of long-term tube-fed single ventricle patients, investigate associations between long-term enteral tube feeding and growth, and determine associations with long-term outcomes after Fontan procedure. STUDY DESIGN We performed a retrospective cohort study of patients in the Australia and New Zealand Fontan Registry undergoing treatment at the Royal Children's Hospital, the Children's Hospital at Westmead, Royal Melbourne Hospital, and Royal Prince Alfred Hospital from 1981-2018. Patients were defined as tube-fed (TF) or non-tube-fed (NTF) based on enteral tube feeding at age 90 days. Feeding groups were compared regarding BMI trajectory, BMI at last follow-up, and long-term incidence of severe Fontan failure. RESULTS Of 390 patients (56(14%) TF, 334(86%) NTF), TF was associated with right ventricular dominance, hypoplastic left heart syndrome, Norwood procedure, increased procedures prior to Fontan, extracardiac conduit Fontan, Fontan fenestration, and atrioventricular valve repair/replacement. TF patients were less likely to be in the higher compared with lowest 0-6 month BMI trajectory (P<0.01,P=0.03), had lower 6month weight-for-age z-scores (P<0.01) and length-for-age z-scores (P=0.01). TF were less likely to be overweight/obese at pediatric follow-up (HR=0.31,95%CI:0.12-0.80;P=0.02) and more likely to be underweight at adult follow-up ((HR=16.51; 5%CI:2.70-101.10;P<0.01).TF compared with NTF was associated with increased risk of severe Fontan failure (HR=4.13;95%CI=1.65,10.31;P<0.01). CONCLUSIONS Prolonged infant enteral tube feeding is an independent marker of poor growth and adverse clinical outcomes extending long-term post-Fontan procedure.
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Affiliation(s)
- Emma Payne
- The University of Sydney, Sydney, AUSTRALIA; The University of Melbourne, Melbourne, AUSTRALIA
| | - Frances Garden
- The University of New South, Sydney, AUSTRALIA; The Ingham Institute of Applied Medical Research, Sydney, AUSTRALIA
| | | | - Robert Weintraub
- The University of Melbourne, Melbourne, AUSTRALIA; The Royal Children's Hospital, Melbourne, AUSTRALIA; The Murdoch Children's Research Institute, Melbourne, AUSTRALIA
| | - Zoe McCallum
- The Royal Children's Hospital, Melbourne, AUSTRALIA
| | | | - Dominica Zentner
- The University of Melbourne, Melbourne, AUSTRALIA; The Royal Melbourne Hospital, Melbourne, AUSTRALIA
| | - Rachael Cordina
- The University of Sydney, Sydney, AUSTRALIA; The Royal Prince Alfred Hospital, Sydney, AUSTRALIA
| | - Thomas G Wilson
- The University of Melbourne, Melbourne, AUSTRALIA; The Royal Children's Hospital, Melbourne, AUSTRALIA
| | - Julian Ayer
- The University of Sydney, Sydney, AUSTRALIA; The Heart Centre for Children, The Sydney Children's Hospital Network, Sydney, AUSTRALIA.
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Backes ER, Afonso NS, Guffey D, Tweddell JS, Tabbutt S, Rudd NA, O'Harrow G, Molossi S, Hoffman GM, Hill G, Heinle JS, Bhat P, Anderson JB, Ghanayem NS. Cumulative comorbid conditions influence mortality risk after staged palliation for hypoplastic left heart syndrome and variants. J Thorac Cardiovasc Surg 2023; 165:287-298.e4. [PMID: 35599210 DOI: 10.1016/j.jtcvs.2022.01.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/29/2021] [Accepted: 01/27/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Prematurity, low birth weight, genetic syndromes, extracardiac conditions, and secondary cardiac lesions are considered high-risk conditions associated with mortality after stage 1 palliation. We report the impact of these conditions on outcomes from a prospective multicenter improvement collaborative. METHODS The National Pediatric Cardiology Quality Improvement Collaborative Phase II registry was queried. Comorbid conditions were categorized and quantified to determine the cumulative burden of high-risk diagnoses on survival to the first birthday. Logistic regression was applied to evaluate factors associated with mortality. RESULTS Of the 1421 participants, 40% (575) had at least 1 high-risk condition. The aggregate high-risk group had lower survival to the first birthday compared with standard risk (76.2% vs 88.1%, P < .001). Presence of a single high-risk diagnosis was not associated with reduced survival to the first birthday (odds ratio, 0.71; confidence interval, 0.49-1.02, P = .066). Incremental increases in high-risk diagnoses were associated with reduced survival to first birthday (odds ratio, 0.23; confidence interval, 0.15-0.36, P < .001) for 2 and 0.17 (confidence interval, 0.10-0.30, P < .001) for 3 to 5 high-risk diagnoses. Additional analysis that included prestage 1 palliation characteristics and stage 1 palliation perioperative variables identified multiple high-risk diagnoses, poststage 1 palliation extracorporeal membrane oxygenation support (odds ratio, 0.14; confidence interval, 0.10-0.22, P < .001), and cardiac reoperation (odds ratio, 0.66; confidence interval, 0.45-0.98, P = .037) to be associated with reduced survival odds to the first birthday. CONCLUSIONS The presence of 1 high-risk diagnostic category was not associated with decreased survival at 1 year. Cumulative diagnoses across multiple high-risk diagnostic categories were associated with decreased odds of survival. Further patient accrual is needed to evaluate the impact of specific comorbid conditions within the broader high-risk categories.
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Affiliation(s)
- Emily R Backes
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex.
| | - Natasha S Afonso
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Danielle Guffey
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - James S Tweddell
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sarah Tabbutt
- Divisions of Critical Care and Cardiology, Department of Pediatrics, University of California San Francisco and Benioff Children's Hospital, San Francisco, Calif
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Ginny O'Harrow
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill
| | - Silvana Molossi
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - George M Hoffman
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Garick Hill
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey S Heinle
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Priya Bhat
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Jeffrey B Anderson
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill; Advocate Children's Hospital, Oak Lawn, Ill
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Increased interstage morbidity and mortality following stage 1 palliation in patients with genetic abnormalities. Cardiol Young 2022; 32:1999-2004. [PMID: 35137681 DOI: 10.1017/s1047951122000166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hypoplastic left heart syndrome and single ventricle variants with aortic hypoplasia are commonly classified as severe forms of CHD. We hypothesised patients with these severe defects and reported genetic abnormalities have increased morbidity and mortality during the interstage period. METHODS AND RESULTS This was a retrospective review of the National Pediatric Cardiology Quality Improvement Collaborative Phase I registry. Three patient groups were identified: major syndromes, other genetic abnormalities, and no reported genetic abnormality. Tukey post hoc test was applied for pairwise group comparisons of length of stay, death, and combined outcome of death, not a candidate for stage 2 palliation, and heart transplant. Participating centres received a survey to establish genetic testing and reporting practices. Of the 2182 patients, 110 (5%) had major genetic syndromes, 126 (6%) had other genetic abnormalities, and 1946 (89%) had no genetic abnormality. Those with major genetic syndromes weighed less at birth and stage 1 palliation. Patients with no reported genetic abnormalities reached full oral feeds sooner and discharged earlier. The combined outcome of death, not a candidate for stage 2 palliation, and heart transplant was more common in those with major syndromes. Survey response was low (n = 23, 38%) with only 14 (61%) routinely performing and reporting genetic testing. CONCLUSIONS Patients with genetic abnormalities experienced greater morbidity and mortality during the interstage period than those with no reported genetic abnormalities. Genetic testing and reporting practices vary significantly between participating centres.
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8
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Meakins LT, Knox P, Legge L, Penner M, Wiebe P, Mackie AS. Interstage mortality among infants with hypoplastic left heart syndrome: Outcomes of a multicentre home monitoring program. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101610] [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: 12/23/2022]
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9
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Vergales J, Figueroa M, Frommelt M, Putschoegl A, Singh Y, Murray P, Wood G, Allen K, Villafane J. Transitioning Neonates With CHD to Outpatient Care: A State-of-the-Art Review. Pediatrics 2022; 150:189880. [PMID: 36317969 DOI: 10.1542/peds.2022-056415m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jeffrey Vergales
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Mayte Figueroa
- Divisions of Pediatric Cardiology and Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Michele Frommelt
- Children's Wisconsin, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Adam Putschoegl
- Division of Pediatric Cardiology, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Yogen Singh
- Division of Pediatric Cardiology and Neonatology, Cambridge University Hospitals, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Peter Murray
- Division of Neonatology, University of Virginia, Charlottesville, Virginia
| | - Garrison Wood
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Kiona Allen
- Division of Pediatric Cardiology and Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Juan Villafane
- Cincinnati Children's Hospital, Division of Pediatric Cardiology, University of Cincinnati, Cincinnati, Ohio
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Broberg MCG, Cheifetz IM, Plummer ST. Current evidence for pharmacologic therapy following stage 1 palliation for single ventricle congenital heart disease. Expert Rev Cardiovasc Ther 2022; 20:627-636. [PMID: 35848073 DOI: 10.1080/14779072.2022.2103542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Infants with single ventricle congenital heart disease are vulnerable to complications between stage 1 and stage 2 of palliation. Pharmaceutical treatment during this period is varied and often dependent on institutional practices as there is little evidence supporting a particular treatment path. AREAS COVERED This review focuses on medical management of patients following stage I palliation. We performed a scoping review of the current literature regarding angiotensin converting enzyme inhibitors and digoxin treatment in the interstage period. In addition, we discuss other medication classes frequently used in these patients. EXPERT OPINION Due to significant heterogeneity of anatomy, rarity of disease, and other confounding factors, there is limited evidence to support most commonly used medications within the interstage period. Digoxin is associated with improved mortality within the interstage period and should be considered; however, no large randomized controlled trial exists supporting its use. Prevention of thrombotic complication with aspirin is also associated with improved outcomes and should be considered unless a contraindication exists. The addition of other prescriptions in this patient population should be considered only after an evaluation of the risks and benefits of each medication, recognizing the burden and risk of polypharmacy in this fragile patient population.
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Affiliation(s)
- Meredith C G Broberg
- Department of Pediatrics, Division of Pediatric Cardiac Critical Care, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ira M Cheifetz
- Department of Pediatrics, Division of Pediatric Cardiac Critical Care, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Pediatrics, Division of Pediatric Cardiology, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sarah T Plummer
- Department of Pediatrics, Division of Pediatric Cardiology, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Bezerra RF, Pacheco JT, Franchi SM, Fittaroni RB, Baumgratz JF, Castro RM, Silva LDFD, Silva JPD. Resultados Precoces do Procedimento de Norwood em um Centro de Referência no Brasil. Arq Bras Cardiol 2022; 119:282-291. [PMID: 35703662 PMCID: PMC9363068 DOI: 10.36660/abc.20201226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/08/2021] [Indexed: 12/02/2022] Open
Abstract
Fundamento Apenas dois artigos abordam os resultados precoces de pacientes com síndrome do coração esquerdo hipoplásico (SHCE) submetidos à operação de Norwood, no Brasil. Objetivos Avaliamos pacientes com SHCE submetidos ao primeiro estágio da operação de Norwood para identificar os fatores preditivos de mortalidade precoce (nos primeiros 30 dias após a cirurgia) e intermediária (desde a sobrevida precoce até o procedimento de Glenn). Métodos Foram incluídos pacientes com SHCE submetidos em nosso serviço ao primeiro estágio da operação de Norwood de janeiro de 2016 a abril de 2019. Dados demográficos, anatômicos e cirúrgicos foram analisados. Os desfechos foram mortalidade precoce (nos primeiros 30 dias após a cirurgia), mortalidade intermediária (desde a sobrevida precoce até o procedimento de Glenn) e a necessidade de suporte pós-operatório com ECMO. Foram realizadas análises univariadas e multivariadas e calculados odds ratios, com intervalos de confiança de 95%. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados Um total de 80 pacientes com SHCE foram submetidos ao primeiro estágio da operação de Norwood. A taxa de sobrevida em 30 dias foi de 91,3% e a taxa de sobrevida intermediária foi de 81,3%. Quatorze pacientes (17,5%) necessitaram de suporte com ECMO. Menor peso (p=0,033), estenose aórtica (vs atresia aórtica; p=0,036) e necessidade de suporte pós-operatório com ECMO (p=0,009) foram fatores preditivos independentes para mortalidade em 30 dias. A estenose da valva mitral ( vs atresia da valva mitral; p=0,041) foi um fator preditivo independente para mortalidade intermediária. Conclusão O presente estudo inclui a maior coorte brasileira de pacientes com SHCE submetidos ao primeiro estágio da operação de Norwood na era recente. Nossas taxas de sobrevida foram comparáveis às mais altas taxas de sobrevida relatadas globalmente. Baixo peso corporal, estenose valvar aórtica e necessidade de suporte pós-operatório com ECMO foram preditores independentes para mortalidade em 30 dias. A estenose da valva mitral foi o único fator preditivo independente para mortalidade intermediária.
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Weisert M, Menteer J, Durazo-Arvizu R, Wood J, Su J. EARLY PREDICTION OF FAILURE TO PROGRESS IN SINGLE VENTRICLE PALLIATION: A STEP TOWARD PERSONALIZING CARE FOR SEVERE CONGENITAL HEART DISEASE. J Heart Lung Transplant 2022; 41:1268-1276. [DOI: 10.1016/j.healun.2022.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/29/2022] [Accepted: 06/02/2022] [Indexed: 10/18/2022] Open
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Socioeconomic Impact on Outcomes During the First Year of Life of Patients with Single Ventricle Heart Disease: An Analysis of the National Pediatric Cardiology Quality Improvement Collaborative Registry. Pediatr Cardiol 2022; 43:605-615. [PMID: 34718855 DOI: 10.1007/s00246-021-02763-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
Socioeconomic status (SES) affects a range of health outcomes but has not been extensively explored in the single ventricle population. We investigate the impact of community-level deprivation on morbidity and mortality for infants with single ventricle heart disease in the first year of life. Retrospective cohort analysis of infants enrolled in the National Pediatric Cardiology Improvement Collaborative who underwent staged single ventricle palliation examining mortality and length of stay (LOS) using a community-level deprivation index (DI). 974 patients met inclusion criteria. Overall mortality was 20.5%, with 15.7% of deaths occurring between the first and second palliations. After adjusting for clinical risk factors, the DI was associated with death (log relative hazard [Formula: see text] = 8.92, p = 0.030) and death or transplant (log relative hazard [Formula: see text] = 8.62, p = 0.035) in a non-linear fashion, impacting those near the mean DI. Deprivation was associated with LOS following the first surgical palliation (S1P) (p = 0.031) and overall hospitalization during the first year of life (p = 0.018). For every 0.1 increase in the DI, LOS following S1P increased by 3.35 days (95% confidence interval 0.31-6.38) and total hospitalized days by 5.08 days (95% CI 0.88-9.27). Community deprivation is associated with mortality and LOS for patients with single ventricle congenital heart disease. While patients near the mean DI had a higher hazard of one year mortality compared to those at the extremes of the DI, LOS and DI were linearly associated, demonstrating the complex nature of SES factors.
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Brown TN, Brown DW, Tweddell JS, Bates KE, Lannon CM, Anderson JB. Digoxin Associated With Greater Transplant-Free Survival in High- vs Low-Risk Interstage Patients. Ann Thorac Surg 2021; 114:1453-1459. [PMID: 34687658 DOI: 10.1016/j.athoracsur.2021.08.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Digoxin has been associated with reduced interstage mortality for patients with functional single ventricles with aortic hypoplasia or ductal-dependent systemic circulation. The NEONATE (type of stage 1 palliation operation, postoperative extracorporeal membrane oxygenation, discharge with opiates, no digoxin at discharge, postoperative arch obstruction, moderate to severe tricuspid regurgitation without an oxygen requirement, and extra oxygen required at discharge in patients with moderate to severe tricuspid regurgitation) score can stratify patients by risk of death or transplantation (DTx) on the basis of clinical factors. The study investigators suspected a variable transplant-free survival benefit of digoxin in high-risk vs low-risk patients. METHODS National Pediatric Cardiology Quality Improvement Collaborative patients discharged after stage 1 palliation with complete data were categorized as high- or low-risk on the basis of a modified NEONATE score. The primary outcome of DTx was evaluated. A mixed-effect regression evaluated associations between digoxin prescription and risk factors. RESULTS A total of 1199 patients were included; 399 (33%) were high risk. Baseline demographics were similar between the cohorts. Blalock-Taussig shunt or a hybrid operation, postoperative extracorporeal membrane oxygenation, opiate prescription, and significant tricuspid regurgitation or arch obstruction were more common in high-risk patients. The odds of DTx were 65% lower in high-risk patients prescribed digoxin compared with patients who were not (P = .001). Digoxin prescription was associated with 60.8% lower DTx in the high-risk cohort (7.8% vs 19.9%; P = .001). There was no significant difference in the DTx rate according to digoxin prescription in the low-risk cohort (4.7% vs 5.7%; P = .46). Blalock-Taussig shunt, aortic arch obstruction, and significant tricuspid regurgitation were most strongly associated with deriving a benefit from digoxin. CONCLUSIONS Digoxin use is associated with significant improvement in transplant-free survival in high-risk but not in low-risk interstage patients. A tailored approach to the use of digoxin in interstage patients may be warranted.
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Affiliation(s)
- Tyler N Brown
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - James S Tweddell
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katherine E Bates
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Carole M Lannon
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey B Anderson
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Hoganson DM, Piekarski BL, Quinonez LG, Kheir JJ, Kaza AK, Zurakowski D, Emani SM, Baird CW. Patch augmentation of small ascending aorta during stage I procedure reduces the risk of morbidity and mortality. Eur J Cardiothorac Surg 2021; 61:555-561. [PMID: 34269379 DOI: 10.1093/ejcts/ezab312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/26/2021] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Hypoplastic left heart syndrome (HLHS) with aortic atresia (AA) patients are prone to coronary insufficiency due to a small ascending aorta. Prophylactic patch augmentation of the small ascending aorta during the stage I procedure (S1P) may reduce the risk of coronary insufficiency as marked by ventricular dysfunction, need for extracorporeal membrane oxygenator (ECMO) support or mortality. METHODS Retrospective analysis of patients with HLHS with AA who underwent an S1P was completed. Baseline ascending aorta size, right ventricular (RV) function and outcome variables of transplant-free survival, ECMO support after the stage 1 operation and RV function at the time of the bidirectional Glenn and latest follow-up were collected. RESULTS Between January 2010 and April 2020, 11 patients underwent prophylactic ascending aorta augmentation at the time of the S1P as a planned portion of the procedure. A total of 125 patients underwent S1P during this period as a comparison. Overall survival was 100% for the augmented group and 74% for the control group (P = 0.66). A composite end point of transplant-free survival, no post-S1P ECMO and less than moderate RV dysfunction was created. At the time of BDG, this composite end point was 100% for the augmented group and 61.8% for the control group (P = 0.008) and at most recent follow-up was 100% for the augmented group and 59.3% for control (P = 0.007). Eight patients required a rescue procedure for the clinical evidence of coronary insufficiency following S1P that included ascending aorta patch augmentation or stent placement. When comparing these rescue versus prophylactic ascending aortic augmentations, there were also differences in the composite outcome 100% for augmented and 60% for rescue (P = 0.009) and at the time of most recent follow-up 100% for augmented and 50% for rescue (P = 0.029). CONCLUSIONS Prophylactic patch augmentation of the ascending aorta in HLHS patients with AA may reduce the risk of mortality, ECMO and reduced RV function. Patients not initially undergoing augmentation but then requiring a rescue procedure have particularly poor outcomes. Patch augmentation for smaller ascending aortic diameters should be considered and further clinical experience may help delineate aorta diameter threshold for augmentation.
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Affiliation(s)
- David M Hoganson
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Breanna L Piekarski
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Luis G Quinonez
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - John J Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Aditya K Kaza
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care, and Pain Management, Boston Children's Hospital, Boston, MA, USA
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Chris W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
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American College of Cardiology Body Mass Index Counseling Quality Improvement Initiative. Pediatr Cardiol 2021; 42:1190-1199. [PMID: 33856499 DOI: 10.1007/s00246-021-02600-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
Overweight/obesity, prevalent cardiovascular risk factors in children, can be associated with increased risk of adverse outcomes in children with heart disease. The American College of Cardiology (ACC) developed quality metrics including a BMI metric related to identifying and counseling overweight and obese children presenting to cardiology clinics. This metric was used for a multicenter collaborative learning Quality improvement (QI) Project through the ACC Quality Network (QNet). Our aim was to increase the percentage of children between ages 3 and 18 years presenting to cardiology clinics at participating centers with BMI > 85th percentile who received appropriate counseling. Participating centers submitted data quarterly to QNet for a sample of patients who received counseling. A Key Driver Diagram was created to help teams drive improvement. Individual centers customized interventions and participated in network-wide educational learning sessions about QI and shared experience. Statistical process control charts were used. From 04/01/2017 to 09/30/2019, 27,511 patient visits were included. Among 32 participating centers, overall counseling rate was 54%. The BMI counseling rate increased from 25% in 2017Q2 to 54% in 2019Q3. There was a wide variation from 10 to 100% in the performance of individual centers. The overall rate of identification and counseling of overweight and obese children presenting to ambulatory cardiology clinics in participating centers is low. There is wide variation in the performance of centers, providing an opportunity for improvement. Using this multicenter learning approach, individual centers have demonstrated improvement. This demonstrates that collaborative learning approaches in QI can increase implementation of the metric.
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O’Byrne ML, Song L, Huang J, Goldberg D, Gardner MM, Ravishankar C, Rome JJ, Glatz AC. Trends in Discharge Prescription of Digoxin After Norwood Operation: An Analysis of Data from the Pediatric Health Information System (PHIS) Database. Pediatr Cardiol 2021; 42:793-803. [PMID: 33528619 PMCID: PMC8113119 DOI: 10.1007/s00246-021-02543-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
Quality improvement efforts have focused on reducing interstage mortality for infants with hypoplastic left heart syndrome (HLHS). In 1/2016, two publications reported that use of digoxin was associated with reduced interstage mortality. The degree to which these findings have affected real world practice has not been evaluated. The discharge medications of neonates with HLHS undergoing Norwood operation between 1/2007 and 12/2018 at Pediatric Health Information Systems Database hospitals were studied. Mixed effects models were calculated to evaluate the hypothesis that the likelihood of digoxin prescription increased after 1/2016, adjusting for measurable confounders with furosemide and aspirin prescription measured as falsification tests. Interhospital practice variation was measured using the median odds ratio. Over the study period, 6091 subjects from 45 hospitals were included. After adjusting for measurable covariates, discharge after 1/2016 was associated with increased odds of receiving digoxin (OR 3.9, p < 0.001). No association was seen between date of discharge and furosemide (p = 0.26) or aspirin (p = 0.12). Prior to 1/2016, the likelihood of receiving digoxin was decreasing (OR 0.9 per year, p < 0.001), while after 1/2016 the rate has increased (OR 1.4 per year, p < 0.001). However, there remains significant interhospital variation in the likelihood of receiving digoxin even after adjusting for known confounders (median odds ratio = 3.5, p < 0.0001). Following publication of studies describing an association between digoxin and improved interstage survival, the likelihood of receiving digoxin at discharge increased without similar changes for furosemide or aspirin. Despite concerted efforts to standardize interstage care, interhospital variation in pharmacotherapy in this vulnerable population persists.
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Affiliation(s)
- Michael L O’Byrne
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Center For Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Lihai Song
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - David Goldberg
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Monique M Gardner
- Division of Cardiac Critical Care, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Chitra Ravishankar
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Center For Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Crawford R, Hughes C, McFadden S, Crawford J. A systematic review examining the clinical and health-care outcomes for congenital heart disease patients using home monitoring programmes. J Telemed Telecare 2021; 29:349-364. [PMID: 33470176 DOI: 10.1177/1357633x20984052] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This review aimed to present the clinical and health-care outcomes for patients with congenital heart disease (CHD) who use home monitoring technologies. METHODS Five databases were systematically searched from inception to November 2020 for quantitative studies in this area. Data were extracted using a pre-formatted data-collection table which included information on participants, interventions, outcome measures and results. Risk of bias was determined using the Cochrane Risk of Bias 2 tool for randomised controlled trials (RCTs), the Newcastle-Ottawa Quality Assessment Scale for cohort studies and the Institute of Health Economics quality appraisal checklist for case-series studies.Data synthesis: Twenty-two studies were included in this systematic review, which included four RCTs, 12 cohort studies and six case-series studies. Seventeen studies reported on mortality rates, with 59% reporting that home monitoring programmes were associated with either a significant reduction or trend for lower mortality and 12% reporting that mortality trended higher. Fourteen studies reported on unplanned readmissions/health-care resource use, with 29% of studies reporting that this outcome was significantly decreased or trended lower with home monitoring and 21% reported an increase. Impact on treatment was reported in 15 studies, with 67% of studies finding that either treatment was undertaken significantly earlier or significantly more interventions were undertaken in the home monitoring groups. CONCLUSION The use of home monitoring programmes may be beneficial in reducing mortality, enabling earlier and more timely detection and treatment of CHD complication. However, currently, this evidence is limited due to weakness in study designs.
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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Smith ME, Finks JF. Collaborative Quality Improvement. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Hill GD, Tanem J, Ghanayem N, Rudd N, Ollberding NJ, Lavoie J, Frommelt M. Selective Use of Inpatient Interstage Management After Norwood Procedure. Ann Thorac Surg 2019; 109:139-147. [PMID: 31518582 DOI: 10.1016/j.athoracsur.2019.07.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 07/08/2019] [Accepted: 07/22/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND We report our intermediate-term results after Norwood procedure, including use of an interstage inpatient management strategy for high-risk patients, and seek to create a predictive model for probability of discharge. METHODS A single-site retrospective review was conducted for all patients undergoing Norwood procedure from 2006 to 2016 (N = 177). We compared those discharged home with those who either remained hospitalized until Glenn procedure or died before Norwood procedure discharge. Multivariable logistic regression was used to develop a predictive model for discharge. RESULTS During the study period, 120 (68%) patients were discharged home, 45 (25%) remained hospitalized, and 12 (7%) died before Glenn procedure (median age: 71 days). Interstage survival for those discharged after Norwood procedure was 100%. Longitudinal survival for the cohort was 86%, 81%, and 77% at 1, 5, and 10 years, resepectively. Ten-year survival was significantly greater for the discharged group compared with the interstage inpatients (86% vs 56%, P < .001). A reduced predictive model of discharge included lower gestational age (odds ratio [OR]: 0.95), lower median income for ZIP code (OR: 0.4), lower birth-weight-for-age z-score (OR: 0.56), longer cardiopulmonary bypass time (OR: 0.45), and Blalock-Taussig shunt (OR: 0.32). CONCLUSIONS Survival up to 10 years after Norwood procedure is good using a strategy of inpatient care for a subset of high-risk patients to mitigate home interstage mortality. A probabilistic model used after Norwood procedure was able to predict interstage discharge with good accuracy, but will require external validation to ensure generalizability. Further work is also needed to determine optimal palliative pathways for the high-risk patients because of the notable attrition beyond successful bidirectional Glenn procedure.
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Affiliation(s)
- Garick D Hill
- Department of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio.
| | - Jena Tanem
- Department of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Nancy Ghanayem
- Department of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas
| | - Nancy Rudd
- Department of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Nicholas J Ollberding
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Department of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Julie Lavoie
- Department of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michele Frommelt
- Department of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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Graupner O, Enzensberger C, Axt-Fliedner R. New Aspects in the Diagnosis and Therapy of Fetal Hypoplastic Left Heart Syndrome. Geburtshilfe Frauenheilkd 2019; 79:863-872. [PMID: 31423021 PMCID: PMC6690741 DOI: 10.1055/a-0828-7968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/29/2018] [Accepted: 12/30/2018] [Indexed: 12/26/2022] Open
Abstract
Fetal hypoplastic left heart syndrome (HLHS) is a severe congenital heart disease with a lethal prognosis without postnatal therapeutic intervention or surgery. The aim of this article is to give a brief overview of new findings in the field of prenatal diagnosis and the therapy of HLHS. As cardiac output in HLHS children depends on the right ventricle (RV), prenatal assessment of fetal RV function is of interest to predict poor functional RV status before the RV becomes the systemic ventricle. Prenatal cardiac interventions such as fetal aortic valvuloplasty and non-invasive procedures such as maternal hyperoxygenation seem to be promising treatment options but will need to be evaluated with regard to long-term outcomes. Novel approaches such as stem cell therapy or neuroprotection provide important clues about the complexity of the disease. New aspects in diagnostics and therapy of HLHS show the potential of a targeted prenatal treatment planning. This could be used to optimize parental counseling as well as pre- and postnatal management of affected children.
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Affiliation(s)
- Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Enzensberger
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Roland Axt-Fliedner
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
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Kurtz JD, Chowdhury SM, Woodard FK, Strelow JR, Zyblewski SC. Factors Associated with Delayed Transition to Oral Feeding in Infants with Single Ventricle Physiology. J Pediatr 2019; 211:134-138. [PMID: 30952511 PMCID: PMC7161424 DOI: 10.1016/j.jpeds.2019.02.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the duration of time to achieve exclusive oral feeding in infants with single ventricle physiology and to identify risk factors associated with prolonged gastrostomy tube dependence. STUDY DESIGN Single center, retrospective study of infants with single ventricle physiology. The primary outcome was duration of time required to achieve oral feeding. Transition periods were defined as exclusive oral feeding by Glenn palliation (early), by 1 year of age (mid), or after 1 year of age (late). RESULTS Seventy-eight infants were analyzed; 46 (59%) were discharged to home with a gastrostomy tube after the initial hospitalization. Overall, 39 infants (50%) achieved early transition, 14 (18%) mid, and 18 (23%) late. The group who achieved early transition had a higher percentage of preoperative oral feeding (P < .01), greater weight-for-age z score at initial discharge (P = .03), shorter initial intensive care unit duration (P < .01), shorter initial hospital length of stay (P < .01), and greater weight-for-age z score at Glenn admission (P = .02). No preoperative oral feeding (OR = 0.12, P = .02) and greater number of cardiac medications at initial discharge (OR = 3.8, P = .03) were associated with failure to achieve early transition. No preoperative oral feeding (OR = 0.09, P = .01) and longer initial intensive care unit duration (OR = 1.1, P = .03) were associated with failure to achieve mid transition. CONCLUSION Preoperative oral feeding may potentially be a modifiable factor to help improve early transition to oral feeding.
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Casar Berazaluce AM, Gibbons AT, Hanke RE, Ponsky TA, Harmon CM. It Is a Wrap! Or Is It?: The Role of Fundoplication in Infant Feeding Intolerance. J Laparoendosc Adv Surg Tech A 2019; 29:1315-1319. [PMID: 31264917 DOI: 10.1089/lap.2019.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Fundoplication is one of the most common procedures performed by pediatric surgeons, frequently for gastroesophageal reflux with feeding intolerance. No consensus exists in its management, with multiple institutions opting for medical therapy over surgical intervention. Methods: A case-based survey was administered at a national pediatric surgery conference. Clinical vignettes described former-premature infants with reflux and feeding intolerance with or without failure to thrive (FTT), neurological impairment, complex cardiopathy, and respiratory symptoms. Odds ratios (ORs) for fundoplication were calculated from participants' responses. Results: Surgeons elected to perform fundoplication in 14%-74% of cases. The OR for performing fundoplication in the presence of FTT was 1.84 (confidence interval [CI] 1.34-2.54, P = .0002) overall, achieving significance in subgroup analysis for cardiopathy (OR 3.56, CI 1.88-6.71, P = .0001) and neurological impairment (OR 1.79, CI 1.04-3.07, P = .04), but not in the absence of these comorbidities (OR 1.05, CI 0.61-1.83, P = .86). The OR for fundoplication in the presence of neurological impairment was 1.97 (CI 1.34-2.90, P = .0005) and that for cardiopathy was 1.70 (CI 1.20-2.40, P = .003), independent of FTT status. In subgroup analysis, the greatest predictors for fundoplication were neurological impairment with FTT (OR 2.63, CI 1.55-4.48, P = .0004) and complex cardiopathy with FTT and cough/syncope (OR 7.14, CI 4.05-12.58, P < .0001). Presence of cardiopathy without FTT had the overall lowest odds of fundoplication (OR 0.40, CI 0.21-0.78, P = .006). Conclusion: Surgeons tend to perform fundoplication in the presence of FTT and other comorbidities, particularly when these are concurrent. Respiratory symptoms are a strong predictor for fundoplication in patients with complex cardiopathies.
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Affiliation(s)
- Alejandra M Casar Berazaluce
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexander T Gibbons
- Department of Surgery, Division of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
| | - Rachel E Hanke
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Todd A Ponsky
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Surgery, Division of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
| | - Carroll M Harmon
- Department of Surgery, Division of Pediatric Surgery, Kaleida Health, John R. Oishei Children's Hospital, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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Pizzuto M, Patel M, Romano J, Retzloff L, Yu S, Lowery R, Gelehrter S. Similar Interstage Outcomes for Single Ventricle Infants Palliated With an Aortopulmonary Shunt Compared to the Norwood Procedure. World J Pediatr Congenit Heart Surg 2018; 9:407-411. [PMID: 29945506 DOI: 10.1177/2150135118768720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Interstage outcomes for single ventricle infants following Norwood operation have been well studied, showing significant mortality. Other single ventricle infants require only an aortopulmonary shunt. The aim of the study was to describe the interstage outcomes of this group compared to Norwood patients and identify risk factors for mortality. METHODS A single-center retrospective cohort review was performed in patients who underwent a Norwood operation (Norwood) or aortopulmonary shunt (Shunt) during 2000 to 2011 and survived to discharge. Hybrid or pulmonary artery banding patients were excluded. Univariate comparison was made between Norwood and Shunt patients as well as a Shunt subgroup analysis. RESULTS A total of 486 patients (368 Norwood and 118 Shunt) were included. Norwood and Shunt patients were similar in terms of preterm birth, surgery weight, and stage 1 complications. Shunt patients were more likely to be female, have an extracardiac or genetic anomaly, and have a shorter hospital length of stay compared to the Norwood patients (all P < .0001). No significant difference in interstage mortality was seen between the Shunt and Norwood patients (6.8% vs 11.1%, respectively; P = .17). Stage 2 mortality was also similar (Shunt 4.6% vs Norwood 7.8%; P = .25). In the Shunt patients, those who died during interstage weighed less at surgery (2.7 [0.7] kg vs 3.3 [0.7] kg, P = .03) and were more likely to have arrhythmias (50% vs 12%, P = .01), compared to survivors. CONCLUSIONS Shunt patients have an interstage mortality that is not significantly less than Norwood patients. Lower weight at surgery and arrhythmias are risk factors for interstage death in Shunt patients.
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Affiliation(s)
- Matthew Pizzuto
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA.,2 Duke Children's Hospital, Duke University, Durham, NC, USA
| | - Mehul Patel
- 3 UT Health Science Center San Antonio, San Antonio, TX, USA
| | - Jennifer Romano
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Lauren Retzloff
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Sunkyung Yu
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Sarah Gelehrter
- 1 C.S. Mott Hospital, University of Michigan, Ann Arbor, MI, USA
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Cohen MS, Dagincourt N, Zak V, Baffa JM, Bartz P, Dragulescu A, Dudlani G, Henderson H, Krawczeski CD, Lai WW, Levine JC, Lewis AB, McCandless RT, Ohye RG, Owens ST, Schwartz SM, Slesnick TC, Taylor CL, Frommelt PC. The Impact of the Left Ventricle on Right Ventricular Function and Clinical Outcomes in Infants with Single-Right Ventricle Anomalies up to 14 Months of Age. J Am Soc Echocardiogr 2018; 31:1151-1157. [PMID: 29980396 PMCID: PMC6475580 DOI: 10.1016/j.echo.2018.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Children with single-right ventricle anomalies such as hypoplastic left heart syndrome (HLHS) have left ventricles of variable size and function. The impact of the left ventricle on the performance of the right ventricle and on survival remains unclear. The aim of this study was to identify whether left ventricular (LV) size and function influence right ventricular (RV) function and clinical outcome after staged palliation for single-right ventricle anomalies. METHODS In the Single Ventricle Reconstruction trial, echocardiography-derived measures of LV size and function were compared with measures of RV systolic and diastolic function, tricuspid regurgitation, and outcomes (death and/or heart transplantation) at baseline (preoperatively), early after Norwood palliation, before stage 2 palliation, and at 14 months of age. RESULTS Of the 522 subjects who met the study inclusion criteria, 381 (73%) had measurable left ventricles. The HLHS subtype of aortic atresia/mitral atresia was significantly less likely to have a measurable left ventricle (41%) compared with the other HLHS subtypes: aortic stenosis/mitral stenosis (100%), aortic atresia/mitral stenosis (96%), and those without HLHS (83%). RV end-diastolic and end-systolic volumes were significantly larger, while diastolic indices suggested better diastolic properties in those subjects with no left ventricles compared with those with measurable left ventricles. However, RV ejection fraction was not different on the basis of LV size and function after staged palliation. Moreover, there was no difference in transplantation-free survival to Norwood discharge, through the interstage period, or at 14 months of age between those subjects who had measurable left ventricles compared with those who did not. CONCLUSIONS LV size varies by anatomic subtype in infants with single-right ventricle anomalies. Although indices of RV size and diastolic function were influenced by the presence of a left ventricle, there was no difference in RV systolic function or transplantation-free survival on the basis of LV measures.
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Affiliation(s)
- Meryl S Cohen
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | | | - Victor Zak
- New England Research Institutes, Boston, Massachusetts
| | - Jeanne Marie Baffa
- Division of Cardiology, A.I. DuPont Hospital for Children, Wilmington, Delaware
| | - Peter Bartz
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andreea Dragulescu
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gul Dudlani
- Division of Cardiology, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida
| | - Heather Henderson
- Division of Pediatric Cardiology, Duke University Medical Center, Raleigh, North Carolina
| | | | - Wyman W Lai
- Division of Cardiology, Morgan Stanley Children's Hospital, New York, New York
| | - Jami C Levine
- Department of Cardiology, Children's Hospital, Boston, Boston, Massachusetts
| | - Alan B Lewis
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California
| | | | - Richard G Ohye
- Division of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Sonal T Owens
- Division of Pediatric Cardiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Steven M Schwartz
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Carolyn L Taylor
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Peter C Frommelt
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Nieves JA, Rudd NA, Dobrolet N. Home surveillance monitoring for high risk congenital heart newborns: Improving outcomes after single ventricle palliation - why, how & results. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Karamlou T, Velez DA, Nigro JJ. Encrypted prediction: A hacker's perspective. J Thorac Cardiovasc Surg 2017; 154:2038-2040. [DOI: 10.1016/j.jtcvs.2017.08.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 08/30/2017] [Indexed: 11/26/2022]
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Nieves JA, Uzark K, Rudd NA, Strawn J, Schmelzer A, Dobrolet N. Interstage Home Monitoring After Newborn First-Stage Palliation for Hypoplastic Left Heart Syndrome: Family Education Strategies. Crit Care Nurse 2017; 37:72-88. [PMID: 28365652 DOI: 10.4037/ccn2017763] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Children born with hypoplastic left heart syndrome are at high risk for serious morbidity, growth failure, and mortality during the interstage period, which is the time from discharge home after first-stage hypoplastic left heart syndrome palliation until the second-stage surgical intervention. The single-ventricle circulatory physiology is complex, fragile, and potentially unstable. Multicenter initiatives have been successfully implemented to improve outcomes and optimize growth and survival during the interstage period. A crucial focus of care is the comprehensive family training in the use of home surveillance monitoring of oxygen saturation, enteral intake, weight, and the early recognition of "red flag" symptoms indicating potential cardiopulmonary or nutritional decompensation. Beginning with admission to the intensive care unit of the newborn with hypoplastic left heart syndrome, nurses provide critical care and education to prepare the family for interstage home care. This article presents detailed nursing guidelines for educating families on the home care of their medically fragile infant with single-ventricle circulation.
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Affiliation(s)
- Jo Ann Nieves
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida. .,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan. .,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program. .,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator. .,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida. .,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System.
| | - Karen Uzark
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Nancy A Rudd
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Jennifer Strawn
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Anne Schmelzer
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Nancy Dobrolet
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
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Gładki M, Składzień T, Żurek R, Broniatowska E, Wójcik E, Skalski JH. Effect of acid-base balance on postoperative course in children with hypoplastic left heart syndrome after the modified Norwood procedure. Medicine (Baltimore) 2017; 96:e7739. [PMID: 28834879 PMCID: PMC5572001 DOI: 10.1097/md.0000000000007739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 12/06/2016] [Accepted: 07/18/2017] [Indexed: 11/27/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is a congenital heart defect that requires 3-stage cardiac surgical treatment and multidirectional specialist care. The condition of newborns in the first postoperative days following the modified Norwood procedure is characterized by considerable hemodynamic instability that may result in a sudden cardiac arrest. It is believed that the most important cause of hemodynamic instability is the fluctuations in redistribution between pulmonary and systemic blood flow.The paper analyzes the postoperative course in 40 neonates with HLHS following the modified Norwood procedure performed under deep hypothermic cardiopulmonary bypass hospitalized in Cardiac Surgical Intensive Care Unit (CSICU) in the years 2014-2015. For all hospitalized children, the arterial blood acid-base balance (ABB) parameters (pH, pO2, pCO2, HCO3, base excess (BE), and lactic acid) were measured 2 times a day during the first 5 postoperative days. The main goal of the studies is to analysis of ABB parameters and their influence on the clinical state of newborns with HLHS. Several descriptors were concerned to describe the neonates clinical state: the date of the surgery (the day of life when the child was operated on), the duration (number of days) of mechanical ventilation employment, the time of hospitalization in intensive care unit, and the total duration of treatment in CSICU.The statistical analysis of the particular ABB parameters revealed a significant dependence (P < .001) between the values of pH, pO2, pCO2, HCO3, BE, lactic acid, and all concerned descriptors of the newborn clinical state.The article shows that monitoring the ABB parameters, proper interpretation of the results, and appropriate modification of pharmacotherapy and respiratory treatment are crucial for therapeutic results and survival rates in neonates with HLHS after the modified Norwood procedure.
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Affiliation(s)
- Marcin Gładki
- Department of Pediatric Cardiac Surgery, University Children's Hospital, Jagiellonian University
| | | | - Rafał Żurek
- Department of Pediatric Cardiac Surgery, University Children's Hospital, Jagiellonian University
| | - Elżbieta Broniatowska
- Department of Bioinformatic and Telemedicine, Jagiellonian University, Krakow, Poland
| | - Elżbieta Wójcik
- Department of Pediatric Cardiac Surgery, University Children's Hospital, Jagiellonian University
| | - Janusz H. Skalski
- Department of Pediatric Cardiac Surgery, University Children's Hospital, Jagiellonian University
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Variability of antithrombotics use in patients with hypoplastic left heart syndrome and its variants following first- and second-stage palliation surgery: a national report using the National Pediatric Cardiology Quality Improvement Collaborative registry. Cardiol Young 2017; 27:731-738. [PMID: 27981915 DOI: 10.1017/s1047951116001189] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED Purpose Patients with hypoplastic left heart syndrome and its variants following palliation surgery are at risk for thrombosis. This study examines variability of antithrombotic practice, the incidence of interstage shunt thrombosis, and other adverse events following Stage I and Stage II palliation within the National Pediatric Cardiology Quality Improvement Collaborative registry. METHODS We carried out a multicentre, retrospective review using the National Pediatric Cardiology Quality Improvement Collaborative registry including patients from 2008 to 2013 across 52 surgical sites. Antithrombotic medications used at Stage I and Stage II discharge were evaluated. Variability of antithrombotics use at the individual patient level and intersite variability, incidence of shunt thrombosis, and other adverse events such as cardiac arrest, seizure, stroke, and need for cardiac catheterisation intervention in the interstage period were identified. Antithrombotic strategies for hybrid Stage I patients were evaluated but they were excluded from the variability and outcomes analysis. RESULTS A total of 932 Stage I and 923 Stage II patients were included in the study: 93.8% of Stage I patients were discharged on aspirin and 4% were discharged on no antithrombotics, and 77% of Stage II patients were discharged on aspirin and 17.5% were discharged on no antithrombotics. Only three patients (0.2%) presented with interstage shunt thrombosis. The majority of patients who died during interstage or required shunt dilation and/or stenting were discharged home on aspirin. CONCLUSION Aspirin is the most commonly used antithrombotic following Stage I and Stage II palliation. There is more variability in the choice of antithrombotics following Stage II compared with Stage I. The incidence of interstage shunt thrombosis and associated adverse events was rare.
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Satou GM, Rheuban K, Alverson D, Lewin M, Mahnke C, Marcin J, Martin GR, Mazur LS, Sahn DJ, Shah S, Tuckson R, Webb CL, Sable CA. Telemedicine in Pediatric Cardiology: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e648-e678. [PMID: 28193604 DOI: 10.1161/cir.0000000000000478] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Hill GD, Rudd NA, Ghanayem NS, Hehir DA, Bartz PJ. Center Variability in Timing of Stage 2 Palliation and Association with Interstage Mortality: A Report from the National Pediatric Cardiology Quality Improvement Collaborative. Pediatr Cardiol 2016; 37:1516-1524. [PMID: 27558553 DOI: 10.1007/s00246-016-1465-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/16/2016] [Indexed: 11/27/2022]
Abstract
For infants with single-ventricle lesions with aortic arch hypoplasia, the interstage period from discharge following stage 1 palliation (S1P) until stage 2 palliation (S2P) remains high risk. Significant variability among institutions exists around the timing of S2P. We sought to describe institutional variation in timing of S2P, determine the association between timing of S2P and interstage mortality, and determine the impact of earlier S2P on hospital morbidity and mortality. The National Pediatric Cardiology Quality Improvement Collaborative registry was queried. Centers were divided based on median age at S2P into early (n = 15) and late (n = 16) centers using a cutoff of 153 days. Groups were compared using Chi-squared or Wilcoxon rank-sum test. Multivariable logistic regression was used to determine risk factors for interstage mortality. The final cohort included 789 patients from 31 centers. There was intra- and inter-center variability in timing of S2P, with the median age by center ranging from 109 to 214 days. Late centers had a higher mortality (9.9 vs. 5.7 %, p = 0.03) than early centers. However, the event rate (late: 8.2 vs. early: 5.8 deaths per 10,000 interstage days) was not different by group (p = 0.26). Survival to hospital discharge and hospital length of stay following S2P were similar between groups. In conclusion, in a large multi-institution collaborative, the median age at S2P varies among centers. Although optimal timing of S2P remains unclear, centers performing early S2P did not experience worse S2P outcomes and experienced less interstage mortality.
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Affiliation(s)
- Garick D Hill
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA.
| | - Nancy A Rudd
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David A Hehir
- Division of Cardiac Critical Care, Department of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Peter J Bartz
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA
- Division of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Castellanos DA, Herrington C, Adler S, Haas K, Ram Kumar S, Kung GC. Home Monitoring Program Reduces Mortality in High-Risk Sociodemographic Single-Ventricle Patients. Pediatr Cardiol 2016; 37:1575-1580. [PMID: 27554255 DOI: 10.1007/s00246-016-1472-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/16/2016] [Indexed: 11/24/2022]
Abstract
A clinician-driven home monitoring program can improve interstage outcomes in single-ventricle patients. Sociodemographic factors have been independently associated with mortality in interstage patients. We hypothesized that even in a population with high-risk sociodemographic characteristics, a home monitoring program is effective in reducing interstage mortality. We defined interstage period as the time period between discharge following Norwood palliation and second-stage surgery. We reviewed the charts of patients for the three-year period before (group 1) and after (group 2) implementation of the home monitoring program. Clinical variables around Norwood palliation, during the interstage period, and at the time of second-stage surgery were analyzed. There were 74 patients in group 1 and 52 in group 2. 59 % patients were Hispanic, and 84 % lived in neighborhoods where over 5 % families lived below poverty line. There was no significant difference in pre-Norwood variables, Norwood discharge variables, age at second surgery, or outcomes at second surgery. There were more Sano shunts performed at the Norwood procedure as the source of pulmonary blood flow in group 2 (p value <0.05). There were more unplanned hospital admissions and percutaneous re-interventions in group 2. Patients in group 2 whose admission criteria included desaturation had a 45 % likelihood of having an unplanned re-intervention. Group 2 noted an 80 % relative reduction in interstage mortality (p < 0.01). In a multiple regression analysis, after accounting for ethnicity, socio-economic status, and source of pulmonary blood flow, enrollment in a home monitoring program independently predicted improved interstage survival (p < 0.01). A clinician-driven home monitoring program reduces interstage mortality even when the majority of patients has high-risk sociodemographic characteristics.
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Affiliation(s)
- Daniel Alexander Castellanos
- Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mailstop #68, Los Angeles, CA, 90027, USA.
| | - Cynthia Herrington
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mailstop #66, Los Angeles, CA, 90027, USA.,Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Stacey Adler
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mailstop #66, Los Angeles, CA, 90027, USA
| | - Karen Haas
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mailstop #66, Los Angeles, CA, 90027, USA
| | - S Ram Kumar
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mailstop #66, Los Angeles, CA, 90027, USA.,Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA.,Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, CA, 90027, USA
| | - Grace C Kung
- Division of Cardiology, Children's Hospital Los Angeles, 4650 Sunset Blvd. MS #34, Los Angeles, CA, 90027, USA.,Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, CA, 90027, USA
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Harahsheh AS, Hom LA, Clauss SB, Cross RR, Curtis AR, Steury RD, Mitchell SJ, Martin GR. The Impact of a Designated Cardiology Team Involving Telemedicine Home Monitoring on the Care of Children with Single-Ventricle Physiology After Norwood Palliation. Pediatr Cardiol 2016; 37:899-912. [PMID: 27037551 DOI: 10.1007/s00246-016-1366-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/19/2016] [Indexed: 12/01/2022]
Abstract
We evaluated the effect of an interdisciplinary single-ventricle task force (SVTF) that utilizes a family-driven, telemedicine home monitoring program on clinical outcomes of stage II admissions and its acceptance by parents and cardiologists. Study population was divided into two cohorts, one with Norwood surgery dates before the SVTF (pre-SVTF) and one interventional (post-SVTF). Post-SVTF data also included surveys of parents and cardiologists on the efficacy of the SVTF. Comparative and multivariate statistical testing was performed. Compared to the pre-SVTF group, the post-SVTF group had lower complications after stage II (18.4 vs. 34.1 %, p = 0.02), higher weight-for-age z scores at stage II (-1.5 ± 0.97 vs. -1.58 ± 1.34, p = 0.02) and were less likely to have a stage II weight-for-age z score below -2 (26.5 vs. 31.7 %, p = 0.03). A multivariate regression analysis showed providing a written red-flag action plan to parents at discharge was independently associated with higher weight at stage II (β = 0.42, p = 0.04) and higher weight-for-age z score (β = 0.48, p = 0.02). Parents' satisfaction with SVTF (α = 0.97) was 4.34 ± 0.62; (95 % CI 4.01-4.67) and cardiologists' acceptance (α = 0.93) was 4.1 ± 0.7 (95 % CI 3.79-4.42). Development of SVTF was associated with a reduction in complications post-stage II and improved weight status at stage II. A written red-flag action plan provided to parents at the time of Norwood discharge was associated with higher weight status at stage II. Parents and cardiologists expressed satisfaction with the utility of SVTF and encouraged expansion to cover all children with congenital heart disease.
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Affiliation(s)
- Ashraf S Harahsheh
- Children's National Health System, 111 Michigan Ave, N.W., Washington, DC, 20010, USA. .,Department of Pediatrics, Division of Cardiology, Children's National Health System, The George Washington University School of Medicine, 111 Michigan Ave, N.W., Washington, DC, 20010, USA.
| | - Lisa A Hom
- Children's National Health System, 111 Michigan Ave, N.W., Washington, DC, 20010, USA
| | - Sarah B Clauss
- Children's National Health System, 111 Michigan Ave, N.W., Washington, DC, 20010, USA.,Department of Pediatrics, Division of Cardiology, Children's National Health System, The George Washington University School of Medicine, 111 Michigan Ave, N.W., Washington, DC, 20010, USA
| | - Russell R Cross
- Children's National Health System, 111 Michigan Ave, N.W., Washington, DC, 20010, USA.,Department of Pediatrics, Division of Cardiology, Children's National Health System, The George Washington University School of Medicine, 111 Michigan Ave, N.W., Washington, DC, 20010, USA
| | - Amy R Curtis
- Children's National Health System, 111 Michigan Ave, N.W., Washington, DC, 20010, USA
| | - Rachel D Steury
- Children's National Health System, 111 Michigan Ave, N.W., Washington, DC, 20010, USA
| | - Stephanie J Mitchell
- Children's Research Institute, Children's National Health System, 111 Michigan Ave, N.W., Washington, DC, 20010, USA
| | - Gerard R Martin
- Children's National Health System, 111 Michigan Ave, N.W., Washington, DC, 20010, USA.,Department of Pediatrics, Division of Cardiology, Children's National Health System, The George Washington University School of Medicine, 111 Michigan Ave, N.W., Washington, DC, 20010, USA
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Siehr SL, Maeda K, Connolly AA, Tacy TA, Reddy VM, Hanley FL, Perry SB, Wright GE. Mitral Stenosis and Aortic Atresia—A Risk Factor for Mortality After the Modified Norwood Operation in Hypoplastic Left Heart Syndrome. Ann Thorac Surg 2016; 101:162-7. [DOI: 10.1016/j.athoracsur.2015.09.056] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 08/26/2015] [Accepted: 09/15/2015] [Indexed: 10/22/2022]
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Hanke SP, Joy B, Riddle E, Ravishankar C, Peterson LE, King E, Mangeot C, Brown DW, Schoettker P, Anderson JB, Bates KE. Risk Factors for Unanticipated Readmissions During the Interstage: A Report From the National Pediatric Cardiology Quality Improvement Collaborative. Semin Thorac Cardiovasc Surg 2016; 28:803-814. [DOI: 10.1053/j.semtcvs.2016.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2016] [Indexed: 11/11/2022]
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Danford DA, Karels Q, Kulkarni A, Hussain A, Xiao Y, Kutty S. Mortality-related resource utilization in the inpatient care of hypoplastic left heart syndrome. Orphanet J Rare Dis 2015; 10:137. [PMID: 26494006 PMCID: PMC4618542 DOI: 10.1186/s13023-015-0355-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/16/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quantifying resource utilization in the inpatient care of congenital heart diease is clinically relevant. Our purpose is to measure the investment of inpatient care resources to achieve survival in hypoplastic left heart syndrome (HLHS), and to determine how much of that investment occurs in hospitalizations that have a fatal outcome, the mortality-related resource utilization fraction (MRRUF). METHODS A collaborative administrative database, the Pediatric Health Information System (PHIS) containing data for 43 children's hospitals, was queried by primary diagnosis for HLHS admissions of patients ≤21 years old during 2004-2013. Institution, patient age, inpatient deaths, billed charges (BC) and length of stay (LOS) were recorded. RESULTS In all, 11,122 HLHS admissions were identified which account for total LOS of 277,027 inpatient-days and $3,928,794,660 in BC. There were 1145 inpatient deaths (10.3%). LOS was greater among inpatient deaths than among patients discharged alive (median 17 vs. 12, p < 0.0001). BC were greater among inpatient deaths than among patients discharged alive (median 4.09 × 10(5) vs. 1.63 × 10(5), p < 0.0001). 16% of all LOS and 21% of all BC were accrued by patients who did not survive their hospitalization. These proportions showed no significant change year-by-year. The highest volume institutions had lower mortality rates, but there was no relation between institutional volume and the MRRUF. CONCLUSIONS These data should alert providers and consumers that current practices often result in major resource expenditure for inpatient care of HLHS that does not result in survival to hospital dismissal. They highlight the need for data-driven critical review of standard practices to identify patterns of care associated with success, and to modify approaches objectively.
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Affiliation(s)
- David A Danford
- University of Nebraska Medical Center and Children's Hospital and Medical Center, 8200 Dodge St, Omaha, NE, 68114, USA.
| | - Quentin Karels
- University of Nebraska Medical Center and Children's Hospital and Medical Center, 8200 Dodge St, Omaha, NE, 68114, USA.
| | - Aparna Kulkarni
- Division of Pediatric Cardiology, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Aysha Hussain
- University of Nebraska Medical Center and Children's Hospital and Medical Center, 8200 Dodge St, Omaha, NE, 68114, USA.
| | - Yunbin Xiao
- University of Nebraska Medical Center and Children's Hospital and Medical Center, 8200 Dodge St, Omaha, NE, 68114, USA.
| | - Shelby Kutty
- University of Nebraska Medical Center and Children's Hospital and Medical Center, 8200 Dodge St, Omaha, NE, 68114, USA.
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Ugonabo N, Hirsch-Romano JC, Uzark K. The role of home monitoring in interstage management of infants following the Norwood procedure. World J Pediatr Congenit Heart Surg 2015; 6:266-73. [PMID: 25870346 DOI: 10.1177/2150135114563771] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although outcomes for infants with complex single ventricle heart defects have steadily improved in recent decades, there is still a significant risk for mortality and morbidity during the interstage period between stage 1 Norwood hospitalization discharge and stage 2 palliation. Home monitoring programs, which involve parental surveillance of daily weight and oxygen saturations during the interstage period, have been shown to significantly improve survival rates. This article describes the potential risk factors or causes of interstage mortality and reviews the role of home monitoring in early detection and potential prevention of adverse outcomes.
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Affiliation(s)
- Nkem Ugonabo
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer C Hirsch-Romano
- Department of Cardiac Surgery, University of Michigan Mott Children's Hospital, Ann Arbor, MI, USA
| | - Karen Uzark
- Department of Cardiac Surgery, University of Michigan Mott Children's Hospital, Ann Arbor, MI, USA
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Abstract
BACKGROUND Recent efforts have focused on optimising interstage outcomes, including growth, for infants following the Norwood operation. The impact of the site of interstage care remains unclear, and it has been hypothesised that care at the surgical site may be beneficial due to greater access to resources such as nutritional support. This study evaluated the relationship between site of interstage care and weight gain in a large multicentre cohort. METHODS Infants enrolled in the National Paediatric Cardiology Quality Improvement Collaborative (2008-2013) surviving up to Stage 2 were included. Change in weight-for-age z-score between Norwood discharge and Stage 2 admission was compared in those receiving care at the surgical versus non-surgical site. RESULTS Of the 487 interstage survivors, 60% received all care at the surgical site, and 40% received care at a non-surgical site. There was no significant difference between groups in change in weight-for-age z-score: +0.36±0.96 for the surgical site group versus +0.46±1.02 for the non-surgical site group, p=0.3. Results were unchanged in multivariable analysis adjusting for differences in important baseline characteristics, duration of interstage, and home surveillance strategy. The proportion of all patients with weight-for-age z-score <-2 decreased from 40% at Norwood discharge to 29% at Stage 2, with no significant difference in change between the two groups (p=0.1). CONCLUSIONS The site of interstage care was not associated with weight gain during the interstage period. Nearly one-third of patients overall had a weight-for-age z-score <-2 at Stage 2. Further study is required to identify methods to optimise weight gain in these patients.
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Abstract
PURPOSE OF REVIEW The National Pediatric Quality Improvement Collaborative (NPCQIC) was established to improve outcomes and quality of life in children with hypoplastic left heart syndrome and other single ventricle lesions requiring a Norwood operation. The NPCQIC consists of a network of providers and families collecting longitudinal data, conducting research, and using quality improvement science to decrease variations in care, develop and spread best practices, and decrease mortality. RECENT FINDINGS Initial descriptive investigation of the collaborative data found interstage care process variations, different surgical strategies, diverse feeding practices, and variable ICU approaches between centers and within sites. Analysis and evaluation of these practice variations have allowed centers to learn from each other and implement change to improve processes. There has been an improvement in performance measures and most importantly, a 39.7% reduction in mortality. SUMMARY The NPCQIC has shown, in a rare disease such as hypoplastic left heart syndrome that a network based on multicenter collaboration, patient (parent) engagement, and quality improvement science can facilitate change in practices and improvement in outcomes.
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Harahsheh A, Sable C, Sinha P, Jonas R. ST segment depression after Norwood/systemic-pulmonary artery shunt. J Saudi Heart Assoc 2014; 27:68-9. [PMID: 25544825 DOI: 10.1016/j.jsha.2014.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- Ashraf Harahsheh
- Department of Pediatrics, Division of Cardiology, Children's National Health System, The George Washington University School of Medicine, Washington, DC
| | - Craig Sable
- Department of Pediatrics, Division of Cardiology, Children's National Health System, The George Washington University School of Medicine, Washington, DC
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, The George Washington University School of Medicine, Washington, DC, USA
| | - Richard Jonas
- Department of Cardiovascular Surgery, Children's National Health System, The George Washington University School of Medicine, Washington, DC, USA
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Sames-Dolzer E, Hakami L, Innerhuber M, Tulzer G, Mair R. Older age at the time of the Norwood procedure is a risk factor for early postoperative mortality†. Eur J Cardiothorac Surg 2014; 47:257-61; discussion 261. [DOI: 10.1093/ejcts/ezu128] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hill GD, Hehir DA, Bartz PJ, Rudd NA, Frommelt MA, Slicker J, Tanem J, Frontier K, Xiang Q, Wang T, Tweddell JS, Ghanayem NS. Effect of feeding modality on interstage growth after stage I palliation: a report from the National Pediatric Cardiology Quality Improvement Collaborative. J Thorac Cardiovasc Surg 2014; 148:1534-9. [PMID: 24607373 DOI: 10.1016/j.jtcvs.2014.02.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/30/2013] [Accepted: 02/03/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Achieving adequate growth after stage 1 palliation for children with single-ventricle heart defects often requires supplemental nutrition through enteral tubes. Significant practice variability exists between centers in the choice of feeding tube. The impact of feeding modality on the growth of patients with a single ventricle after stage 1 palliation was examined using the multiinstitutional National Pediatric Cardiology Quality Improvement Collaborative data registry. METHODS Characteristics of patients were compared by feeding modality, defined as oral only, nasogastric tube only, oral and nasogastric tube, gastrostomy tube only, and oral and gastrostomy tube. The impact of feeding modality on change in weight for age z-score during the interstage period, from stage 1 palliation discharge to stage 2 palliation, was evaluated by multivariable linear regression, adjusting for important patient characteristics and postoperative morbidities. RESULTS In this cohort of 465 patients, all groups demonstrated improved weight for age z-score during the interstage period with a mean increase of 0.3±0.8. In multivariable analysis, feeding modality was not associated with differences in the change in weight for age z-score during the interstage period (P=.72). Risk factors for poor growth were a diagnosis of hypoplastic left heart syndrome (P=.003), vocal cord injury (P=.007), and lower target caloric goal at discharge (P=.001). CONCLUSIONS In this large multicenter cohort, interstage growth improved for all groups and did not differ by feeding modality. With appropriate caloric goals and interstage monitoring, adequate growth may be achieved regardless of feeding modality and therefore local comfort and complication risk should dictate feeding modality.
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Affiliation(s)
- Garick D Hill
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.
| | - David A Hehir
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Peter J Bartz
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wis
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Michele A Frommelt
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Julie Slicker
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Jena Tanem
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Katherine Frontier
- Division of Speech and Audiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Qun Xiang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wis
| | - Tao Wang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wis
| | - James S Tweddell
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
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Congenital Cardiac Forum. Semin Cardiothorac Vasc Anesth 2013; 17:90-1. [DOI: 10.1177/1089253213488699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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