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Ashfaq A, Lorts A, Rosenthal D, Adachi I, Rossano J, Davies R, Simpson KE, Maeda K, Wisotzkey B, Koehl D, Cantor RS, Jacobs JP, Peng D, Kirklin JK, Morales DLS. Predicting Stroke for Pediatric Patients Supported With Ventricular Assist Devices: A Pedimacs Report. Ann Thorac Surg 2024; 118:889-897. [PMID: 38802036 DOI: 10.1016/j.athoracsur.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/03/2024] [Accepted: 05/06/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) provides detailed understanding on pediatric patients supported with ventricular assist devices (VADs). We sought to identify important variables affecting the incidence of stroke in pediatric VADs. METHODS Between 2012 and 2022, 1463 devices in 1219 patients were reported to Pedimacs from 40 centers in patients aged <19 years at their first VAD implantation. Multiphase parametric hazard modeling was used to identify risk factors for stroke among all device types. RESULTS Of the 1219 patients, the most common devices were implantable continuous (472 [39%]), followed by paracorporeal pulsatile (342 [28%]), and paracorporeal continuous (327 [27%]). Overall freedom from stroke at 6 months was higher in the recent era (2012-2016; 80.2% [95% CI, 77.1%-82.9%] vs 2017-2023; 87.9% [95% CI, 86.2%-89.4%], P = .009). Implantable continuous VADs had the highest freedom from stroke at 3 months (92.7%; 95% CI, 91.1%-93.9%) and 6 months (91.1%; 95% CI, 89.3%-92.6%), followed by paracorporeal pulsatile (87.0% [95% CI, 84.8%-88.9%] and 82.8% [95% CI, 79.8%-85.5%], respectively), and paracorporeal continuous (76.0% [95% CI, 71.8%-79.5%] and 69.5% [95% CI, 63.4%-74.8%], respectively) VADs. Parametric modeling identified risk factors for stoke early after implant and later. Overall, and particularly for paracorporeal pulsatile devices, early stroke risk has decreased in the most recent era (hazard ratio, 5.01). Among implantable continuous devices, cardiogenic shock was the major risk factor. For patients <10 kg, early hazard was only seen in the previous era. For congenital patients, early hazard was seen in nonimplantable device use and use of extracorporeal membrane oxygenation. CONCLUSIONS The overall stroke rate has decreased from 20% to 15% at 6 months, with particular improvement among paracorporeal pulsatile devices. Risk factor analyses offer insights for identification of higher stroke risk subsets and further management refinements.
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Affiliation(s)
- Awais Ashfaq
- Division of Cardiovascular Surgery, Department of Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Angela Lorts
- Division of Cardiovascular Surgery, Department of Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Salter Packard Children's Hospital, Palo Alto, California
| | - Iki Adachi
- Division of Cardiovascular Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Joseph Rossano
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ryan Davies
- Division of Cardiovascular Surgery, Department of Surgery, UT Southwestern, Dallas, Texas
| | - Kathleen E Simpson
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado
| | - Katsuhide Maeda
- Division of Cardiovascular Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bethany Wisotzkey
- Division of Pediatric Cardiology, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, Arizona
| | | | | | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Congenital Heart Center, Division of Cardiovascular Surgery, Department of Pediatrics, University of Florida, Gainesville, Florida
| | - David Peng
- Division of Pediatric Cardiology, Department of Pediatrics, Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | | | - David L S Morales
- Division of Cardiovascular Surgery, Department of Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Lorts A, VanderPluym C, Adachi I, Perry T, Alexander PMA, Almond CS, Auerbach SR, Barbaro RP, Bhavsar S, Bourque K, Conway J, Danziger-Isakov LA, Davies RR, Eghtesady P, Hirata Y, Ichord RN, Kormos RL, Kroslowitz R, Krucoff M, Lantz J, Mehegan M, Mehran R, Morales DLS, Murray J, Niebler RA, O'Connor MJ, Pagani FD, Peng DM, Rossano JW, Spitzer E, Steiner ME, Sutcliffe DL, Taylor JM, Villa CR, Wearden PD, Rosenthal D. ACTION-ARC Pediatric and Adult Congenital Heart Disease Ventricular Assist Device Adverse Event Definitions-2023. ASAIO J 2024:00002480-990000000-00567. [PMID: 39330959 DOI: 10.1097/mat.0000000000002288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024] Open
Abstract
Adverse events (AEs) experienced by children and adults with congenital heart disease (CHD) on ventricular assist devices (VADs) are sometimes unique to these populations. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) and the Academic Research Consortium (ARC) aimed to harmonize definitions of pediatric and CHD AEs for use in clinical trials, registries, and regulatory evaluation. Data from the ACTION registry and adjudication committee were used to adapt general mechanical circulatory support ARC definitions. This ACTION-ARC international expert panel of trialists, clinicians, patients, families, statisticians, biomedical engineers, device developers, and regulatory agencies drafted and iterated definitions harmonized to ACTION data and existing literature during sessions conducted between December 2022 and May 2023, followed by dissemination across clinical/research audiences and professional organizations and further revision. Both email-linked, internet-based surveys and in-person discussions were used as a modified Delphi process. Nineteen AE types were identified and defined, including seven new event types and six event types that were deleted and will no longer be collected, achieving consensus. ACTION-ARC paired rigorous development with methodical stakeholder involvement and dissemination to define pediatric VAD AEs to facilitate assimilation of data across future clinical trials and evaluation of devices for VAD-supported children and adults with CHD.
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Affiliation(s)
- Angela Lorts
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Iki Adachi
- Division of Cardiac Surgery, Texas Children's Hospital, Houston, Texas
| | - Tanya Perry
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peta M A Alexander
- Division of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Christopher S Almond
- Division of Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Scott R Auerbach
- The Heart Institute, University of Colorado Denver Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - Ryan P Barbaro
- Division of Critical Care, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | | | - Jennifer Conway
- Division of Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Lara A Danziger-Isakov
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ryan R Davies
- Division of Cardiac Surgery, University of Texas Southwestern Medical Center, Children's Health, Dallas, Texas
| | - Pirooz Eghtesady
- Division of Cardiac Surgery, Washington University, St. Louis Children's Hospital, St. Louis, Missouri
| | - Yasutaka Hirata
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Rebecca N Ichord
- Division of neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert L Kormos
- Global Medical Affairs Heart Failure, Abbott Laboratories, Austin, Texas
| | | | - Mitchell Krucoff
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Jodie Lantz
- Division of Cardiac Surgery, University of Texas Southwestern Medical Center, Children's Health, Dallas, Texas
| | - Mary Mehegan
- Division of Cardiac Surgery, Washington University, St. Louis Children's Hospital, St. Louis, Missouri
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David L S Morales
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jenna Murray
- Division of Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Robert A Niebler
- Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Matthew J O'Connor
- Division of neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - David M Peng
- Division of Critical Care, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joseph W Rossano
- Division of neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Marie E Steiner
- Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota
| | - David L Sutcliffe
- Department of Cardiology, Children's Mercy Hospital-Kansas City, Kansas City, Missouri
| | - J Michael Taylor
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chet R Villa
- From the Heart Institute Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peter D Wearden
- Department of Cardiovascular Services, Nemours Children's Health, Orlando, Florida
| | - David Rosenthal
- Division of Cardiology, Stanford University School of Medicine, Palo Alto, California
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Schauer JS, Hong B. A Review of Pediatric Cardiomyopathy. Semin Cardiothorac Vasc Anesth 2024; 28:165-176. [PMID: 38708810 DOI: 10.1177/10892532241250241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Though pediatric cardiomyopathy is rare in children, there is significant associated morbidity and mortality. Etiology varies from inborn errors of metabolism to familial genetic mutations and myocyte injury. Major classes include dilated, hypertrophic, restrictive, and non-compaction. Diagnosis generally involves a combination of clinical history and echocardiography. The use of cross-sectional imaging is gaining popularity. Management varies between subtype and may involve a combination of medical and surgical interventions depending on clinical status.
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Affiliation(s)
- Jenna S Schauer
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Borah Hong
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
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4
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Adderley J, Pidborochynski T, Buchholz H, Holinski P, Anand V, De Villiers Jonker I, Freed DH, Al-Aklabi M, Conway J. Risk factors for thromboembolic events in pediatric patients with ventricular assist devices. JTCVS OPEN 2024; 20:132-140. [PMID: 39296449 PMCID: PMC11405981 DOI: 10.1016/j.xjon.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/27/2024] [Accepted: 05/07/2024] [Indexed: 09/21/2024]
Abstract
Objective Pediatric patients on ventricular assist devices (VAD) are at risk of thromboembolic (TE) complications. Our objective was to identify factors associated with TE events, including the role of initial anticoagulation strategy and device type in the pediatric VAD population. Methods This was a retrospective, single-center review (2005-2022) of children who were implanted with paracorporeal pulsatile (PP), paracorporeal continuous (PC), or a combination of devices. Patient- and device-related factors were collected. Kaplan-Meier survival analysis was performed to determine freedom from TE. Cox proportional hazard analysis was conducted to look for factors associated with TE events. Results Ninety-five patients included with a median age of 0.9 years (interquartile range, 0.3, 5.4); median weight of 8.4 kg (interquartile range, 4.5, 17.8), and 63.2% with noncongenital heart disease. Device breakdown included 47.4% PC, 24.2% PP, and 23.2% combination of devices. Initial anticoagulation was either heparin (61.5%) or bivalirudin (38.5%). In Kaplan-Meier analysis, unadjusted freedom from a TE event was significantly greater in those who received bivalirudin as their initial anticoagulation strategy (P = .02) and PP VADs (P = .02). In multivariate analysis, initial anticoagulation strategy with bivalirudin (hazard ratio, 0.30; 95% confidence interval, 0.12-0.75, P = .01) was associated with a reduced hazard of TE events, whereas PC device strategy was found to be associated with an increased hazard (hazard ratio, 2.78; 95% confidence interval, 1.12-6.88, P = .03). Conclusions This study suggests that PC device strategy and heparin as an initial anticoagulation strategy are associated with increased hazard of TE events. Further research is required to understand the interaction between device type and initial anticoagulation strategy.
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Affiliation(s)
- Jeremy Adderley
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Holger Buchholz
- Department of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Paula Holinski
- Division of Pediatric Critical Care, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Vijay Anand
- Division of Pediatric Critical Care, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Izak De Villiers Jonker
- Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Darren H Freed
- Department of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
- Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Mohammed Al-Aklabi
- Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jennifer Conway
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
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5
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Hollis IB, Jennings DL, Krim S, Ton VK, Ducharme A, Cowger J, Looby M, Eulert-Green JJ, Bansal N, Horn E, Byku M, Katz J, Michaud CJ, Rajapreyar I, Campbell P, Vale C, Cosgrove R, Hernandez-Montfort J, Otero J, Ingemi A, Raj S, Weeks P, Agarwal R, Martinez ES, Tops LF, Ahmed MM, Kiskaddon A, Kremer J, Keebler M, Ratnagiri RK. An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device. J Heart Lung Transplant 2024; 43:1199-1234. [PMID: 38878021 DOI: 10.1016/j.healun.2024.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 07/15/2024] Open
Abstract
Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.
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Affiliation(s)
- Ian B Hollis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina; University of North Carolina Medical Center, Chapel Hill, North Carolina.
| | - Douglas L Jennings
- New York Presbyterian Columbia Irving Medical Center/Long Island University College of Pharmacy, New York, New York
| | - Selim Krim
- John Ochsner Heart and Vascular Institute, New Orleans, Louisiana
| | - Van-Khue Ton
- Massachusetts General Hospital, Boston, Massachusetts
| | - Anique Ducharme
- Montreal Heart Institute/Université de Montréal, Montreal, Quebec, Canada
| | | | - Mary Looby
- Inova Fairfax Medical Campus, Falls Church, Virginia
| | | | - Neha Bansal
- Mount Sinai Kravis Children's Hospital, New York, New York
| | - Ed Horn
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mirnela Byku
- University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Jason Katz
- Division of Cardiology, NYU Grossman School of Medicine & Bellevue Hospital, New York, New York
| | | | | | | | - Cassandra Vale
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Richard Cosgrove
- Cornerstone Specialty Hospital/University of Arizona College of Pharmacy, Tucson, Arizona
| | | | - Jessica Otero
- AdventHealth Littleton Hospital, Littleton, Colorado
| | | | | | - Phillip Weeks
- Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | | | - Laurens F Tops
- Leiden University Medical Center, Leiden, the Netherlands
| | | | - Amy Kiskaddon
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mary Keebler
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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6
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Cashen K, Saini A, Brandão LR, Le J, Monagle P, Moynihan KM, Ryerson LM, Gehred A, Lyman E, Muszynski JA, Alexander PMA, Dalton HJ. Anticoagulant Medications: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e7-e13. [PMID: 38959355 PMCID: PMC11216397 DOI: 10.1097/pcc.0000000000003495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding the medications used for anticoagulation for pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE (PEACE). DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION Included studies assessed anticoagulation used in pediatric ECMO. DATA EXTRACTION Two authors reviewed all citations independently, with a third reviewer adjudicating any conflicts. Eighteen references were used for data extraction as well as for creation of recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-informed recommendations and, when evidence was lacking, expert-based consensus statements, or good practice statements for anticoagulation during pediatric ECMO. A web-based modified Delphi process was used to build consensus via the Research and Development/University of California Appropriateness Method. Consensus was based on a modified Delphi process with agreement defined as greater than 80%. Two recommendations, two consensus statements, and one good practice statement were developed, and, in all, agreement greater than 80% was reached. CONCLUSIONS There is insufficient evidence to formulate optimal anticoagulation therapy during pediatric ECMO. Additional high-quality research is needed to inform evidence-based practice for anticoagulation during pediatric ECMO.
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Affiliation(s)
- Katherine Cashen
- Division of Critical Care Medicine, Department of Pediatrics, Duke University and Duke University Health System, Durham, NC
| | - Arun Saini
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Leonardo R Brandão
- Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Paul Monagle
- University of Melbourne, Melbourne, VIC, Australia
- Kids Cancer Centre Sydney Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Westmead Children's Hospital, Sydney, NSW, Australia
| | - Lindsay M Ryerson
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, OH
| | - Elizabeth Lyman
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Heidi J Dalton
- Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA
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Almond CS, Davies R, Adachi I, Richmond M, Law S, Tunuguntla H, Mao C, Shaw F, Lantz J, Wearden PD, Jordan LC, Ichord RN, Burns K, Zak V, Magnavita A, Gonzales S, Conway J, Jeewa A, Freemon D'A, Stylianou M, Sleeper L, Dykes JC, Ma M, Fynn-Thompson F, Lorts A, Morales D, Vanderpluym C, Dasse K, Patricia Massicotte M, Jaquiss R, Mahle WT. A prospective multicenter feasibility study of a miniaturized implantable continuous flow ventricular assist device in smaller children with heart failure. J Heart Lung Transplant 2024; 43:889-900. [PMID: 38713124 DOI: 10.1016/j.healun.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 01/15/2024] [Accepted: 02/03/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND There is no FDA-approved left ventricular assist device (LVAD) for smaller children permitting routine hospital discharge. Smaller children supported with LVADs typically remain hospitalized for months awaiting heart transplant-a major burden for families and a challenge for hospitals. We describe the initial outcomes of the Jarvik 2015, a miniaturized implantable continuous flow LVAD, in the NHLBI-funded Pumps for Kids, Infants, and Neonates (PumpKIN) study, for bridge-to-heart transplant. METHODS Children weighing 8 to 30 kg with severe systolic heart failure and failing optimal medical therapy were recruited at 7 centers in the United States. Patients with severe right heart failure and single-ventricle congenital heart disease were excluded. The primary feasibility endpoint was survival to 30 days without severe stroke or non-operational device failure. RESULTS Of 7 children implanted, the median age was 2.2 (range 0.7, 7.1) years, median weight 10 (8.2 to 20.7) kilograms; 86% had dilated cardiomyopathy; 29% were INTERMACS profile 1. The median duration of Jarvik 2015 support was 149 (range 5 to 188) days where all 7 children survived including 5 to heart transplant, 1 to recovery, and 1 to conversion to a paracorporeal device. One patient experienced an ischemic stroke on day 53 of device support in the setting of myocardial recovery. One patient required ECMO support for intractable ventricular arrhythmias and was eventually transplanted from paracorporeal biventricular VAD support. The median pump speed was 1600 RPM with power ranging from 1-4 Watts. The median plasma free hemoglobin was 19, 30, 19 and 30 mg/dL at 7, 30, 90 and 180 days or time of explant, respectively. All patients reached the primary feasibility endpoint. Patient-reported outcomes with the device were favorable with respect to participation in a full range of activities. Due to financial issues with the manufacturer, the study was suspended after consent of the eighth patient. CONCLUSION The Jarvik 2015 LVAD appears to hold important promise as an implantable continuous flow device for smaller children that may support hospital discharge. The FDA has approved the device to proceed to a 22-subject pivotal trial. Whether this device will survive to commercialization remains unclear because of the financial challenges faced by industry seeking to develop pediatric medical devices. (Supported by NIH/NHLBI HHS Contract N268201200001I, clinicaltrials.gov 02954497).
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Affiliation(s)
| | - Ryan Davies
- University of Texas Southwestern, Dallas, Texas
| | - Iki Adachi
- Texas Children's Hospital, Houston, Texas
| | | | | | | | - Chad Mao
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Fawwaz Shaw
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jodie Lantz
- University of Texas Southwestern, Dallas, Texas
| | | | - Lori C Jordan
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Kristin Burns
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | | | - Selena Gonzales
- Stanford University School of Medicine, Palo Alto, California
| | | | - Aamir Jeewa
- Toronto Sick Kids Hospital, Toronto, Ontario, Canada
| | | | - Mario Stylianou
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Lynn Sleeper
- Boston Children's Hospital, Boston, Massachusetts
| | - John C Dykes
- Stanford University School of Medicine, Palo Alto, California
| | - Michael Ma
- Stanford University School of Medicine, Palo Alto, California
| | | | - Angela Lorts
- Cinciannati Children's Hospital, Cincinnati, Ohio
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8
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Mikulski MF, Iyer S, Well A, Mery CM, Owens WR, Glass LD, Castleberry CD, Fraser CD. Successful explantation of children from the Berlin Heart EXCOR® ventricular assist device: A systematic review. Artif Organs 2024; 48:444-455. [PMID: 38419587 DOI: 10.1111/aor.14727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The Berlin Heart EXCOR® (BHE) can bridge children with severe heart failure to transplantation, but some are successfully weaned and spared transplantation. This study seeks to identify characteristics of children amenable to successful explantation with BHE support. METHODS Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 guidelines were used. Five databases were screened for original, English articles measuring BHE support in patients <18 years old based on title and abstract. Exclusion criteria were applied: full-text availability, <10 total pediatric BHE patients, zero successful explantations from BHE, nonprimary literature, adult and pediatric results that could not be separated, and studies with overlapping patient information. Studies were analyzed with descriptive statistics. RESULTS From 41 857 potential studies, 14 were analyzed with data from 58 hospitals on four continents from 1990 to 2020. There were 984 BHE patients. The most common diagnosis was dilated cardiomyopathy (n = 318, 32.3%), followed by congenital heart disease (n = 249, 25.3%). There were 85 (8.6%) children explanted with favorable outcomes. The underlying diagnosis was known in 44 (51.8%) cases: 14 (8.4%) of 166 cardiomyopathies, 17 (48.6%) of 35 myocarditis, and 12 (16.7%) of 72 with congenital heart disease were explanted. When the type of support was known, the rate of LVAD patients explanted was 21.3% (n = 19/89) and 2.4% (n = 1/42) of BiVAD patients were explanted. CONCLUSION Explantation from BHE is not uncommon at 8.6%, but significant variation exists in the explantation data reported. Myocarditis and LVAD support may be populations suitable for weaning. Standardization of reporting measures and prospective registries may help identify patients suitable for this alternative to transplant and help develop weaning protocols.
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Affiliation(s)
- Matthew F Mikulski
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, Texas, USA
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Swati Iyer
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, Texas, USA
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Andrew Well
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, Texas, USA
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, Texas, USA
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - W Richard Owens
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, Texas, USA
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Lauren D Glass
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, Texas, USA
- Department of Pediatrics, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Chesney D Castleberry
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, Texas, USA
- Department of Pediatrics, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Charles D Fraser
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, Texas, USA
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
- Department of Pediatrics, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
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9
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Idrovo A, Hollander SA, Neumayr TM, Bell C, Munoz G, Choudhry S, Price J, Adachi I, Srivaths P, Sutherland S, Akcan-Arikan A. Long-term kidney outcomes in pediatric continuous-flow ventricular assist device patients. Pediatr Nephrol 2024; 39:1289-1300. [PMID: 37971519 DOI: 10.1007/s00467-023-06190-8] [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: 05/26/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Continuous-flow ventricular assist devices (CF-VADs) are used increasingly in pediatric end-stage heart failure (ESHF) patients. Alongside common risk factors like oxidant injury from hemolysis, non-pulsatile flow constitutes a unique circulatory stress on kidneys. Post-implantation recovery after acute kidney injury (AKI) is commonly reported, but long-term kidney outcomes or factors implicated in the evolution of chronic kidney disease (CKD) with prolonged CF-VAD support are unknown. METHODS We studied ESHF patients supported > 90 days on CF-VAD from 2008 to 2018. The primary outcome was CKD (per Kidney Disease Improving Global Outcomes (KDIGO) criteria). Secondary outcomes included AKI incidence post-implantation and CKD evolution in the 6-12 months of CF-VAD support. RESULTS We enrolled 134 patients; 84/134 (63%) were male, median age was 13 [IQR 9.9, 15.9] years, 72/134 (54%) had preexisting CKD at implantation, and 85/134 (63%) had AKI. At 3 months, of the 91/134 (68%) still on a CF-VAD, 34/91 (37%) never had CKD, 13/91 (14%) developed de novo CKD, while CKD persisted or worsened in 49% (44/91). Etiology of heart failure, extracorporeal membrane oxygenation use, duration of CF-VAD, AKI history, and kidney replacement therapy were not associated with different CKD outcomes. Mortality was higher in those with AKI or preexisting CKD. CONCLUSIONS In the first multicenter study to focus on kidney outcomes for pediatric long-term CF-VAD patients, preimplantation CKD and peri-implantation AKI were common. Both de novo CKD and worsening CKD can happen on prolonged CF-VAD support. Proactive kidney function monitoring and targeted follow-up are important to optimize outcomes.
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Affiliation(s)
- Alexandra Idrovo
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA.
- Renal Section, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Seth A Hollander
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tara M Neumayr
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School, St. Louis, MO, USA
- Division of Nephrology, Department of Pediatrics, Washington University School, St. Louis, MO, USA
| | - Cynthia Bell
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Genevieve Munoz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School, St. Louis, MO, USA
| | - Swati Choudhry
- Pediatrics, Cardiology Section, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Jack Price
- Pediatrics, Cardiology Section, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Department of Pediatrics, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Poyyapakkam Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA
| | - Scott Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ayse Akcan-Arikan
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA
- Department of Pediatrics Critical Care Section, Baylor College of Medicine, Texas Children's, Houston, TX, USA
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10
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Perdomo AA, Badawy MK, Mignone C, Forster JC. Exceeding radiation thresholds for cataract induction in diagnostic imaging: a paediatric case report. RADIATION PROTECTION DOSIMETRY 2024; 200:417-422. [PMID: 38195763 DOI: 10.1093/rpd/ncad310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/17/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
This case report investigates the radiation dose received by a paediatric patient with a ventricular assist device who underwent four non-contrast brain computed tomography (CT) scans, two brain perfusion CT scans and two head angiographic CT scans. The total estimated absorbed dose to the lens of the eye is above the 500 mGy radiation-induced cataract threshold. It is recommended that this patient and those with similar imaging histories have routine follow-up with an ophthalmologist. It is also recommended that radiation dose tracking and an electronic medical alert program be implemented to allow the identification of patients who may exceed tissue reaction thresholds.
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Affiliation(s)
- Amanda Alison Perdomo
- Department of Physics, University of Adelaide, Adelaide 5005, South Australia, Australia
- Department of Medical Imaging, The Royal Children's Hospital, 50 Flemington Road, Parkville 3052, Victoria, Australia
| | - Mohamed Khaldoun Badawy
- Monash Health Imaging, Monash Health, 246 Clayton Rd, Clayton 3168, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton 3800, VIC, Australia
| | - Cristina Mignone
- Department of Medical Imaging, The Royal Children's Hospital, 50 Flemington Road, Parkville 3052, Victoria, Australia
| | - Jake Cameron Forster
- Department of Physics, University of Adelaide, Adelaide 5005, South Australia, Australia
- Medical Physics & Radiation Safety, South Australia Medical Imaging, Adelaide 5005, South Australia, Australia
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11
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Silva DLM, Lemouche SO, Takahashi TY, Zanon IDC, Siqueira A, Machado D, Azeka E, de Melo SL. Case Report: Sustained ventricular arrhythmia in a child supported by a Berlin heart EXCOR ventricular assist device. FRONTIERS IN TRANSPLANTATION 2024; 3:1302060. [PMID: 38993747 PMCID: PMC11235354 DOI: 10.3389/frtra.2024.1302060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/07/2024] [Indexed: 07/13/2024]
Abstract
Mechanical circulatory support is an established therapy to support failing hearts as a bridge to transplantation. Although tolerated overall, arrhythmias may occur after ventricular assist device implantation and can complicate patient management. We report on an infant with dilated cardiomyopathy who developed ventricular tachycardia followed by recalcitrant ventricular fibrillation, refractory to comprehensive medical therapy post Berlin Heart EXCOR® (BHE) implant.
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Affiliation(s)
| | | | | | | | - Adailson Siqueira
- Division of Congenital Heart Disease, Heart Institute (InCor), São Paulo, Brazil
| | - Desiree Machado
- Division of Pediatric Cardiology, Department of Pediatrics, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Estela Azeka
- Division of Congenital Heart Disease, Heart Institute (InCor), São Paulo, Brazil
| | - Sissy Lara de Melo
- Division of Congenital Heart Disease, Heart Institute (InCor), São Paulo, Brazil
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12
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Oesch G, Münger R, Steinlin M. Be aware of childhood stroke: Proceedings from EPNS Webinar. Eur J Paediatr Neurol 2024; 49:82-94. [PMID: 38447504 DOI: 10.1016/j.ejpn.2024.02.001] [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] [Revised: 12/11/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024]
Abstract
Childhood arterial ischaemic stroke (AIS) is a significant health concern with increasing incidence. This review aims to provide an overview of the current understanding of childhood AIS. The incidence of childhood AIS is on the rise especially in developing countries, likely due to improved awareness and diagnostic capabilities. Aetiology of childhood AIS is multifactorial, with both modifiable risk factors and genetic predisposition playing important roles. Identifying and addressing these risk factors, such as infection, sickle cell disease, and congenital heart defects, is essential in prevention and management. Identifying underlying conditions through genetic testing is important for appropriate management and long-term prognosis. Clinically, distinguishing stroke from stroke mimics can be challenging. Awareness of important stroke mimics, including migraines, seizures, and metabolic disorders, is crucial to avoid misdiagnosis and ensure appropriate treatment. The diagnostic approach to childhood AIS involves a comprehensive "chain of care," including initial assessment, neuroimaging, and laboratory investigations. National guidelines play a pivotal role in standardizing and streamlining the diagnostic process, ensuring prompt and accurate management. Early intervention is critical in the management of childhood AIS. Due to the critical time window, the question if mechanical thrombectomy is feasible and beneficial should be addressed as fast as possible. Early initiation of antiplatelet or anticoagulation therapy and, in select cases, thrombolysis can help restore blood flow and minimize long-term neurological damage. Additionally, rehabilitation should start as soon as possible to optimize recovery and improve functional outcomes. In conclusion, childhood AIS is a growing concern. Understanding the increasing incidence, age distribution, risk factors, clinical presentation, diagnostic approach, and management strategies is crucial for optimized management of these patients.
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Affiliation(s)
- Gabriela Oesch
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Robin Münger
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland
| | - Maja Steinlin
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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13
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Tuttle MG, Yan K, Zhang J, Niebler RA. Argatroban Use in Pediatric Patients Supported by Paracorporeal Ventricular Assist Devices. ASAIO J 2024; 70:224-229. [PMID: 37934717 DOI: 10.1097/mat.0000000000002086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Direct thrombin inhibitor (DTI) use has been associated with decreased stroke and death rates in children on ventricular assist devices (VADs). Most information about DTI use for children on VADs has focused on bivalirudin with limited data on argatroban. We hypothesized that, compared to unfractionated heparin (UFH), argatroban would be associated with decreased bleeding, stroke, and death rates in children on VADs. We retrospectively collected data from patients <18 years old on paracorporeal VADs at Children's Wisconsin between January 1, 2010 and July 1, 2021. We divided patients into cohorts based on anticoagulation strategy with heparin or argatroban. Definitions of bleeding and neurologic events were the same as in other published reports on this population. We compared categorical variables with the χ 2 or Fisher's exact test, and continuous variables with the Mann-Whitney U test. Nineteen children were anticoagulated with argatroban, and 16 with heparin. Demographics between groups were not significantly different. Stroke, bleeding, and death rates did not differ between patients treated with UFH versus argatroban. The study population was complex with a high rate of extracorporeal membrane oxygenation (ECMO) use before VAD support, which likely impacted our findings. Our study does not support argatroban as a superior alternative anticoagulant compared to UFH in children requiring VADs.
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Affiliation(s)
- Merritt G Tuttle
- From the Department of Pediatric Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ke Yan
- Department of Quantitative Health Sciences, Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jian Zhang
- Department of Quantitative Health Sciences, Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert A Niebler
- From the Department of Pediatric Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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14
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Jentzer JC, Drakos SG, Selzman CH, Owyang C, Teran F, Tonna JE. Timing of Initiation of Extracorporeal Membrane Oxygenation Support and Outcomes Among Patients With Cardiogenic Shock. J Am Heart Assoc 2024; 13:e032288. [PMID: 38240232 PMCID: PMC11056129 DOI: 10.1161/jaha.123.032288] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/27/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (ECMO) provides full hemodynamic support for patients with cardiogenic shock, but optimal timing of ECMO initiation remains uncertain. We sought to determine whether earlier initiation of ECMO is associated with improved survival in cardiogenic shock. METHODS AND RESULTS We analyzed adult patients with cardiogenic shock who received venoarterial ECMO from the international Extracorporeal Life Support Organization (ELSO) registry from 2009 to 2019, excluding those cannulated following an operation. Multivariable logistic regression evaluated the association between time from admission to ECMO initiation and in-hospital death. Among 8619 patients (median, 56.7 [range, 44.8-65.6] years; 33.5% women), the median duration from admission to ECMO initiation was 14 (5-32) hours. Patients who had ECMO initiated within 24 hours (n=5882 [68.2%]) differed from those who had ECMO initiated after 24 hours, with younger age, more preceding cardiac arrest, and worse acidosis. After multivariable adjustment, patients with ECMO initiated >24 hours after admission had higher risk of in-hospital death (adjusted odds ratio, 1.20 [95% CI, 1.06-1.36]; P=0.004). Each 12-hour increase in the time from admission to ECMO initiation was incrementally associated with higher adjusted in-hospital mortality rate (adjusted odds ratio, 1.06 [95% CI, 1.03-1.10]; P<0.001). The association between longer time to ECMO and worse outcomes appeared stronger in patients with lower shock severity. CONCLUSIONS Longer delays from admission to ECMO initiation were associated with higher a mortality rate in a large-scale, international registry. Our analysis supports optimization of door-to-support time and the avoidance of inappropriately delayed ECMO initiation.
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Affiliation(s)
| | - Stavros G. Drakos
- Division of Cardiovascular Medicine and Nora Eccles Harrison Cardiovascular Research Training InstituteUniversity of UtahSalt Lake CityUTUSA
| | - Craig H. Selzman
- Division of Cardiothoracic Surgery, Department of SurgeryUniversity of UtahSalt Lake CityUTUSA
| | - Clark Owyang
- Department of Emergency MedicineNew York Presbyterian Hospital‐Weill Cornell Medical CenterNew YorkNYUSA
| | - Felipe Teran
- Department of Emergency MedicineNew York Presbyterian Hospital‐Weill Cornell Medical CenterNew YorkNYUSA
| | - Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of SurgeryUniversity of UtahSalt Lake CityUTUSA
- Department of Emergency MedicineUniversity of UtahSalt Lake CityUTUSA
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15
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Kamsheh AM, Edelson JB, Faerber J, Mondal A, Quarshie W, Edwards JJ, Lin KY, O’Connor MJ, Wittlieb-Weber C, Maeda K, Goldsmith MP, Rossano JW. Mechanical Circulatory Support in Pediatric Myocarditis: Support Strategies and Outcomes in a Nationally Representative Cohort. JHLT OPEN 2024; 3:100026. [PMID: 39015662 PMCID: PMC11251716 DOI: 10.1016/j.jhlto.2023.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
Background Myocarditis is a common cause of pediatric heart failure which may require mechanical circulatory support (MCS). The purpose of this study is to describe MCS strategies used in a nationwide cohort of pediatric patients with myocarditis, identify trends over time, and compare outcomes between MCS strategies. Methods This study utilized the Kids' Inpatient Database (KID), a national sample of administrative discharge data. KID admissions from 2003-2016 were queried using ICD-9/10 codes to identify those with a diagnosis of myocarditis. MCS outcomes were compared using logistic regression. Results Of 5,661 admissions for myocarditis, MCS was used in 424 (7.5%), comprised of extracorporeal membrane oxygenation (ECMO) in 312 (73.6%), including 32 (10.2%) instances of extracorporeal cardiopulmonary resuscitation (ECPR), temporary ventricular assist devices (tVAD) in 28 (6.6%), durable VAD (dVAD) in 42 (9.9%) and combination MCS in 42 (9.9%). MCS use increased over time (p=0.031), but MCS strategies did not significantly change. Mortality was high in the MCS group (28.3%). There was no difference in odds of death in the VAD only or combination MCS group compared to the non-ECPR ECMO group (p=0.07 and p=0.65, respectively). Conclusion MCS is used in 1 in 13 pediatric myocarditis cases, and MCS use is increasing over time with ECMO remaining the most frequently used modality. Mortality remains high in patients that receive MCS but does not differ between those receiving VAD or combination MCS as compared to non-ECPR ECMO on unadjusted analysis. Further prospective analysis is required to evaluate the relative effectiveness of MCS modalities in this disease.
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Affiliation(s)
- Alicia M. Kamsheh
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, MO
| | - Jonathan B. Edelson
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer Faerber
- Data Science and Biostatistics Unit, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Antara Mondal
- Data Science and Biostatistics Unit, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - William Quarshie
- Data Science and Biostatistics Unit, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jonathan J. Edwards
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kimberly Y. Lin
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Matthew J. O’Connor
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Michael P. Goldsmith
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Joseph W. Rossano
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
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16
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Tonna JE, Boonstra PS, MacLaren G, Paden M, Brodie D, Anders M, Hoskote A, Ramanathan K, Hyslop R, Fanning JJ, Rycus P, Stead C, Barrett NA, Mueller T, Gómez RD, Kapoor PM, Fraser JF, Bartlett RH, Alexander PM, Barbaro RP. Extracorporeal Life Support Organization Registry International Report 2022: 100,000 Survivors. ASAIO J 2024; 70:131-143. [PMID: 38181413 PMCID: PMC10962646 DOI: 10.1097/mat.0000000000002128] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
The Extracorporeal Life Support Organization (ELSO) maintains the world's largest extracorporeal membrane oxygenation (ECMO) registry by volume, center participation, and international scope. This 2022 ELSO Registry Report describes the program characteristics of ECMO centers, processes of ECMO care, and reported outcomes. Neonates (0-28 days), children (29 days-17 years), and adults (≥18 years) supported with ECMO from 2009 through 2022 and reported to the ELSO Registry were included. This report describes adjunctive therapies, support modes, treatments, complications, and survival outcomes. Data are presented descriptively as counts and percent or median and interquartile range (IQR) by year, group, or level. Missing values were excluded before calculating descriptive statistics. Complications are reported per 1,000 ECMO hours. From 2009 to 2022, 154,568 ECMO runs were entered into the ELSO Registry. Seven hundred and eighty centers submitted data during this time (557 in 2022). Since 2009, the median annual number of adult ECMO runs per center per year increased from 4 to 15, whereas for pediatric and neonatal runs, the rate decreased from 12 to 7. Over 50% of patients were transferred to the reporting ECMO center; 20% of these patients were transported with ECMO. The use of prone positioning before respiratory ECMO increased from 15% (2019) to 44% (2021) for adults during the coronavirus disease-2019 (COVID-19) pandemic. Survival to hospital discharge was greatest at 68.5% for neonatal respiratory support and lowest at 29.5% for ECPR delivered to adults. By 2022, the Registry had enrolled its 200,000th ECMO patient and 100,000th patient discharged alive. Since its inception, the ELSO Registry has helped centers measure and compare outcomes across its member centers and strategies of care. Continued growth and development of the Registry will aim to bolster its utility to patients and centers.
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Affiliation(s)
- Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah
| | - Philip S. Boonstra
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore, Singapore
| | - Matthew Paden
- Department of Surgery, Division of Pediatric Critical Care Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Daniel Brodie
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marc Anders
- Department of Surgery, Division of Critical Care, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Aparna Hoskote
- Department of Surgery, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Surgery, Institute of Cardiovascular Science, University College London, Zayed Centre for Research into Rare Diseases in Children, London, UK
| | - Kollengode Ramanathan
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Surgery, Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rob Hyslop
- Department of Surgery, Heart Institute, Children’s Hospital Colorado, Aurora, Colorado
| | - Jeffrey J. Fanning
- Department of Pediatrics, Extracorporeal Life Support Program, Medical City Children’s Hospital, Dallas, Texas
| | - Peter Rycus
- Department of Surgery, Extracorporeal Life Support Organization (ELSO), Ann Arbor, Michigan
| | - Christine Stead
- Department of Surgery, Extracorporeal Life Support Organization (ELSO), University of Michigan, Ann Arbor, Michigan
| | - Nicholas A. Barrett
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Surgery, Centre for Human & Applied Physiological Sciences, King’s College London, London, UK
| | - Thomas Mueller
- Intensive Care Medicine, Department of Internal Medicine II, University Hospital Regensburg, Germany
| | - Rene D. Gómez
- Department of Surgery, Terapias Avanzadas de Soporte Cardiopulmonar, Hospitales Tec Salud, Escuela de Medicina ITESM, Monterrey, Mexico
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesiology and Critical Care, Cardio Thoracic Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - John F. Fraser
- Department of Surgery, University of Queensland, The Prince Charles Hospital, Brisbane, Australia
| | | | - Peta M.A. Alexander
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Ryan P. Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
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17
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Kozik D, Alsoufi B. Pediatric mechanical circulatory support - a review. Indian J Thorac Cardiovasc Surg 2023; 39:80-90. [PMID: 37525715 PMCID: PMC10386992 DOI: 10.1007/s12055-023-01499-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
The history of mechanical circulatory support began in 1953, as the first heart-lung machine enabled surgeons to perform complex open heart surgery. Heart failure is more prevalent in adults than pediatric patients which has led to the development of devices for adults with end-stage heart failure at a faster pace. Pediatric mechanical circulatory support has been derived from adult durable devices and subsequently applied in the adolescent population. The application of adult devices in children is inherently problematic due to size mismatch, especially in smaller patients. There has been an increasing interest in developing durable pumps that are appropriate for children for several reasons, with the primary factor being the number of children with end-stage heart failure far exceeding the number of potential donors. Mechanical circulatory support (MCS) for children can be divided into short-term temporary support and long-term durable support. The goal of this review is to discuss the devices available for the pediatric population and review the options for support in complex patients including single-ventricle anatomy, biventricular support, and total artificial heart options. We will also briefly discuss the Pumps for Kids, Infants, and Neonates (PumpKIN) Trial and MCS registries, including the Advanced Cardiac Therapies Improving Outcomes Network (ACTION).
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Affiliation(s)
- Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
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18
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Freniere V, Salerno DM, Corbo H, Law S, McAllister J, Neunert C, Chen JK. Bivalirudin Compared to Heparin as the Primary Anticoagulant in Pediatric Berlin Heart Recipients. ASAIO J 2023; 69:e205-e211. [PMID: 36943709 DOI: 10.1097/mat.0000000000001921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Bivalirudin has been used in increasing frequency as an alternative to unfractionated heparin (UFH) in pediatric recipients of Berlin Heart EXCOR ventricular assist devices (VAD). This single-center, retrospective review characterizes anticoagulant trends and outcomes in pediatric Berlin Heart VAD recipients implanted between September 1, 2013, and August 31, 2021, anticoagulated with either bivalirudin or UFH. Thirty-one patients were included; 65% who received bivalirudin and 35% who received UFH. The median age was 2.9 years, included 64.5% females, with 61.3% of patients diagnosed with dilated cardiomyopathy and 25.8% of patients with congenital heart disease. Therapeutic anticoagulation was achieved sooner in the bivalirudin group compared to UFH via anti-Xa monitoring (median 5.7 and 69.5 hours, respectively, p < 0.001). Bivalirudin had a greater number of therapeutic values comparatively to UFH (52% and 24%, respectively; p < 0.001) and a superior number of hours in the therapeutic range (67% and 32%, respectively; p < 0.001). Secondary outcomes were similar among the two groups, apart from greater chest tube output (UFH), more frequent events of elevated plasma-free hemoglobin (bivalirudin), and more frequent elevated inflammatory markers postimplant (bivalirudin). Prevalence of pump replacements secondary to significant clot burden and prevalence of stroke was comparable. In this patient cohort, bivalirudin demonstrated greater anticoagulation stability comparatively to UFH. Multicenter collaboration would be necessary to identify whether this further translates into improved patient outcomes.
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Affiliation(s)
| | - David M Salerno
- From the Department of Pharmacy, NewYork-Presbyterian Hospital
| | - Heather Corbo
- From the Department of Pharmacy, NewYork-Presbyterian Hospital
| | - Sabrina Law
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Jennie McAllister
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Cindy Neunert
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Justin K Chen
- From the Department of Pharmacy, NewYork-Presbyterian Hospital
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19
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Kwiatkowski DM, Shezad M, Barnes AP, Ploutz MS, Law SP, Zafar F, Morales DLS, O'Connor MJ. Impact of Weight on Ventricular Assist Device Outcomes in Dilated Cardiomyopathy Patients in Pediatric Centers: An ACTION Registry Study. ASAIO J 2023; 69:496-503. [PMID: 37071761 DOI: 10.1097/mat.0000000000001861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
Ventricular assist device (VAD) options vary for children in different weight groups. This study evaluates contemporary device usage and outcomes for children based on weight. Data from the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry were examined for patients with dilated cardiomyopathy (DCM) in 4 weight cohorts: <8 kg, 8-20 kg, 21-40 kg, and >40 kg, for devices implanted 3/2013-10/2020. Adverse event rates and ultimate outcome (deceased, alive on device, transplanted, or ventricular recovery) were analyzed. 222 DCM patients were identified with 24% in cohort 1, 23% in cohort 2, 15% in cohort 3, and 38% in cohort 4. Of 272 total implants, paracorporeal pulsatile devices were most common (95%) in cohorts 1 and 2 and intracorporeal continuous devices (81%) in cohorts 3 and 4. Stroke was noted in 17%, 12%, 6%, and 4% of cohorts, respectively (Cohort 1 vs. 4 and 2 vs. 4 - p = 0.01; other comparisons - not significant). Incidences of major bleeding, device malfunction, and infection was not different. All cohorts had >90% positive outcomes. Stroke incidence was higher in smaller cohorts, but other outcomes were similar. Positive outcomes were attained in over 90% across all weight groups, demonstrating excellent outcomes using current VADs in this DCM population.
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Affiliation(s)
- David M Kwiatkowski
- From the Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA
| | - Muhammad Shezad
- The Heart Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Aliessa P Barnes
- Division of Pediatric Cardiology, The Children's Mercy Hospital, Kansas City, MO
| | - Michelle S Ploutz
- Division of Pediatric Cardiology, University of Utah Health, Salt Lake City, UT
| | - Sabrina P Law
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, NY
| | - Farhan Zafar
- The Heart Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - David L S Morales
- The Heart Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Matthew J O'Connor
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
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20
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Extracorporeal Membrane Oxygenation Then and Now; Broadening Indications and Availability. Crit Care Clin 2023; 39:255-275. [PMID: 36898772 DOI: 10.1016/j.ccc.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life support technology provided to children to support respiratory failure, cardiac failure, or cardiopulmonary resuscitation after failure of conventional management. Over the decades, ECMO has expanded in use, advanced in technology, shifted from experimental to a standard of care, and evidence supporting its use has increased. The expanded ECMO indications and medical complexity of children have also necessitated focused studies in the ethical domain such as decisional authority, resource allocation, and equitable access.
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21
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Burstein D, Kimmel S, Putt M, Rossano J, VanderPluym C, Ankola A, Lorts A, Maeda K, O'Connor M, Edelson J, Lin K, Buchholz H, Conway J. Cost-effectiveness of bivalirudin in pediatric ventricular assist devices. J Heart Lung Transplant 2023; 42:390-397. [PMID: 36333207 DOI: 10.1016/j.healun.2022.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/14/2022] [Accepted: 10/06/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Despite recent data suggesting improved outcomes with bivalirudin vs heparin in pediatric Ventricular assist devices (VAD), higher costs remain a barrier. This study quantified trends in bivalirudin use and compared outcomes, resource utilization, and cost-effectiveness associated with bivalirudin vs heparin. METHODS Children age 0 to 6 year who received VAD from 2009 to 2021 were identified in Pediatric Health Information System. Bivalirudin use was evaluated using trend analysis and outcomes were compared using Fine-Gray subdistrubtion hazard ratios (SHR). Daily-level hospital costs were compared due to differences in length of stay. Cost-effectiveness was evaluated using incremental cost-effectiveness ratio (ICER). RESULTS Of 691 pediatric VAD recipients (median age 1 year, IQR 0-2), 304 (44%) received bivalirudin with 90% receiving bivalirudin in 2021 (trend p-value <0.01). Bivalirudin had lower hospital mortality (26% vs 32%; adjusted SHR 0.57, 95% CI 0.40-0.83) driven by lower VAD mortality (20% vs 27%; adjusted SHR 0.46, 95% CI 0.32-0.77) after adjusting for year, age, diagnosis, and center VAD volume. Post-VAD length of stay was longer for bivalirudin than heparin (median 91 vs 64 days, respectively, p < 0.001). Median daily-level costs were lower among bivalirudin (cost ratio 0.87, 95% CI 0.79-0.96) with higher pharmacy costs offset by lower imaging, laboratory, supply, and room/board costs. Estimated ICER for bivalirudin vs heparin was $61,192 per quality-adjusted life year gained with a range of $27,673 to $131,243. CONCLUSIONS Bivalirudin use significantly increased over the past decade and is now used in 90% young pediatric VAD recipients. Bivalirudin was associated with significantly lower hospital mortality and an ICER <$65,000, making it a cost-effective therapy for pediatric VAD recipients.
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Affiliation(s)
- Danielle Burstein
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Stephen Kimmel
- Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainsville, Florida
| | - Mary Putt
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Ashish Ankola
- Division of Cardiology, Texas Children's Hospital, Houston, Texas
| | - Angela Lorts
- Division of Cardiology, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jonathan Edelson
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kimberly Lin
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holger Buchholz
- Division of Cardiothoracic Surgery, University of Alberta, Edmonton, Alberta, California
| | - Jennifer Conway
- Division of Cardiology, University of Alberta, Edmonton, Alberta, California
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22
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Sabbah HN, Taylor C, Vernon HJ. Temporal evolution of the heart failure phenotype in Barth syndrome and treatment with elamipretide. Future Cardiol 2023; 19:211-225. [PMID: 37325898 DOI: 10.2217/fca-2023-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/19/2023] [Indexed: 06/17/2023] Open
Abstract
Barth syndrome (BTHS) is a rare genetic disorder caused by pathogenic variants in TAFAZZIN leading to reduced remodeled cardiolipin (CL), a phospholipid essential to mitochondrial function and structure. Cardiomyopathy presents in most patients with BTHS, typically appearing as dilated cardiomyopathy (DCM) in infancy and evolving to hypertrophic cardiomyopathy (HCM) resembling heart failure (HF) with preserved ejection fraction (HFpEF) in some patients ≥12 years. Elamipretide localizes to the inner mitochondrial membrane where it associates with CL, improving mitochondrial function, structure and bioenergetics, including ATP synthesis. Numerous preclinical and clinical studies in BTHS and other forms of HF have demonstrated that elamipretide improves left ventricular relaxation by ameliorating mitochondrial dysfunction, making it well suited for therapeutic use in adolescent and adult patients with BTHS.
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Affiliation(s)
- Hani N Sabbah
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Henry Ford Health, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Carolyn Taylor
- Department of Pediatrics, Division of Cardiology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Hilary J Vernon
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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23
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Ham H, Xu Y, Haller CA, Dai E, Stancanelli E, Liu J, Chaikof EL. Design of an Ultralow Molecular Weight Heparin That Resists Heparanase Biodegradation. J Med Chem 2023; 66:2194-2203. [PMID: 36706244 DOI: 10.1021/acs.jmedchem.2c02118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Heparanase, an endo-β-d-glucuronidase produced by a variety of cells and tissues, cleaves the glycosidic linkage between glucuronic acid (GlcA) and a 3-O- or 6-O-sulfated glucosamine, typified by the disaccharide -[GlcA-GlcNS3S6S]-, which is found within the antithrombin-binding domain of heparan sulfate or heparin. As such, all current forms of heparin are susceptible to degradation by heparanase with neutralization of anticoagulant properties. Here, we have designed a heparanase-resistant, ultralow molecular weight heparin as the structural analogue of fondaparinux that does not contain an internal GlcA residue but otherwise displays potent anticoagulant activity. This heparin oligosaccharide was synthesized following a chemoenzymatic scheme and displays nanomolar anti-FXa activity yet is resistant to heparanase digestion. Inhibition of thrombus formation was further demonstrated after subcutaneous administration of this compound in a murine model of venous thrombosis. Thrombus inhibition was comparable to that observed for enoxaparin with a similar effect on bleeding time.
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Affiliation(s)
- Hyunok Ham
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 3 Blackfan Circle, CLS-11090, Boston, Massachusetts 02215, United States
| | - Yongmei Xu
- Division of Chemical Biology and Medicinal Chemistry, Eshelman School of Pharmacy, University of North Carolina, Rm 1044, Genetic Medicine Building, Chapel Hill, North Carolina 27599, United States
| | - Carolyn A Haller
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 3 Blackfan Circle, CLS-11090, Boston, Massachusetts 02215, United States
| | - Erbin Dai
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 3 Blackfan Circle, CLS-11090, Boston, Massachusetts 02215, United States
| | - Eduardo Stancanelli
- Division of Chemical Biology and Medicinal Chemistry, Eshelman School of Pharmacy, University of North Carolina, Rm 1044, Genetic Medicine Building, Chapel Hill, North Carolina 27599, United States
| | - Jian Liu
- Division of Chemical Biology and Medicinal Chemistry, Eshelman School of Pharmacy, University of North Carolina, Rm 1044, Genetic Medicine Building, Chapel Hill, North Carolina 27599, United States
| | - Elliot L Chaikof
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 3 Blackfan Circle, CLS-11090, Boston, Massachusetts 02215, United States
- Wyss Institute of Biologically Inspired Engineering at Harvard University; Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology; Department of Surgery, Beth Israel Deaconess Medical Center, 110 Francis Street, Suite 9F, Boston, Massachusetts 02215, United States
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24
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Stiller B, Kubicki R. The little ones are catching up-mechanical circulatory support with a pulsatile pneumatic ventricular assist device. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6935787. [PMID: 36534818 DOI: 10.1093/ejcts/ezac570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Brigitte Stiller
- Department of Congenital Heart Disease and Paediatric Cardiology, University Heart Centre Freiburg, Medical Centre-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Rouven Kubicki
- Department of Congenital Heart Disease and Paediatric Cardiology, University Heart Centre Freiburg, Medical Centre-University of Freiburg, Faculty of Medicine, Freiburg, Germany
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25
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 117] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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26
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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27
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An Up-to-Date Literature Review on Ventricular Assist Devices Experience in Pediatric Hearts. LIFE (BASEL, SWITZERLAND) 2022; 12:life12122001. [PMID: 36556366 PMCID: PMC9788166 DOI: 10.3390/life12122001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022]
Abstract
Ventricular assist devices (VAD) have gained popularity in the pediatric population during recent years, as more and more children require a heart transplant due to improved palliation methods, allowing congenital heart defect patients and children with cardiomyopathies to live longer. Eventually, these children may require heart transplantation, and ventricular assist devices provide a bridge to transplantation in these cases. The FDA has so far approved two types of device: pulsatile and continuous flow (non-pulsatile), which can be axial and centrifugal. Potential eligible studies were searched in three databases: Medline, Embase, and ScienceDirect. Our endeavor retrieved 16 eligible studies focusing on five ventricular assist devices in children. We critically reviewed ventricular assist devices approved for pediatric use in terms of implant indication, main adverse effects, and outcomes. The main adverse effects associated with these devices have been noted to be thromboembolism, infection, bleeding, and hemolysis. However, utilizing left VAD early on, before end-organ dysfunction and deterioration of heart function, may give the patient enough time to recuperate before considering a more long-term solution for ventricular support.
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28
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Rohde S, Sandica E, Veen K, Kraemer US, Thiruchelvam T, Miera O, Lopez MLP, Sliwka J, Amodeo A, Bogers AJJC, de By TMMH. Outcomes in small children on Berlin Heart EXCOR support: age and body surface area as clinical predictive factors. Eur J Cardiothorac Surg 2022; 63:6809124. [PMID: 36346169 PMCID: PMC9825200 DOI: 10.1093/ejcts/ezac516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/25/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The Berlin Heart EXCOR (BHE) offers circulatory support across all paediatric ages. Clinically, the necessary care and the outcomes differ in various age groups. The EUROMACS database was used to study age- and size-related outcomes for this specific device. METHODS All patients <19 years of age from the EUROMACS database supported with a BHE between 2000 and November 2021 were included. Maximally selected rank statistics were used to determine body surface area (BSA) cut-off values. Multivariable Cox proportional hazard regression using ridge penalization was performed to identify factors associated with outcomes. RESULTS In total, 303 patients were included [mean age: 2.0 years (interquartile range: 0.6-8.0, males: 48.5%)]. Age and BSA were not significantly associated with mortality (n = 74, P = 0.684, P = 0.679). Factors associated with a transplant (n = 175) were age (hazard ratio 1.07, P = 0.006) and aetiology other than congenital heart disease (hazard ratio 1.46, P = 0.020). Recovery rates (n = 42) were highest in patients with a BSA of <0.53 m2 (21.8% vs 4.3-7.6% at 1 year, P = 0.00534). Patients with a BSA of ≥0.73 m2 had a lower risk of early pump thrombosis but a higher risk of early bleeding compared to children with a BSA of <0.73 m2. CONCLUSIONS Mortality rates in Berlin Heart-supported patients cannot be predicted by age or BSA. Recovery rates are remarkably high in the smallest patient category (BSA <0.53 m2). This underscores that the BHE is a viable therapeutic option, even for the smallest and youngest patients.
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Affiliation(s)
- Sofie Rohde
- Corresponding author. Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands. E-mail: (S. Rohde)
| | - Eugen Sandica
- Clinic for Pediatric Cardiac Surgery and Congenital Heart Defects, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Kevin Veen
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ulrike S Kraemer
- Department of Paediatric Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Oliver Miera
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Maria L Polo Lopez
- Department of Pediatric and Congenital Cardiac Surgery, La Paz University Hospital, Madrid, Spain
| | - Joanna Sliwka
- Department of Cardiac Surgery, Transplantology and Vascular Surgery, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Ad J J C Bogers
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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29
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Lessons Learned from Managing Antithrombotic Therapy in Children Supported with Pediatric Ventricular Assist Devices. ASAIO J 2022; 68:1321-1331. [PMID: 35920759 DOI: 10.1097/mat.0000000000001782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Stroke, thromboembolism, and bleeding are the most recognized complications associated with pediatric ventricular assist devices (VADs) and the leading cause of death and disability on VAD support. Recently, newer antithrombotic strategies like bivalirudin have emerged that appear to be associated with a reduction in the neurologic event rates, especially for smaller pediatric-specific VADs like the Berlin Heart and PediMag/CentriMag systems where the risk of stroke is the highest. While contemporary antithrombotic therapies have likely contributed to lowering adverse event rates, we speculate that clotting and bleeding adverse events may have dropped because of a variety of other seemingly small changes to antithrombotic management that are independent of the antithrombotic agents used. This view is supported by recent reports documenting low stroke rates with anticoagulants other than bivalirudin, a drug that may have a wider therapeutic window but is not available in all locations throughout the world. The primary purpose of this report is 1) to summarize contemporary antithrombotic regimens used for smaller pediatric VADs today associated with low event rates in the United States and abroad and () to review 10 practical lessons learned and pitfalls to avoid that we believe to be important to reducing bleeding and clotting events based on our collective experience managing pediatric VADs over the past 20 years irrespective of the antithrombotic agents used.
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30
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Torres-Maestro B, Polo-López L, González-Rocafort Á, Ramchandani-Ramchandani B, Rey-Lois J, Sánchez-Pérez R, Centella-Hernández T, Lamas-Hernández MJ, Menéndez-Suso JJ, Uceda-Galiano Á, González-Pizarro P, Aroca-Peinado Á. Asistencia de larga duración en pacientes pediátricos: 15 años de experiencia. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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31
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Govender K, Jani VP, Cabrales P. The Disconnect Between Extracorporeal Circulation and the Microcirculation: A Review. ASAIO J 2022; 68:881-889. [PMID: 35067580 DOI: 10.1097/mat.0000000000001618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal circulation (ECC) procedures, such as cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO), take over the function of one or more organs, providing clinicians time to treat underlying pathophysiological conditions. ECMO and CPB carry significant mortality rates for patients, despite prior decades of research focused on the resulting failure of critical organs. Since the focus of these procedures is to support blood flow and provide oxygen-rich blood to tissues, a shift in research toward the effects of ECMO and CPB on the microcirculation is warranted. Along with provoking systemic responses, both procedures disrupt the integrity of red blood cells, causing release of hemoglobin (Hb) from excessive foreign surface contact and mechanical stresses. The effects of hemolysis are especially pronounced in the microcirculation, where plasma Hb leads to nitric oxide scavenging, oxidization, formation of reactive oxygen species, and inflammatory responses. A limited number of studies have investigated the implications of ECMO in the microcirculation, but more work is needed to minimize ECMO-induced reduction of microcirculatory perfusion and consequently oxygenation. The following review presents existing information on the implications of ECMO and CPB on microvascular function and proposes future studies to understand and leverage key mechanisms to improve patient outcomes.
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Affiliation(s)
- Krianthan Govender
- From the Functional Cardiovascular Engineering Laboratory, University of California, San Diego, La Jolla, California
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32
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Standards of Psychological Care for Pediatric Patients Awaiting Heart Transplantation and Those Requiring Mechanical Circulatory Support. Transplant Proc 2022; 54:1058-1059. [DOI: 10.1016/j.transproceed.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 11/23/2022]
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33
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Edelson JB, Rossano JW. Pediatric Device Trials are the Ideal way to Bring Devices to Market. World J Pediatr Congenit Heart Surg 2022; 13:231-234. [PMID: 35238711 DOI: 10.1177/21501351221075572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jonathan B Edelson
- The Cardiac Center, 372699Children's Hospital of Philadelphia and Division of Cardiology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph W Rossano
- The Cardiac Center, 372699Children's Hospital of Philadelphia and Division of Cardiology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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34
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Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers 2022; 8:12. [PMID: 35210461 DOI: 10.1038/s41572-022-00337-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 01/09/2023]
Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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35
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Owyang CG, Donnat C, Brodie D, Gershengorn HB, Hua M, Qadir N, Tonna JE. Similarities in extracorporeal membrane oxygenation management across intensive care unit types in the United States: An analysis of the Extracorporeal Life Support Organization Registry. Artif Organs 2022; 46:1369-1381. [PMID: 35122290 DOI: 10.1111/aor.14193] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/21/2021] [Accepted: 01/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) use in the United States occurs often in cardiothoracic ICUs (CTICU). It is unknown how it varies across ICU types. METHODS We identified 10,893 ECMO runs from the Extracorporeal Life Support Organization (ELSO) Registry across 2018 and 2019. Primary outcome was ECMO case volume by ICU type (CTICU vs. non-CTICU). Adjusting for pre-ECMO characteristics and case mix, secondary outcomes were on-ECMO physiologic variables by ICU location stratified by support type. RESULTS CTICU ECMO occurred in 65.1% and 55.1% (2018 and 2019) of total runs. A minority of total runs related to cardiac surgery procedures (CTICU: 21.7% [2018], 18% [2019]; non-CTICU: 11.2% [2018], 13% [2019]). After multivariate adjustment, non-CTICU ECMO for cardiac support associated with lower 4- and 24-hour circuit flow (3.9 liters per minute [LPM] vs. 4.1 LPM, p<0.0001; 4.1 LPM vs. 4.3 LPM, p<0.0001); for respiratory support, lower on-ECMO mean fraction of inspired oxygen ([Fi O2 ], 67% versus 69%, p=0.02) and lower respiratory rate (14 versus 15, p<0.0001); and, for extracorporeal cardiopulmonary resuscitation (ECPR), lower ECMO flow rates at 24 hours (3.5 liters per minute [LPM] versus 3.7 LPM, p=0.01). CONCLUSIONS ECMO mostly remains in CTICUs though a minority is associated with cardiac surgery. Statistically significant but clinically minor differences in on-ECMO metrics were observed across ICU types.
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Affiliation(s)
- Clark G Owyang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York.,Department of Emergency Medicine, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York
| | - Claire Donnat
- Department of Statistics, Stanford University, Stanford
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx
| | - May Hua
- Department of Anesthesiology, Columbia University College of Physicians & Surgeons.,Department of Epidemiology, Mailman School of Public Health, Columbia University
| | - Nida Qadir
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City.,Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City
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36
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Komori M, Hoashi T, Sakaguchi H, Imai K, Okuda N, Fukushima N, Kurosaki K, Ichikawa H. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6545045. [PMID: 35260893 PMCID: PMC9252124 DOI: 10.1093/icvts/ivac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/30/2022] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Motoki Komori
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
- Corresponding author. Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan. Tel: +81-6-6170-1070; fax: +81-6-6170-1348; e-mail: (T. Hoashi)
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenta Imai
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Naoki Okuda
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Norihide Fukushima
- Department of Pediatric Transplantation, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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37
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Cortesi V, Raffaeli G, Amelio GS, Amodeo I, Gulden S, Manzoni F, Cervellini G, Tomaselli A, Colombo M, Araimo G, Artoni A, Ghirardello S, Mosca F, Cavallaro G. Hemostasis in neonatal ECMO. Front Pediatr 2022; 10:988681. [PMID: 36090551 PMCID: PMC9458915 DOI: 10.3389/fped.2022.988681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving support for cardio-respiratory function. Over the last 50 years, the extracorporeal field has faced huge technological progress. However, despite the improvements in technique and materials, coagulation problems are still the main contributor to morbidity and mortality of ECMO patients. Indeed, the incidence and survival rates of the main hemorrhagic and thrombotic complications in neonatal respiratory ECMO are relevant. The main culprit is related to the intrinsic nature of ECMO: the contact phase activation. The exposure of the human blood to the non-endothelial surface triggers a systemic inflammatory response syndrome, which chronically activates the thrombin generation and ultimately leads to coagulative derangements. Pre-existing illness-related hemostatic dysfunction and the peculiarity of the neonatal clotting balance further complicate the picture. Systemic anticoagulation is the management's mainstay, aiming to prevent thrombosis within the circuit and bleeding complications in the patient. Although other agents (i.e., direct thrombin inhibitors) have been recently introduced, unfractionated heparin (UFH) is the standard of care worldwide. Currently, there are multiple tests exploring ECMO-induced coagulopathy. A combination of the parameters mentioned above and the evaluation of the patient's underlying clinical context should be used to provide a goal-directed antithrombotic strategy. However, the ideal algorithm for monitoring anticoagulation is currently unknown, resulting in a large inter-institutional diagnostic variability. In this review, we face the features of the available monitoring tests and approaches, mainly focusing on the role of point-of-care (POC) viscoelastic assays in neonatal ECMO. Current gaps in knowledge and areas that warrant further study will also be addressed.
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Affiliation(s)
- Valeria Cortesi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo S Amelio
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Gulden
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Manzoni
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gaia Cervellini
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Andrea Tomaselli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Marta Colombo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gabriella Araimo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Merritt T, Gazit AZ, Carvajal H, Montgomery BK, Shepard M, Mehegan M, Canter M, Miller J, Eghtesady P, Nath DS. Evolution of Ventricular Assist Device Support Strategy in Children with Univentricular Physiology. Ann Thorac Surg 2021; 114:1739-1744. [PMID: 34710386 DOI: 10.1016/j.athoracsur.2021.09.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Since 2012, we have supported 18 children with single ventricle (SV) physiology on ventricular assist devices (VAD) as a bridge to decision, transplant, or recovery. We provide a detailed report of our cumulative surgical experience and lessons learned from these patients. METHODS We reviewed all SV-VADs between March 2012 and April 2020. Implanted SV-VADs intended for short-term support were excluded. Demographic and clinical data included palliation stage at the time of VAD implantation, cannulation configuration, device type, duration of support, circuit and device interventions, postoperative support, anticoagulation strategy, complications, mortality, and one-year survival post-discharge. RESULTS Five SV-newborns without prior surgical palliation, 8 infants post-Norwood/hybrid procedure, 4 post-Glenn, and 1 post-Fontan were initially supported with either continuous flow13/18(72%) or pulsatile flow 5/18(28%) devices. 3/18(17%) transitioned to another device during support. Before VAD conversion, 9/18(50%) were supported by extracorporeal membrane oxygenation. Outcomes include; 7/18(39%) transplanted, 2/18(11%) recovered, and 9/18(50%) died prior to discharge. Of these deaths, 2 occurred following transplant, 2 following explant and 5 had redirection of care while on support secondary to previously undiagnosed pulmonary veno-occlusive disease (n=2) or severe neurologic events (n=3). Overall, 6/18(33%) experienced neurologic injury. At last follow-up 9/18(50%) children were alive [1.2(0.8-4.3) years post-explant/transplant]. CONCLUSIONS Our experience shows that SV children, including newborns, can be successfully bridged to desired end-points with proper patient selection and using specific cannulation strategies. Continuing utilization of this strategy is warranted for future children requiring VAD support.
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Affiliation(s)
- Taylor Merritt
- Saint Louis Children's Hospital, The Heart Center; Washington University School of Medicine-St. Louis, Pediatric Cardiothoracic Surgery
| | - Avihu Z Gazit
- Washington University School of Medicine-St. Louis, Pediatric Critical Care
| | - Horacio Carvajal
- Washington University School of Medicine-St. Louis, Pediatric Cardiothoracic Surgery
| | | | - Mark Shepard
- Saint Louis Children's Hospital, The Heart Center
| | - Mary Mehegan
- Saint Louis Children's Hospital, The Heart Center
| | - Matthew Canter
- Washington University School of Medicine-St. Louis, Pediatric Cardiothoracic Surgery
| | - Jacob Miller
- Washington University School of Medicine-St. Louis, Pediatric Cardiothoracic Surgery
| | - Pirooz Eghtesady
- Washington University School of Medicine-St. Louis, Pediatric Cardiothoracic Surgery
| | - Dilip S Nath
- Washington University School of Medicine-St. Louis, Pediatric Cardiothoracic Surgery.
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39
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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Giorni C, Rizza A, Favia I, Amodeo A, Chiusolo F, Picardo SG, Luciani M, Di Felice G, Di Chiara L. Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options. Front Cardiovasc Med 2021; 8:671241. [PMID: 34540910 PMCID: PMC8440876 DOI: 10.3389/fcvm.2021.671241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
Pediatric mechanical circulatory support (MCS) is considered a strategy for heart failure management as a bridge to recovery and transplantation or as a destination therapy. The final outcome is significantly impacted by the number of complications that may occur during MCS. Children on ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) are at high risk for bleeding and thrombotic complications that are managed through anticoagulation. The first detailed guideline in pediatric VADs (Edmonton Anticoagulation and Platelet Inhibition Protocol) was based on conventional antithrombotic drugs, such as unfractionated heparin (UFH) and warfarin. UFH is the first-line anticoagulant in pediatric MCS, although its profile is not considered optimal in pediatric setting. The broad variation in heparin doses among children is associated with frequent occurrence of cerebrovascular accidents, bleeding, and thrombocytopenia. Direct thrombin inhibitors (DTIs) have been utilized as alternative strategies to heparin. Since 2018, bivalirudin has become the chosen anticoagulant in the long-term therapy of patients undergoing MCS implantation, according to the most recent protocols shared in North America. This article provides a review of the non-traditional anticoagulation strategies utilized in pediatric MCS, focusing on pharmacodynamics, indications, doses, and monitoring aspects of bivalirudin. Moreover, it exposes the efforts and the collaborations among different specialized centers, which are committed to an ongoing learning in order to minimize major complications in this special pediatric population. Further prospective trials regarding DTIs in a pediatric MCS setting are necessary and in specific well-designed randomized control trials between UFH and bivalirudin. To conclude, based on the reported literature, the clinical use of the bivalirudin in pediatric MCS seems to be a value added in controlling and maybe reducing thromboembolic complications. Further research is necessary to confirm all the results provided by this literature review.
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Affiliation(s)
- Chiara Giorni
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Alessandra Rizza
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Isabella Favia
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Antonio Amodeo
- Mechanical Circulatory Support Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Fabrizio Chiusolo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Sergio G Picardo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Matteo Luciani
- Department of Oncohematology, Haemostasis and Thrombosis Center, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Giovina Di Felice
- Hemostasis Laboratory, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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41
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O'Connor MJ, Lorts A, Kwiatkowski D, Butts R, Barnes A, Jeewa A, Knoll C, Fenton M, McQueen M, Cousino MK, Shugh S, Rosenthal DN. Learning networks in pediatric heart failure and transplantation. Pediatr Transplant 2021; 25:e14073. [PMID: 34138489 DOI: 10.1111/petr.14073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Learning networks have emerged in medicine as a novel organizational structure that contains elements of quality improvement, education, and research with the goal of effecting rapid improvements in clinical care. In this article, the concept of a learning network is defined and highlighted in the field of pediatric heart failure and transplantation. METHODS Learning networks are defined, with particular attention paid to the recent creation of the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) for children with heart failure and those being supported with ventricular assist devices (VAD). RESULTS The mission, goals, and organizational structure of ACTION are described, and recent initiatives promoted by ACTION are highlighted, such as stroke reduction initiatives, practice harmonization protocols, and use of ACTION data to support the recent US Food and Drug Administration approval of newer VAD for pediatric patients. CONCLUSIONS The learning network, exemplified by ACTION, is distinguished from traditional clinical research collaboratives by contributions in research, quality improvement, patient-reported outcomes, and education, and serves as an effective vehicle to drive clinical improvement in the care of children with advanced heart failure.
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Affiliation(s)
- Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Ryan Butts
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Medical Center of Dallas, Dallas, TX, USA
| | | | - Aamir Jeewa
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christopher Knoll
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Matthew Fenton
- Great Ormond Street Hospital for Children Foundation Trust, London, UK
| | | | | | - Svetlana Shugh
- Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
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42
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Sughimoto K, Pidborochynski T, Buchholz H, Freed DH, Al-Aklabi M, Jonker D, Anand V, Holinski P, Conway J. Paracorporeal Support in Pediatric Patients: The Role of the Patient-Device Interaction. Ann Thorac Surg 2021; 114:1442-1451. [PMID: 34331928 DOI: 10.1016/j.athoracsur.2021.06.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/13/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ventricular assist devices (VADs) are important in the treatment of pediatric heart failure. While paracorporeal pulsatile (PP) devices have historically been used, there has been increased use of paracorporeal continuous (PC) devices. We sought to compare the outcomes of children supported with a PP, PC, or combination of devices. METHODS Retrospective review (2005-19) of patients <19 years of age from a single center, who received a PC, PP or combination of devices. Patient characteristics were compared between device strategies and Kaplan-Meier survival analysis was performed. RESULTS Sixty-six patients were included (62% male, 62% non-congenital heart disease, median age 0.9 years (IQR 0.2, 4.9), median weight 8.5 kg (IQR 4.3, 17.7). PC devices were used in 45% of patients, PP in 35% and a combination in 20%. Patients on PC devices had a lower median weight (p=.02), a higher proportion of CHD (p=.02) and more patients requiring pre-VAD dialysis (p=.01). There was no difference in pre-VAD ECMO (p=.15) use. There was a difference in survival between the three device strategies (p=.02) CONCLUSIONS: Differences in survival was evident, with those on PC support having worse outcomes. Transition from PC to a PP devices was associated with a survival advantage. These findings may be driven by differences in patient characteristics across device strategies. Further studies are required to confirm these findings and to better understand the interaction between patient characteristics and device options.
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Affiliation(s)
- Koichi Sughimoto
- Department of Cardiac Surgery, University of Alberta, Edmonton AB, Canada; Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton AB, Canada
| | - Tara Pidborochynski
- Department of Pediatric Cardiology University of Alberta, Edmonton AB, Canada
| | - Holger Buchholz
- Department of Cardiac Surgery, University of Alberta, Edmonton AB, Canada
| | - Darren H Freed
- Department of Cardiac Surgery, University of Alberta, Edmonton AB, Canada; Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton AB, Canada
| | - Mohammed Al-Aklabi
- Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton AB, Canada
| | - Devilliers Jonker
- Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton AB, Canada
| | - Vijay Anand
- Division of Pediatric Critical Care, Stollery Children's Hospital, Edmonton AB, Canada
| | - Paula Holinski
- Division of Pediatric Critical Care, Stollery Children's Hospital, Edmonton AB, Canada
| | - Jennifer Conway
- Department of Pediatric Cardiology University of Alberta, Edmonton AB, Canada; Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton AB, Canada.
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Ham HO, Haller CA, Su G, Dai E, Patel MS, Liu DR, Liu J, Chaikof EL. A rechargeable anti-thrombotic coating for blood-contacting devices. Biomaterials 2021; 276:121011. [PMID: 34303154 PMCID: PMC8405571 DOI: 10.1016/j.biomaterials.2021.121011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 07/01/2021] [Accepted: 07/04/2021] [Indexed: 12/24/2022]
Abstract
Despite the potential of anti-thrombogenic coatings, including heparinized surfaces, to improve the performance of blood-contacting devices, the inevitable deterioration of bioactivity remains an important factor in device failure and related thrombotic complications. As a consequence, the ability to restore the bioactivity of a surface coating after implantation of a blood-contacting device provides a potentially important strategy to enhance its clinical performance. Here, we report the regeneration of a multicomponent anti-thrombogenic coating through use of an evolved sortase A to mediate reversible transpeptidation. Both recombinant thrombomodulin and a chemoenzymatically synthesized ultra-low molecular weight heparin were repeatedly and selectively immobilized or removed in a sequential, alternating, or simultaneous manner. The generation of activated protein C (aPC) and inhibition of activated factor X (FXa) was consistent with the molecular composition of the surface. The fabrication of a rechargeable anti-thrombogenic surface was demonstrated on an expanded polytetrafluoroethylene (ePTFE) vascular graft with reconstitution of the surface bound coating 4 weeks after in vivo implantation in a rat model.
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Affiliation(s)
- Hyun Ok Ham
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Carolyn A Haller
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Guowei Su
- Division of Chemical Biology and Medicinal Chemistry, Eshelman School of Pharmacy, University of North Carolina, Rm 1044, Genetic Medicine Building, Chapel Hill, NC, 27599, USA
| | - Erbin Dai
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Madhukar S Patel
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - David R Liu
- Merkin Institute of Transformative Technologies in Healthcare, Broad Institute of Harvard and MIT, Cambridge, 02142, USA; Department of Chemistry and Chemical Biology, Harvard University, Howard Hughes Medical Institute, Cambridge, MA, 02138, USA
| | - Jian Liu
- Division of Chemical Biology and Medicinal Chemistry, Eshelman School of Pharmacy, University of North Carolina, Rm 1044, Genetic Medicine Building, Chapel Hill, NC, 27599, USA
| | - Elliot L Chaikof
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA; Wyss Institute of Biologically Inspired Engineering, Harvard University, Boston, MA, 02115, USA.
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44
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Marcel L, Specklin M, Kouidri S. The evolution of long-term pediatric ventricular assistance devices: a critical review. Expert Rev Med Devices 2021; 18:783-798. [PMID: 34160345 DOI: 10.1080/17434440.2021.1947245] [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: 10/21/2022]
Abstract
Introduction: The gap between the number of heart failure patients and the number of potential heart donors has never been larger than today, especially among the pediatric population. The use of mechanical circulatory support is seen as a potential alternative for clinicians to treat more patients. This treatment has proven its efficiency on short-term use. However, in order to replace heart transplant, the techniques should be used over longer periods of time.Areas covered: This review aims at furnishing an engineering vision of the evolution of ventricular assistance devices used in pediatrics. A critical analysis of the clinical complications related to devices generation is made to give an overview of the design improvements made since their inception.Expert opinion: The long-term use of a foreign device in the body is not without consequences, especially among fragile pediatric patients. Moreover, the size of their body parts increases the technical difficulties of such procedure. The balance between the living cells of the body is disturbed by the devices, mostly by the shear stress generated. To provide a safe mechanical circulatory support for long-term use, the devices should be more hemocompatible, preserving blood cells, adapted to the patient's systemic grid and miniaturized for pediatric use.
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Affiliation(s)
- Louis Marcel
- Arts Et Metiers Institute of Technology, CNAM, LIFSE, HESAM University, Paris, France
| | - Mathieu Specklin
- Arts Et Metiers Institute of Technology, CNAM, LIFSE, HESAM University, Paris, France
| | - Smaine Kouidri
- Arts Et Metiers Institute of Technology, CNAM, LIFSE, HESAM University, Paris, France
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Amdani S, Boyle G, Saarel EV, Godown J, Liu W, Worley S, Karamlou T. Waitlist and Post–Heart Transplant Outcomes for Children With Nondilated Cardiomyopathy. Ann Thorac Surg 2021; 112:188-196. [DOI: 10.1016/j.athoracsur.2020.05.170] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 11/26/2022]
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Romlin B, Dahlin A, Hallhagen S, Björk K, Wåhlander H, Söderlund F. Clinical course and outcome after treatment with ventricular assist devices in paediatric patients: A single-centre experience. Acta Anaesthesiol Scand 2021; 65:785-791. [PMID: 33616235 DOI: 10.1111/aas.13804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Heart failure is a rare condition in the paediatric population, associated with high morbidity and mortality. When medical therapy is no longer sufficient, mechanical circulatory support such as a ventricular assist device can be used to bridge these children to transplant or recovery. Coagulation-related complications such as thrombi, embolism and bleeding events represent the greatest challenge in paediatric patients on mechanical support. We aimed to describe the outcomes and coagulation-related complications in this patient population at our institution. METHODS A total of 20 patients with either Berlin Heart EXCOR® or HeartWare® implantation were reviewed in this retrospective study. Study endpoints were survival to heart transplant, weaning due to recovery or death. Thrombotic events were defined as thrombus formation in the device or in the patient, or cardioembolic strokes. Bleeding events were defined as events requiring interventional surgery or transfusion of red blood cells. RESULTS The aetiology of heart failure included cardiomyopathy (n = 12), end-stage congenital heart disease (n = 6) and myocarditis (n = 2). Of the 20 patients, 12 were bridged to transplant, 7 recovered and could be weaned and 1 died. The median duration of mechanical support was 84 days (range: 20-524 days). At least one major or minor bleeding event occurred in 45% of the patients. Thrombotic events occurred 21 times in 10 patients. Four of the patients (20%) had no bleeding or thromboembolic event. CONCLUSION In all, 95% of the patients were successfully bridged to transplant or recovery. Bleeding events and thrombotic events were common.
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Affiliation(s)
- Birgitta Romlin
- Department of Paediatric Anaesthesiology and Intensive Care Queen Silvia Children's Hospital Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Anna Dahlin
- Department of Paediatric Anaesthesiology and Intensive Care Queen Silvia Children's Hospital Gothenburg Sweden
| | - Stefan Hallhagen
- Department of Cardiothoracic Surgery Sahlgrenska University Hospital Gothenburg Sweden
| | - Kerstin Björk
- Department of Cardiothoracic Surgery Sahlgrenska University Hospital Gothenburg Sweden
| | - Håkan Wåhlander
- Paediatric Heart Centre Queen Silvia Children's Hospital Gothenburg Sweden
- Department of Paediatrics Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Fredrik Söderlund
- Department of Paediatric Anaesthesiology and Intensive Care Queen Silvia Children's Hospital Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
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47
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Risk Factors of Thrombotic Complications and Antithrombotic Therapy in Paediatric Cardiosurgical Patients. ACTA BIOMEDICA SCIENTIFICA 2021. [DOI: 10.29413/abs.2021-6.2.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The development of cardiosurgical care for paediatric and neonatal patients is undergoing the rapid growth. Complex, multi-stage reconstructive operations and the use of invasive monitoring are associated with high risk of venous and arterial thrombosis.The cardiac surgery patient is inherently unique, since it requires controlled anticoagulation during cardiopulmonary bypass. Moreover, the most cardiovascular pediatric patients require antithrombotic measures over the perioperative period. In addition to medication support with the use of various groups of antithrombotic agents, vascular access management is justified in order to minimize the risk of thromboembolic complications, which can affect both the functional status, and common and inter-stage mortality.The purpose of this review was to systematize the available data on risk factors contributing to the development of thrombotic complications in patients with congenital heart disease.An information search was carried out using Internet resources (PubMed, Web of Science, eLibrary.ru); literature sources for period 2015–2020 were analysed. As a result of the analysis of the literature data age-dependent features of the haemostatic system, and associated with the defect pathophysiology, and undergone reconstructive interventions were described. The issues of pathophysiology of univentricular heart defects and risk factors associated with thrombosis were also covered.Moreover, aspects of intraoperative anti-thrombotic support are discussed, as well as measures to prevent thromboembolic complications in this population.Coordinated actions of haematologists, cardiologists, anaesthesiologists, intensivists, and cardiac surgeons will allow achieving a fine balance between risks of bleeding and thrombosis in the population of paediatric patients undergoing cardiovascular surgery.
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48
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Strobel AM, Alblaihed L. Cardiac Emergencies in Kids. Emerg Med Clin North Am 2021; 39:605-625. [PMID: 34215405 DOI: 10.1016/j.emc.2021.04.010] [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: 11/25/2022]
Abstract
Encountering a child with congenital heart disease after surgical palliation in the emergency department, specifically the single-ventricle or ventricular assist device, without a basic familiarity of these surgeries can be extremely anxiety provoking. Knowing what common conditions or complications may cause these children to visit the emergency department and how to stabilize will improve the chance for survival and is the premise for this article, regardless of practice setting.
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Affiliation(s)
- Ashley M Strobel
- Department of Emergency Medicine, University of Minnesota Medical School, Hennepin County Medical Center, University of Minnesota Masonic Children's Hospital, 701 South Park Avenue R2.123, Minneapolis, MN 55414, USA.
| | - Leen Alblaihed
- Department of Emergency Medicine, University of Maryland School of Medicine, University of Maryland Upper Chesapeake Medical System, 500 Upper Chesapeake Drive, Bel Air, MD 21014, USA
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49
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Auerbach SR, Simpson KE. HVAD Usage and Outcomes in the Current Pediatric Ventricular Assist Device Field: An Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Analysis. ASAIO J 2021; 67:675-680. [PMID: 33587465 DOI: 10.1097/mat.0000000000001373] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Advanced Cardiac Therapies Improving Outcomes Network (ACTION) is the first pediatric ventricular assist device (VAD) quality improvement network (46 centers). We aimed to describe outcomes with the HeartWare HVAD from ACTION centers. Patients with an HVAD implant in the ACTION registry (April 2018-April 2020) were analyzed. Baseline characteristics, adverse events, and survival were described. There were 50 patients implanted with a HVAD during the study period [36 cardiomyopathy, 8 congenital heart disease (CHD), and 6 other] and 21 (42%) had a prior sternotomy. Median age (range) was 12.9 years (3.4-19.1), body surface area was 1.3 m2 (0.56-2.62), and weight was 41.8 kg (12.8-135.3). Most were INTERMACS profile 2 (n = 26, 52%). Mechanical ventilation and ECMO were used pre-HVAD in 13 (26%) and 6 (12%), respectively. Median time on VAD was 71 (5-602) days. Survival was 96% at 1 year; 3 deaths were recorded, all of whom had CHD (p = 0.001). Neither ECMO nor mechanical ventilation were associated with death (p > 0.29). Most frequent AEs were bleeding (n = 7, 14%) and infection (n = 7, 14%). Stroke was rare (n = 2, 4%). ACTION Network HVAD outcomes were excellent, with 96% survival at 1 year and only 4% occurrence of stroke. Major bleeding and infection were the most common adverse events.
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Affiliation(s)
- Scott R Auerbach
- From the Children's Hospital of Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
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50
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Lorts A, Conway J, Schweiger M, Adachi I, Amdani S, Auerbach SR, Barr C, Bleiweis MS, Blume ED, Burstein DS, Cedars A, Chen S, Cousino-Hood MK, Daly KP, Danziger-Isakov LA, Dubyk N, Eastaugh L, Friedland-Little J, Gajarski R, Hasan A, Hawkins B, Jeewa A, Kindel SJ, Kogaki S, Lantz J, Law SP, Maeda K, Mathew J, May LJ, Miera O, Murray J, Niebler RA, O'Connor MJ, Özbaran M, Peng DM, Philip J, Reardon LC, Rosenthal DN, Rossano J, Salazar L, Schumacher KR, Simpson KE, Stiller B, Sutcliffe DL, Tunuguntla H, VanderPluym C, Villa C, Wearden PD, Zafar F, Zimpfer D, Zinn MD, Morales IRD, Cowger J, Buchholz H, Amodeo A. ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association. J Heart Lung Transplant 2021; 40:709-732. [PMID: 34193359 DOI: 10.1016/j.healun.2021.04.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Angela Lorts
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio.
| | | | - Martin Schweiger
- Universitäts-Kinderspitals Zürich - Herzchirurgie, Zurich, Switzerland
| | - Iki Adachi
- Texas Children's Hospital, Houston, Texas
| | | | - Scott R Auerbach
- Anschutz Medical Campus, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado
| | - Charlotte Barr
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | - Mark S Bleiweis
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | | | - Ari Cedars
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sharon Chen
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Kevin P Daly
- Boston Children's Hospital, Boston, Massachusetts
| | - Lara A Danziger-Isakov
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Nicole Dubyk
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lucas Eastaugh
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Asif Hasan
- Freeman Hospital, Newcastle upon Tyne, UK
| | - Beth Hawkins
- Boston Children's Hospital, Boston, Massachusetts
| | - Aamir Jeewa
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Steven J Kindel
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | - Jodie Lantz
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sabrina P Law
- Morgan Stanley Children's Hospital of New York Presbyterian, New York, New York
| | - Katsuhide Maeda
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Jacob Mathew
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Jenna Murray
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Robert A Niebler
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | | | - David M Peng
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joseph Philip
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | - David N Rosenthal
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Joseph Rossano
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Kurt R Schumacher
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | | | - David L Sutcliffe
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Chet Villa
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Matthew D Zinn
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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