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Kulp BE, Khan MN, Gazit AZ, Eghtesady P, Scheel JN, Said AS, Rabinowitz EJ. Single Ventricular Assist Device Care and Outcomes for Failed Stage I Palliation: A Single-Center Decade of Experience. ASAIO J 2024; 70:517-526. [PMID: 38346282 DOI: 10.1097/mat.0000000000002149] [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: 02/15/2024] Open
Abstract
Single ventricular assist device (SVAD) use before and after stage I palliation (S1P) is increasing with limited data on outcomes. To address this knowledge gap, we conducted a single-center retrospective review to assess pre- and post-SVAD clinical status, complications, and outcomes. We leveraged a granular, longitudinal, local database that captures end-organ support, procedural interventions, hematologic events, laboratory data, and antithrombotic strategy. We identified 25 patients between 2013 and 2023 implanted at median age of 53 days (interquartile range [IQR] = 16-130); 80% had systemic right ventricles and underwent S1P. Median SVAD days were 54 (IQR = 29-86), and 40% were implanted directly from ECMO. Compared to preimplant, there was a significant reduction in inotrope use ( p = 0.013) and improved weight gain ( p = 0.008) post-SVAD. Complications were frequent including bleeding (80%), stroke (40%), acute kidney injury (AKI) (40%), infection (36%), and unanticipated catheterization (56%). Patients with in-hospital mortality had significantly more bleeding complications ( p = 0.02) and were more likely to have had Blalock-Thomas-Taussig shunts pre-SVAD ( p = 0.028). Survival to 1 year postexplant was 40% and included three recovered and explanted patients. At 1 year posttransplant, all survivors have technology dependence or neurologic injury. This study highlights the clinical outcomes and ongoing support required for successful SVAD use in failed single-ventricle physiology before or after S1P.
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Affiliation(s)
- Blaire E Kulp
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
| | - Marium N Khan
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Critical Care Medicine, St Louis, MO
| | - Avihu Z Gazit
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Critical Care Medicine, St Louis, MO
- Division of Pediatric Cardiology, St Louis, MO
| | - Pirooz Eghtesady
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Cardiothoracic Surgery, St Louis, MO
| | - Janet N Scheel
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Cardiology, St Louis, MO
| | - Ahmed S Said
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Critical Care Medicine, St Louis, MO
| | - Edon J Rabinowitz
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Critical Care Medicine, St Louis, MO
- Division of Pediatric Cardiology, St Louis, MO
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2
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Joong A, Maeda K, Peng DM. Ventricular Assist Device Outcomes in Infants and Children With Stage 1 Single Ventricle Palliation. ASAIO J 2022; 68:e188-e195. [PMID: 36326704 DOI: 10.1097/mat.0000000000001817] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Data on ventricular assist device (VAD) outcomes in infants with stage 1 single ventricle (SV) palliation are limited. We examined the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry for outcomes of pre/poststage 1 SV patients undergoing VAD implantation between March 2018 and October 2020. Data are collected from 32 centers and major adverse events undergo central adjudication. During the study period, 30 stage 1 SV patients underwent VAD implant with median age of 0.9 months (range 0.1-25) and weight 3.7 kg (2.4-17). Preimplant illness severity was high: ventilator support (90%), ECMO (30%), prior cerebral vascular accident (CVA, 23%), and dialysis (13%). Devices used included paracorporeal pulsatile (50%), paracorporeal continuous-flow (37%), and multiple devices (13%). Median support duration was 56 days (range 3-246). A positive clinical outcome (transplanted or weaned) was attained in 63% (63% transplanted, 37% mortality, 0% weaned). VAD adverse events included: major infection (43%), neurologic dysfunction (any = 30%; CVA = 20%), major bleeding (17%), renal dysfunction (13%), and device malfunction (3%). In conclusion, stage 1 SV patients undergoing VAD support have high preimplant illness severity and complexity, as well as significant morbidity and mortality postimplant. A variety of devices and strategies are employed by centers to support this challenging population.
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Affiliation(s)
- Anna Joong
- From the, Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David M Peng
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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McMahon CJ, Sendžikaitė S, Jegatheeswaran A, Cheung YF, Madjalany DS, Hjortdal V, Redington AN, Jacobs JP, Asoodar M, Sibbald M, Geva T, van Merrienboer JJG, Tretter JT. Managing uncertainty in decision-making of common congenital cardiac defects. Cardiol Young 2022; 32:1705-1717. [PMID: 36300500 DOI: 10.1017/s1047951122003316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Decision-making in congenital cardiac care, although sometimes appearing simple, may prove challenging due to lack of data, uncertainty about outcomes, underlying heuristics, and potential biases in how we reach decisions. We report on the decision-making complexities and uncertainty in management of five commonly encountered congenital cardiac problems: indications for and timing of treatment of subaortic stenosis, closure or observation of small ventricular septal defects, management of new-onset aortic regurgitation in ventricular septal defect, management of anomalous aortic origin of a coronary artery in an asymptomatic patient, and indications for operating on a single anomalously draining pulmonary vein. The strategy underpinning each lesion and the indications for and against intervention are outlined. Areas of uncertainty are clearly delineated. Even in the presence of "simple" congenital cardiac lesions, uncertainty exists in decision-making. Awareness and acceptance of uncertainty is first required to facilitate efforts at mitigation. Strategies to circumvent uncertainty in these scenarios include greater availability of evidence-based medicine, larger datasets, standardised clinical assessment and management protocols, and potentially the incorporation of artificial intelligence into the decision-making process.
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Affiliation(s)
- Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, Dublin4, Ireland
- School of Health Professions Education (SHE), Maastricht University, Maastricht, Netherlands
| | - Skaistė Sendžikaitė
- Clinic of Children´s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Anusha Jegatheeswaran
- Divisions of Cardiovascular Surgery and Cardiology, Department of Surgery, Hospital for Sick Children, The Labatt Family Heart Center, University of Toronto, ON, Canada
| | - Yiu-Fai Cheung
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, People's Republic of China
| | | | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andrew N Redington
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA
| | - Maryam Asoodar
- School of Health Professions Education (SHE), Maastricht University, Maastricht, Netherlands
| | - Matthew Sibbald
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jeroen J G van Merrienboer
- School of Health Professions Education (SHE), Maastricht University, Maastricht, Netherlands
- Institute of Education, National Research University Higher School of Economics, Moscow, Russia
| | - Justin T Tretter
- Department of Pediatric Cardiology, Pediatric Institute, Cleveland Clinic Children's, 9500 Euclid Avenue, M-41, Cleveland, OH 44195, USA
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Friedland-Little JM, Joong A, Shugh SB, O'Connor MJ, Bansal N, Davies RR, Ploutz MS. Patient and Device Selection in Pediatric MCS: A Review of Current Consensus and Unsettled Questions. Pediatr Cardiol 2022; 43:1193-1204. [PMID: 35325280 DOI: 10.1007/s00246-022-02880-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/15/2022] [Indexed: 01/24/2023]
Abstract
The field of pediatric ventricular assist device (VAD) support has expanded significantly over the past 20 years, with one third of pediatric heart transplant recipients currently being bridged to transplant with a VAD. Despite increased pediatric VAD utilization, however, there remains little formalized guidance for patient or device selection. The population of children with advanced heart failure is quite heterogeneous, and the available data suggest that VAD outcomes vary significantly based upon patient size, anatomy, level of illness, and type of device implanted. In an effort to better understand current practice patterns and identify populations for whom there does not appear to be a consensus approach to achieving optimal VAD outcomes, the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) has surveyed clinical decision-making among member sites and conducted a review of the available literature regarding patient population-specific VAD outcomes and center-specific practices related to patient and device selection. Rather than aiming to provide clinical guidelines, this document offers an overview of contemporary approaches to patient and device selection, highlighting specific populations for whom there is not a consensus approach to achieving reliably good VAD outcomes, as these populations may benefit most from future research and quality improvement efforts directed toward identifying best practice.
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Affiliation(s)
| | - Anna Joong
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Svetlana B Shugh
- Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Matthew J O'Connor
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Neha Bansal
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ryan R Davies
- UT Southwestern Medical Center and Children's Health, Dallas, TX, USA
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Puri K, Denfield SW, Adachi I, Dreyer WJ, Price JF, Spinner JA, Choudhry S, Brackett J, Santucci G, Rainusso NC, Tunuguntla HP. Ventricular assist device support for children with chemotherapy-induced cardiomyopathy and advanced heart failure: Perspectives gained from a single-center experience. Pediatr Transplant 2022; 26:e14286. [PMID: 35474630 DOI: 10.1111/petr.14286] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Guidance and data on ventricular assist device (VAD) support for children with chemotherapy-induced cardiomyopathy, particularly within the first 2 years after chemotherapy, are limited. METHODS We performed a single-center retrospective case series, reviewing medical records of children <18 years of age with chemotherapy-induced cardiomyopathy and advanced heart failure (HF) who received durable VAD support. RESULTS Six patients met inclusion criteria-5 HeartWare™ HVAD, 1 Berlin Heart EXCOR® . Median age at cancer diagnosis was 6 years (IQR 4.5-10 years). Median dose of anthracycline received was 540 mg/m2 (IQR 450-630 mg/m2 ). All patients developed HF within 1 year after initiation of cancer treatment (median 8 months, IQR 6-11.5 months) and were initiated on durable VAD support at a median of 8 months after completion of cancer treatment (IQR 3.3-43.5 months). Four patients had significant right ventricular dysfunction needing oral pulmonary vasodilator therapy, one patient had a major bleeding complication, and two patients had thromboembolic strokes while on VAD support. Median duration of VAD support was 7.5 months (IQR 3-11.3 months). Two patients underwent VAD explant due to recovery of LV function, one died due to cancer progression, and three underwent heart transplantation. CONCLUSIONS Durable VAD support should be considered as a therapeutic option for children who have advanced HF due to chemotherapy-induced cardiomyopathy, even within 2 years of completing cancer treatment. A multi-disciplinary approach is essential for appropriate patient selection prior to implant and to ensure comprehensive care throughout the duration of VAD support.
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Affiliation(s)
- Kriti Puri
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Susan W Denfield
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Iki Adachi
- Michael E. DeBakey Department of Surgery and Pediatrics, Baylor College of Medicine, Mechanical Circulatory Support, Texas Children's Hospital, Houston, Texas, USA
| | - William J Dreyer
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jack F Price
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph A Spinner
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Swati Choudhry
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Julienne Brackett
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Gina Santucci
- Department of Pediatrics, Division of Palliative Care, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Nino C Rainusso
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Hari P Tunuguntla
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Townsend M, Jeewa A, Adachi I, Al Aklabi M, Honjo O, Armstrong K, Buchholz H, Conway J. Ventricular Assist Device Use in Single Ventricle Circulation. Can J Cardiol 2022; 38:1086-1099. [DOI: 10.1016/j.cjca.2022.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 01/09/2023] Open
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Amdani S, Boyle GJ, Cantor RS, Conway J, Godown J, Kirklin JK, Koehl D, Lal AK, Law Y, Lorts A, Rosenthal DN. Significance of pre and post-implant MELD-XI score on survival in children undergoing VAD implantation. J Heart Lung Transplant 2021; 40:1614-1624. [PMID: 34598872 DOI: 10.1016/j.healun.2021.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Derangements in liver and renal function often accompany end-stage heart failure. We sought to assess the utility of an objective risk assessment tool, the Model for End-stage Liver Disease eXcluding INR (MELD-XI), to identify pediatric patients at increased risk for adverse outcomes post-ventricular assist device (VAD) implantation. METHODS The Pedimacs database was queried for all pediatric patients who underwent VAD implantation from September 19, 2012 to December 31, 2019. Pre-implant and early (1-week) post-implant MELD-XI scores were used to stratify patients into low, intermediate and high score cohorts. Comparison of pre-implant characteristics and post-implant outcomes were conducted across groups. Multiphase parametric hazard modeling was utilized to identify independent predictors of post-implant mortality. RESULTS A total of 742 patients had a calculable MELD-XI score pre-implant. When stratified by MELD-XI scores pre-implant, patients in the high MELD-XI score cohort (score >13.6) had inferior survival and increased bleeding, renal dysfunction and respiratory failure post-implant compared to intermediate and low score cohorts. Risk factors for mortality post-VAD implantation were: increasing MELD-XI scores (HR 1.1 per 1 unit rise), Pedimacs profile 1 (HR 1.6), congenital heart disease (HR 2.3) and being on a percutaneous VAD (HR 2.7). Importantly, MELD-XI score was a better predictor of post-VAD implant mortality than bilirubin or creatinine alone, neither of which were significant in the final model. Patients with increasing or continued high MELD-XI scores early post-implant had the worst survival. CONCLUSION The MELD-XI is an easily calculated score that serves as a promising risk assessment tool in identifying children at risk for poor outcomes post VAD implantation.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
| | - Gerard J Boyle
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer Conway
- Department of Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Justin Godown
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashwin K Lal
- Division of Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Yuk Law
- Department of Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Angela Lorts
- Department of Cardiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - David N Rosenthal
- Department of Cardiology, Stanford University, Palo Alto, California
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Tunuguntla HP, Puri K, Denfield SW. Management of Advanced Heart Failure in Children with Cancer Therapy-Related Cardiac Dysfunction. CHILDREN (BASEL, SWITZERLAND) 2021; 8:872. [PMID: 34682138 PMCID: PMC8534565 DOI: 10.3390/children8100872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/20/2021] [Accepted: 09/25/2021] [Indexed: 11/16/2022]
Abstract
The evolution of cancer therapies has led to marked improvement in survival of those affected by childhood malignancies, while also increasing the recognition of early and late toxicities associated with cancer therapies. Cardiotoxicity can include cardiomyopathy/heart failure, coronary artery disease, stroke, pericardial disease, arrhythmias, and valvular and vascular dysfunction as a result of exposure to chemotherapy and/or radiation. Anthracyclines remain the most common cause of chemotherapy-induced cardiomyopathy (CCM) with varying clinical presentations including: acute, early onset, and late-onset. Many individuals develop cardiac dysfunction over the long-term, ranging from subclinical cardiac dysfunction to end-stage symptomatic heart failure. The focus of this review is on characterization of symptomatic heart failure in children with cancer therapy-related cardiac dysfunction (CTRCD) primarily due to CCM and utilization of advanced heart failure therapies, including ventricular assist device (VAD) support and heart transplantation, with consideration of unique patient-related factors.
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Affiliation(s)
- Hari P. Tunuguntla
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA; (H.P.T.); (K.P.)
| | - Kriti Puri
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA; (H.P.T.); (K.P.)
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Susan W. Denfield
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA; (H.P.T.); (K.P.)
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