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Esangbedo ID, Yu P, Choudhury TA, Tume SC, Lasa JJ. Ventricular Assist Device Training and Emergency Management Among Pediatric Cardiac Intensive Care Physicians - Multicenter Cross-Sectional Survey. World J Pediatr Congenit Heart Surg 2024; 15:202-208. [PMID: 38128949 DOI: 10.1177/21501351231205804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Background/Aim: Pediatric cardiac intensive care physicians practicing at centers that implant ventricular assist devices (VAD's) are exposed to increasing numbers of VAD patients, with a significant number of VAD-days. We aimed to delineate pediatric cardiac critical care practices surrounding routine and emergency management of VADs. Methodology: We administered a multicenter cross-sectional survey of pediatric cardiac intensive care unit (CICU) physicians in the United States and Canada. Survey distribution occurred between August 31st and October 26th 2021. Results: A total of 254 CICU physicians received a formal invitation to participate, with 108 returning completed surveys (42.5% response rate). Responses came from CICU attending physicians at 26 separate institutions. Respondents' level of experience was well distributed across junior, mid-level, and senior staff: less than 5 years (38%), 5-9 years (25%), and >/= 10 years (37%). Most respondents had received formal training in the management of VAD patients (n = 93, 86.1%), with training format including fellowship (61%), simulation (36%), and national/international conferences (26.5%). Dedicated advanced cardiac therapies teams were available at the institutions of 97.2% of respondents. A total of 78/108 (72.2%) described themselves as "comfortable" or "very comfortable" in pediatric VAD management. While 63% (68/108) of respondents reported that they had never performed (or overseen the performance of) chest compressions in a pediatric patient with a VAD, 37% (40/108) reported performing CPR at least once in a VAD patient. Conclusion: With no existing international guidelines for emergency cardiovascular care in the pediatric VAD population, our survey identifies an important gap in resuscitation recommendations.
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Affiliation(s)
- Ivie D Esangbedo
- Division of Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Priscilla Yu
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarif A Choudhury
- Division of Critical Care Medicine, Division of Cardiology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Sebastian C Tume
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Javier J Lasa
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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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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3
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Wright LK, Rossano JW. Reducing Pediatric Heart Failure Readmissions: The Time Is Now. JACC. HEART FAILURE 2024; 12:97-99. [PMID: 37999663 DOI: 10.1016/j.jchf.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Lydia K Wright
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA.
| | - Joseph W Rossano
- The Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Berry AE, Bearl DW. Rethinking status 1A criteria in pediatric cardiac transplantation: A case for the prioritization of patients with single ventricle anatomy supported by ventricular assist devices. Front Pediatr 2023; 11:1057903. [PMID: 36911016 PMCID: PMC9998663 DOI: 10.3389/fped.2023.1057903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Over the past 2 years advancements in the techniques and technology of pediatric heart transplantation have exponentially increased. However, even as the number of pediatric donor hearts has grown, demand for this limited resource continues to far outpace supply. Thus, lifesaving support in the form of ventricular assist devices (VAD) has become increasingly utilized in bridging pediatric patients to cardiac transplant. In the current pediatric heart transplant listing criteria, adopted by the United Network for Organ Sharing (UNOS) in 2016, all pediatric patients with a VAD are granted 1A status and assigned top transplant priority regardless of their underlying pathology. However, should this be the case? We suggest that the presence of a VAD alone may not be sufficient for status 1A listing. In doing so, we specifically highlight the heightened acuity, resource utilization, risk profile, and diminished outcomes in patients with single ventricle physiology supported with VAD as compared to patients with structurally normal hearts who would both be listed under 1A status. Given this, from a distributive justice perspective, we further suggest that the lack of granularity in current pediatric cardiac transplant listing categories may inadvertently lead to an inequitable distribution of donor organs and hospital resources especially as it pertains to those with single ventricle anatomy on VAD support. We propose revisiting the current listing priorities in light of improved techniques, technology, and recent data to mitigate this phenomenon. By doing this, pediatric patients with single ventricle disease might be more equitably stratified while awaiting heart transplant.
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Affiliation(s)
- Anna E Berry
- Internal Medicine-Pediatrics Residency Program, Monroe Carell Jr. Children's Hospital and Vanderbilt University Hospital, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David W Bearl
- Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, United States
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Rottermann K, Dittrich S, Dewald O, Teske A, Kwapil N, Bleck S, Purbojo A, Münch F. Mobility and freedom of movement: A novel out-of-hospital treatment for pediatric patients with terminal cardiac insufficiency and a ventricular assist device. Front Cardiovasc Med 2022; 9:1055228. [PMID: 36465431 PMCID: PMC9708718 DOI: 10.3389/fcvm.2022.1055228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/31/2022] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Due to rapid medical and technological progress, more and more pediatric patients with terminal cardiac insufficiency are being implanted with a ventricular assist device as a bridge to transplant without legal approval for hospital discharge. EXCOR® Active is a recently developed mobile driving unit for the EXCOR® ventricular assist device (EXCOR® VAD) with a long-lasting battery life that can manage small blood pumps, offering improved mobility for pediatric patients. This study strives to elaborate the requirements necessary for a safe home healthcare environment (HHE) for pediatric patients on EXCOR® VAD powered by the EXCOR® Active driving unit. MATERIALS AND METHODS Patient- and device-related preconditions (medical, ethical, psychological, technical, structural, organizational) were analyzed with regard to feasibility and safety in three individual patient cases. Included were pediatric patients with terminal cardiac insufficiency in a stable medical condition receiving in-hospital treatment with a univentricular or biventricular EXCOR® VAD powered by EXCOR® Active. Analysis was single-center, data was obtained 05/2020-02/2022. RESULTS A total of three patients on EXCOR® VAD were identified for HHE treatment with the EXCOR® Active driving unit. Switch was performed safely and increased mobility led to improved psychomotor development and improved quality of life. No complications directly related to HHE-treatment occurred. One patient recently underwent an orthotopic heart transplant, one patient remains in HHE, and one patient died due to a complication not related to the HHE. Ethical approval for off-label use was obtained and patients and parents were given the required technical training and psychological support. Caregivers and medical professionals involved in the patients' care at home were briefed intensely. Remote consultations were implemented and interdisciplinary in-hospital checks reduced to a long-term 4-week-scheme. CONCLUSION While it is challenging to discharge pediatric patients being treated with a paracorporeal ventricular assist device (EXCOR® VAD) from hospital, it is feasible and can be managed safely with the novel driving unit EXCOR® Active. A HHE may help to improve patients' psychomotor development, offer normalized social contacts and strengthen both patients' and parents' physical and mental resources. Legal approval and another study with a larger sample size are warranted.
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Affiliation(s)
- Kathrin Rottermann
- Department of Pediatric Cardiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Oliver Dewald
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Andreas Teske
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Nicola Kwapil
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Steffen Bleck
- Department of Pediatric Cardiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ariawan Purbojo
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Frank Münch
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
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Esangbedo ID, Yu P. Chest Compressions in Pediatric Patients With Continuous-Flow Ventricular Assist Devices: Case Series and Proposed Algorithm. Front Pediatr 2022; 10:883320. [PMID: 35799702 PMCID: PMC9253534 DOI: 10.3389/fped.2022.883320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/16/2022] [Indexed: 12/02/2022] Open
Abstract
Patients with continuous flow ventricular assist devices (CF-VAD's) in the systemic ventricle (left ventricle or single ventricle) often have no palpable pulses, unreliable pulse oximetry waveforms and non-pulsatile arterial waveforms despite hemodynamic stability. When circulatory decompensation occurs, standard indicators to begin cardiopulmonary resuscitation (CPR) which are used in other pediatric patients (i.e., significant bradycardia or loss of pulse) cannot be applied in the same fashion. In this population, there may already be pulselessness and development of bradycardia in and of itself would not trigger chest compressions. There are no universal guidelines to dictate when to consider chest compressions in this population. As such, there may be a delay in decision-making or in recognizing the need for chest compressions, even in patients hospitalized in intensive care units (ICU) and cared for by experienced staff who perform CPR regularly. We present four examples of pediatric cardiac ICU patients from a single center who underwent CPR between 2018 and 2019. Based on this case series, we propose a decision-making algorithm for chest compressions in pediatric patients with CF-VADs in the systemic ventricle.
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Affiliation(s)
- Ivie D Esangbedo
- Division of Critical Care, Seattle Children's Hospital, University of Washington, Seattle, WA, United States
| | - Priscilla Yu
- Division of Critical Care, University of Texas (UT) Southwestern Medical Center, Children's Medical Center Dallas, Dallas, TX, United States
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O'Connor MJ, Lorts A, Kwiatkowski D, Butts R, Barnes A, Jeewa A, Knoll C, Fenton M, McQueen M, Cousino MK, Shugh S, Rosenthal DN. Learning networks in pediatric heart failure and transplantation. Pediatr Transplant 2021; 25:e14073. [PMID: 34138489 DOI: 10.1111/petr.14073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Learning networks have emerged in medicine as a novel organizational structure that contains elements of quality improvement, education, and research with the goal of effecting rapid improvements in clinical care. In this article, the concept of a learning network is defined and highlighted in the field of pediatric heart failure and transplantation. METHODS Learning networks are defined, with particular attention paid to the recent creation of the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) for children with heart failure and those being supported with ventricular assist devices (VAD). RESULTS The mission, goals, and organizational structure of ACTION are described, and recent initiatives promoted by ACTION are highlighted, such as stroke reduction initiatives, practice harmonization protocols, and use of ACTION data to support the recent US Food and Drug Administration approval of newer VAD for pediatric patients. CONCLUSIONS The learning network, exemplified by ACTION, is distinguished from traditional clinical research collaboratives by contributions in research, quality improvement, patient-reported outcomes, and education, and serves as an effective vehicle to drive clinical improvement in the care of children with advanced heart failure.
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Affiliation(s)
- Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Ryan Butts
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Medical Center of Dallas, Dallas, TX, USA
| | | | - Aamir Jeewa
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christopher Knoll
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Matthew Fenton
- Great Ormond Street Hospital for Children Foundation Trust, London, UK
| | | | | | - Svetlana Shugh
- Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
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8
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Pediatric Palliative Care in the Heart Failure, Ventricular Assist Device and Transplant Populations: Supporting Patients, Families and Their Clinical Teams. CHILDREN-BASEL 2021; 8:children8060468. [PMID: 34199474 PMCID: PMC8228348 DOI: 10.3390/children8060468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 12/03/2022]
Abstract
Heart failure is a life-changing diagnosis for a child and their family. Pediatric patients with heart failure experience significant morbidity and frequent hospitalizations, and many require advanced therapies such as mechanical circulatory support and/or heart transplantation. Pediatric palliative care is an integral resource for the care of patients with heart failure along its continuum. This includes support during the grief of a new diagnosis in a child critically ill with decompensated heart failure, discussion of goals of care and the complexities of mechanical circulatory support, the pensive wait for heart transplantation, and symptom management and psychosocial support throughout the journey. In this article, we discuss the scope of pediatric palliative care in the realm of pediatric heart failure, ventricular assist device (VAD) support, and heart transplantation. We review the limited, albeit growing, literature in this field, with an added focus on difficult conversation and decision support surrounding re-transplantation, HF in young adults with congenital heart disease, the possibility of destination therapy VAD, and the grimmest decision of VAD de-activation.
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9
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Patterson KN, Fabia R, Giles S, Verlee SN, Marx D, Aguayo P, Ziegfeld S, Parrish C, Stewart FD, Fritzeen J, Burd RS, Vitale L, Cloutier D, Shanti C, Klein J, Thakkar RK. Defining Benchmarks in Pediatric Burn Care: Inception of the Pediatric Injury Quality Improvement Collaborative (PIQIC). J Burn Care Res 2021; 43:277-280. [PMID: 33677547 DOI: 10.1093/jbcr/irab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Pediatric burn care is highly variable nationwide. Standardized quality and performance benchmarks are needed for guiding performance improvement within pediatric burn centers. A network of pediatric burn centers was established to develop and evaluate pediatric-specific best practices. A multi-disciplinary team including pediatric surgeons, nurses, advanced practice providers, pediatric intensivists, rehabilitation staff, and child psychologists from five pediatric burn centers established a collaborative to share and compare performance improvement data, evaluate outcomes, and exchange best care practices. In December 2016, the Pediatric Injury Quality Improvement Collaborative (PIQIC) was established. PIQIC members chose quality improvement indicators, drafted and approved a memorandum of understanding (MOU), data use agreement (DUA) and charter, formalized the multidisciplinary membership, and established a steering committee. Since inception, PIQIC has conducted monthly teleconferences and biannual in-person or virtual group meetings. A centralized data repository has been established where data is collated and analyzed for benchmarking in a blinded fashion. PIQIC has shown the feasibility of multi-institutional data collection, implementation of performance improvement metrics, publication of research, and enhancement of aggregate and institution-specific pediatric burn care.
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Affiliation(s)
- Kelli N Patterson
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Renata Fabia
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH.,Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Sheila Giles
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Sarah N Verlee
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Daniel Marx
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO
| | - Pablo Aguayo
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO
| | - Susan Ziegfeld
- Department of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD
| | - Carisa Parrish
- Department of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD
| | - F Dylan Stewart
- Department of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD
| | - Jennifer Fritzeen
- Division Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Randall S Burd
- Division Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Lisa Vitale
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, Detroit MI
| | - Dawn Cloutier
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, Detroit MI
| | - Christina Shanti
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, Detroit MI
| | - Justin Klein
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, Detroit MI
| | - Rajan K Thakkar
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH.,Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
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