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Torpoco Rivera DM, Joong A, D'Souza N, Duganiero T, Lorts A, Spinner JA. Clinical Outcomes of SARS-CoV-2 Infection in Pediatric Patients on Ventricular Assist Device Support: An ACTION Registry Analysis. ASAIO J 2024; 70:154-158. [PMID: 37862686 DOI: 10.1097/mat.0000000000002080] [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: 10/22/2023] Open
Abstract
Adult patients on left ventricular assist device (LVAD) support have increased morbidity and mortality after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. There are no reported clinical data describing outcomes among pediatric patients on ventricular assist device (VAD) support infected with SARS-CoV-2. We conducted a retrospective study using the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry to evaluate patient characteristics and clinical outcomes after SARS-CoV-2 infection. A total of 22 children on VAD support (median age at infection 10.6 years) from 16 centers tested positive for SARS-CoV-2. Cardiomyopathy (59.1%) and congenital heart disease (40.9%) were the most common primary diagnoses. The type of support included LVAD in 19 (86.4%), biventricular assist device (BIVAD) in one (4.5%), and single ventricle VAD in two (9%) patients. At the time of infection, 50% were outpatients, 23% were inpatients on a general cardiology floor, and 27% were in the cardiac intensive care unit (CICU). Most patients (82%) were symptomatic at time of diagnosis, but only 13% required escalation of respiratory support, and 31% received SARS-CoV-2 therapies. Notably, no mortality occurred, and significant morbidity was rare after SARS-CoV-2 infection in pediatric patients on VAD support.
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Affiliation(s)
- Diana M Torpoco Rivera
- From the Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, California
| | - Anna Joong
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Nikita D'Souza
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Toni Duganiero
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Angela Lorts
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joseph A Spinner
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas
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2
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Chen JK, Salerno DM, Law S, Freniere V, Neunert C. Anticoagulation Stability With Bivalirudin: Positioning the Horse Before the Cart. ASAIO J 2023; 69:e468-e469. [PMID: 37220194 DOI: 10.1097/mat.0000000000001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Affiliation(s)
- Justin K Chen
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
| | - Sabrina Law
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Victoria Freniere
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
| | - Cindy Neunert
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
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3
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Arias K, Sun W, Han D, Griffith BP, Wu ZJ. Neutrophil Structural and Functional Alterations After High Mechanical Shear Stress Exposure. ASAIO J 2023; 69:841-848. [PMID: 37159479 PMCID: PMC11441310 DOI: 10.1097/mat.0000000000001985] [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: 05/11/2023] Open
Abstract
Patients on mechanical circulatory support are prone to infections, increasing morbidity and mortality. These circulatory support devices generate high mechanical shear stress (HMSS) that can causes trauma to blood. When leukocytes become damaged, their immune response function may be impaired or weakened, leading to increased infection vulnerability. This study examined neutrophil structural and functional alterations after exposure to 75, 125, and 175 Pa HMSS for 1 second. Human blood was exposed to three levels of HMSS using a blood shearing device. Neutrophil morphological alteration was characterized by examining blood smears. Flow cytometry assays were used to analyze expression levels of CD62L and CD162 receptors, activation level (CD11b), and aggregation (platelet-neutrophil aggregates). Neutrophil phagocytosis and rolling were examined via functional assays. The results show neutrophil structure (morphology and surface receptors) and function (activation, aggregation, phagocytosis, rolling) were significantly altered after HMSS exposure. These alterations include cell membrane damage, loss of surface receptors (CD62L and CD162), initiation of activation and aggregation, upregulation of phagocytic ability and increased rolling speed. The alterations were the most severe after 175 Pa exposure. HMSS caused damage and activation of neutrophils, potentially impairing normal neutrophil function, leading to weakened immune defense and increasing a patient's vulnerability to infections.
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Affiliation(s)
- Katherin Arias
- From the Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Dong Han
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Zhongjun J Wu
- From the Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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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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5
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Sun W, Zhang J, Shah A, Arias K, Berk Z, Griffith BP, Wu ZJ. Neutrophil dysfunction due to continuous mechanical shear exposure in mechanically assisted circulation in vitro. Artif Organs 2022; 46:83-94. [PMID: 34516005 PMCID: PMC8688241 DOI: 10.1111/aor.14068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/10/2021] [Accepted: 09/04/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Leukocytes play an important role in the body's immune system. The aim of this study was to assess alterations in neutrophil phenotype and function in pump-assisted circulation in vitro. METHODS Human blood was circulated for four hours in three circulatory flow loops with a CentriMag blood pump operated at a flow of 4.5 L/min at three rotational speeds (2100, 2800, and 4000 rpm), against three pressure heads (75, 150, and 350 mm Hg), respectively. Blood samples were collected hourly for analyses of neutrophil activation state (Mac-1, CD62L, CD162), neutrophil reactive oxygen species (ROS) production, apoptosis, and neutrophil phagocytosis. RESULTS Activated neutrophils indicated by both Mac-1 expression and decreased surface expression of CD62L and CD162 receptors increased with time in three loops. The highest level of neutrophil activation was observed in the loop with the highest rotational speed. Platelet-neutrophil aggregates (PNAs) progressively increased in two loops with lower rotational speeds. PNAs peaked at one hour after circulation and decreased subsequently in the loop with the highest rotational speed. Neutrophil ROS production dramatically increased at one hour after circulation and decreased subsequently in all three loops with similar levels and trends. Apoptotic neutrophils increased with time in all three loops. Neutrophil phagocytosis capacity in three loops initially elevated at one hour after circulation and decreased subsequently. Apoptosis and altered phagocytosis were dependent on rotational speed. CONCLUSIONS Our study revealed that the pump-assisted circulation induced neutrophil activation, apoptosis, and functional impairment. The alterations were strongly associated with pump operating condition and duration.
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Affiliation(s)
- Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jiafeng Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aakash Shah
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Katherin Arias
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland, USA
| | - Zachary Berk
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Zhongjun J Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland, USA
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6
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Javier Delmo EM, Javier MFDM, Hetzer R. The role of ventricular assist device in children. Cardiovasc Diagn Ther 2021; 11:193-201. [PMID: 33708492 DOI: 10.21037/cdt-20-282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The first and successful implantation of a ventricular assist device in 1990 has allowed an 8-year-old child with an end-stage heart failure to undergo a heart transplantation. This milestone paved the way to consider support with ventricular assist in the armamentarium of heart failure management in infants, children and adolescents. Several systems have evolved and faded owing to unacceptable complications. Indications and contraindications to implantation have been established. Anticoagulation management is still on its way to impeccability. Despite the challenges, issues and concerns revolving around ventricular assist devices, the system definitely supports pediatric patients with end-stage heart failure until heart transplantation and could allow recovery of the myocardium.
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Affiliation(s)
| | | | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
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Sun W, Wang S, Zhang J, Arias K, Griffith BP, Wu ZJ. Neutrophil injury and function alterations induced by high mechanical shear stress with short exposure time. Artif Organs 2020; 45:577-586. [PMID: 33237583 DOI: 10.1111/aor.13874] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/09/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022]
Abstract
High mechanical shear stresses (HMSS) can cause damage to blood, which manifests as morphologic changes, shortened life span, biochemical alterations, and complete rupture of blood cells and proteins, leading to the alterations of normal blood function. The aim of this study is to determine the state of neutrophil activation and function alterations caused by HMSS with short exposure time relevant to ventricular assist devices. Blood from healthy donors was exposed to three levels of HMSS (75Pa, 125Pa, and 175Pa) for a short exposure time (0.5 s) using our Couette-type blood-shearing device. Neutrophil activation (Mac-1, platelet-neutrophil aggregates) and surface expression levels of two key functional receptors (CD62L and CD162) on neutrophils were evaluated by flow cytometry. Neutrophil phagocytosis and transmigration were also examined with functional assays. Results showed that the expression of Mac-1 on neutrophils and platelet-neutrophil aggregates increased significantly while the level of CD62L expression on neutrophils decreased significantly after the exposure to HMSS. The Mac-1 expression progressively increased while the CD62L expression progressively decreased with the increased level of HMSS. The level of CD162 expression on neutrophils slightly increased after the exposure to HMSS, but the increase was not significant. The phagocytosis assay data revealed that the ability of neutrophils to phagocytose latex beads coated with fluorescently labeled rabbit IgG increased significantly with the increased level of HMSS. The transmigration ability of neutrophils slightly increased after the exposure to HMSS, but did not reach a significant level. In summary, HMSS with a short exposure time of 0.5 seconds could induce neutrophil activation, platelet-neutrophil aggregation, shedding of CD62L receptor, and increased phagocytic ability. However, the exposure to the three levels of HMSS did not cause a significant change in neutrophil transmigration capacity and shedding of CD162 receptor on neutrophils.
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Affiliation(s)
- Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shigang Wang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jiafeng Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherin Arias
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
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Fibrinogen Albumin Ratio and Ischemic Stroke During Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2020; 66:277-282. [PMID: 30973402 DOI: 10.1097/mat.0000000000000992] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Fibrinogen is a clotting factor and a major determinant of platelet aggregation. Albumin, on the other hand, inhibits platelet function and thrombus formation. Taken together, an elevated fibrinogen albumin ratio (FAR) has been described as a marker of disease severity during prothrombotic conditions. We evaluated the association of FAR and ischemic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support. A single center, retrospective study was performed including all adult patients placed on VA ECMO. FAR was calculated from fibrinogen and albumin measurements in the first 24 hours of VA-ECMO initiation. Patients were categorized into high (≥125) and low (<125) FAR groups and the risk of eventual ischemic stroke was determined. There were 201 patients who underwent VA ECMO placement and 157 had a FAR. They were 56 ± 14 years old and 66 (42%) had a high FAR. Patients with a high FAR had lower survival free from an ischemic stroke during VA ECMO (log rank p < 0.001; adjusted hazard ratio 5.51; 95% CI: 1.8-16.5). In tertile analysis, the level of FAR was associated with an incrementally higher likelihood of eventual ischemic stroke (log rank p = 0.004). Those with a high FAR had greater mean platelet volume (10.8[10.4-12] vs. 10.5[10.2-11.9]fl, p = 0.004). An elevated FAR during the first 24 hours of VA ECMO placement is associated with a greater risk of a subsequent ischemic stroke. Our findings suggest that assessment of FAR soon after VA ECMO placement may assist with early stratification of patients at risk for an ischemic stroke.
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9
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Philip J, Powers E, Machado D, Colon DL, Gupta D, Shih R, Ebraheem M, Fudge C, Bleiweis M. Pulsatile ventricular assist device as a bridge to transplant for the early high-risk single-ventricle physiology. J Thorac Cardiovasc Surg 2020; 162:405-413.e4. [PMID: 33546851 DOI: 10.1016/j.jtcvs.2020.09.071] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/05/2020] [Accepted: 09/04/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of ventricular assist devices (VADs) as a bridge-to-transplant in patients with single-ventricle physiology post-stage one palliation has been associated with poor outcomes. We describe our center's successful experience in the use of paracorporeal pulsatile VADs in the palliation of high-risk single ventricle physiology before or after the first stage of palliation with an impetus on pre-palliation implant. METHODS This is a single-center retrospective review of univentricular patients implanted with the Berlin Heart EXCOR VAD. Our center's approach includes early implantation of the Berlin Heart EXCOR with common atrial cannulation, a cardiac index between 3.5 and 5 L/min/m2, and a bivalirudin-based anticoagulation regimen. Patient-related data were collected postimplant at week 1 and months 1, 2, and 3. Post-transplant data, including neurological outcomes, were collected. RESULTS Nine patients were supported. Survival to discharge post-transplant was 83% (5/6) in patients bridged-to-transplant and 33% (1/3) in patients bridged-to-decision. Six patients had no previous palliation. Median hospital stay before implantation was 111 days for nonsurvivors versus 20 days for survivors. The need for extracorporeal membrane oxygenation and cardiopulmonary resuscitation in nonsurvivors versus survivors was 1 in 3 versus 1 in 6 and 2 in 3 versus 1 in 6, respectively. There were no major central nervous system complications except for 1 significant hemorrhagic event. The pediatric overall performance category score on follow-up was normal to mild disability in 83% of survivors. Limitations include hemolysis and intermittent periods of infection and/or inflammation. CONCLUSIONS The use of pulsatile paracorporeal VADs is a feasible option as a bridge-to-transplant in the peri-stage one high-risk single ventricle.
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Affiliation(s)
- Joseph Philip
- Division of Pediatric Cardiac Intensive Care, University of Florida, Gainesville, Fla; Congenital Heart Center, University of Florida, Gainesville, Fla
| | - Emma Powers
- College of Medicine, University of Florida, Gainesville, Fla
| | - Desiree Machado
- Division of Pediatric Cardiac Intensive Care, University of Florida, Gainesville, Fla; Congenital Heart Center, University of Florida, Gainesville, Fla
| | | | - Dipankar Gupta
- Congenital Heart Center, University of Florida, Gainesville, Fla; Division of Pediatric Cardiology, University of Florida, Gainesville, Fla
| | - Renata Shih
- Congenital Heart Center, University of Florida, Gainesville, Fla; Division of Pediatric Cardiology, University of Florida, Gainesville, Fla
| | - Mohammad Ebraheem
- Division of Pediatric Cardiac Intensive Care, University of Florida, Gainesville, Fla; Congenital Heart Center, University of Florida, Gainesville, Fla
| | - Curt Fudge
- Congenital Heart Center, University of Florida, Gainesville, Fla; Division of Pediatric Cardiology, University of Florida, Gainesville, Fla
| | - Mark Bleiweis
- Congenital Heart Center, University of Florida, Gainesville, Fla; Division of Cardiothoracic Surgery, University of Florida, Gainesville, Fla.
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Ragusa R, Di Molfetta A, Amodeo A, Trivella MG, Caselli C. Pathophysiology and molecular signalling in pediatric heart failure and VAD therapy. Clin Chim Acta 2020; 510:751-759. [PMID: 32949569 DOI: 10.1016/j.cca.2020.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
Heart Failure (HF) is a progressive clinical syndrome characterized by molecular and structural abnormalities that result in impaired ventricular filling and a reduced blood ejection. In pediatric patients, HF represents an important cause of morbidity and mortality, but underlying cause, presentation and disease course remains unclear in many cases. It is evident that a child is not a "small adult" and findings are not comparable. The adoption of a standardized clinical and surgical tools as well as increased biomolecular research and therapeutic trials targeting pediatric patients with HF would greatly improve the management of this special class of patients. This review examines the most current information about the pathophysiology and molecular mechanisms related to HF in children to identify gaps in our knowledge base to further improve clinical care and outcomes.
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Affiliation(s)
- Rosetta Ragusa
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Institute of Clinical Physiology, CNR, Pisa, Italy
| | - Arianna Di Molfetta
- Department of Cardiothoracic Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Antonio Amodeo
- Department of Cardiothoracic Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy
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11
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Cayir S, Kayabasi S, Hizli O. Predictor parameters for poor prognosis in patients with sudden sensorineural hearing loss: fibrinogen to albumin ratio vs C-reactive protein to albumin ratio. Braz J Otorhinolaryngol 2020; 87:457-461. [PMID: 32788059 PMCID: PMC9422658 DOI: 10.1016/j.bjorl.2020.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/13/2020] [Accepted: 06/07/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction Prognosis of sudden sensorineural hearing loss may be predicted using several parameters of laboratory blood analysis. Objective To identify and investigate the most significant indicator parameters related to the poor prognosis of sudden sensorineural hearing loss. Methods Eighty-eight patients were included, and three groups were constituted: non-recovery group with14 patients, recovery group with 33 patients and control group with 41 individuals. We compared fibrinogen-to-albumin ratio, C-reactive protein-to-albumin ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, white blood cell and hemoglobin of the groups. Then, we investigated the most significant indicator parameters related to the poor prognosis of sudden hearing loss. Results The mean hemoglobin, mean platelet-lymphocyte ratio and median white blood cell values did not significantly differ among three groups (p = 0.36, p = 0.86 and p = 0.79, respectively). A significant difference of median fibrinogen-albumin ratio, C-reactive protein-albumin ratio, neutrophil-to-lymphocyte ratio was evident among three groups (p < 0.001, p = 0.003 and p = 0.002, respectively). Median fibrinogen-albumin ratio, C-reactive protein-albumin ratio and neutrophil-to-lymphocyte ratio values were significantly greater in the non-recovery group, compared with the controls (p < 0.001, p = 0.003 and p = 0.005, respectively). Median fibrinogen-to-albumin ratio, C-reactive protein-to-albumin ratio and neutrophil-to-lymphocyte ratio were significantly greater in the recovery group, compared with the controls (p < 0.001, p = 0.013 and p = 0.005, respectively). Moreover, the median fibrinogen-albumin ratio was significantly greater in the non-recovery group compared with the recovery group (p = 0.017). However, no statistically significant difference of median C-reactive protein-albumin ratio, neutrophil-to-lymphocyte was evident between the non-recovery and recovery groups (p = 0.15). Conclusion Increased levels of fibrinogen-albumin ratio may be predictive for poor prognosis in patients with sudden sensorineural hearing loss.
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Affiliation(s)
- Serkan Cayir
- Aksaray University, Aksaray Education and Research Hospital, Department of ENT, Aksaray, Turkey.
| | - Serkan Kayabasi
- Aksaray University, Faculty of Medicine, Department of ENT, Aksaray, Turkey
| | - Omer Hizli
- Giresun University, Prof Dr. A. Ilhan Ozdemir Education and Research Hospital, Department of ENT, Giresun, Turkey
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12
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Hetzer R, Javier MFDM, Javier Delmo EM. Pediatric ventricular assist devices: what are the key considerations and requirements? Expert Rev Med Devices 2019; 17:57-74. [PMID: 31779486 DOI: 10.1080/17434440.2020.1699404] [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: 10/25/2022]
Abstract
Introduction: The development of ventricular assist devices (VADs) have enabled myocardial recovery and improved patient survival until heart transplantation. However, device options remain limited for children and lag in development.Areas covered: This review focuses on the evolution of pediatric VADs in becoming to be an accepted treatment option in advanced heart failure, discusses the classification of VADs available for children, i.e. types of pumps and duration of support, and defines implantation indications and explantation criteria, describes attendant complications and long-term outcome of VAD support. Furthermore, we emphasize the key considerations and requirements in the application of these devices in infants, children and adolescents.Expert opinion: Increasing use of VADs has facilitated a leading edge in management of advanced heart failure either as a bridge to transplantation or as a bridge to myocardial recovery. In newborns and small children, the EXCOR Pediatric VAD remains the only reliable option. In some patients ventricular unloading may lead to complete myocardial recovery. There is a strong need for pumps that are fully implantable, suitable for single ventricle physiology, such as the right ventricle.
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Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
| | | | - Eva Maria Javier Delmo
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
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13
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Tume SC, Conway J, Ryan KR, Philip J, Fortkiewicz JM, Murray J. Developments in Pediatric Ventricular Assist Device Support. World J Pediatr Congenit Heart Surg 2019; 10:759-768. [PMID: 31663841 DOI: 10.1177/2150135119880890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Mechanical support devices have revolutionized the management of circulatory failure. This has been met by a dramatic increase in ventricular assist device (VAD) utilization in children over the last two decades. Previous wide gaps in experience and knowledge have significantly narrowed in the recent years. As we continue to gain experience with this technology, we face new challenges such as complex congenital circulations and small patient size. The emergence of new pharmacologic therapies and device technology offers more opportunities and requires constant adjustment in practice. As we continue to embark on this journey, constant insight is needed to refine patient selection criteria, minimize complications, and continue to push the field for safer smaller devices to accommodate these complex patient populations. In this review focused at inpatient critical care environment, we discuss the recent field developments and focus on challenging patient populations, the emergence of temporary support, management of anticoagulation, and diagnostic approach to stroke in the setting of VAD support.
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Affiliation(s)
- Sebastian C Tume
- Department of Pediatrics, Section of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer Conway
- Division of Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Kathleen R Ryan
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital at Stanford, Palo Alto, CA, USA
| | - Joseph Philip
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, FL, USA
| | | | - Jenna Murray
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital at Stanford, Palo Alto, CA, USA
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14
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Non-physiological shear stress-induced blood damage in ventricular assist device. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2019. [DOI: 10.1016/j.medntd.2019.100024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Radley G, Pieper IL, Ali S, Bhatti F, Thornton CA. The Inflammatory Response to Ventricular Assist Devices. Front Immunol 2018; 9:2651. [PMID: 30498496 PMCID: PMC6249332 DOI: 10.3389/fimmu.2018.02651] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/26/2018] [Indexed: 12/27/2022] Open
Abstract
The therapeutic use of ventricular assist devices (VADs) for end-stage heart failure (HF) patients who are ineligible for transplant has increased steadily in the last decade. In parallel, improvements in VAD design have reduced device size, cost, and device-related complications. These complications include infection and thrombosis which share underpinning contribution from the inflammatory response and remain common risks from VAD implantation. An added and underappreciated difficulty in designing a VAD that supports heart function and aids the repair of damaged myocardium is that different types of HF are accompanied by different inflammatory profiles that can affect the response to the implanted device. Circulating inflammatory markers and changes in leukocyte phenotypes receive much attention as biomarkers for mortality and disease progression. However, they are seldom used to monitor progress during and outcomes from VAD therapy or during the design phase for new devices. Even the partial reversal of heart damage associated with heart failure is a desirable outcome from VAD use. Therefore, improved understanding of the interplay between VADs and the recipient's inflammatory response would potentially increase their uptake, improve patient lives, and fuel research related to other blood-contacting medical devices. Here we provide a review of what is currently known about inflammation in heart failure and how this inflammatory profile is altered in heart failure patients receiving VAD therapy.
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Affiliation(s)
- Gemma Radley
- Swansea University Medical School, Swansea, United Kingdom.,Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, United Kingdom
| | - Ina Laura Pieper
- Swansea University Medical School, Swansea, United Kingdom.,Scandinavian Real Heart AB, Västerås, Sweden
| | - Sabrina Ali
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, United Kingdom
| | - Farah Bhatti
- Department of Cardiology, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, United Kingdom
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Miera O, Schmitt KL, Akintuerk H, Boet A, Cesnjevar R, Chila T, Fleck T, Goldwasser R, Guereta LG, Heineking B, Hoerer J, Horke A, Hsia TY, Huebler M, Kansy A, Karimova A, Maruszewski B, Medrano C, Pawlak S, Reinhardt Z, Romlin B, Sandica E, Schmidt F, Schramm R, Schweiger M, Śliwka J, Stiller B, Thul J, Amodeo A. Antithrombotic therapy in pediatric ventricular assist devices: Multicenter survey of the European EXCOR Pediatric Investigator Group. Int J Artif Organs 2018; 41:385-392. [DOI: 10.1177/0391398818773040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives: Mechanical circulatory support for pediatric heart failure patients with the Berlin Heart EXCOR ventricular assist system is the only approved and established bridging strategy for recovery or heart transplantation. In recent years, the burden of thromboembolic events has led to modifications of the recommended antithrombotic therapy. Therefore, we aimed to assess modifications of antithrombotic practice among the European EXCOR Pediatric Investigator Group members. Methods: We sent a questionnaire assessing seven aspects of antithrombotic therapy to 18 European hospitals using the EXCOR device for children. Returned questionnaires were analyzed and identified antithrombotic strategies were descriptively compared to “Edmonton protocol” recommendations developed for the US EXCOR pediatric approval study. Results: Analysis of 18 received surveys revealed substantial deviations from the Edmonton protocol, including earlier start of heparin therapy at 6–12 h postoperatively and in 50% of surveyed centers, monitoring of heparin effectiveness with aPTT assay, administering vitamin K antagonists before 12 months of age. About 39% of centers use higher international normalized ratio targets, and platelet inhibition is changed in 56% including the use of clopidogrel instead of dipyridamole. Significant inter-center variability with multiple deviations from the Edmonton protocol was discovered with only one center following the Edmonton protocol completely. Conclusion: Current antithrombotic practice among European EXCOR users representing the treatment of more than 600 pediatric patients has changed over time with a trend toward a more aggressive therapy. There is a need for systematic evidence-based evaluation and harmonization of developmentally adjusted antithrombotic management practices in prospective studies toward revised recommendations.
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Affiliation(s)
- Oliver Miera
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Katharina L Schmitt
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Hakan Akintuerk
- Pediatric Heart Center, University Hospital Giessen, Justus Liebig University, Giessen, Germany
| | - Angele Boet
- Cardiac ICU, “Marie Lannelongue” Surgical Center, South Paris University Hospitals, Paris, France
| | - Robert Cesnjevar
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Teresa Chila
- Department of Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Thilo Fleck
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg, Freiburg, Germany
| | - Ranny Goldwasser
- Department of Pediatric Cardiology/Congenital Heart Disease, Heidelberg University Hospital, Heidelberg, Germany
| | - Luis G Guereta
- Pediatric Cardiology, University Hospital La Paz, Madrid, Spain
| | - Beatrice Heineking
- Department of Pediatric Cardiology and Pediatric Intensive Care, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Juergen Hoerer
- Cardiac ICU, “Marie Lannelongue” Surgical Center, South Paris University Hospitals, Paris, France
| | - Alexander Horke
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Tain Y Hsia
- Department of Pediatric Cardiology, Great Ormond Street Hospital for Children, London, UK
| | - Michael Huebler
- Department of Congenital Pediatric Surgery, Zurich Children’s Hospital, Zurich, Switzerland
| | - Andrzej Kansy
- Department of Cardiothoracic Surgery, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Ann Karimova
- Department of Pediatric Cardiology, Great Ormond Street Hospital for Children, London, UK
| | - Bohdan Maruszewski
- Department of Cardiothoracic Surgery, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Constancio Medrano
- Pediatric Cardiology Division, Hospital Materno Infantil, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Szymon Pawlak
- Department of Cardiac Surgery and Transplantology, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Zdenka Reinhardt
- Department of Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Birgitta Romlin
- Department of Pediatric Anesthesia and Intensive Care, Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Eugen Sandica
- Center for Congenital Heart Defects, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - René Schramm
- Department of Pediatric Cardiology and Pediatric Intensive Care, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children’s Hospital, Zurich, Switzerland
| | - Joanna Śliwka
- Department of Cardiac Surgery and Transplantology, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Brigitte Stiller
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg, Freiburg, Germany
| | - Josef Thul
- Pediatric Heart Center, University Hospital Giessen, Justus Liebig University, Giessen, Germany
| | - Antonio Amodeo
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
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17
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Chan JL, Kobashigawa JA, Aintablian TL, Li Y, Perry PA, Patel JK, Kittleson MM, Czer LS, Zarrini P, Velleca A, Rush J, Arabia FA, Trento A, Esmailian F. Vasoplegia after heart transplantation: outcomes at 1 year. Interact Cardiovasc Thorac Surg 2017; 25:212-217. [PMID: 28459983 DOI: 10.1093/icvts/ivx081] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 02/15/2017] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Vasoplegia syndrome is a potentially life-threatening condition that can occur following cardiopulmonary bypass. Heart transplantation is a recognized risk factor for developing this vasodilatory state. The objective of this study was to determine the effects of vasoplegia syndrome on 1-year heart transplant outcomes. METHODS A retrospective review of orthotopic heart transplants at a single institution between November 2010 and December 2014 was performed. Of the 347 consecutive adult patients, 107 patients (30.8%) met criteria for vasoplegia syndrome. Preoperative factors and intraoperative variables were collected and compared between vasoplegia and non-vasoplegia cohorts. The incidence of postoperative complications, transplant rejection and patient survival within 1 year were evaluated. RESULTS Demographics and preoperative medication profiles were similar in both groups, while mechanical circulatory support device use was associated with vasoplegia syndrome (30.8% vs 20.0%; P = 0.039). Perioperative characteristics such as longer cardiopulmonary bypass [165.0 (interquartile range [IQR] 74) min vs 140.0 (IQR 42.7) min; P < 0.001] and increased blood product usage (24.7 ± 17.2 units vs 17.7 ± 14.3 units; P < 0.001) were associated with vasoplegia. Non-vasoplegia patients were more likely to be extubated [42.9 (IQR 37.3) h vs 66.8 (IQR 50.2) h; P < 0.001] and discharged earlier [10.0 (IQR 6) days vs 14.0 (IQR 11.5) days; P < 0.001]. One-year patient survival (92.0% vs 88.6%; P = 0.338) and any-treated rejection rates (82.7% vs 84.3%; P = 0.569) were not significantly different between groups. CONCLUSIONS Although vasoplegia syndrome was associated with an increase in perioperative morbidity, including greater mechanical ventilation time and hospital length of stay, no significant differences in survival or allograft rejection at 1 year was demonstrated.
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Affiliation(s)
- Joshua L Chan
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Yanqing Li
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Paul A Perry
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | | | | | | | - Jenna Rush
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Francisco A Arabia
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alfredo Trento
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Fardad Esmailian
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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18
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Padera RF. A perfect storm: Understanding hemostasis, coagulation and inflammation with artificial material. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Steiner ME, Bomgaars LR, Massicotte MP. Antithrombotic Therapy in a Prospective Trial of a Pediatric Ventricular Assist Device. ASAIO J 2017; 62:719-727. [PMID: 27556152 PMCID: PMC5098459 DOI: 10.1097/mat.0000000000000434] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Efficacious ventricular assist device (VAD) support in pediatric patients depends on successful antithrombotic management. The experience with antithrombotic management for the EXCOR Pediatric VAD Investigational Device Exemption (IDE) study is described. All 68 children in North America enrolled in the IDE study from May 9, 2007 to December 10, 2010 are included. The Edmonton Anticoagulation and Platelet Inhibition Protocol was provided for management guidance. Monitoring parameters, drug dosing, targeted serious adverse events, and pump changes were reviewed. Major bleeding occurred in 43% of all subjects with most events occurring within 14 days of implantation. Bleeding events were probably/definitely related in 24% to antithrombotic management. Neurologic events occurred in 28% of subjects and were probably/definitely related in 9% to antithrombotic therapy intensity. Most neurologic events occurred between 4 and 30 days postimplantation and sporadically thereafter. Pump change occurred in 56% of subjects. Use of an antithrombotic protocol for enrolled subjects was possible in this multicenter study. Incidence of significant bleeding and thromboembolic events was acceptable when balanced against life-saving benefits of VADs. Further studies are needed to optimize the antithrombotic management of this patient population.
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Affiliation(s)
- Marie E. Steiner
- From the Department of Pediatrics, Divisions of Hematology and Critical Care, University of Minnesota, Minneapolis, Minnesota; Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas; and Department of Pediatrics, Stollery Children’s Hospital, Alberta, Canada
| | - Lisa R. Bomgaars
- From the Department of Pediatrics, Divisions of Hematology and Critical Care, University of Minnesota, Minneapolis, Minnesota; Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas; and Department of Pediatrics, Stollery Children’s Hospital, Alberta, Canada
| | - M. Patricia Massicotte
- From the Department of Pediatrics, Divisions of Hematology and Critical Care, University of Minnesota, Minneapolis, Minnesota; Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas; and Department of Pediatrics, Stollery Children’s Hospital, Alberta, Canada
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20
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Association Between Hematologic and Inflammatory Markers and 31 Thrombotic and Hemorrhagic Events in Berlin Heart Excor Patients. Pediatr Cardiol 2017; 38:770-777. [PMID: 28184979 DOI: 10.1007/s00246-017-1578-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
Bleeding and thrombotic events remain a significant cause of morbidity in pediatric patients supported with ventricular assist devices (VADs). The objective of this study is to identify the association between markers of anticoagulation and bleeding and thrombosis events during Berlin Heart ExCor support. A retrospective, single-center analysis of 9 patients supported with the Berlin Heart ExCor was performed. Inflammatory and anticoagulation parameters including C-reactive protein, fibrinogen, partial thromboplastin time (PTT), and platelet count were measured at 48 and 24 h before and after bleeding or thrombosis events. Patients served as their own controls, and the same parameters were measured during a control period where subjects did not experience either event. All patients received the anticoagulation regimen proposed by Berlin Heart. A total of 31 bleeding or thrombotic events were identified and matched to 18 control events. Patient with predominantly thrombotic events tended to weigh less than those with bleeding events (Δ7.7 kg, p < 0.001). PTT levels were higher before and after bleeding (Δ17.36, p = 0.002) and thrombosis (Δ8.75, p < 0.001) events relative to control. Heparin dose decreased after a thrombosis event (Δ-5.67, p = 0.097), and this decrease was significantly different from control (p = 0.032). Non-collinearity between heparin dose and PTT should prompt further inflammatory and hematological investigation. In addition, heavier patients were more prone to bleeding complications. The role of inflammation in the development of thrombus or hemorrhages in the pediatric VAD population needs to be studied further.
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21
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Villavicencio MA, Larraín E, Larrea R, Peralta JP, Lim JS, Rojo P, Donoso E, Gajardo F, Hurtado M, Rossel V. Bridge to transplant or recovery in cardiogenic shock in a developing country. Asian Cardiovasc Thorac Ann 2017; 25:105-112. [PMID: 28084085 DOI: 10.1177/0218492316689177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Durable mechanical support devices are prohibitively expensive in our health system and may be unsuitable for critically ill patients. CentriMag is an alternative bridge to transplantation or recovery. Methods We retrospectively reviewed 28 patients (23 males) aged 13-60 years who received CentriMag support. The etiology was ischemic in 13 (46%), dilated cardiomyopathy in 8 (29%), and others in 7 (25%). All patients were in Interagency Registry for Mechanically Assisted Circulatory Support class I, and 27 (96%) had multiorgan failure; 2 (7%) were post-cardiotomy and 12 (43%) had a previous cardiac arrest (mean arrest time 21 ± 17 min). Results Thirty-day post-implant survival was 79% (22 patients). Twenty (71%) patients were successfully bridged to transplantation or recovery. The mean support time was 40 days; 12 (43%) patients had >4-weeks' support (longest was 292 days). Eight (29%) patients died on support. Complications included bleeding in 10 (36%) cases, immediate stroke in 4 (14%), and dialysis in 8 (29%). There was no stroke during subsequent support. Eighteen (64%) patients underwent transplantation, and 17 of them were discharged. Two (7%) patients recovered and were discharged. Two-year survival was 62% ± 10%. Mean follow-up was 21 months (total follow-up 579 months). Two (7%) patients died during follow-up. All survivors were in New York Heart Association class I. Conclusions CentriMag is useful for medium-term support for cardiogenic shock in a developing country. Support for >4 weeks is feasible. The stroke rate is low during support. The major drawback is prolonged intensive care unit stay.
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Affiliation(s)
- Mauricio A Villavicencio
- 1 Department of Cardiovascular Diseases, Clínica Dávila, Santiago, Chile.,2 Cardiovascular Surgery Service, Instituto Nacional del Tórax, Santiago, Chile.,3 Department of Surgery and Medicine, Universidad de Chile, Santiago, Chile
| | - Ernesto Larraín
- 1 Department of Cardiovascular Diseases, Clínica Dávila, Santiago, Chile
| | - Ricardo Larrea
- 1 Department of Cardiovascular Diseases, Clínica Dávila, Santiago, Chile
| | - Juan Pablo Peralta
- 1 Department of Cardiovascular Diseases, Clínica Dávila, Santiago, Chile
| | - Jong S Lim
- 2 Cardiovascular Surgery Service, Instituto Nacional del Tórax, Santiago, Chile
| | - Pamela Rojo
- 1 Department of Cardiovascular Diseases, Clínica Dávila, Santiago, Chile
| | - Erika Donoso
- 2 Cardiovascular Surgery Service, Instituto Nacional del Tórax, Santiago, Chile
| | - Francesca Gajardo
- 2 Cardiovascular Surgery Service, Instituto Nacional del Tórax, Santiago, Chile
| | - Margarita Hurtado
- 1 Department of Cardiovascular Diseases, Clínica Dávila, Santiago, Chile
| | - Víctor Rossel
- 1 Department of Cardiovascular Diseases, Clínica Dávila, Santiago, Chile.,3 Department of Surgery and Medicine, Universidad de Chile, Santiago, Chile
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Abstract
OBJECTIVES The objectives of this review are to discuss the process of patient and mechanical device selection, operative management, and postoperative care with a focus on the management of right ventricular failure, anticoagulation strategies, device-related infections and neurologic sequelae. DATA SOURCES MEDLINE, PubMed. CONCLUSION The number of patients with advanced heart failure due to either acquired or congenital heart disease continues to increase, necessitating in some mechanical circulatory support and in others cardiac transplantation. With a limited cardiac donor pool, mechanical circulatory support is playing a greater role in the management of this population. The perioperative morbidity associated with mechanical circulatory support has lessened with improved postoperative management strategies.
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Hehir DA, Easley RB, Byrnes J. Noncardiac Challenges in the Cardiac ICU: Feeding, Growth and Gastrointestinal Complications, Anticoagulation, and Analgesia. World J Pediatr Congenit Heart Surg 2016; 7:199-209. [PMID: 26957404 DOI: 10.1177/2150135115615847] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Outcomes following cardiac intensive care unit (CICU) admission are influenced by many factors including initial cardiac diagnosis, surgical complexity, and burden of critical illness. Additionally, the presence of noncardiac issues may have a significant impact on outcomes and the patient experience during and following an intensive care unit stay. This review focuses on three common noncardiac areas which impact outcomes and patient experience in and beyond the CICU: feeding and growth, pain and analgesia, and anticoagulation. Growth failure and feeding dysfunction are commonly encountered in infants requiring cardiac surgery and have been associated with worse surgical and developmental outcomes. Recent studies most notably in the single ventricle population have demonstrated improved weight gain and outcomes when feeding protocols are implemented. Children undergoing cardiac surgery may experience both acute and chronic pain. Emerging research is investigating the impact of sedatives and analgesics on neurodevelopmental outcomes and quality of life. Improved pain scores and standardized management of pain and withdrawal may improve the patient experience and outcomes. Effective anticoagulation is a critical component of perioperative care but may be complicated by inflammation, multiorgan dysfunction, and patient factors. Advances in monitoring of anticoagulation and emerging therapies are reviewed.
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Affiliation(s)
- David A Hehir
- Nemours Cardiac Center, AI Dupont Hospital for Children, Thomas Jefferson Medical College, Philadelphia, PA, USA
| | - R Blaine Easley
- Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jonathan Byrnes
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Byrnes JW, Bhutta AT, Rettiganti MR, Gomez A, Garcia X, Dyamenahalli U, Johnson C, Jaquiss RD, Imamura M, Prodhan P. Steroid Therapy Attenuates Acute Phase Reactant Response Among Children on Ventricular Assist Device Support. Ann Thorac Surg 2015; 99:1392-8. [DOI: 10.1016/j.athoracsur.2014.11.046] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 11/07/2014] [Accepted: 11/18/2014] [Indexed: 11/28/2022]
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25
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Güvener M, Korun O, Demirtürk OS. Risk factors for systemic inflammatory response after congenital cardiac surgery. J Card Surg 2014; 30:92-6. [PMID: 25382731 DOI: 10.1111/jocs.12465] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study aims to assess the frequency of systemic inflammatory response syndrome (SIRS) following congenital heart surgery and risk factors associated with this clinical syndrome. METHODS Charts of all patients undergoing surgery for congenital heart disease in a single institution over a five-year period were analyzed retrospectively. The presence of SIRS was evaluated based on the criteria of the International Pediatric Sepsis Consensus Conference. RESULTS Of the 246 patients included in the study 22 (8.9%) had clinical parameters indicating SIRS. The patients in the SIRS group had significantly longer cardiopulmonary bypass time (105.14 ± 27.27 vs. 66.86 ± 26.64 min; p < 0.01), aortic cross clamp time (69.36 ± 21.52 vs. 44.30 ± 24.27 min; p < 0.01), higher postoperative alanine aminotransferase (1419.00 ± 3260.99 vs. 81.95 ± 808.61 U/L; p < 0.01) and aspartate aminotransferase (2137.14 ± 4905.40 vs. 171.33 ± 1303.21 U/L; p < 0.01), white blood cell counts (20,827 ± 3603 vs. 12,242 ± 3782/µL; p < 0.01) and lower body surface area (0.52 ± 0.32 vs. 0.71 ± 0.36 m(2) ; p < 0.05) compared to patients in the no-SIRS group. Binary logistic regression revealed cardiopulmonary bypass time (OR: 1.05, p < 0.05), low body weight (<10 kg) (OR: 2.44; p < 0.05), and preoperative diagnosis of right to left shunt congenital heart disease (OR: 8.06; p < 0.01) as independent predictors of SIRS. SIRS was also found to be a strong independent predictor of mortality (OR: 10.13, p < 0.01). CONCLUSIONS SIRS after congenital heart surgery is associated with increased mortality. Independent risk factors for SIRS in the patient population of the study were cardiopulmonary bypass time, body weight below 10 kg and preoperative diagnosis of right to left shunt congenital heart disease.
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Affiliation(s)
- Murat Güvener
- Department of Cardiovascular Surgery, Hacettepe University School of Medicine, Ankara, Turkey
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