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de By TMMH, Schweiger M, Hussain H, Amodeo A, Martens T, Bogers AJJC, Damman K, Gollmnan-Tepeköylü C, Hulman M, Iacovoni A, Krämer U, Loforte A, Napoleone CP, Němec P, Netuka I, Özbaran M, Polo L, Pya Y, Ramjankhan F, Sandica E, Sliwka J, Stiller B, Kadner A, Franceschini A, Thiruchelvam T, Zimpfer D, Meyns B, Berger F, Miera O. The European Registry for Patients with Mechanical Circulatory Support (EUROMACS): third Paediatric (Paedi-EUROMACS) report. Eur J Cardiothorac Surg 2022; 62:6618527. [PMID: 35758622 DOI: 10.1093/ejcts/ezac355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/23/2022] [Accepted: 06/25/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Children's Hospital Zürich, Zürich, Switzerland
| | | | | | | | - Ad J J C Bogers
- Department of Cardio-thoracic surgery, Erasmus MC, Rotterdam, Netherlands
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | | | | | - Ulrike Krämer
- Department of Pediatric Intensive Care, Erasmus MC, Rotterdam, Netherlands
| | | | - Carlo Pace Napoleone
- Pediatric Cardiac Surgery Department, Regina Margherita Children's Hospital, Torino, Italy
| | - Petr Němec
- Center for Cardiovascular and Transplant Surgery Brno
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | | | - Luz Polo
- La Paz University Hospital, Madrid, Spain
| | - Yuri Pya
- National Research Cardiac Surgery Center, Astana, Kazakhstan
| | | | - Eugen Sandica
- Clinic for Pediatric Cardiac Surgery and Congenital Heart Defects, Heart and Diabetes Centre North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Joanna Sliwka
- Department of Cardiac Surgery, Transplantology and Vascular Surgery, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Germany
| | - Alexander Kadner
- Department of Herz- und Gefässchirurgie, University Hospital Bern, Switzerland
| | | | | | | | - Bart Meyns
- Katholieke Universiteit Leuven, Leuven, Belgium
| | - Felix Berger
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
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Pokrajac N, Cantwell LM, Murray JM, Dykes JC. Characteristics and Outcomes of Pediatric Patients With a Ventricular Assist Device Presenting to the Emergency Department. Pediatr Emerg Care 2022; 38:e924-e928. [PMID: 34225326 DOI: 10.1097/pec.0000000000002493] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES A growing number of children receive support from left ventricular assist devices (LVADs) in the outpatient setting. Unexpected complications of LVAD support occur that require emergent management, and no studies examine how pediatric LVAD patients present to the emergency department (ED). The goals of this study were (1) to describe frequency of visits, clinical characteristics, adverse events, and outcomes of LVAD-supported children treated in ED settings and (2) to evaluate for associations between specified patient outcomes and ED care location. METHODS This was a retrospective cohort study of children in a single-center outpatient VAD program who presented to several EDs during a 10-year period. We defined adverse events according to the Advanced Cardiac Therapies Improving Outcomes Network registry guidelines. Secondary analysis evaluated for associations between specified patient outcomes (adverse events, hospitalizations, intensive care unit admissions) and ED care location (institutional vs other ED). RESULTS Of 104 subjects with LVAD implantations during the study period, 30 (28.8%) transitioned to outpatient care. Among subjects in the outpatient VAD program, 24 (80%) of 30 had 54 visits to various EDs over 141.9 patient-months. The median age at time of ED visit was 13.5 years (range, 7.2-17.9 years). The median number of visits per subject was 1 (range, 0-6). The most common complaints on arrival to the ED were vomiting or abdominal pain (16.7%), fever (15.3%), and headache (13.9%). Seventeen adverse events occurred during 14 (25.9%) of 54 ED visits. The most common adverse events were major infection (33.3%) and right heart failure (16.7%). Hospital admission resulted from 41 (75.9%) of 54 ED visits, including 17 (41.5%) of 41 to a cardiovascular intensive care unit. Care at a nonspecialty ED was associated with a higher rate of hospitalization (93.8% vs 68.4%, P = 0.049). During the study period, 4 subjects (13.3%) died, including 1 patient on destination therapy, 1 with multisystem organ failure due to cardiogenic shock, and 2 with hemorrhagic stroke. No patient died while in the ED. CONCLUSIONS Among subjects in a single outpatient pediatric VAD program presenting to the ED, the most common complaints were abdominal pain/vomiting, fever, and headache. The most common adverse events were major infection and right heart failure. Subjects had a high rate of ED utilization and hospital admission.
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Affiliation(s)
- Nicholas Pokrajac
- From the Department of Emergency Medicine, Stanford University School of Medicine
| | - Lauren M Cantwell
- From the Department of Emergency Medicine, Stanford University School of Medicine
| | - Jenna M Murray
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - John C Dykes
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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Lorts A, Conway J, Schweiger M, Adachi I, Amdani S, Auerbach SR, Barr C, Bleiweis MS, Blume ED, Burstein DS, Cedars A, Chen S, Cousino-Hood MK, Daly KP, Danziger-Isakov LA, Dubyk N, Eastaugh L, Friedland-Little J, Gajarski R, Hasan A, Hawkins B, Jeewa A, Kindel SJ, Kogaki S, Lantz J, Law SP, Maeda K, Mathew J, May LJ, Miera O, Murray J, Niebler RA, O'Connor MJ, Özbaran M, Peng DM, Philip J, Reardon LC, Rosenthal DN, Rossano J, Salazar L, Schumacher KR, Simpson KE, Stiller B, Sutcliffe DL, Tunuguntla H, VanderPluym C, Villa C, Wearden PD, Zafar F, Zimpfer D, Zinn MD, Morales IRD, Cowger J, Buchholz H, Amodeo A. ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association. J Heart Lung Transplant 2021; 40:709-732. [PMID: 34193359 DOI: 10.1016/j.healun.2021.04.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Angela Lorts
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio.
| | | | - Martin Schweiger
- Universitäts-Kinderspitals Zürich - Herzchirurgie, Zurich, Switzerland
| | - Iki Adachi
- Texas Children's Hospital, Houston, Texas
| | | | - Scott R Auerbach
- Anschutz Medical Campus, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado
| | - Charlotte Barr
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | - Mark S Bleiweis
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | | | - Ari Cedars
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sharon Chen
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Kevin P Daly
- Boston Children's Hospital, Boston, Massachusetts
| | - Lara A Danziger-Isakov
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Nicole Dubyk
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lucas Eastaugh
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Asif Hasan
- Freeman Hospital, Newcastle upon Tyne, UK
| | - Beth Hawkins
- Boston Children's Hospital, Boston, Massachusetts
| | - Aamir Jeewa
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Steven J Kindel
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | - Jodie Lantz
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sabrina P Law
- Morgan Stanley Children's Hospital of New York Presbyterian, New York, New York
| | - Katsuhide Maeda
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Jacob Mathew
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Jenna Murray
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Robert A Niebler
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | | | - David M Peng
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joseph Philip
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | - David N Rosenthal
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Joseph Rossano
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Kurt R Schumacher
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | | | - David L Sutcliffe
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Chet Villa
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Matthew D Zinn
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Discharge and Readmission to the Pediatric Cardiac ICU in Pediatric Patients With Durable Ventricular Assist Devices. Pediatr Crit Care Med 2020; 21:e810-e818. [PMID: 32769703 DOI: 10.1097/pcc.0000000000002456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Pediatric patients implanted with a durable ventricular assist device are initially managed in the pediatric cardiac ICU but are eligible for discharge to the ward. Our objectives were to characterize discharge and readmission of ventricular assist device patients to the pediatric cardiac ICU, identify risk factors for readmission, and determine whether discharge or readmission is associated with mortality. DESIGN Retrospective study. SETTING Stollery Children's Hospital. PATIENTS Patients implanted with a durable ventricular assist device at less than 18 years old between 2005 and 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 44 patients who underwent ventricular assist device implantation at a median age of 3.7 years (interquartile range, 0.6-9.0 yr), with the most common etiology being noncongenital heart disease (76.7%). Median time of total ventricular assist device support was 110.0 days (interquartile range, 42.3-212.3 d) with the median index pediatric cardiac ICU stay being 34.0 days (interquartile range, 19.8-81.0 d). Thirty patients (68.0%) were discharged to the ward with 18 (60.0%) having at least one readmission. The median time to first readmission was 18.0 days (interquartile range, 14.8-109.8 d) with a median of two readmissions per patient (interquartile range, 1.0-3.0). The most common reason for readmission was pump thrombosis (30.4%), followed by neurologic dysfunction (23.9%). There were no statistically significant pre- or post-implant factors associated with readmission, and readmission was not associated with mortality (p = 0.600). Univariate Kaplan-Meier survival analysis indicated that use of pre-implant extracorporeal membrane oxygenation, post-implant continuous renal replacement therapy, as well as failure to be discharged from the index pediatric cardiac ICU stay were associated with mortality. CONCLUSIONS Readmissions to the pediatric cardiac ICU occurred in 60.0% of pediatric patients on durable ventricular assist devices with the first readmission occurring within a month of discharge from the index pediatric cardiac ICU stay. While readmission was not associated with mortality, lack of discharge from index pediatric cardiac ICU stay was likely due to a worse pre-implant clinical status.
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Sert DE, Kocabeyoglu SS, Kervan U, Karahan M, Beyazal OF, Akdi M, Yilmaz A, Catav Z. Cerebrovascular events in children on intracorporeal continuous-flow left ventricular assist devices. Artif Organs 2020; 44:1251-1258. [PMID: 32663321 DOI: 10.1111/aor.13778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/13/2020] [Accepted: 07/10/2020] [Indexed: 12/31/2022]
Abstract
Continuous-flow intracorporeal left ventricular assist devices (CF-LVAD) are used more frequently in the pediatric population. One of the major complications of CF-LVAD is cerebrovascular events (CVEs). Limited information is available on this complication in pediatric patients. We hereby present our experience on CVEs in children under CF-LVAD support in our institution. A retrospective, single center review of 21 patients younger than 19 years of age who underwent CF-LVAD implantation between June 2014 and September 2018 was performed. Patients on biventricular support and extracorporeal devices were excluded. Cerebrovascular accidents (CVAs)-ischemic or hemorrhagic-were investigated. CVE was confirmed by brain computed tomographic scan. Of 21 pediatric patients, 11 were male. Mean BSA was 1.05 ± 0.41 m2 and mean age was 11.05 ± 4.07 years. Dilated cardiomyopathy was the leading cause of heart failure. The patients were implanted with HeartWare hVAD (n = 19), HeartMate II (n = 1), and HeartMate 3 (n = 1). Mean support time was 421 ± 448 (18-1460) days. Target international normalized ratio was between 2.5 and 3.0. Nine (43%) patients underwent transplantation, one patient recovered with subsequent device explantation. Four (17%) patients were still on support. One patient (5%) died in the early postoperative period and six (28%) patients died on VAD support after a mean duration of 194 days. There were overall five cerebral hemorrhagic strokes in four patients (0.2 events per patient-year). CVA occurred between 250 and 1320 days (mean 600 days). No ischemic stroke was documented. Only one (20%) patient died after hemorrhagic stroke; the other three patients recovered and were discharged from the hospital with minor sequelae. Incidence of CVE in children on CF-LVAD is relatively low compared with adults on VAD and severity of stroke is milder than adult population.
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Affiliation(s)
- Dogan Emre Sert
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | | | - Umit Kervan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Mehmet Karahan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | | | - Mustafa Akdi
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Abdulkadir Yilmaz
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Zeki Catav
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
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Knoll C, Kaufman B, Chen S, Murray J, Cohen H, Sourkes BM, Rosenthal DN, Hollander SA. Palliative Care Engagement for Pediatric Ventricular Assist Device Patients: A Single-Center Experience. ASAIO J 2020; 66:929-932. [PMID: 32740354 DOI: 10.1097/mat.0000000000001092] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Outcomes in pediatric patients with ventricular assist devices (VADs) for advanced heart failure (HF) are improving, but the risk of associated morbidity and mortality remains substantial. Few data exist on the involvement of pediatric palliative care (PPC) in this high-risk patient population. We aimed to characterize the extent of palliative care involvement in the care of patients requiring VAD placement at our institution. Single-center retrospective chart review analyzing all VAD patients at a large pediatric center over a 4 year period. Timing and extent of palliative care subspecialty involvement were analyzed. Between January 2014 and December 2017, 55 HF patients underwent VAD implantation at our institution. Pediatric palliative care utilization steadily increased over consecutive years (2014: <10% of patients, 2015: 20% of patients, 2016: 50% of patients, and 2017: 65% of patients) and occurred in 42% (n = 23) of all patients. Of these, 57% (n = 13) occurred before VAD placement while 43% (n = 10) occurred after implantation. Patients who died during their VAD implant hospitalization (24%, n = 13) were nearly twice as likely to have PPC involvement (62%) as those who reached transplant (38%). Of those who died, patients who had PPC involved in their care were more likely to limit resuscitation efforts before their death. Four patients had advanced directives in place before VAD implant, of which three had PPC consultation before device placement. Three families (5%) refused PPC involvement when offered. Pediatric palliative care utilization is increasing in VAD patients at our institution. Early PPC involvement occurred in the majority of patients and appears to lead to more frequent discussion of goals-of-care and advanced directives.
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Affiliation(s)
- Christopher Knoll
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Beth Kaufman
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Sharon Chen
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Jenna Murray
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Harvey Cohen
- Division of Hematology/Oncology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Barbara M Sourkes
- Division of Pediatric Critical Care, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - David N Rosenthal
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Seth A Hollander
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
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Intracorporeal Biventricular Assist Devices Using the Heartware Ventricular Assist Device in Children. ASAIO J 2020; 66:1031-1034. [DOI: 10.1097/mat.0000000000001149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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8
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Abstract
Pump thrombosis represents a significant cause of morbidity and mortality in patients on continuous flow ventricular assist devices (CF-VAD). Pump thrombosis in the pediatric CF-VAD population has been reported between 11% and 44%, with the largest reported series from the PediMACS registry reporting a rate of approximately 15%. We report our early experience with four pediatric patients who developed pump thrombosis on a CF-VAD. Our limited experience suggests that the treatment of pediatric VAD thrombosis can be approached with similar principles to the adult population. Our current strategy includes:i. Initiating treatment with bivalirudin for an isolated rise in lactate dehydrogenase (LDH) with no corresponding rapid rise in plasma-free hemoglobin which may prevent further progression.ii. Treatment with a low-dose systemic tissue plasminogen activator (TPA) protocol as opposed to targeted therapy via catheter intervention if bivalirudin fails.iii. If there are concerns with respect to the impact of hemolysis on kidney function or the patient is close to a previous surgery, device exchange can be considered.The balance between achieving appropriate anticoagulation/antiplatelet therapy in the face of bleeding/hemorrhagic complications remains a challenge. There is a need for larger studies in the pediatric population to outline an algorithm for the definitive management of VAD thrombosis.
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Hyotala K. Caring for Pediatric Heart Failure Patients With Long-Term Mechanical Circulatory Support. Crit Care Nurse 2019; 38:44-56. [PMID: 30275063 DOI: 10.4037/ccn2018313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Pediatric cardiac failure is a significant problem that may be caused by cardiomyopathy, myocarditis, or congenital defects that cannot be surgically repaired. Long-term mechanical circulatory support (LTMCS) devices provide hemodynamic support for patients in heart failure as a bridge to heart transplant and, sometimes, cardiac recovery or destination therapy. Critical care nurses must have a comprehensive understanding of LTMCS device function and keen assessment skills to detect signs of impaired perfusion and device failure. Nurses should anticipate postoperative interventions, prevent adverse events, and be prepared to respond during emergencies. Patient care should be family centered and nurses must strive to maximize patients' quality of life throughout device implantation. This article provides a basic guide to caring for pediatric patients receiving LTMCS, including specific information regarding 4 devices that are often used for pediatric heart failure: Berlin Heart EXCOR, SynCardia Total Artificial Heart, HeartWare HVAD, and HeartMate II.
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Affiliation(s)
- Kari Hyotala
- Kari Hyotala is a nurse practitioner in the pediatric intensive care unit at Cook Children's Medical Center in Fort Worth, Texas.
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Huang JY, Monagle P, Massicotte MP, VanderPluym CJ. Antithrombotic therapies in children on durable Ventricular Assist Devices: A literature review. Thromb Res 2018; 172:194-203. [DOI: 10.1016/j.thromres.2018.02.145] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/12/2018] [Accepted: 02/22/2018] [Indexed: 11/30/2022]
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12
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Das BB, Chrisant M, Lavandosky G, Zakrzewski M, Winchester R, Turner I, Bibevski S, Scholl F. An Adolescent with Left Ventricular Noncompaction and Ebstein Anomaly Presenting with Advanced Heart Failure: Discharge from Hospital with a Biventricular Assist Device. J Pediatr 2018; 202:304-310.e1. [PMID: 30217690 DOI: 10.1016/j.jpeds.2018.07.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/03/2018] [Accepted: 07/11/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Bibhuti B Das
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL.
| | | | - Gerald Lavandosky
- Division of Critical Care, Joe DiMaggio Children's Hospital, Hollywood, FL
| | | | | | - Immanuel Turner
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL
| | - Steven Bibevski
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL
| | - Frank Scholl
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL
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13
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Extracorporeal membrane oxygenation, Berlin, and ventricular assist devices: a primer for the cardiologist. Curr Opin Cardiol 2018; 33:87-94. [PMID: 29059075 DOI: 10.1097/hco.0000000000000479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) has become an indispensable tool in the management of children with impending respiratory and cardiac failure. Though extracorporeal membrane oxygenation (ECMO) was classically the only form of support available to pediatric patients, considerable advances have allowed ventricular assist devices (VADs) to become increasingly utilized in children. This review provides an update of recent advances in ECMO and VAD management in children. RECENT FINDINGS The options for mechanical support in infants and small children with end-stage heart failure are limited. As such, the greatest advances in the past decade have come in the successful adoption of the Berlin Heart EXCOR device, with a marked improvement in survival to transplant over ECMO. Further advances have been made in the use of adult VADs in children. For instance, the HeartWare HVAD has been utilized in children as young as 3 years of age, despite being designed for use in adult patients. SUMMARY The availability of mechanical support options for children remains limited to ECMO and a small number of VADs. While outcomes of VAD support in pediatric patients have been promising, further study in smaller and more complex pediatric patients is necessary.
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Godown J, Smith AH, Thurm C, Hall M, Dodd DA, Soslow JH, Mettler BA, Bearl DW, Feingold B. Mechanical circulatory support costs in children bridged to heart transplantation - analysis of a linked database. Am Heart J 2018; 201:77-85. [PMID: 29780004 DOI: 10.1016/j.ahj.2018.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 04/02/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pediatric mechanical circulatory support (MCS) has evolved considerably over the past decade. Though marked improvements in waitlist survival have been realized, costs have not been reassessed. This project aimed to assess contemporary MCS costs in children bridged to heart transplant (HT). METHODS All pediatric HT recipients (2002-2016) were identified from a unique, linked PHIS/SRTR dataset. Costs were calculated from hospital charges, inflated to 2016 Dollars and adjusted for patient-specific characteristics using generalized linear mixed-effects models. Costs and length of stay (LOS) were compared across support strategies at the time of HT (no MCS, VAD, or ECMO) with select subgroup analyses. RESULTS A total of 2873 pediatric HT recipients were included; no MCS: 2268 (78.9%), VAD: 470 (16.4%), and ECMO: 135 (4.7%). Both VAD and ECMO were associated with greater total hospitalization costs compared to no MCS ($755,345 and $808,771 vs. $457,086; P < .001). Total costs and LOS were similar between VAD and ECMO groups; however, costs and LOS were greatest for VAD-supported patients in the pre-HT period and greatest for ECMO-supported patients post-HT. Post-HT costs and LOS were similar between patients who did not require MCS and those supported with a VAD ($324,887 and 18 days vs. $329,198 and 18 days respectively, p = NS). Outpatients with VAD support at HT demonstrated significantly lower total costs compared to those who were inpatient with continuous flow devices ($552,222 vs. $663,071, P = .003). CONCLUSIONS MCS as a bridge to HT in children is associated with greater total costs. While costs are similar between VAD and ECMO groups, the majority of costs associated with VAD support is incurred pre-HT while ECMO costs are incurred primarily post-HT. Discharging patients on VAD support awaiting HT may represent a strategy to reduce costs in this population.
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Affiliation(s)
- Justin Godown
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN.
| | - Andrew H Smith
- Pediatric Critical Care, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Cary Thurm
- Children's Hospital Association, Lenexa, KS
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Debra A Dodd
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Jonathan H Soslow
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Bret A Mettler
- Pediatric Cardiothoracic Surgery, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - David W Bearl
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Brian Feingold
- Pediatrics and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Mechanical circulatory support challenges in pediatric and (adult) congenital heart disease. Curr Opin Organ Transplant 2018; 23:301-307. [DOI: 10.1097/mot.0000000000000522] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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di Bari S, Tunuguntla H, Elias B, Elhoff J. The pediatric experience of living with a ventricular assist device. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
As continuous-flow ventricular assist devices (CF-VADs) are used increasingly in children and adolescents, more pediatric patients will be supported as outpatients. Herein we report the patterns of rehospitalization after CF-VAD implantation at a single center. We retrospectively reviewed the medical records of 19 consecutive patients who received CF-VADs between December 6, 2010 and November 5, 2016 and were discharged on device therapy. The frequency, duration, and indications for all hospitalizations between the time of implant hospitalization discharge and January 8, 2016 were analyzed. There were a total of 52 rehospitalization episodes in 16 (84%) patients over 5,101 (median 93, interquartile range [IQR] 38, 226) follow-up days. There were a median of two (IQR 1, 3) hospitalizations per patient. The median time to first hospitalization was 14 (IQR 7, 62) days. The most common admitting diagnoses were suspected infection 13 (28%) and suspected pump thrombosis in 8 (17%). Thirty-one (60%) hospitalizations included procedures, including seven (13%) requiring device-related surgery. Overall, 89% of postimplant discharge days were spent outside of the hospital. Children with CF-VADs can be discharged with acceptable readmission rates and significant time spent out of hospital. Most patients will be rehospitalized at least once between implant hospitalization and transplantation, often within 2 weeks of hospital discharge, with the most common indications for admission being suspected infection and suspected pump thrombosis. Device-related complications necessitating surgical intervention most frequently occur in destination therapy patients who are supported for longer periods of time.
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Hollander SA. Left ventricular assist device support as destination therapy in pediatric patients with end-stage heart failure. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Schweiger M, Miera O, de By TMMH, Hübler M, Berger F, Özbaran M, Loforte A, Seifert B, Gargiulo G, Gummert J, Mohacsi P. Cerebral strokes in children on intracorporeal ventricular assist devices: analysis of the EUROMACS Registry. Eur J Cardiothorac Surg 2017; 53:416-421. [DOI: 10.1093/ejcts/ezx342] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 08/07/2017] [Accepted: 08/09/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Martin Schweiger
- Pediatric Heart Center, Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Oliver Miera
- Department of Congenital Heart Disease/Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | | | - Michael Hübler
- Pediatric Heart Center, Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Felix Berger
- Department of Congenital Heart Disease/Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Mustafa Özbaran
- Ege Üniversitesi Tıp Fakültesi, Kalp Damar Cerrahisi Kliniği, Bornova-İzmir, Türkiye
| | - Antonio Loforte
- Dipartimento di Chirurgia Cardio-Toraco-Vascolare e Trapianti, Policlinico S. Orsola-Malpighi, Università di Bologna, Bologna, Italy
| | - Burkhardt Seifert
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Gaetano Gargiulo
- Dipartimento di Chirurgia Cardio-Toraco-Vascolare e Trapianti, Policlinico S. Orsola-Malpighi, Università di Bologna, Bologna, Italy
| | - Jan Gummert
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Paul Mohacsi
- Department of Cardiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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United States Trends in Pediatric Ventricular Assist Implantation as Bridge to Transplantation. ASAIO J 2017; 63:470-475. [DOI: 10.1097/mat.0000000000000524] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Advanced practice nursing in pediatric heart failure- therapeutics and models of care. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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