1
|
Iskander C, Nwankwo U, Kumanan KK, Chiwane S, Exil V, Lowrie L, Tan C, Huddleston C, Agarwal HS. Comparison of Morbidity and Mortality Outcomes between Hybrid Palliation and Norwood Palliation Procedures for Hypoplastic Left Heart Syndrome: Meta-Analysis and Systematic Review. J Clin Med 2024; 13:4244. [PMID: 39064284 PMCID: PMC11277754 DOI: 10.3390/jcm13144244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/20/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Hybrid palliation (HP) procedures for hypoplastic left heart syndrome (HLHS) are increasing. Our objective was to compare mortality and morbidity following HP and NP (Norwood palliation) procedures. Methods: Systematic review and meta-analysis of HLHS patients of peer-reviewed literature between 2000 and 2023. Mortality and/or heart transplantation in HP versus NP in the neonatal period, interstage period, and at 1, 3 and 5 years of age, and morbidity including completion of Stage II and Stage III palliation, unexpected interventions, pulmonary artery pressures, right ventricle function, neurodevelopmental outcomes and length of hospital stay were evaluated. Results: Twenty-one (meta-analysis: 16; qualitative synthesis: 5) studies evaluating 1182 HLHS patients included. HP patients had higher interstage mortality (RR = 1.61; 95% CI: 1.10-2.33; p = 0.01) and 1-year mortality (RR = 1.22; 95% CI: 1.03-1.43; p = 0.02) compared to NP patients without differences in 3- and 5-years mortality. HP procedure in high-risk HLHS patients had lower mortality (RR = 0.48; 95% CI: 0.27-0.87; p = 0.01) only in the neonatal period. HP patients underwent fewer Stage II (RR = 0.90; 95% CI: 0.81-1.00; p = 0.05) and Stage III palliation (RR = 0.78; 95% CI: 0.69-0.90; p < 0.01), had more unplanned interventions (RR = 3.38; 95% CI: 2.04-5.59; p < 0.01), and longer hospital stay after Stage I palliation (weighted mean difference = 12.88; 95% CI: 1.15-24.62; p = 0.03) compared to NP patients. Conclusions: Our study reveals that HP, compared to NP for HLHS, is associated with increased morbidity risk without an improved survival rate.
Collapse
Affiliation(s)
- Christopher Iskander
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Ugonna Nwankwo
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Krithika K. Kumanan
- Advanced Data Health Institution, Saint Louis University, Saint Louis, MO 63104, USA;
| | - Saurabh Chiwane
- Division of Pediatric Critical Care Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
| | - Vernat Exil
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Lia Lowrie
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
| | - Corinne Tan
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Charles Huddleston
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Hemant S. Agarwal
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
| |
Collapse
|
2
|
Butler SC, Rofeberg V, Smith-Parrish M, LaRonde M, Vittner DJ, Goldberg S, Bailey V, Weeks MM, McCowan S, Severtson K, Glowick K, Rachwal CM. Caring for hearts and minds: a quality improvement approach to individualized developmental care in the cardiac intensive care unit. Front Pediatr 2024; 12:1384615. [PMID: 38655280 PMCID: PMC11037267 DOI: 10.3389/fped.2024.1384615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction Infants with congenital heart disease (CHD) are at high risk for developmental differences which can be explained by the cumulative effect of medical complications along with sequelae related to the hospital and environmental challenges. The intervention of individualized developmental care (IDC) minimizes the mismatch between the fragile newborn brain's expectations and the experiences of stress and pain inherent in the intensive care unit (ICU) environment. Methods A multidisciplinary group of experts was assembled to implement quality improvement (QI) to increase the amount of IDC provided, using the Newborn Individualized Developmental Care and Assessment Program (NIDCAP), to newborn infants in the cardiac ICU. A Key Driver Diagram was created, PDSA cycles were implemented, baseline and ongoing measurements of IDC were collected, and interventions were provided. Results We collected 357 NIDCAP audits of bedside IDC. Improvement over time was noted in the amount of IDC including use of appropriate lighting, sound management, and developmentally supportive infant bedding and clothing, as well as in promoting self-regulation, therapeutic positioning, and caregiving facilitation. The area of family participation and holding of infants in the CICU was the hardest to support change over time, especially with the most ill infants. Infants with increased medical complexity were less likely to receive IDC. Discussion This multidisciplinary, evidence-based QI intervention demonstrated that the implementation of IDC in the NIDCAP model improved over time using bedside auditing of IDC.
Collapse
Affiliation(s)
- Samantha C. Butler
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, MA, United States
- Department of Psychiatry (Psychology), Harvard Medical School, Boston, MA, United States
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Melissa Smith-Parrish
- Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, United States
| | - Meena LaRonde
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Dorothy J. Vittner
- Egan School of Nursing and Health Studies, Fairfield University, Fairfield, CT, United States
- Connecticut Children's Medical Center, NICU, Hartford, CT, United States
| | - Sarah Goldberg
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Valerie Bailey
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Malika M. Weeks
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Sarah McCowan
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Katrina Severtson
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Kerri Glowick
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | | |
Collapse
|
3
|
O'Byrne ML, Song L, Huang J, Lemley B, Goldberg D, Gardner MM, Ravishankar C, Rome JJ, Glatz AC. Attributable mortality benefit of digoxin treatment in hypoplastic left heart syndrome after the Norwood operation: An instrumental variable-based analysis using data from the Pediatric Health Information Systems Database. Am Heart J 2023; 263:35-45. [PMID: 37169122 DOI: 10.1016/j.ahj.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Observational studies have demonstrated an association between the use of digoxin and reduced interstage mortality after Norwood operation for hypoplastic left heart syndrome (HLHS). Digoxin use has increased significantly but remains variable between different hospitals, independent of case-mix. Instrumental variable analyses have the potential to overcome unmeasured confounding, the major limitation of previous observational studies and to generate an estimate of the attributable benefit of treatment with digoxin. METHODS A cohort of neonates with HLHS born from January 1, 2007 to December 31, 2021 who underwent Norwood operation at Pediatric Health Information Systems Database hospitals and survived >14 days after operation were studied. Using hospital-specific, 6-month likelihood of administering digoxin as an instrumental variable, analyses adjusting for both unmeasured confounding (using the instrumental variable) and measured confounders with multivariable logistic regression were performed. RESULTS The study population included 5,148 subjects treated at 47 hospitals of which 63% were male and 46% non-Hispanic white. Of these, 44% (n = 2,184) were prescribed digoxin. Treatment with digoxin was associated with superior 1-year transplant-free survival in unadjusted analyses (85% vs 82%, P = .02). This survival benefit persisted in an instrumental-variable analysis (OR: 0.71, 95% CI: 0.54-0.94, P = .01), which can be converted to an absolute risk reduction of 5% (number needed to treat of 20). CONCLUSIONS In this observational study of patients with HLHS after Norwood using instrumental variable techniques, a significant benefit in 1-year transplant-free survival attributable to digoxin was demonstrated. In the absence of clinical trial data, this should encourage the use of digoxin in this vulnerable population.
Collapse
Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center For Pediatric Clinical Effectiveness, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA.
| | - Lihai Song
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bethan Lemley
- Division of Cardiology, Department of Pediatrics, Lurie Children's Hospital, Feinberg School of Medicine Northwestern University, Chicago, IL
| | - David Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Monique M Gardner
- Division of Cardiac Critical Care, The Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chitra Ravishankar
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology St. Louis Children's Hospital and Department of Pediatrics Washington University Medical School, St. Louis, MO
| |
Collapse
|
4
|
Zaleski KL, Valencia E, Matte GS, Kaza AK, Nasr VG. How We Would Treat Our Own Hypoplastic Left Heart Syndrome Neonate for Stage 1 Surgery. J Cardiothorac Vasc Anesth 2023; 37:504-512. [PMID: 36717315 DOI: 10.1053/j.jvca.2023.01.003] [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: 10/17/2022] [Revised: 12/26/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
Affiliation(s)
- Katherine L Zaleski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
5
|
Callahan KP, Taha D, Dewitt A, Munson DA, Behringer K, Feudtner C. Clinician Distress with Treatments at the Frontier of Mortality. J Pediatr 2023; 252:183-187. [PMID: 36115624 PMCID: PMC10251120 DOI: 10.1016/j.jpeds.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Katharine Press Callahan
- The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Dalal Taha
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Aaron Dewitt
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - David A Munson
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Chris Feudtner
- The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
6
|
Outcomes for unplanned reinterventions following paediatric cardiac surgery for tetralogy of Fallot. Cardiol Young 2022; 32:1592-1597. [PMID: 34839836 DOI: 10.1017/s1047951121004571] [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] [Indexed: 11/07/2022]
Abstract
BACKGROUND Advances in surgical techniques and post-operative management of children with CHD have significantly lowered mortality rates. Unplanned cardiac interventions are a significant complication with implications on morbidity and mortality. METHODS We conducted a single-centre retrospective case-control study for patients (<18 years) undergoing cardiac surgery for repair of Tetralogy of Fallot between January 2009 and December 2019. Data included patient characteristics, operative variables and outcomes. This study aimed to assess the incidence and risk factors for reintervention of Tetralogy of Fallot after cardiac surgery. The secondary outcome was to examine the incidence of long-term morbidity and mortality in those who underwent unplanned reinterventions. RESULTS During the study period 29 patients (6.8%) underwent unplanned reintervention, and were matched to 58 patients by age, weight and sex. Median age was 146 days, and median weight was 5.8 kg. Operative mortality was 7%, and 1-year survival was 86% for the entire cohort (cases and controls). Hispanic patients were more likely to have reinterventions (p = 0.04) in the unadjusted analysis, while Asian, Pacific Islander and Native American (p = 0.01) in the multi-variate analysis. Patients that underwent reintervention were more likely to have post-op arrhythmia, genetic syndromes and higher operative and 1-year mortality (p < 0.05). CONCLUSION Unplanned cardiac interventions following Tetralogy of Fallot repair are common, and associated with increased operative, and 1-year mortality. Race, genetic syndromes and post-operative arrhythmia are associated with increased odds of unplanned reinterventions. Future studies are needed to identify modifiable risk factors to minimise unplanned reinterventions.
Collapse
|
7
|
O'Byrne ML, McHugh KE, Huang J, Song L, Griffis H, Anderson BR, Bucholz EM, Chanani NK, Elhoff JJ, Handler SS, Jacobs JP, Li JS, Lewis AB, McCrindle BW, Pinto NM, Sassalos P, Spar DS, Pasquali SK, Glatz AC. Cumulative In-Hospital Costs Associated With Single-Ventricle Palliation. JACC. ADVANCES 2022; 1:100029. [PMID: 38939312 PMCID: PMC11198056 DOI: 10.1016/j.jacadv.2022.100029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 06/29/2024]
Abstract
Background In the SVR (Single Ventricle Reconstruction) Trial, 1-year survival in recipients of right ventricle to pulmonary artery shunts (RVPAS) was superior to that in those receiving modified Blalock-Taussig-Thomas shunts (MBTTS), but not in subsequent follow-up. Cost analysis is an expedient means of evaluating value and morbidity. Objectives The purpose of this study was to evaluate differences in cumulative hospital costs between RVPAS and MBTTS. Methods Clinical data from SVR and costs from Pediatric Health Information Systems database were combined. Cumulative hospital costs and cost-per-day-alive were compared serially at 1, 3, and 5 years between RVPAS and MBTTS. Potential associations between patient-level factors and cost were explored with multivariable models. Results In total, 303 participants (55% of the SVR cohort) from 9 of 15 sites were studied (48% MBTTS). Observed total costs at 1 year were lower for MBTTS ($701,260 ± 442,081) than those for RVPAS ($804,062 ± 615,068), a difference that was not statistically significant (P = 0.10). Total costs were also not significantly different at 3 and 5 years (P = 0.21 and 0.32). Similarly, cost-per-day-alive did not differ significantly for either group at 1, 3, and 5 years (all P > 0.05). In analyses of transplant-free survivors, total costs and cost-per-day-alive were higher for RVPAS at 1 year (P = 0.05 for both) but not at 3 and 5 years (P > 0.05 for all). In multivariable models, aortic atresia and prematurity were associated with increased cost-per-day-alive across follow-up (P < 0.05). Conclusions Total costs do not differ significantly between MBTTS and RVPAS. The magnitude of longitudinal costs underscores the importance of efforts to improve outcomes in this vulnerable population.
Collapse
Affiliation(s)
- Michael L. O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly E. McHugh
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brett R. Anderson
- Division of Cardiology, New York-Presbyterian Morgan-Stanley Children’s Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Emily M. Bucholz
- Department of Cardiology, Children’s Hospital Boston and Harvard University Medical School, Boston, Massachusetts, USA
| | - Nikhil K. Chanani
- Children’s Healthcare of Atlanta, Sibley Heart Center and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Justin J. Elhoff
- Sections of Critical Care and Cardiology, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA
| | | | - Jeffery P. Jacobs
- Division of Cardiothoracic Surgery, Departments of Surgery and Pediatrics, Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Jennifer S. Li
- Division of Pediatric Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alan B. Lewis
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Brian W. McCrindle
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nelangi M. Pinto
- Division of Cardiology, Primary Children’s Hospital and University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Peter Sassalos
- Division of Pediatric Cardiothoracic Surgery, C.S. Mott Children’s Hospital and University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - David S. Spar
- The Heart Institute, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Sara K. Pasquali
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew C. Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
8
|
Abstract
INTRODUCTION AND BACKGROUND Mortality between stages 1 and 2 single-ventricle palliation is significant. Home-monitoring programmes are suggested to reduce mortality. Outcomes and risk factors for adverse outcomes for European programmes have not been published. AIMS To evaluate the performance of a home-monitoring programme at a medium-sized United Kingdom centre with regards survival and compare performance with other home-monitoring programmes in the literature. METHODS All fetal and postnatal diagnosis of a single ventricle were investigated with in-depth analysis of those undergoing stage 1 palliation and entered the home-monitoring programme between 2016 and 2020. The primary outcome was survival. Secondary outcomes included multiple parameters as potential predictors of death or adverse outcome. RESULTS Of 217 fetal single-ventricle diagnoses during the period 2016-2020, 50.2% progressed to live birth, 35.4% to stage 1 and 29.5% to stage 2. Seventy-four patients (including 10 with postnatal diagnosis) entered the home-monitoring programme with six deaths making home-monitoring programme mortality 8.1%. Risk factors for death were the hybrid procedure as the only primary procedure (OR 33.0, p < 0.01), impaired cardiac function (OR 10.3, p < 0.025), Asian ethnicity (OR 9.3, p < 0.025), lower mean birth-weight (2.69 kg versus 3.31 kg, p < 0.01), and lower mean weight centiles during interstage follow-up (mean centiles of 3.1 versus 10.8, p < 0.01). CONCLUSION Survival in the home-monitoring programme is comparable with other home-monitoring programmes in the literature. Hybrid procedure, cardiac dysfunction, sub-optimal weight gain, and Asian ethnicity were significant risk factors for death. Home-monitoring programmes should continue to raise awareness of these factors and seek solutions to mitigate adverse events. Future work to generalise home-monitoring programme and single-ventricle fetus to stage 2 outcomes in the United Kingdom will require multi-centre collaboration.
Collapse
|
9
|
Medical Therapies for Heart Failure in Hypoplastic Left Heart Syndrome. J Cardiovasc Dev Dis 2022; 9:jcdd9050152. [PMID: 35621863 PMCID: PMC9143150 DOI: 10.3390/jcdd9050152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 02/05/2023] Open
Abstract
Significant surgical and medical advances over the past several decades have resulted in a growing number of infants and children surviving with hypoplastic left heart syndrome (HLHS) and other congenital heart defects associated with a single systemic right ventricle (RV). However, cardiac dysfunction and ultimately heart failure (HF) remain the most common cause of death and indication for transplantation in this population. Moreover, while early recognition and treatment of single ventricle-related complications are essential to improving outcomes, there are no proven therapeutic strategies for single systemic RV HF in the pediatric population. Importantly, prototypical adult HF therapies have been relatively ineffective in mitigating the need for cardiac transplantation in HLHS, likely due to several unique attributes of the failing HLHS myocardium. Here, we discuss the most commonly used medical therapies for the treatment of HF symptoms in HLHS and other single systemic RV patients. Additionally, we provide an overview of potential novel therapies for systemic ventricular failure in the HLHS and related populations based on fundamental science, pre-clinical, clinical, and observational studies in the current literature.
Collapse
|
10
|
Flow-Mediated Factors in the Pathogenesis of Hypoplastic Left Heart Syndrome. J Cardiovasc Dev Dis 2022; 9:jcdd9050154. [PMID: 35621865 PMCID: PMC9144087 DOI: 10.3390/jcdd9050154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/01/2022] [Accepted: 05/06/2022] [Indexed: 12/03/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is a life-threatening congenital heart disease that is characterized by severe underdevelopment of left heart structures. Currently, there is no cure, and affected individuals require surgical palliation or cardiac transplantation to survive. Despite these resource-intensive measures, only about half of individuals reach adulthood, often with significant comorbidities such as liver disease and neurodevelopmental disorders. A major barrier in developing effective treatments is that the etiology of HLHS is largely unknown. Here, we discuss how intracardiac blood flow disturbances are an important causal factor in the pathogenesis of impaired left heart growth. Specifically, we highlight results from a recently developed mouse model in which surgically reducing blood flow through the mitral valve after cardiogenesis led to the development of HLHS. In addition, we discuss the role of interventional procedures that are based on improving blood flow through the left heart, such as fetal aortic valvuloplasty. Lastly, using the surgically-induced mouse model, we suggest investigations that can be undertaken to identify the currently unknown biological pathways in left heart growth failure and their associated therapeutic targets.
Collapse
|
11
|
Han B, Yang JK, Ling AY, Ma M, Kipps AK, Shin AY, Beshish AG. Early Functional Status After Surgery for Congenital Heart Disease: A Single-Center Retrospective Study. Pediatr Crit Care Med 2022; 23:109-117. [PMID: 34593740 DOI: 10.1097/pcc.0000000000002838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study is to investigate the change in functional status in infants, children, and adolescents undergoing congenital heart surgery using the Functional Status Scale. DESIGN A single-center retrospective study. SETTING A 26-bed cardiac ICU in a free-standing university-affiliated tertiary children's hospital. PATIENTS All patients 0-18 years who underwent congenital heart surgery from January 1, 2014, to December 31, 2017. INTERVENTIONS None. MEASUREMENTS AND MIN RESULTS The primary outcome variable was change in Functional Status Scale scores from admission to discharge. Additionally, two binary outcomes were derived from the primary outcome: new morbidity (change in Functional Status Scale ≥ 3) and unfavorable functional outcome (change in Functional Status Scale ≥ 5); their association with risk factors was assessed using modified Poisson regression. Out of 1,398 eligible surgical encounters, 65 (4.6%) and 15 (1.0%) had evidence of new morbidity and unfavorable functional outcomes, respectively. Higher Surgeons Society of Thoracic and the European Association for Cardio-Thoracic Surgery score, single-ventricle physiology, and longer cardiopulmonary bypass time were associated with new morbidity. Longer hospital length of stay was associated with both new morbidity and unfavorable outcome. CONCLUSIONS This study demonstrates the novel application of the Functional Status Scale on patients undergoing congenital heart surgery. New morbidity was noted in 4.6%, whereas unfavorable outcome in 1%. There was a small change in the total Functional Status Scale score that was largely attributed to changes in the feeding domain. Higher Society of Thoracic and the European Association for Cardio-Thoracic Surgery score, single-ventricle physiology, and longer cardiopulmonary bypass times were associated with new morbidity, whereas longer hospital length of stay was associated with both new morbidity and unfavorable outcome. Further studies with larger sample size will need to be done to confirm our findings and to better ascertain the utility of Functional Status Scale on this patient population.
Collapse
Affiliation(s)
- Brian Han
- Department of Pediatrics, Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Jeffrey K Yang
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Albee Y Ling
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, CA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Alaina K Kipps
- Department of Pediatrics, Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Andrew Y Shin
- Department of Pediatrics, Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Asaad G Beshish
- Department of Pediatrics, Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
12
|
OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6527954. [DOI: 10.1093/ejcts/ezac033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/21/2021] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
|
13
|
Czosek RJ, Anderson JB, Baskar S, Khoury PR, Jayaram N, Spar DS. Predictors and outcomes of heart block during surgical stage I palliation of patients with a single ventricle: A report from the NPC-QIC. Heart Rhythm 2021; 18:1876-1883. [PMID: 34029735 PMCID: PMC8607956 DOI: 10.1016/j.hrthm.2021.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/12/2021] [Accepted: 05/16/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mortality in cohorts with a single ventricle remains high with multiple associated factors. The effect of heart block during stage I palliation remains unclear. OBJECTIVE The purpose of this study was to study patient and surgical risks of heart block and its effect on 12-month transplant-free survival in patients with a single ventricle. METHODS Patient, surgical, outcome data and heart block status (transient and permanent) were obtained from the National Pediatric Cardiology Quality Improvement Collaborative single ventricle database. Bivariate analysis was performed comparing patients with and without heart block, and multivariate modeling was used to identify variables associated with block. One-year outcomes were analyzed to identify variables associated with lower 12-month transplant-free survival. RESULTS In total, 1423 patients were identified, of whom 28 (2%) developed heart block (second degree or complete) during their surgical admission. Associated risk factors for block included heterotaxy syndrome (odds ratio [OR] 6.4) and atrial flutter/fibrillation (OR 3.8). Patients with heart block had lower 12-month survival, though only in patients with complete heart block as opposed to second degree block. At 12 months of age, 43% (12/28) of patients with heart block died and were more likely to experience mortality at 12 months than patients without block (OR 4.9; 95% confidence interval 1.4-17.5; P = .01). CONCLUSION Although rare, complete heart block after stage I palliation represents an additional risk of poor outcomes in this high-risk patient population. Heterotaxy syndrome was the most significant risk factor for the development of heart block after stage I palliation. The role of transient block in outcomes and potential rescue with long-term pacing remains unknown and requires additional study.
Collapse
Affiliation(s)
- Richard J Czosek
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Jeffrey B Anderson
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shankar Baskar
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Philip R Khoury
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Natalie Jayaram
- Division of Cardiology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - David S Spar
- Division of Cardiology, Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
14
|
Ono M, Kido T, Wallner M, Burri M, Lemmer J, Ewert P, Strbad M, Cleuziou J, Hager A, Hörer J. Preoperative risk factors influencing inter-stage mortality after the Norwood procedure. Interact Cardiovasc Thorac Surg 2021; 33:218-226. [PMID: 33948647 PMCID: PMC8691571 DOI: 10.1093/icvts/ivab073] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/29/2021] [Accepted: 02/18/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES With improvements in early survival after the stage I palliation (S1P) Norwood procedure for hypoplastic left heart syndrome (HLHS) and its variants, inter-stage death accounts for an increasing proportion of mortality. Our aim was to identify the risk factors for inter-stage mortality. METHODS The records of 322 neonates with HLHS or a variant who underwent the Norwood procedure at our centre between 2001 and 2019 were retrospectively analysed. RESULTS The diagnoses included 271 neonates with HLHS (84%) and 51 with variants (16%). Aortic atresia was observed in 138 (43%) patients, mitral atresia in 91 (28%), extracardiac anomalies in 42 (13%) and genetic disorder in 14 (4%). The median age and weight of the patients at the S1P Norwood procedure were 9 (interquartile range: 7-12) days and 3.2 (2.9-3.5) kg, respectively. The median cardiopulmonary bypass time was 137 (107-163) min. Modified Blalock-Taussig shunts were used in 159 (49%) and unvalved right ventricle-to-pulmonary artery shunts in 163 (51%) patients. The number of inter-stage deaths was as follows: between S1P and stage II palliation (S2P), 61 including 38 early (<30 days) and 23 late (>30 days) deaths, and between S2P and stage III palliation, 32 deaths. Low birth weight (<2.5 kg) (odds ratio 4.37, P = 0.020) and restrictive atrial septum (odds ratio 2.97, P = 0.013) were identified as risks for early mortality. Low birth weight [hazard ratio (HR) 0.99/g, P = 0.002] was a risk for inter-stage mortality between S1P and S2P. Extracardiac anomalies (HR 4.75, P = 0.049) and significant pre-S1P atrioventricular valve regurgitation (HR: 7.72, P = 0.016) were risks for inter-stage mortality between S2P and stage III palliation. Other anatomical variables including aortic atresia, anatomical subtypes and the diameter of the ascending aorta nor shunt type were not identified as risk factors for mortality during any inter-stage period. CONCLUSIONS The risk factors for inter-stage attrition after the Norwood procedure were different between each stage. Preoperative factors, including birth weight, restrictive atrial septum and extracardiac anomalies, adversely affected the inter-stage mortality.
Collapse
Affiliation(s)
- Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Marie Wallner
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julia Lemmer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
15
|
Tanem J, Rudd N, Rauscher J, Scott A, Frommelt MA, Hill GD. Survival After Norwood Procedure in High-Risk Patients. Ann Thorac Surg 2019; 109:828-833. [PMID: 31520639 DOI: 10.1016/j.athoracsur.2019.07.070] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/08/2019] [Accepted: 07/23/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Multiple single-ventricle populations are noted to be at increased risk for mortality after the Norwood procedure. Preoperative risk factors include low birth weight, restrictive/intact atrial septum, obstructed pulmonary veins, ventricular dysfunction, and atrioventricular valve regurgitation. We report outcomes of the Norwood procedure in standard- and high-risk patients in the recent era. METHODS All patients born with hypoplastic left heart syndrome between 2006 and 2016 who underwent a Norwood procedure at our institution were included. Patient data were retrospectively reviewed, and Kaplan-Meier analysis was used to evaluate survival between groups. RESULTS The cohort included 177 patients. Fifty patients were determined high-risk preoperatively: low birth weight (n = 18), ventricular dysfunction/atrioventricular valve regurgitation (n = 13), intact or restrictive atrial septum/obstructed anomalous pulmonary venous return (n = 14), and multiple factors (n = 5). There were 2 (1.6%) deaths before Glenn in the standard-risk group, with a total of 10 (20%) from the high-risk groups (P < .0001). Survival at 1 year differed greatly between groups, with highest being standard risk at 89% and lowest in the intact septum/obstructed veins group at 54%. The difference between groups in long-term survival was significant (P < .001). CONCLUSIONS Outcomes after the Norwood procedure have improved for standard-risk patients. Those with preoperative risk factors account for most of the early deaths after the Norwood procedure. This high-risk status does not resolve after Glenn, because longer-term survival continues to diverge from the standard-risk group.
Collapse
Affiliation(s)
- Jena Tanem
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
| | - Nancy Rudd
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Rauscher
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Ann Scott
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michele A Frommelt
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Garick D Hill
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
16
|
Best KE, Tennant PWG, Rankin J. Survival, by Birth Weight and Gestational Age, in Individuals With Congenital Heart Disease: A Population-Based Study. J Am Heart Assoc 2017; 6:JAHA.116.005213. [PMID: 28733436 PMCID: PMC5586271 DOI: 10.1161/jaha.116.005213] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Congenital heart disease (CHD) survival estimates are important to understand prognosis and evaluate health and social care needs. Few studies have reported CHD survival estimates according to maternal and fetal characteristics. This study aimed to identify predictors of CHD survival and report conditional survival estimates. METHODS AND RESULTS Cases of CHD (n=5070) born during 1985-2003 and notified to the Northern Congenital Abnormality Survey (NorCAS) were matched to national mortality information in 2008. Royston-Parmar regression was performed to identify predictors of survival. Five-year survival estimates conditional on gestational age at delivery, birth weight, and year of birth were produced for isolated CHD (ie, CHD without extracardiac anomalies). Year of birth, gestational age, birth weight, and extracardiac anomalies were independently associated with mortality (all P≤0.001). Five-year survival for children born at term (37-41 weeks) in 2003 with average birth weight (within 1 SD of the mean) was 96.3% (95% CI, 95.6-97.0). Survival was most optimistic for high-birth-weight children (>1 SD from the mean) born post-term (≥42 weeks; 97.9%; 95% CI, 96.8-99.1%) and least optimistic for very preterm (<32 weeks) low-birth-weight (<1 SD from mean) children (78.8%; 95% CI, 72.8-99.1). CONCLUSIONS Five-year CHD survival is highly influenced by gestational age and birth weight. For prenatal counseling, conditional survival estimates provide best- and worst-case scenarios, depending on final gestational age and birth weight. For postnatal diagnoses, they can provide parents with more-accurate predictions based on their baby's birth weight and gestational age.
Collapse
Affiliation(s)
- Kate E Best
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Judith Rankin
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
17
|
Hanke SP, Joy B, Riddle E, Ravishankar C, Peterson LE, King E, Mangeot C, Brown DW, Schoettker P, Anderson JB, Bates KE. Risk Factors for Unanticipated Readmissions During the Interstage: A Report From the National Pediatric Cardiology Quality Improvement Collaborative. Semin Thorac Cardiovasc Surg 2016; 28:803-814. [DOI: 10.1053/j.semtcvs.2016.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2016] [Indexed: 11/11/2022]
|
18
|
Marino BS, Lipkin PH, Newburger JW, Peacock G, Gerdes M, Gaynor JW, Mussatto KA, Uzark K, Goldberg CS, Johnson WH, Li J, Smith SE, Bellinger DC, Mahle WT. Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association. Circulation 2012; 126:1143-72. [PMID: 22851541 DOI: 10.1161/cir.0b013e318265ee8a] [Citation(s) in RCA: 1034] [Impact Index Per Article: 86.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The goal of this statement was to review the available literature on surveillance, screening, evaluation, and management strategies and put forward a scientific statement that would comprehensively review the literature and create recommendations to optimize neurodevelopmental outcome in the pediatric congenital heart disease (CHD) population. METHODS AND RESULTS A writing group appointed by the American Heart Association and American Academy of Pediatrics reviewed the available literature addressing developmental disorder and disability and developmental delay in the CHD population, with specific attention given to surveillance, screening, evaluation, and management strategies. MEDLINE and Google Scholar database searches from 1966 to 2011 were performed for English-language articles cross-referencing CHD with pertinent search terms. The reference lists of identified articles were also searched. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. A management algorithm was devised that stratified children with CHD on the basis of established risk factors. For those deemed to be at high risk for developmental disorder or disabilities or for developmental delay, formal, periodic developmental and medical evaluations are recommended. A CHD algorithm for surveillance, screening, evaluation, reevaluation, and management of developmental disorder or disability has been constructed to serve as a supplement to the 2006 American Academy of Pediatrics statement on developmental surveillance and screening. The proposed algorithm is designed to be carried out within the context of the medical home. This scientific statement is meant for medical providers within the medical home who care for patients with CHD. CONCLUSIONS Children with CHD are at increased risk of developmental disorder or disabilities or developmental delay. Periodic developmental surveillance, screening, evaluation, and reevaluation throughout childhood may enhance identification of significant deficits, allowing for appropriate therapies and education to enhance later academic, behavioral, psychosocial, and adaptive functioning.
Collapse
|
19
|
Feinstein JA, Benson DW, Dubin AM, Cohen MS, Maxey DM, Mahle WT, Pahl E, Villafañe J, Bhatt AB, Peng LF, Johnson BA, Marsden AL, Daniels CJ, Rudd NA, Caldarone CA, Mussatto KA, Morales DL, Ivy DD, Gaynor JW, Tweddell JS, Deal BJ, Furck AK, Rosenthal GL, Ohye RG, Ghanayem NS, Cheatham JP, Tworetzky W, Martin GR. Hypoplastic left heart syndrome: current considerations and expectations. J Am Coll Cardiol 2012; 59:S1-42. [PMID: 22192720 PMCID: PMC6110391 DOI: 10.1016/j.jacc.2011.09.022] [Citation(s) in RCA: 349] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 09/06/2011] [Accepted: 09/20/2011] [Indexed: 01/25/2023]
Abstract
In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.
Collapse
Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Dean PN, Hillman DG, McHugh KE, Gutgesell HP. Inpatient costs and charges for surgical treatment of hypoplastic left heart syndrome. Pediatrics 2011; 128:e1181-6. [PMID: 21987703 PMCID: PMC9923876 DOI: 10.1542/peds.2010-3742] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Hypoplastic left heart syndrome (HLHS) is one of the most serious congenital cardiac anomalies. Typically, it is managed with a series of 3 palliative operations or cardiac transplantation. Our goal was to quantify the inpatient resource burden of HLHS across multiple academic medical centers. METHODS The University HealthSystem Consortium is an alliance of 101 academic medical centers and 178 affiliated hospitals that share diagnostic, procedural, and financial data on all discharges. We examined inpatient resource use by patients with HLHS who underwent a staged palliative procedure or cardiac transplantation between 1998 and 2007. RESULTS Among 1941 neonates, stage 1 palliation (Norwood or Sano procedure) had a median length of stay (LOS) of 25 days and charges of $214,680. Stage 2 and stage 3 palliation (Glenn and Fontan procedures, respectively) had median LOS and charges of 8 days and $82,174 and 11 days and $79,549, respectively. Primary neonatal transplantation had an LOS of 87 days and charges of $582,920, and rescue transplantation required 36 days and $411,121. The median inpatient wait time for primary and rescue transplants was 42 and 6 days, respectively. Between 1998 and 2007, the LOS for stage 1 palliation increased from 16 to 28 days and inflation-adjusted charges increased from $122,309 to $280,909, largely because of increasing survival rates (57% in 1998 and 83% in 2007). CONCLUSIONS Patients with HLHS demand considerable inpatient resources, whether treated with the Norwood-Glenn-Fontan procedure pathway or cardiac transplantation. Improved survival rates have led to increased hospital stays and costs.
Collapse
Affiliation(s)
| | - Diane G. Hillman
- Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia; and
| | - Kimberly E. McHugh
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Howard P. Gutgesell
- Departments of Pediatrics and ,Address correspondence to Howard P. Gutgesell, MD, Department of Pediatrics, University of Virginia Health System, PO Box 800386, Charlottesville, VA 22908-0386. E-mail:
| |
Collapse
|
21
|
Berry JG, Bloom S, Foley S, Palfrey JS. Health inequity in children and youth with chronic health conditions. Pediatrics 2010; 126 Suppl 3:S111-9. [PMID: 21123473 DOI: 10.1542/peds.2010-1466d] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Over the last decades, there have been great advances in health care delivered to children with chronic conditions, but not all children have benefitted equally from them. OBJECTIVES To describe health inequities experienced by children with chronic health conditions. METHODS We performed a literature review of English-language studies identified from the Medline, Centers for Disease Control and Prevention, National Cancer Institute, and Cystic Fibrosis Foundation Web sites that were published between January 1985 and May 2009, included children aged 0 to 18 years, and contained the key words "incidence," "prevalence," "survival," "mortality," or "disparity" in the title or abstract for the following health conditions: acute leukemia, asthma, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders, cerebral palsy, cystic fibrosis, diabetes mellitus, Down syndrome, HIV/AIDS, major congenital heart defects, major depressive disorder, sickle cell anemia, spina bifida, and traumatic brain injury. RESULTS Black children had higher rates of cerebral palsy and HIV/AIDS, were less likely to be diagnosed with ADHD, had more emergency department visits, hospitalizations, and had higher mortality rates associated with asthma; and survived less often with Down syndrome, type 1 diabetes, and traumatic brain injury when compared with white children. Hispanic children had higher rates of spina bifida from Mexico-born mothers, had higher rates of HIV/AIDS and depression, were less likely to be diagnosed with ADHD, had poorer glycemic control with type 1 diabetes, and survived less often with acute leukemia compared with white children. CONCLUSIONS Serious racial and ethnic health and health care inequities persist for children with chronic health conditions.
Collapse
Affiliation(s)
- Jay G Berry
- Complex Care Service, Program for Patient Safety and Quality, Children's Hospital Boston, Fegan 10, 300 Longwood Ave, Boston, MA 02115, USA.
| | | | | | | |
Collapse
|
22
|
Prsa M, Holly CD, Carnevale FA, Justino H, Rohlicek CV. Attitudes and practices of cardiologists and surgeons who manage HLHS. Pediatrics 2010; 125:e625-30. [PMID: 20156891 DOI: 10.1542/peds.2009-1678] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We conducted a survey to determine which management options pediatric cardiologists and cardiac surgeons in North America discuss and recommend when counseling parents after the diagnosis of hypoplastic left heart syndrome (HLHS). METHODS Pediatric cardiologists and cardiac surgeons across North America were asked to complete an anonymous, Internet-based survey about their attitudes and practices regarding the management of HLHS. RESULTS We contacted 1621 pediatric cardiologists and surgeons, of whom 749 (46%) completed the survey. When counseling parents of newborns with HLHS, 99.7% of respondents discussed staged palliative surgery, 67% discussed cardiac transplantation, and 62.2% discussed compassionate care without surgery. Only a minority (14.9%) discussed all of those options. Staged palliative surgery was recommended over cardiac transplantation or compassionate care without surgery by 76.2% of respondents. When counseling parents after prenatal diagnosis of HLHS, 98.8% of respondents discussed continuation of pregnancy with staged palliative surgery after birth, 53.5% discussed continuation of pregnancy with cardiac transplantation after birth, 56.9% discussed continuation of pregnancy with compassionate care after birth, and 74.3% discussed termination of pregnancy. Only 36.5% discussed all of those options. Continuation of pregnancy with staged palliative surgery after birth was recommended over the other options by 56% of respondents. CONCLUSIONS Virtually all North American pediatric cardiologists and cardiac surgeons surveyed discuss a surgical intervention when counseling parents about the care of their child or fetus with HLHS. However, only a minority discuss all options. Most physicians recommend staged palliative surgery for management of HLHS.
Collapse
Affiliation(s)
- Milan Prsa
- Montreal Children's Hospital, Division of Cardiology, 2300 Tupper St, Montreal, Quebec, H3H 1P3, Canada
| | | | | | | | | |
Collapse
|
23
|
Fixler DE, Nembhard WN, Salemi JL, Ethen MK, Canfield MA. Mortality in first 5 years in infants with functional single ventricle born in Texas, 1996 to 2003. Circulation 2010; 121:644-50. [PMID: 20100974 DOI: 10.1161/circulationaha.109.881904] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Infants with functional single ventricle have a high risk of death during the early years of life. Studies have reported improvement in postoperative survival, but they do not include preoperative deaths or those occurring before transfer. The purpose of this population-based study was to estimate 5-year survival in infants with functional single ventricle, to define factors associated with survival, and to estimate improvement in outcome. METHODS AND RESULTS Patients with hypoplastic left heart syndrome, pulmonary atresia intact ventricular septum, single ventricle, and tricuspid atresia born in 1996 to 2003 were identified from the Texas Birth Defects Registry and linked to state and national birth and death vital records. We examined the effects of defect type, birth era, birth weight, gestational age, maternal race/ethnicity, extracardiac anomalies, sex, and maternal age and education on survival. Five-year survival varied by defect type: hypoplastic left heart syndrome, 38.0% (95% confidence interval, 32.6 to 43.5); single ventricle, 56.1% (95% confidence interval, 49.9 to 61.7); pulmonary atresia intact ventricular septum, 55.7% (95% confidence interval, 45.8 to 64.4); and tricuspid atresia, 74.6% (95% confidence interval, 62.4 to 83.4). The presence of extracardiac defects increased the adjusted risk of death by 84%. Non-Hispanic blacks had an adjusted risk of death that was 41% higher than that for non-Hispanic whites, and Hispanics had a 26% higher risk. Patients born in 2001 to 2003 had a 47% lower risk than those born in 1996 to 2000. CONCLUSIONS This population-based study demonstrates significant improvement in overall 5-year survival, particularly in cases of hypoplastic left heart syndrome and single ventricle. Additional studies are needed to determine the factors causing racial/ethnic and regional differences in outcome.
Collapse
Affiliation(s)
- David E Fixler
- Department of Pediatrics, University of Texas Health Science Center, Dallas, USA.
| | | | | | | | | |
Collapse
|
24
|
Szwast A, Tian Z, McCann M, Donaghue D, Rychik J. Vasoreactive response to maternal hyperoxygenation in the fetus with hypoplastic left heart syndrome. Circ Cardiovasc Imaging 2009; 3:172-8. [PMID: 20044513 DOI: 10.1161/circimaging.109.848432] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cardiopulmonary interactions play an important role in the pathophysiology of hypoplastic left heart syndrome (HLHS). Pulmonary vasculopathy has been identified, especially in those with restrictive/intact atrial septum. Responsiveness of the pulmonary vasculature to maternal hyperoxygenation (MH) may provide a tool to assess the degree of pulmonary vasculopathy present before birth. METHODS AND RESULTS Doppler echocardiography was performed in 27 normal and 43 HLHS fetuses. In HLHS, sampling was repeated after 10 minutes of MH with 60% FiO(2) and after 5 minutes of recovery. Sampling was performed in the proximal, midportion, and distal branch pulmonary artery (PA). Pulsatility index (PI) was used as a measure of vascular impedance. Of the HLHS fetuses, 34 had an open interatrial septum and 9 had a restrictive/intact atrial septum. At birth, 5 fetuses underwent immediate intervention on the interatrial septum. Middle cerebral artery PI was lower in HLHS versus normal fetuses (P<0.001). There was no difference in UA, DA, or branch PA PI between normal fetuses and those with HLHS. MH led to a significant decrease in PI at each of the PA sites sampled in fetuses with an open atrial septum (P<0.001); however, there no was significant change in the PI in fetuses that required immediate intervention on the atrial septum at birth. Using a cutoff value of <10% vasoreactivity, the sensitivity of MH testing for determining need for immediate intervention at birth is 100% (0.46 to 1.0); specificity, 94% (0.78 to 0.99); positive predictive value, 71% (0.30 to 0.95); and negative predictive value, 100% (0.86 to 1.0). No untoward effects were seen with MH. CONCLUSIONS PA vasoreactivity to MH occurs in the fetus with HLHS. MH testing accurately identifies fetuses requiring urgent postnatal intervention at birth and may be used to select candidates for fetal atrial septoplasty.
Collapse
Affiliation(s)
- Anita Szwast
- The Fetal Heart Program at Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | | | | | | | | |
Collapse
|
25
|
McElhinney DB, Marshall AC, Wilkins-Haug LE, Brown DW, Benson CB, Silva V, Marx GR, Mizrahi-Arnaud A, Lock JE, Tworetzky W. Predictors of technical success and postnatal biventricular outcome after in utero aortic valvuloplasty for aortic stenosis with evolving hypoplastic left heart syndrome. Circulation 2009; 120:1482-90. [PMID: 19786635 DOI: 10.1161/circulationaha.109.848994] [Citation(s) in RCA: 208] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic stenosis in the midgestation fetus with a normal-sized or dilated left ventricle predictably progresses to hypoplastic left heart syndrome when associated with certain physiological findings. Prenatal balloon aortic valvuloplasty may improve left heart growth and function, possibly preventing evolution to hypoplastic left heart syndrome. METHODS AND RESULTS Between March 2000 and October 2008, 70 fetuses underwent attempted aortic valvuloplasty for critical aortic stenosis with evolving hypoplastic left heart syndrome. We analyzed this experience to determine factors associated with procedural and postnatal outcome. The median gestational age at intervention was 23 weeks. The procedure was technically successful in 52 fetuses (74%). Relative to 21 untreated comparison fetuses, subsequent prenatal growth of the aortic and mitral valves, but not the left ventricle, was improved after intervention. Nine pregnancies (13%) did not reach a viable term or preterm birth. Seventeen patients had a biventricular circulation postnatally, 15 from birth. Larger left heart structures and higher left ventricular pressure at the time of intervention were associated with biventricular outcome. A multivariable threshold scoring system was able to discriminate fetuses with a biventricular outcome with 100% sensitivity and modest positive predictive value. CONCLUSIONS Technically successful aortic valvuloplasty alters left heart valvar growth in fetuses with aortic stenosis and evolving hypoplastic left heart syndrome and, in a subset of cases, appeared to contribute to a biventricular outcome after birth. Fetal aortic valvuloplasty carries a risk of fetal demise. Fetuses undergoing in utero aortic valvuloplasty with an unfavorable multivariable threshold score at the time of intervention are very unlikely to achieve a biventricular circulation postnatally.
Collapse
Affiliation(s)
- Doff B McElhinney
- Department of Cardiology, Children's Hospital, Boston, MA 02115, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Atallah J, Dinu IA, Joffe AR, Robertson CM, Sauve RS, Dyck JD, Ross DB, Rebeyka IM. Two-Year Survival and Mental and Psychomotor Outcomes After the Norwood Procedure. Circulation 2008; 118:1410-8. [DOI: 10.1161/circulationaha.107.741579] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The Norwood procedure for stage 1 palliation of hypoplastic left heart syndrome is performed with either the modified Blalock-Taussig (MBTS) or the right ventricle–to–pulmonary artery (RVPA) shunt. In our institution, surgical practice changed from use of the MBTS to use of the RVPA shunt in 2002. We analyzed survival and mental and psychomotor outcomes of the 2 consecutive surgical eras.
Methods and Results—
Between September 1996 and July 2005, 94 neonates with hypoplastic left heart syndrome underwent the Norwood procedure. Patients were recruited as neonates and followed up prospectively. Health, mental, and psychomotor outcomes (Bayley Scales of Infant Development-II) were assessed at 2 years. The study subjects were from the Norwood-MBTS era (n=62; 1996 to 2002) or the Norwood-RVPA era (n=32; 2002 to 2005). In the MBTS era, early and 2-year mortality rates were 23% (14/62) and 52% (32/62); the mean (SD) mental and psychomotor developmental indices were 79 (18) and 67 (19). In the RVPA era, early and 2-year mortality rates were 6% (2/32) and 19% (6/32); the mean (SD) mental and psychomotor developmental indices were 85 (18) and 78 (18). The 2-year mortality rate (
P
=0.002) and the psychomotor developmental index (
P
=0.029) were improved in the more recent surgical era. On multivariable Cox regression analysis, postoperative highest serum lactate independently predicted 2-year mortality in the MBTS and RVPA eras.
Conclusions—
Analysis of 2 consecutive surgical eras of hypoplastic left heart syndrome patients undergoing the Norwood procedure showed a significant improvement in 2-year survival and psychomotor development in the more recent era. Adverse neurodevelopmental outcome in this patient population remains a concern.
Collapse
Affiliation(s)
- Joseph Atallah
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Irina A. Dinu
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Ari R. Joffe
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Charlene M.T. Robertson
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Reg S. Sauve
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - John D. Dyck
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - David B. Ross
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | - Ivan M. Rebeyka
- From the Department of Pediatrics (J.A., A.R.J., C.M.T.R., J.D.D., I.M.R.), School of Public Health (I.A.D.), and Department of Surgery (D.B.R., I.M.R.), University of Alberta, Edmonton, Alberta, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit (C.M.T.R.), Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada; and Department of Pediatrics (R.S.S.), University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
27
|
Canter CE, Shaddy RE, Bernstein D, Hsu DT, Chrisant MRK, Kirklin JK, Kanter KR, Higgins RSD, Blume ED, Rosenthal DN, Boucek MM, Uzark KC, Friedman AH, Friedman AH, Young JK. Indications for Heart Transplantation in Pediatric Heart Disease. Circulation 2007; 115:658-76. [PMID: 17261651 DOI: 10.1161/circulationaha.106.180449] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Since the initial utilization of heart transplantation as therapy for end-stage pediatric heart disease, improvements have occurred in outcomes with heart transplantation and surgical therapies for congenital heart disease along with the application of medical therapies to pediatric heart failure that have improved outcomes in adults. These events justify a reevaluation of the indications for heart transplantation in congenital heart disease and other causes of pediatric heart failure.
Methods and Results—
A working group was commissioned to review accumulated experience with pediatric heart transplantation and its use in patients with unrepaired and/or previously repaired or palliated congenital heart disease (children and adults), in patients with pediatric cardiomyopathies, and in pediatric patients with prior heart transplantation. Evidence-based guidelines for the indications for heart transplantation or retransplantation for these conditions were developed.
Conclusions—
This evaluation has led to the development and refinement of indications for heart transplantation for patients with congenital heart disease and pediatric cardiomyopathies in addition to indications for pediatric heart retransplantation.
Collapse
|
28
|
De Oliveira NC, Ashburn DA, Khalid F, Burkhart HM, Adatia IT, Holtby HM, Williams WG, Van Arsdell GS. Prevention of early sudden circulatory collapse after the Norwood operation. Circulation 2005; 110:II133-8. [PMID: 15364852 DOI: 10.1161/01.cir.0000138399.30587.8e] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND After modifications in our perioperative management protocol, we have observed a decrease in sudden circulatory collapse after the Norwood operation. The current study examines early outcomes after the Norwood operation in our unit in an attempt to identify variables that may have altered the risk of unexpected circulatory collapse. METHODS AND RESULTS We studied 105 consecutive neonates who underwent a Norwood operation in our institution. Our treatment protocol has changed in the past 3 years to include the use of alpha-blockade with phenoxybenzamine (POB) for systemic afterload reduction and selective cerebral perfusion. Forty-eight infants had selective cerebral perfusion. Forty-two infants received POB. Sixty patients had hypoplastic left heart syndrome. There was no difference in age, diagnosis, number of neonates with weight <2.5 kg, aortic size diameter <2 mm, highest preoperative lactate level, and shunt size indexed to body weight among patients with or without use of POB. Twenty-five infants had circulatory collapse during the first 72 hours. Twelve of them could be explained by technical issues. Thirteen others who appeared clinically stable had early sudden circulatory collapse without an apparent cause. Sixteen out of 25 neonates died. Of those with technical problems, 8 out of 12 died. Based on the hazard function, 3 incremental risk factors for early circulatory collapse were technical issue at operation (P<0.001), longer cross-clamp time (P<0.007), and no use of POB (P<0.002). For a technically successful operation, freedom from circulatory collapse at 72 hours is 95% with the use of POB versus 69% without (P<0.002). Diagnosis, aortic size, atrioventricular valve function, birth weight, age at operation, and total circulatory arrest time and were not predictive of early sudden circulatory collapse. CONCLUSIONS Recent changes in our treatment protocol have resulted in a decrease incidence of sudden circulatory collapse after the Norwood operation. Optimal surgical technique is the most important predictor of early survival. The use of aggressive afterload reduction with POB reduced the risk of early sudden arrest.
Collapse
Affiliation(s)
- Nilto C De Oliveira
- Division of Cardiovascular Surgery, Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | |
Collapse
|