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Bonilla-Ramirez C, Lorts A, Spinner JA, Wright L, Niebler RA, Peng DM, Davies RR, Rosenthal DN, O'Connor MJ. Development and Validation of a Novel Pediatric Mechanical Circulatory Support Risk Stratification Tool: The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Ventricular Assist Device Score. ASAIO J 2024:00002480-990000000-00544. [PMID: 39150771 DOI: 10.1097/mat.0000000000002297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024] Open
Abstract
We sought to develop and validate a new risk stratification score for mortality for children supported with a ventricular assist device (VAD). This retrospective, multicenter study used data from patients undergoing VAD implantation between April 2018 and February 2023 at 44 participating institutions in the Advanced Cardiac Therapies Improving Outcomes (ACTION) network. Multivariable Cox proportional-hazards modeled mortality after VAD implantation. A total of 1,022 patients were enrolled. The 1 year mortality was 19% (95% confidence interval [CI]: 16-23). The multivariable model was used to build the ACTION VADs risk stratification score with four components: ventilation, advanced organ support (dialysis or ECMO), diagnosis, and size (weight ≤5 kg). One point is added for each risk factor. Based on the sum of the risk factors, patients were classified into four classes: class 0-green (4% mortality at 1 year), class 1-yellow (16% mortality at 1 year), class 2-orange (21% mortality at 1 year), and class 3 or higher-red (42% mortality at 1 year). The score performed well, with area under the curve (AUC) of 0.72 and excellent calibration. The ACTION VADs score for mortality can be calculated easily and offers risk stratification and prognostic information for pediatric VAD candidates. This is the first validated risk assessment tool for pediatric mechanical circulatory support.
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Affiliation(s)
| | - Angela Lorts
- From the Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Joseph A Spinner
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Lydia Wright
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Robert A Niebler
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Herma Heart Institute, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David M Peng
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Ryan R Davies
- Cardiovascular and Thoracic Surgery, University of Texas (UT) Southwestern Medical Center and Children's Health, Dallas, Texas
| | - David N Rosenthal
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California
| | - Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, California
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2
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Cho J, Tunuguntla HP, Tume SC, Spinner JA, Bocchini CE, Teruya J, Heinle JS, Hickey EJ, Adachi I. Long-term implantable ventricular assist device support in children. J Thorac Cardiovasc Surg 2024; 167:1417-1426.e1. [PMID: 37913838 DOI: 10.1016/j.jtcvs.2023.10.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/17/2023] [Accepted: 10/22/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND In pediatrics, implantable continuous-flow ventricular assist devices (IC-VAD) are often used as a "temporary" support, bridging children to cardiac transplantation during the same hospital admission. METHODS We conducted a retrospective review of our consecutive patients undergoing IC-VAD support at a tertiary pediatric heart center between 2008 and 2022. RESULTS We identified 100 IC-VAD implant encounters: HeartWare HVAD (67; 67%), HeartMate II (17; 17%), and HeartMate 3 (16; 16%). The median (range) age, weight, and body surface area at implantation were 14.1 (3.0-56.5) years, 54.8 (13.3-140) kg, and 1.6 (0.6-2.6) m2, respectively. Cardiomyopathy (58; 58%) was the most common etiology, followed by congenital heart disease (37; 37%, including 13 single ventricle). At 6 months of IC-VAD support, 94 (94%) encounters achieved positive outcomes: ongoing support (59; 59%), transplant (33; 33%), and cardiac recovery (2; 2%). Eighty-two encounters (82%) resulted in home discharge with ongoing VAD support, including 38 (46%, out of 82) requiring readmission and 7 (9%, out of 82) resulting in death. There was a clinically significant decrease in morbidity rates before versus after home discharge: bleeding (1.55 vs 0.06), infection (0.84 vs 0.37), and stroke (0.84 vs 0.15 event per patient-year). Overall, 86 encounters (86%) reached positive end points at the latest follow-up (64 transplant, 15 ongoing support, and 7 recovery). Infection (29%; 4 of 14) was the most common cause of negative outcomes, followed by cerebrovascular accident (21%; 3), and unresolved frailty (21%; 3). The estimated overall survival at 1, 2, and 5 years was 90%, 86%, and 77%, respectively. CONCLUSIONS This study suggests the feasibility of outpatient management of pediatric IC-VAD support. The ability to offer true long-term support maximizes the potential of IC-VAD support, not limited to a temporary bridging tool for heart transplantation.
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Affiliation(s)
- Junsang Cho
- Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Hari P Tunuguntla
- Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Sebastian C Tume
- Pediatric Critical Care, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Joseph A Spinner
- Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Claire E Bocchini
- Pediatric Infectious Disease, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Jun Teruya
- Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Jeffrey S Heinle
- Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Edward J Hickey
- Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Iki Adachi
- Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex.
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Schumacher KR, Cedars A, Allen K, Goldberg D, Batazzi A, Reichle G, DiPaola F, Selewski D, Cousino M, Rosenthal DN. Achieving Consensus: Severity-Graded Definitions of Fontan-Associated Complications to Characterize Fontan Circulatory Failure. J Card Fail 2024:S1071-9164(24)00075-7. [PMID: 38452996 DOI: 10.1016/j.cardfail.2024.02.015] [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: 10/04/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Fontan physiology leads to chronic changes in other organ systems that may affect long-term survival and the success of heart transplantation. Inadequate assessment and treatment of the extra-cardiac effects of Fontan may contribute to poor outcomes. Severity-graded/ordinal consensus definitions of Fontan complications are lacking, which limits understanding of how Fontan-specific morbidity affects patients' outcomes. METHODS AND RESULTS A panel of Fontan patient and physiology experts, including pediatric, adult congenital, heart failure, and critical-care cardiology as well as pediatric nephrology, hepatology and psychology, convened to develop definitions of Fontan complications. Definitions were created by using a severity-graded ordinal scale: grade 1, mild; grade 2, moderate; grade 3, severe; grade 4, disabling or life threatening. Following definition creation, a second panel of 21 experts in Fontan circulatory failure used a modified Delphi methodology to modify and vote on definitions until consensus (> 90% agreement without recommended further modification) was reached on final definitions. After 3 rounds of modifications and voting, consensus agreement was achieved on all Fontan-specific definitions. The defined complications and morbidities of Fontan include: anatomic Fontan pathway obstruction, cyanosis, systemic venous abnormalities resulting from venous insufficiency, atrial arrhythmia, ventricular arrhythmia, bradycardia, chronic pleural effusions, chronic ascites, protein-losing enteropathy, plastic bronchitis, hemoptysis and pulmonary hemorrhage, sleep apnea, Fontan-associated liver disease, portal and hepatic variceal disease, acute kidney injury affecting clinical treatment, polycythemia, thrombotic disease, recurrent or severe bacterial infection, skin atrophy, adrenal insufficiency, physical impact of previous stroke, mood/behavior disorder, and neurodevelopmental disorder. CONCLUSION Consensus and severity-graded definitions of Fontan-specific cardiac and extra-cardiac complications were achieved and are available for use in research. They will allow future robust analyses of Fontan patient outcomes.
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Affiliation(s)
- Kurt R Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI.
| | | | - Kiona Allen
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Evanston, IL
| | - David Goldberg
- University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Adrianna Batazzi
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI
| | - Garrett Reichle
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI
| | - Frank DiPaola
- University of Virginia, UVA Health Children's Health, Charlottesville, VA
| | - David Selewski
- Medical University of South Carolina, MUSC Children's Health, Charleston, SC
| | - Melissa Cousino
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI
| | - David N Rosenthal
- Stanford University, Lucille Packard Children's Hospital, Stanford, CA
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4
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Schweiger M, Miera O. Not little adults: Outcomes in pediatric intra-corporeal LVAD patients. J Heart Lung Transplant 2024; 43:182-183. [PMID: 37683894 DOI: 10.1016/j.healun.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/22/2023] [Accepted: 09/02/2023] [Indexed: 09/10/2023] Open
Affiliation(s)
- Martin Schweiger
- Department of Congenital Cardiovascular Surgery, Pediatric Heart Center, University Children's Hospital, Zurich, Switzerland.
| | - Oliver Miera
- Deutsches Herzzentrum der Charité, Berlin, Germany
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Kozik D, Alsoufi B. Pediatric mechanical circulatory support - a review. Indian J Thorac Cardiovasc Surg 2023; 39:80-90. [PMID: 37525715 PMCID: PMC10386992 DOI: 10.1007/s12055-023-01499-3] [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: 11/27/2022] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
The history of mechanical circulatory support began in 1953, as the first heart-lung machine enabled surgeons to perform complex open heart surgery. Heart failure is more prevalent in adults than pediatric patients which has led to the development of devices for adults with end-stage heart failure at a faster pace. Pediatric mechanical circulatory support has been derived from adult durable devices and subsequently applied in the adolescent population. The application of adult devices in children is inherently problematic due to size mismatch, especially in smaller patients. There has been an increasing interest in developing durable pumps that are appropriate for children for several reasons, with the primary factor being the number of children with end-stage heart failure far exceeding the number of potential donors. Mechanical circulatory support (MCS) for children can be divided into short-term temporary support and long-term durable support. The goal of this review is to discuss the devices available for the pediatric population and review the options for support in complex patients including single-ventricle anatomy, biventricular support, and total artificial heart options. We will also briefly discuss the Pumps for Kids, Infants, and Neonates (PumpKIN) Trial and MCS registries, including the Advanced Cardiac Therapies Improving Outcomes Network (ACTION).
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Affiliation(s)
- Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
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6
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Jone PN, Gearhart A, Lei H, Xing F, Nahar J, Lopez-Jimenez F, Diller GP, Marelli A, Wilson L, Saidi A, Cho D, Chang AC. Artificial Intelligence in Congenital Heart Disease: Current State and Prospects. JACC. ADVANCES 2022; 1:100153. [PMID: 38939457 PMCID: PMC11198540 DOI: 10.1016/j.jacadv.2022.100153] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/04/2022] [Accepted: 10/07/2022] [Indexed: 06/29/2024]
Abstract
The current era of big data offers a wealth of new opportunities for clinicians to leverage artificial intelligence to optimize care for pediatric and adult patients with a congenital heart disease. At present, there is a significant underutilization of artificial intelligence in the clinical setting for the diagnosis, prognosis, and management of congenital heart disease patients. This document is a call to action and will describe the current state of artificial intelligence in congenital heart disease, review challenges, discuss opportunities, and focus on the top priorities of artificial intelligence-based deployment in congenital heart disease.
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Affiliation(s)
- Pei-Ni Jone
- Section of Pediatric Cardiology, Department of Pediatrics, Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Addison Gearhart
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Howard Lei
- Division of Pediatric Cardiology, Children’s Hospital of Orange County, Orange, California, USA
| | - Fuyong Xing
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jai Nahar
- Department of Cardiology, Children's National Hospital, Washington, DC, USA
| | | | - Gerhard-Paul Diller
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield National Health Service Foundation Trust, Imperial College London, London, UK
- National Register for Congenital Heart Defects, Berlin, Germany
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Laura Wilson
- Department of Pediatrics, University of Florida-Congenital Heart Center, Gainesville, Florida, USA
| | - Arwa Saidi
- Department of Pediatrics, University of Florida-Congenital Heart Center, Gainesville, Florida, USA
| | - David Cho
- Department of Cardiology, University of California at Los Angeles, Los Angeles, California, USA
| | - Anthony C. Chang
- Division of Pediatric Cardiology, Children’s Hospital of Orange County, Orange, California, USA
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7
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McDonald PL, Phillips J, Harwood K, Maring J, van der Wees PJ. Identifying requisite learning health system competencies: a scoping review. BMJ Open 2022; 12:e061124. [PMID: 35998963 PMCID: PMC9403130 DOI: 10.1136/bmjopen-2022-061124] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Learning health systems (LHS) integrate knowledge and practice through cycles of continuous quality improvement and learning to increase healthcare quality. LHS have been conceptualised through multiple frameworks and models. Our aim is to identify and describe the requisite individual competencies (knowledge, skills and attitudes) and system competencies (capacities, characteristics and capabilities) described in existing literature in relation to operationalising LHS. METHODS A scoping review was conducted with descriptive and thematic analysis to identify and map competencies of LHS for individuals/patients, health system workers and systems. Articles until April 2020 were included based on a systematic literature search and selection process. Themes were developed using a consensus process until agreement was reached among team members. RESULTS Eighty-nine articles were included with most studies conducted in the USA (68 articles). The largest number of publications represented competencies at the system level, followed by health system worker competencies. Themes identified at the individual/patient level were knowledge and skills to understand and share information with an established system and the ability to interact with the technology used to collect data. Themes at the health system worker level were skills in evidence-based practice, leadership and teamwork skills, analytical and technological skills required to use a 'digital ecosystem', data-science knowledge and skill and self-reflective capacity. Researchers embedded within LHS require a specific set of competencies. Themes identified at the system level were data, infrastructure and standardisation; integration of data and workflow; and culture and climate supporting ongoing learning. CONCLUSION The identified individual stakeholder competencies within LHS and the system capabilities of LHS provide a solid base for the further development and evaluation of LHS. International collaboration for stimulating LHS will assist in further establishing the knowledge base for LHS.
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Affiliation(s)
- Paige L McDonald
- Department of Clinical Research and Leadership, The George Washington University, Washington, District of Columbia, USA
| | - Jessica Phillips
- Department of Clinical Research and Leadership, The George Washington University, Washington, District of Columbia, USA
| | - Kenneth Harwood
- College of Health and Education, Marymount University, Arlington, Virginia, USA
| | - Joyce Maring
- Department of Health, Human Function, The George Washington University, Washington, District of Columbia, USA
| | - Philip J van der Wees
- Department of Clinical Research and Leadership, The George Washington University, Washington, District of Columbia, USA
- Rehabilitation and IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
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8
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Peng DM, Yu S, Lowery R, Ventresco C, Cousino MK, St Louis JD, Blume ED, Uzark K. Self-reported quality of life in children with ventricular assist devices. Pediatr Transplant 2022; 26:e14237. [PMID: 35102660 DOI: 10.1111/petr.14237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/15/2021] [Accepted: 01/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND We sought to describe QOL in children with VAD and to identify factors associated with impaired QOL. METHODS There were 82 children (6-19 years) in the Pediatric Interagency Registry for Mechanical Circulatory Support who completed the PedsQL +/- a VAD-specific QOL assessment pre-VAD implant (n = 18), 3 months post-VAD (n = 63), and/or 6 months post-VAD (n = 38). Significantly impaired QOL is a score >1 SD below norms. RESULTS Study patients were 59% male, 67% Caucasian, with cardiomyopathy diagnosis in 82%, and median age at implant of 14 y (IQR 11-17). PedsQL scores were lower than norms for physical (p < .0001) and psychosocial (p < .01) QOL in pre- and post-VAD groups. Compared to chronic health condition and complex or severe heart disease groups, PedsQL scores were lower for physical and psychosocial QOL in the pre-VAD group (p < .0001); however, psychosocial QOL was not significantly different in post-VAD groups. Psychosocial QOL was impaired in 67%, 40%, and 24% in pre-VAD, 3-month, and 6-month post-VAD groups, respectively. Total and psychosocial QOL scores were significantly higher in the 3-month and 6-month post-VAD group than pre-VAD (all p ≤ .02). VAD patients were most bothered by their inability to participate in usual play activities. Impaired QOL 3 months post-VAD was associated with inotropic support >2 weeks/ongoing post-VAD (p = .04). CONCLUSION Physical QOL is significantly impaired in most children pre- and post-VAD. However, psychosocial QOL is not significantly impaired in most children post-VAD suggesting VAD implantation may improve psychosocial QOL in children.
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Affiliation(s)
- David M Peng
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Sunkyung Yu
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Ray Lowery
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Courtney Ventresco
- Department of Cardiology, Boston Children's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Melissa K Cousino
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - James D St Louis
- Department of Surgery, Medical College of Georgia, Children's Hospital of Georgia, Augusta, Georgia, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Karen Uzark
- Department of Pediatrics (Cardiology), CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
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9
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Adverse Events Associated with Cardiac Catheterization in Children Supported with Ventricular Assist Devices. ASAIO J 2021; 68:1174-1181. [PMID: 34967779 DOI: 10.1097/mat.0000000000001627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Children on ventricular assist device (VAD) support can present several unique challenges, including small patient size, univentricular or biventricular congenital heart disease (1V- or 2V-CHD) and need for biventricular VAD (BiVAD) support. While cardiac catheterization can provide valuable information, it is an invasive procedure with inherent risks. We sought to evaluate the safety of catheterization in pediatric patients on VAD support. We performed a retrospective review of patients on VAD support who underwent catheterization at Lucile Packard Children's Hospital between January 1, 2014 and September 1, 2019. Using definitions adapted from Pedimacs, adverse events (AEs) after catheterization were identified, including arrhythmia; major bleeding or acute kidney injury within 24 hours; respiratory failure persisting at 24 hours; and stroke, pericardial effusion, device malfunction, bacteremia or death within 7 days. AEs were categorized as related or unrelated to catheterization. Sixty procedures were performed on 39 patients. Underlying diagnoses were dilated cardiomyopathy (48%), 1V-CHD (35%), 2V-CHD (8%), and other (8%). Devices were implantable continuous flow (72%), paracorporeal pulsatile (18%) and paracorporeal continuous flow (10%). Catheterizations were performed on patients in the ICU (60%), on inotropic support (42%), with deteriorating clinical status (37%) and on BiVAD support (12%). There were 9 AEs possibly related to catheterization including 6 episodes of respiratory failure, 2 major bleeding events, and 1 procedural arrhythmia. AE occurrence was associated with ICU status (P = 0.01), BiVAD support (P = 0.04) and procedural indication to evaluate worsening clinical status (P = 0.04). Despite high medical acuity, catheterization can be performed with an acceptable AE profile in children on VAD support.
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10
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Van den Eynde J, Manlhiot C, Van De Bruaene A, Diller GP, Frangi AF, Budts W, Kutty S. Medicine-Based Evidence in Congenital Heart Disease: How Artificial Intelligence Can Guide Treatment Decisions for Individual Patients. Front Cardiovasc Med 2021; 8:798215. [PMID: 34926630 PMCID: PMC8674499 DOI: 10.3389/fcvm.2021.798215] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/09/2021] [Indexed: 01/06/2023] Open
Abstract
Built on the foundation of the randomized controlled trial (RCT), Evidence Based Medicine (EBM) is at its best when optimizing outcomes for homogeneous cohorts of patients like those participating in an RCT. Its weakness is a failure to resolve a clinical quandary: patients appear for care individually, each may differ in important ways from an RCT cohort, and the physician will wonder each time if following EBM will provide best guidance for this unique patient. In an effort to overcome this weakness, and promote higher quality care through a more personalized approach, a new framework has been proposed: Medicine-Based Evidence (MBE). In this approach, big data and deep learning techniques are embraced to interrogate treatment responses among patients in real-world clinical practice. Such statistical models are then integrated with mechanistic disease models to construct a “digital twin,” which serves as the real-time digital counterpart of a patient. MBE is thereby capable of dynamically modeling the effects of various treatment decisions in the context of an individual's specific characteristics. In this article, we discuss how MBE could benefit patients with congenital heart disease, a field where RCTs are difficult to conduct and often fail to provide definitive solutions because of a small number of subjects, their clinical complexity, and heterogeneity. We will also highlight the challenges that must be addressed before MBE can be embraced in clinical practice and its full potential can be realized.
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Affiliation(s)
- Jef Van den Eynde
- Department of Cardiovascular Sciences, KU Leuven and Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium.,Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, The Johns Hopkins Hospital and School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Cedric Manlhiot
- Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, The Johns Hopkins Hospital and School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Alexander Van De Bruaene
- Department of Cardiovascular Sciences, KU Leuven and Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium
| | - Gerhard-Paul Diller
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Alejandro F Frangi
- Department of Cardiovascular Sciences, KU Leuven and Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium.,Centre for Computational Imaging and Simulation Technologies in Biomedicine (CISTIB), School of Computing and Medicine, University of Leeds, Leeds, United Kingdom.,Leeds Institute for Cardiovascular and Metabolic Medicine, Schools of Medicine, University of Leeds, Leeds, United Kingdom
| | - Werner Budts
- Department of Cardiovascular Sciences, KU Leuven and Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium
| | - Shelby Kutty
- Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, The Johns Hopkins Hospital and School of Medicine, Johns Hopkins University, Baltimore, MD, United States
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11
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Martinez HR, Beasley GS, Goldberg JF, Absi M, Ryan KA, Guerrier K, Joshi VM, Johnson JN, Morin CE, Hurley C, Morrison RR, Rai P, Hankins JS, Bishop MW, Triplett BM, Ehrhardt MJ, Pui CH, Inaba H, Towbin JA. Pediatric Cardio-Oncology Medicine: A New Approach in Cardiovascular Care. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121200. [PMID: 34943396 PMCID: PMC8699848 DOI: 10.3390/children8121200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 12/11/2022]
Abstract
Survival for pediatric patients diagnosed with cancer has improved significantly. This achievement has been made possible due to new treatment modalities and the incorporation of a systematic multidisciplinary approach for supportive care. Understanding the distinctive cardiovascular characteristics of children undergoing cancer therapies has set the underpinnings to provide comprehensive care before, during, and after the management of cancer. Nonetheless, we acknowledge the challenge to understand the rapid expansion of oncology disciplines. The limited guidelines in pediatric cardio-oncology have motivated us to develop risk-stratification systems to institute surveillance and therapeutic support for this patient population. Here, we describe a collaborative approach to provide wide-ranging cardiovascular care to children and young adults with oncology diseases. Promoting collaboration in pediatric cardio-oncology medicine will ultimately provide excellent quality of care for future generations of patients.
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Affiliation(s)
- Hugo R. Martinez
- Division of Pediatric Cardiology, The Heart Institute at Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (G.S.B.); (J.F.G.); (M.A.); (K.A.R.); (K.G.); (V.M.J.); (J.N.J.); (J.A.T.)
- Correspondence:
| | - Gary S. Beasley
- Division of Pediatric Cardiology, The Heart Institute at Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (G.S.B.); (J.F.G.); (M.A.); (K.A.R.); (K.G.); (V.M.J.); (J.N.J.); (J.A.T.)
| | - Jason F. Goldberg
- Division of Pediatric Cardiology, The Heart Institute at Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (G.S.B.); (J.F.G.); (M.A.); (K.A.R.); (K.G.); (V.M.J.); (J.N.J.); (J.A.T.)
| | - Mohammed Absi
- Division of Pediatric Cardiology, The Heart Institute at Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (G.S.B.); (J.F.G.); (M.A.); (K.A.R.); (K.G.); (V.M.J.); (J.N.J.); (J.A.T.)
| | - Kaitlin A. Ryan
- Division of Pediatric Cardiology, The Heart Institute at Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (G.S.B.); (J.F.G.); (M.A.); (K.A.R.); (K.G.); (V.M.J.); (J.N.J.); (J.A.T.)
| | - Karine Guerrier
- Division of Pediatric Cardiology, The Heart Institute at Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (G.S.B.); (J.F.G.); (M.A.); (K.A.R.); (K.G.); (V.M.J.); (J.N.J.); (J.A.T.)
| | - Vijaya M. Joshi
- Division of Pediatric Cardiology, The Heart Institute at Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (G.S.B.); (J.F.G.); (M.A.); (K.A.R.); (K.G.); (V.M.J.); (J.N.J.); (J.A.T.)
| | - Jason N. Johnson
- Division of Pediatric Cardiology, The Heart Institute at Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (G.S.B.); (J.F.G.); (M.A.); (K.A.R.); (K.G.); (V.M.J.); (J.N.J.); (J.A.T.)
| | - Cara E. Morin
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
| | - Caitlin Hurley
- Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (C.H.); (R.R.M.)
- Department of Bone Marrow Transplantation & Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
| | - Ronald Ray Morrison
- Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (C.H.); (R.R.M.)
| | - Parul Rai
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (P.R.); (J.S.H.)
| | - Jane S. Hankins
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (P.R.); (J.S.H.)
| | - Michael W. Bishop
- Division of Solid Tumor, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
| | - Brandon M. Triplett
- Department of Bone Marrow Transplantation & Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
| | - Matthew J. Ehrhardt
- Division of Cancer Survivorship, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA
| | - Ching-Hon Pui
- Division of Leukemia/Lymphoma, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (C.-H.P.); (H.I.)
| | - Hiroto Inaba
- Division of Leukemia/Lymphoma, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (C.-H.P.); (H.I.)
| | - Jeffrey A. Towbin
- Division of Pediatric Cardiology, The Heart Institute at Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (G.S.B.); (J.F.G.); (M.A.); (K.A.R.); (K.G.); (V.M.J.); (J.N.J.); (J.A.T.)
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12
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Impact of Age on Emergency Resource Utilization and Outcomes in Pediatric and Young Adult Patients Supported with a Ventricular Assist Device. ASAIO J 2021; 68:1074-1082. [PMID: 34743138 PMCID: PMC9061895 DOI: 10.1097/mat.0000000000001603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
There are minimal data describing outcomes in ambulatory pediatric and young adult ventricular assist device (VAD)-supported patient populations. We performed a retrospective analysis of encounter-level data from 2006 to 2017 Nationwide Emergency Department Sample (NEDS) to compare emergency department (ED) resource utilization and outcomes for pediatric (≤18 years, n = 494) to young adult (19-29 years, n = 2,074) VAD-supported patient encounters. Pediatric encounters were more likely to have a history of congenital heart disease (11.3% vs. 4.8%). However, Pediatric encounters had lower admission/transfer rates (37.8% vs. 57.8%) and median charges ($3,334 (IQR $1,473-$19,818) vs. $13,673 ($3,331-$45,884)) (all p < 0.05). Multivariable logistic regression modeling revealed that age itself was not a predictor of admission, instead high acuity primary diagnoses and medical complexity were: (adjusted odds ratio; 95% confidence intervals): cardiac (3.0; 1.6-5.4), infection (3.4; 1.7-6.5), bleeding (3.9; 1.7-8.8), device complication (7.2; 2.7-18.9), and ≥1 chronic comorbidity (4.1; 2.5-6.7). In this largest study to date describing ED resource use and outcomes for pediatric and young adult VAD-supported patients, we found that, rather than age, high acuity presentations and comorbidities were primary drivers of clinical outcomes. Thus, reducing morbidity in this population should target comorbidities and early recognition of VAD-related complications.
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13
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Giorni C, Rizza A, Favia I, Amodeo A, Chiusolo F, Picardo SG, Luciani M, Di Felice G, Di Chiara L. Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options. Front Cardiovasc Med 2021; 8:671241. [PMID: 34540910 PMCID: PMC8440876 DOI: 10.3389/fcvm.2021.671241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
Pediatric mechanical circulatory support (MCS) is considered a strategy for heart failure management as a bridge to recovery and transplantation or as a destination therapy. The final outcome is significantly impacted by the number of complications that may occur during MCS. Children on ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) are at high risk for bleeding and thrombotic complications that are managed through anticoagulation. The first detailed guideline in pediatric VADs (Edmonton Anticoagulation and Platelet Inhibition Protocol) was based on conventional antithrombotic drugs, such as unfractionated heparin (UFH) and warfarin. UFH is the first-line anticoagulant in pediatric MCS, although its profile is not considered optimal in pediatric setting. The broad variation in heparin doses among children is associated with frequent occurrence of cerebrovascular accidents, bleeding, and thrombocytopenia. Direct thrombin inhibitors (DTIs) have been utilized as alternative strategies to heparin. Since 2018, bivalirudin has become the chosen anticoagulant in the long-term therapy of patients undergoing MCS implantation, according to the most recent protocols shared in North America. This article provides a review of the non-traditional anticoagulation strategies utilized in pediatric MCS, focusing on pharmacodynamics, indications, doses, and monitoring aspects of bivalirudin. Moreover, it exposes the efforts and the collaborations among different specialized centers, which are committed to an ongoing learning in order to minimize major complications in this special pediatric population. Further prospective trials regarding DTIs in a pediatric MCS setting are necessary and in specific well-designed randomized control trials between UFH and bivalirudin. To conclude, based on the reported literature, the clinical use of the bivalirudin in pediatric MCS seems to be a value added in controlling and maybe reducing thromboembolic complications. Further research is necessary to confirm all the results provided by this literature review.
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Affiliation(s)
- Chiara Giorni
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Alessandra Rizza
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Isabella Favia
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Antonio Amodeo
- Mechanical Circulatory Support Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Fabrizio Chiusolo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Sergio G Picardo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Matteo Luciani
- Department of Oncohematology, Haemostasis and Thrombosis Center, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Giovina Di Felice
- Hemostasis Laboratory, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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Godown J, Lambert AN. Minimizing the Risk of Severe Primary Graft Dysfunction in Infant Heart Transplant Recipients: Time for a Paradigm Shift. J Am Heart Assoc 2021; 10:e022184. [PMID: 34184546 PMCID: PMC8403289 DOI: 10.1161/jaha.121.022184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Justin Godown
- Division of Pediatric Cardiology Monroe Carell Jr. Children's Hospital at Vanderbilt Nashville TN
| | - A Nicole Lambert
- Division of Pediatric Cardiology Monroe Carell Jr. Children's Hospital at Vanderbilt Nashville TN
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15
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Avanceña ALV, Hutton DW, Lee J, Schumacher KR, Si MS, Peng DM. Cost-effectiveness of implantable ventricular assist devices in older children with stable, inotrope-dependent dilated cardiomyopathy. Pediatr Transplant 2021; 25:e13975. [PMID: 33481355 DOI: 10.1111/petr.13975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In a stable, inotrope-dependent pediatric patient with dilated cardiomyopathy, we evaluated the cost-effectiveness of continuous-flow VAD implantation compared to a watchful waiting approach using chronic inotropic therapy. METHODS We used a state-transition model to estimate the costs and outcomes of 14-year-old (INTERMACS profile 3) patients receiving either VAD or watchful waiting. We measured benefits in terms of lifetime QALYs gained. Model inputs were taken from the literature. We calculated the ICER, or the cost per additional QALY gained, of VADs and performed multiple sensitivity analyses to test how our assumptions influenced the results. RESULTS Compared to watchful waiting, VADs produce 0.97 more QALYs for an additional $156 639, leading to an ICER of $162 123 per QALY gained from a healthcare perspective. VADs have 17% chance of being cost-effective given a cost-effectiveness threshold of $100 000 per QALY gained. Sensitivity analyses suggest that VADs can be cost-effective if the costs of implantation decrease or if hospitalization costs or mortality among watchful waiting patients is higher. CONCLUSIONS As a bridge to transplant, VADs provide a health benefit to children who develop stable, inotrope-dependent heart failure, but immediate implantation is not yet a cost-effective strategy compared to watchful waiting based on commonly used cost-effectiveness thresholds. Early VAD support can be cost-effective in sicker patients and if device implantation is cheaper. In complex conditions such as pediatric heart failure, cost-effectiveness should be just one of many factors that inform clinical decision-making.
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Affiliation(s)
- Anton L V Avanceña
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - David W Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Department of Industrial and Operations Engineering, College of Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Josie Lee
- Undergraduate Program, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David M Peng
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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16
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Rea KE, McCormick AM, Lim HM, Cousino MK. Psychosocial outcomes in pediatric patients with ventricular assist devices and their families: A systematic review. Pediatr Transplant 2021; 25:e14001. [PMID: 33704884 PMCID: PMC8141009 DOI: 10.1111/petr.14001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 11/30/2022]
Abstract
Ventricular assist device (VAD) therapy has provided pediatric patients with severe heart failure new therapeutic options. However, pediatric patients and families receiving VAD therapy also experience psychosocial challenges. No synthesis of the literature on psychosocial outcomes within the pediatric VAD population has been conducted; thus, the current review sought to systematically investigate the impact of pediatric VAD on patient, parent, and family psychosocial outcomes and assess variables associated with poorer outcomes. Literature searches were conducted in PsycInfo, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases and full texts were assessed according to pre-established inclusion criteria. Main findings and study quality were reviewed. Sixteen studies were included in the present review. Findings highlighted the likelihood for psychological sequelae among pediatric patients and families receiving VAD therapy, including decreased psychological and emotional well-being, elevated stress, and difficulty coping with changes to family dynamics and responsibilities. Health-related quality of life was reported comparable to that of healthy peers and children with other cardiac conditions. Patients and families on VAD therapy experience significant difficulties in psychological well-being and challenges related to adjustment. The current review underscores the importance of ongoing support for families and continued assessment of psychosocial functioning across VAD support. Three critical periods for increased distress were identified: 1) immediately following VAD implantation, 2) discharge home and the weeks following discharge, and 3) long-term VAD therapy.
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Affiliation(s)
| | | | - Heang M. Lim
- Department of Pediatrics, Michigan Medicine, University of Michigan
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17
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Systemic ventricular assist device support in Fontan patients: A report by ACTION. J Heart Lung Transplant 2021; 40:368-376. [DOI: 10.1016/j.healun.2021.01.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/03/2021] [Accepted: 01/13/2021] [Indexed: 12/31/2022] Open
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18
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Perito ER, Squires JE, Bray D, Bucuvalas J, Krise-Confair C, Eisenberg E, Gonzalez-Peralta RP, Gupta N, Hsu EK, Kosmach-Park B, Lobritto S, Logan B, Mohammad S, Ng VL, Pillari T, Rasmussen S, Shemesh E, Soltys K, Szolna J, Superina R, Tunno J, Mazariegos GV. A Learning Health System for Pediatric Liver Transplant: The Starzl Network for Excellence in Pediatric Transplantation. J Pediatr Gastroenterol Nutr 2021; 72:417-424. [PMID: 33560758 DOI: 10.1097/mpg.0000000000002974] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Learning health systems (LHS) integrate research, improvement, management, and patient care, such that every child receives "the right care at the right time...every time," that is, evidence-based, personalized medicine. Here, we report our efforts to establish a sustainable, productive, multicenter LHS focused on pediatric liver transplantation. METHODS The Starzl Network for Excellence in Pediatric Transplantation (SNEPT) is the first multicenter effort by pediatric liver transplant families and providers to develop shared priorities and a shared agenda for innovation in clinical care. This report outlines SNEPT's structure, accomplishments, and challenges as an LHS. RESULTS We prioritized 4 initial projects: immunosuppression, perioperative anticoagulation, quality of life, and transition of care. We shared center protocols/management to identify areas of practice variability between centers. We prioritized actionable items that address barriers to providing "the right care at the right time" to every pediatric liver transplant recipient: facilitating transparency of practice variation and the connection of practices to patient outcomes, harnessing existing datasets to reduce the burden of tracking outcomes, incorporating patient-reported outcomes into outcome metrics, and accelerating the implementation of knowledge into clinical practice. This has allowed us to strengthen collaborative relationships, design quality improvement projects, and collect pilot data for each of our priority projects. CONCLUSIONS The field of pediatric liver transplantation can be advanced through application of LHS principles. Going forward, SNEPT will continue to unite patient advocacy, big data, technology, and transplant thought leaders to deliver the best care, while developing new, scalable solutions to pediatric transplantation's most challenging problems.
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Affiliation(s)
- Emily R Perito
- University of California San Francisco, Benioff Children's Hospital, San Francisco, CA
| | - James E Squires
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David Bray
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | - John Bucuvalas
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, NY
| | - Cassandra Krise-Confair
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Elizabeth Eisenberg
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | | | - Nitika Gupta
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Evelyn K Hsu
- University of Washington School of Medicine, Department of Pediatrics, Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, WA
| | - Beverly Kosmach-Park
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Steven Lobritto
- Columbia University Medical Center, Children's Hospital of New York, New York, NY
| | - Beth Logan
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Saeed Mohammad
- Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, IL
| | - Vicky L Ng
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Eyal Shemesh
- Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, NY
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Jonathan Szolna
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Riccardo Superina
- Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, IL
| | - John Tunno
- Patient and Family Voice. Starzl Network for Excellence in Pediatric Transplantation
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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19
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Stidham J, Feingold B, Almond CS, Burstein DS, Krack P, Price JF, Schumacher KR, Spinner JA, Rosenthal DN, Lorts A, Godown J. Establishing Baseline Metrics of Heart Failure Medication Use in Children: A Collaborative Effort from the ACTION Network. Pediatr Cardiol 2021; 42:315-323. [PMID: 33044586 DOI: 10.1007/s00246-020-02485-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
Heart failure metrics specific to the pediatric population are required to successfully implement quality improvement initiatives in children with heart failure. Medication use at the time of discharge following admission for decompensated heart failure has been identified as a potential quality metric in this population. This study aimed to report medication use at discharge in the current era for children admitted with acute decompensated heart failure. All patients < 21 years of age with an index admission (1/1/2011-12/31/2019) for acute heart failure and a coexisting diagnosis of cardiomyopathy were identified from the Pediatric Health Information System. Medication use patterns were described and compared across age groups and centers. A total of 2288 patients were identified for inclusion. An angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker (ACEi/ARB) was prescribed in 1479 (64.6%), beta blocker in 1132 (49.5%), and mineralocorticoid receptor antagonist (MRA) in 864 (37.8%) patients at discharge. The use of ACEi/ARB at discharge has decreased over time (64.6% vs. 69.6%, p = 0.001) and the use of beta blockers has increased (49.5% vs. 36.8%, p < 0.001) compared to a historical cohort (2001-2010). There is considerable variability in medication use across centers with an overall increase in beta blocker and decrease in ACEi/ARB use over time. Collaborative efforts are needed to standardize care and define quality metrics to identify best practices in the management of pediatric heart failure.
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Affiliation(s)
- Joseph Stidham
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian Feingold
- Division of Pediatric Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher S Almond
- Department of Pediatrics (Pediatric Cardiology), Stanford University, Palo Alto, CA, USA
| | - Danielle S Burstein
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Paige Krack
- Division of Pediatric Cardiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Jack F Price
- Division of Pediatric Cardiology, Texas Children's Hospital, Houston, TX, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Joseph A Spinner
- Division of Pediatric Cardiology, Texas Children's Hospital, Houston, TX, USA
| | - David N Rosenthal
- Department of Pediatrics (Pediatric Cardiology), Stanford University, Palo Alto, CA, USA
| | - Angela Lorts
- Division of Pediatric Cardiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Justin Godown
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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20
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Abstract
Pediatric heart failure is a complex, heterogenous syndrome that occurs relatively rarely in children, but carries a high burden of morbidity and mortality. This article reflects on the current state of medical therapy for both acute and chronic pediatric heart failure, based on expert consensus guidelines, and the extrapolation of data from trials performed in adults. For the management of acute heart failure specifically, we rely on an initial assessment of the perfusion and volume status of a patient, to guide medical therapy. This paradigm was adapted from adult studies that demonstrated increased morbidity and mortality in heart failure patients whose hemodynamics or examination findings were consistent with a PCWP >18 mmHg and a CI ≤2.2 L/min/m2. The cornerstone of treatment in the acute setting therefore relies on achieving a euvolemic state with adequate cardiac output. In the chronic setting, patients are typically maintained on a regimen of an angiotensin converting enzyme inhibitor, a beta-blocker, and spironolactone. For those with refractory heart failure, intravenous milrinone therapy has become a mainstay of bridging children to cardiac transplantation. The pediatric-specific data driving these clinical practices are limited and often times, conflicting. The future of pediatric heart failure depends on collaboration, quality improvement, and a commitment to pediatric-specific indications for new medical and device therapies.
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Affiliation(s)
- Humera Ahmed
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina VanderPluym
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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21
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Joong A, Gossett JG, Blume ED, Thrush P, Pahl E, Mongé MC, Backer CL, Patel A. Variability in clinical decision-making for ventricular assist device implantation in pediatrics. Pediatr Transplant 2020; 24:e13840. [PMID: 33070459 DOI: 10.1111/petr.13840] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/03/2020] [Accepted: 08/12/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Minimal data exist on clinical decision-making in VAD implantation in pediatrics. This study aims to identify areas of consensus/variability among pediatric VAD physicians in determining eligibility and factors that guide decision-making. METHODS An 88-item survey with clinical vignettes was sent to 132 pediatric HT cardiologists and surgeons at 37 centers. Summary statistics are presented for the variables assessed. RESULTS Total respondents were 65 (72% cardiologists, 28% surgeons) whose centers implanted 1-5 (34%), 6-10 (40%), or >10 (26%) VADs in the past year. Consensus varied by patients' age, diagnosis, and Pedimacs profile. Highest agreement to offer VAD (97%) was a mechanically ventilated teenager with dilated cardiomyopathy. Patients stable on inotropes were less likely offered VAD (11%-25%). SV infant with Pedimacs profile 2 had the most varied responses: 37% offered VAD; estimated survival ranged from 15% to 90%. Variables considered for VAD eligibility included mild developmental delays (100% offered VAD), moderate-severe behavioral concerns (46%), cancer in remission >2 years (100%), active malignancy with good prognosis (68%) or uncertain prognosis (36%), and BMI >35 (74%) or <15 (69%). Most respondents (91%) would consider destination therapy VADs in pediatrics, though not currently feasible at 1/3 of centers. Factors with greatest influence on decision-making included HT candidacy, families' goals of care, and risks of complications. CONCLUSIONS Significant variation exists among pediatric VAD physicians when determining VAD eligibility and estimating survival, which can lead to differences in access to emerging technologies across institutions. Further work is needed to understand and mitigate these differences.
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Affiliation(s)
- Anna Joong
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jeffrey G Gossett
- Division of Pediatric Cardiology, Benioff Children's Hospital, University of San Francisco California, San Francisco, CA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philip Thrush
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elfriede Pahl
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael C Mongé
- Division of Pediatric Cardiovascular Surgery, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK Healthcare Kentucky Children's Hospital, Lexington, KY, USA
| | - Angira Patel
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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23
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Discharge and Readmissions After Ventricular Assist Device Placement in the US Pediatric Hospitals: A Collaboration in ACTION. ASAIO J 2020; 67:785-791. [PMID: 33196481 DOI: 10.1097/mat.0000000000001307] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Discharging children on ventricular assist device (VAD) support offers advantages for quality of life. We sought to describe discharge and readmission frequency in children on VAD support. All VAD-implanted patients aged 10-21 years at Advanced Cardiac Therapies Improving Outcomes Network (ACTION) centers were identified from the Pediatric Health Information System database (2009-2018). Discharge frequency on VAD was calculated. Patients discharged on VAD were compared with those not discharged. Freedom from readmission was assessed using the Kaplan-Meier method. A total of 298 VAD-implanted patients from 25 centers were identified, of which 163 (54.7%) were discharged. Discharges increased over time (36.9% [2009-2012] vs. 59.7% [2013-2018], p = 0.001). Of 144 discharged patients with follow-up, 96 (66.7%) were readmitted for reasons other than transplantation. Heart failure was the most common reason for readmission (27.7%), followed by infection (25.8%) and hematologic concerns (16.8%). In-hospital mortality on readmission was uncommon (1.8%) and the median length of stay was 6 days (interquartile range 2-19 days). Discharge of children on VAD support has increased over time, although variability exists across centers. Readmissions are common with diverse indications; however, the risk of mortality is low. Further interventions, including collaboration in ACTION, are critical to increasing discharges and optimizing outpatient management.
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Hollander SA, Nandi D, Bansal N, Godown J, Zafar F, Rosenthal DN, Lorts A, Jeewa A. A coordinated approach to improving pediatric heart transplant waitlist outcomes: A summary of the ACTION November 2019 waitlist outcomes committee meeting. Pediatr Transplant 2020; 24:e13862. [PMID: 32985785 DOI: 10.1111/petr.13862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
The number of children needing heart transplantation continues to rise. Although improvements in heart failure therapy, particularly durable mechanical support, have reduced waitlist mortality, the number of children who die while waiting for a suitable donor organ remains unacceptably high. Roughly, 13% of children and 25% of infants on the heart transplant waitlist will not survive to transplantation. With this in mind, the Advanced Cardiac Therapies Improving Outcomes Collaborative Learning Network (ACTION), through its Waitlist Outcomes Committee, convened a 2-day symposium in Ann Arbor, Michigan, from 2-3 November 2019, to better understand the factors that contribute to pediatric heart transplant waitlist mortality and to focus future efforts on improving the organ allocation rates for children needing heart transplantation. Using improvement science methodology, the heart failure-transplant trajectory was broken down into six key steps, after which modes of failure and opportunities for improvement at each step were discussed. As a result, several projects aimed at reducing waitlist mortality were initiated.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Deipanjan Nandi
- Division of Pediatrics (Cardiology), Nationwide Children's Hospital, Columbus, OH, USA
| | - Neha Bansal
- Division of Pediatrics Cardiology, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Justin Godown
- Department of Pediatrics (Cardiology), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Aamir Jeewa
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, USA
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Abstract
PURPOSE OF REVIEW The goal of this paper is to provide an overview of contemporary knowledge specific to the causes, management, and outcome of heart failure in children. RECENT FINDINGS While recently there have been subtle improvements in heart failure outcomes in children, these improvements lag significantly behind that of adults. There is a growing body of literature suggesting that pediatric heart failure is a unique disease process with age- and disease-specific myocardial adaptations. In addition, the heterogenous etiologies of heart failure in children contribute to differential response to therapies and challenge the ability to obtain meaningful results from prospective clinical trials. Consideration of novel clinical trial designs with achievable but clinically relevant endpoints and focused study of the mechanisms underlying pediatric heart failure secondary to cardiomyopathies and structural heart disease are essential if we hope to advance care and identify targeted and effective therapies.
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Affiliation(s)
| | - Anastacia M Garcia
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Roni M Jacobsen
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Shelley D Miyamoto
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA.
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O'Connor MJ, Lorts A, Davies RR, Fynn-Thompson F, Joong A, Maeda K, Mascio CE, McConnell PI, Mongé MC, Nandi D, Peng DM, Rosenthal DN, Si MS, Sutcliffe DL, VanderPluym CJ, Viegas M, Zafar F, Zinn M, Morales DL. Early experience with the HeartMate 3 continuous-flow ventricular assist device in pediatric patients and patients with congenital heart disease: A multicenter registry analysis. J Heart Lung Transplant 2020; 39:573-579. [DOI: 10.1016/j.healun.2020.02.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/31/2020] [Accepted: 02/06/2020] [Indexed: 11/17/2022] Open
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Rohde S, Antonides CFJ, Muslem R, van de Woestijne PC, van der Meulen MH, Kraemer US, Dalinghaus M, Bogers AJJC. Pediatric Ventricular Assist Device Support in the Netherlands. World J Pediatr Congenit Heart Surg 2020; 11:275-283. [PMID: 32294020 PMCID: PMC7163248 DOI: 10.1177/2150135120902114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/20/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND This study aimed to evaluate the changes in heart transplantation (HTx) waiting list mortality following the introduction of the Berlin Heart EXCOR (BH EXCOR) in the Netherlands, as well as the occurrence of adverse events in these children. METHODS A retrospective, single-center study was conducted including all pediatric patients (≤18 years) awaiting HTx. Patients were grouped in two eras based on availability of the BH EXCOR in our center, era I (1998-2006; not available) and era II (2007 to July 31, 2018; available). RESULTS In total, 87 patients were included, 15 in era I and 72 in era II. Extracorporeal membrane oxygenator support was required in 1 (7%) patient in era I and in 13 (18%) patients in era II. Overall mortality (7/15 in era I vs 16/72 in era II; 47% vs 22%, P = .06) and transplantation rates (8/15 in era I vs 47/72 in era II; 53% vs 65%, P = .39) did not differ significantly. Eleven (39%) patients of the pediatric ventricular assist device (VAD) population died, with the predominant cause being cerebrovascular accidents (CVAs) in eight (29%) patients. Furthermore, 14 (50%) of the pediatric VAD patients survived to transplantation. Adverse events most frequently occurring in VAD patients included CVA in 14 (50%), mostly (68%) within 30 days after VAD implantation, and bleeding requiring rethoracotomy in 14 (50%), all within 30 days after VAD implantation. CONCLUSIONS The introduction of the BH EXCOR has positively impacted the survival of pediatric patients with end-stage heart failure in our center. The predominant cause of death changed from end-stage heart failure in era I to CVA in era II. We emphasize the need for large prospective registry-based studies.
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Affiliation(s)
- Sofie Rohde
- Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the
Netherlands
| | | | - Rahatullah Muslem
- Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the
Netherlands
| | | | | | - Ulrike S. Kraemer
- Pediatric Cardiology, Erasmus University Medical Center, Rotterdam, the
Netherlands
- Pediatric Intensive Care Unit, Erasmus University Medical Center, Rotterdam,
the Netherlands
| | - Michiel Dalinghaus
- Pediatric Cardiology, Erasmus University Medical Center, Rotterdam, the
Netherlands
| | - Ad J. J. C. Bogers
- Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the
Netherlands
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Square Peg, Round Hole. Ventricular Assist Devices in Single Ventricles. How do We Get it Right? ASAIO J 2020; 66:212-213. [PMID: 32000195 DOI: 10.1097/mat.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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