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Milligan C, Williams RJ, Singh TP, Bastardi HJ, Esteso P, Almond CS, Gauvreau K, Daly KP. Impact of a positive crossmatch on pediatric heart transplant outcomes. J Heart Lung Transplant 2024:S1053-2498(24)01501-8. [PMID: 38423415 DOI: 10.1016/j.healun.2024.02.1457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 02/08/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Pediatric heart transplant (HT) candidates experience high waitlist mortality due to a limited donor pool that is constrained in part by anti-HLA sensitization. We evaluated the impact of CDC and Flow donor-specific crossmatch (XM) results on pediatric HT outcomes. METHODS All pediatric HTs between 1999 and 2019 in the OPTN database were included. Donor-specific XM results were sub-categorized based on CDC and Flow results. Primary outcomes were treated rejection in the first year and time to death or allograft loss. Propensity scores were utilized to adjust for differences in baseline characteristics. RESULTS A total of 4,695 pediatric HT patients with T-cell XM data were included. After propensity score adjustment, a positive T-cell CDC-XM was associated with 2 times higher odds of treated rejection (OR 2.29 (1.56, 3.37)) and shorter time to death/allograft loss (HR 1.50 (1.19, 1.88)) compared to a negative Flow-XM. HT recipients who were Flow-XM positive with negative/unknown CDC-XM did not have higher odds of rejection or shorter time to death/allograft loss. An isolated positive B-cell XM was also not associated with worse outcomes. Over the study period XM testing shifted from CDC- to Flow-based assays. CONCLUSIONS A positive donor-specific T-cell CDC-XM was associated with rejection and death/allograft loss following pediatric HT. This association was not observed with a positive T-cell Flow-XM or B-cell XM result alone. The shift away from performing the CDC-XM may result in loss of important prognostic information unless the clinical relevance of quantitative Flow-XM results on heart transplant outcomes is systematically studied.
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Affiliation(s)
- Caitlin Milligan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Ryan J Williams
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Tajinder P Singh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Heather J Bastardi
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Paul Esteso
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Almond
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Kevin P Daly
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
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Chubb H, Mah DY, Shah M, Lin KY, Peng DM, Hale BW, May L, Etheridge S, Goodyer W, Ceresnak SR, Motonaga KS, Rosenthal DN, Almond CS, McElhinney DB, Dubin AM. Multicenter Study of Survival Benefit of Cardiac Resynchronization Therapy in Pediatric and Congenital Heart Disease. JACC Clin Electrophysiol 2023:S2405-500X(23)00836-8. [PMID: 38206260 DOI: 10.1016/j.jacep.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Evidence for the efficacy of cardiac resynchronization therapy (CRT) in pediatric and congenital heart disease (CHD) has been limited to surrogate outcomes. OBJECTIVES This study aimed to assess the impact of CRT upon the risk of transplantation or death in a retrospective, high-risk, controlled cohort at 5 quaternary referral centers. METHODS Both CRT patients and control patients were <21 years of age or had CHD; had systemic ventricular ejection fraction <45%; symptomatic heart failure; and significant electrical dyssynchrony (QRS duration z score >3 or single-site ventricular pacing >40%) at enrollment. Patients with CRT were matched with control patients via 1:1 propensity score matching. CRT patients were enrolled at CRT implantation; control patients were enrolled at the outpatient clinical encounter where inclusion criteria were first met. The primary endpoint was transplantation or death. RESULTS In total, 324 control patients and 167 CRT recipients were identified. Mean follow-up was 4.2 ± 3.7 years. Upon propensity score matching, 139 closely matched pairs were identified (20 baseline indices). Of the 139 matched pairs, 52 (37.0%) control patients and 31 (22.0%) CRT recipients reached the primary endpoint. On both unadjusted and multivariable Cox regression analysis, the risk reduction associated with CRT for the primary endpoint was significant (HR: 0.40; 95% CI: 0.25-0.64; P < 0.001; and HR: 0.44; 95% CI: 0.28-0.71; P = 0.001, respectively). On longitudinal assessment, the CRT group had significantly improved systemic ventricular ejection fraction (P < 0.001) and shorter QRS duration (P = 0.015), sustained to 5 years. CONCLUSIONS In pediatric and CHD patients with symptomatic systolic heart failure and electrical dyssynchrony, CRT was associated with improved heart transplantation-free survival.
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Affiliation(s)
- Henry Chubb
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Boston Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston Massachusetts, USA
| | - Maully Shah
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly Y Lin
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David M Peng
- Department of Cardiology, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Benjamin W Hale
- Department of Cardiology, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsay May
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Susan Etheridge
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - William Goodyer
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Scott R Ceresnak
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Kara S Motonaga
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Christopher S Almond
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Doff B McElhinney
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
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Zook N, Schultz L, Rizzuto S, Aufdermauer A, Hollander AM, Almond CS, Hollander SA. Supplemental nutrition, feeding disorders, and renourishment in pediatric heart failure through transplantation. Pediatr Transplant 2023; 27:e14601. [PMID: 37706571 DOI: 10.1111/petr.14601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Tube feeds are used commonly in children listed for heart transplant; however, rates of renourishment and development of feeding disorders are not sufficiently characterized. METHODS Retrospective review of pediatric heart transplant recipients from January 1, 2014, to January 3, 2021. Demographics, anthropometric, and nutritional data were collected from heart transplant listing through 3 years post-transplant. Renourishment rates, presence of a feeding disorder, and need for a gastric feeding tube were analyzed. Multivariable analysis was conducted to identify risks for poor nutritional outcomes. RESULTS Of 104 patients, 35 (34%) and 36 (35%) were malnourished at heart transplant listing and transplant, respectively, persisting in 21/91 (23%) 1 year postheart transplant. Forty (38%) received tube feeds at listing, 42 (40%) at heart transplant, and 18/90 (20%) 1 year post-transplant. Rates of feeding disorders fell from 23% at transplantation to 10% 1 year post-transplant. Feeding disorders were associated with younger age at heart transplant (p < .001) and congenital heart disease (p = .03). Forty-six percent of infants required a gastric feeding tube. Renourishment occurred in 20% during listing and was associated with ventricular assist device support (p = .03) and noncalorically dense feeds (p = .03). Malnutrition at transplant was associated with inferior post-transplant survival (6/36 (17%) vs. 2/68 (3%); p = .02). CONCLUSIONS Malnourishment requiring tube feeds is common in pediatric heart transplant candidates; however, most patients who eventually survive to transplant remain malnourished at time of transplantation and 1 year later. While some children develop feeding disorders, they generally resolve by 1 year post-transplant.
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Affiliation(s)
- Nina Zook
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Lisa Schultz
- Department of Nutrition Services, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Sandra Rizzuto
- Department of Occupational Therapy, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Amanda Aufdermauer
- Department of Nutrition Services, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Amanda M Hollander
- Department of Physical Therapy, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Christopher S Almond
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
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Khan RS, Khoury PR, Zafar F, Morales DL, Chin C, Peng DM, Almond CS, Burstein DS, Odeniyi F, Wittekind SG. Functional status predicts pediatric heart transplant outcomes: A united network for organ sharing (UNOS) database study. J Heart Lung Transplant 2023; 42:964-973. [PMID: 37029062 DOI: 10.1016/j.healun.2023.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 12/18/2022] [Accepted: 02/13/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Functional status predicts waitlist survival in adult heart transplantation and is an independent predictor of outcomes in pediatric liver transplantation. This has not been studied in pediatric heart transplantation. Study aims were to determine the association of: (1) functional status at listing with waitlist and post-transplant outcomes, and (2) functional status at transplant with post-transplant outcomes in pediatric heart transplantation. METHODS Retrospective United Network of Organ Sharing database study of pediatric patients listed for heart transplant between 2005 and 2019 with Lansky Play Performance Scale (LPPS) scores at listing. Standard statistical methods were used to assess relationships between LPPS and outcomes (waitlist and post-transplant). Negative waitlist outcome was defined as death or removal from waitlist due to clinical deterioration. RESULTS There were 4,169 patients identified, including 1,080 with LPPS 80-100 (normal activity), 1,603 with LPPS 50-70 (mild limitations), and 1,486 with LPPS 10-40 (severe limitations). LPPS 10-40 correlated with negative waitlist outcomes (HR 1.69, CI 1.59-1.80, p < 0.0001). While LLPS at listing had no association with post-transplant survival, those with LPPS 10-40 at transplant had inferior 1-year post-transplant survival compared to those with LPPS ≥50 (92% vs 95%-96%, p = 0.0011). Functional status was an independent predictor of post-transplant outcomes in patients with cardiomyopathy. A functional improvement of ≥20 points between listing and transplant (N = 770, 24%) was associated with higher 1-year post-transplant survival (HR 1.63, 95% CI: 1.10-2.41, p = 0.018). CONCLUSIONS Functional status is associated with waitlist and post-transplant outcomes. Interventions targeting functional impairment may improve pediatric heart transplantation outcomes.
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Affiliation(s)
- Rabia S Khan
- University of Iowa Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa.
| | - Philip R Khoury
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Farhan Zafar
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L Morales
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Clifford Chin
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David M Peng
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | - Danielle S Burstein
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Samuel G Wittekind
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Kaufman BD, Garcia A, He Z, Tesi-Rocha C, Buu M, Rosenthal D, Gordish-Dressman H, Almond CS, Duong T. Major Adverse Dystrophinopathy Events (MADE) Score as Marker of Cumulative Morbidity and Risk for Mortality in Boys with Duchenne Muscular Dystrophy. Prog Pediatr Cardiol 2023; 69:101639. [PMID: 37990740 PMCID: PMC10659574 DOI: 10.1016/j.ppedcard.2023.101639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Background Overlapping symptoms from cardiomyopathy, respiratory insufficiency, and skeletal myopathy confound assessment of heart failure in Duchenne Muscular Dystrophy. We developed an ordinal scale of multiorgan clinical variables that reflect cumulative disease burden-the Major Adverse Dystrophinopathy Event (MADE) Score. We hypothesized that a higher MADE score would be associated with increased mortality in boys with Duchenne Muscular Dystrophy. The Cooperative International Neuromuscular Research Group Duchenne Natural History Study dataset was utilized for validation. Methods Duchenne Natural History Study variables were selected based on clinical relevance to prespecified domains: Cardiac, Pulmonary, Myopathy, Nutrition. Severity points (0-4) were assigned and summed for study visits. MADE score for cohorts defined by age, ambulatory status, and survival were compared at enrollment and longitudinally.Associations between MADE score and mortality were examined. Results Duchenne Natural History Study enrolled 440 males, 12.6 ±6.1 years old, with 3,559 visits over 4.6 ±2.8 years, 45 deaths. MADE score increased with age and nonambulatory status. Mean MADE score per visit was 19 ±10 for those who died vs. 9.8 ±9.3 in survivors p=0.03. Baseline MADE score >12 predicted mortality independent of age (78% sensitivity, CPE.70). Rising MADE score trajectory was associated with mortality in models adjusted for enrollment age, follow-up time, and ambulatory status, all p<.001. Conclusion A multiorgan severity score, MADE, was developed to track cumulative morbidities that impact heart failure in Duchenne muscular dystrophy. MADE score predicted Duchenne Natural History Study mortality. MADE score can be used for serial heart failure assessment in males and may serve as an endpoint for Duchenne muscular dystrophy clinical research.
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Affiliation(s)
- Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Ariadna Garcia
- Quantitative Sciences Unit, Stanford University, Palo Alto, CA
| | - Zihuai He
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA
| | - Carolina Tesi-Rocha
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA
| | - MyMy Buu
- Department of Pediatrics (Pulmonary Medicine), Stanford University School of Medicine, Palo Alto, CA
| | - David Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | | | - Christopher S Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Tina Duong
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA
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Almond CS, Sleeper LA, Rossano JW, Bock MJ, Pahl E, Auerbach S, Lal A, Hollander SA, Miyamoto SD, Castleberry C, Lee J, Barkoff LM, Gonzales S, Klein G, Daly KP. The teammate trial: Study design and rationale tacrolimus and everolimus against tacrolimus and MMF in pediatric heart transplantation using the major adverse transplant event (MATE) score. Am Heart J 2023; 260:100-112. [PMID: 36828201 DOI: 10.1016/j.ahj.2023.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Currently there are no immunosuppression regimens FDA-approved to prevent rejection in pediatric heart transplantation (HT). In recent years, everolimus (EVL) has emerged as a potential alternative to standard tacrolimus (TAC) as the primary immunosuppressant to prevent rejection that may also reduce the risk of cardiac allograft vasculopathy (CAV), chronic kidney disease (CKD) and cytomegalovirus (CMV) infection. However, the 2 regimens have never been compared head-to-head in a randomized trial. The study design and rationale are reviewed in light of the challenges inherent in rare disease research. METHODS The TEAMMATE trial (IND 127980) is the first multicenter randomized clinical trial (RCT) in pediatric HT. The primary purpose is to evaluate the safety and efficacy of EVL and low-dose TAC (LD-TAC) compared to standard-dose TAC and mycophenolate mofetil (MMF). Children aged <21 years at HT were randomized (1:1 ratio) at 6 months post-HT to either regimen, and followed for 30 months. Children with recurrent rejection, multi-organ transplant recipients, and those with an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m2 were excluded. The primary efficacy hypothesis is that, compared to TAC/MMF, EVL/LD-TAC is more effective in preventing 3 MATEs: acute cellular rejection (ACR), CKD and CAV. The primary safety hypothesis is that EVL/LD-TAC does not have a higher cumulative burden of 6 MATEs (antibody mediated rejection [AMR], infection, and post-transplant lymphoproliferative disorder [PTLD] in addition to the 3 above). The primary endpoint is the MATE score, a composite, ordinal surrogate endpoint reflecting the frequency and severity of MATEs that is validated against graft loss. The study had a target sample size of 210 patients across 25 sites and is powered to demonstrate superior efficacy of EVL/LD-TAC. Trial enrollment is complete and participant follow-up will be completed in 2023. CONCLUSION The TEAMMATE trial is the first multicenter RCT in pediatric HT. It is anticipated that the study will provide important information about the safety and efficacy of everolimus vs tacrolimus-based regimens and will provide valuable lessons into the design and conduct of future trials in pediatric HT.
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Affiliation(s)
- Christopher S Almond
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA.
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Joseph W Rossano
- Department of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Matthew J Bock
- Division of Pediatric Cardiology, Loma Linda University Children's Hospital, Loma Linda University School of Medicine, Loma Linda, CA
| | - Elfriede Pahl
- Department of Pediatrics, Lurie Children's Hospital, Northwestern School of Medicine, Chicago, IL
| | - Scott Auerbach
- Children's Hospital Colorado Heart Institute, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Ashwin Lal
- Department of Pediatrics Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Seth A Hollander
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Shelley D Miyamoto
- Children's Hospital Colorado Heart Institute, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Chesney Castleberry
- Departments of Pediatrics, St. Louis Children's Hospital, Washington University in Saint Louis, Saint Louis, MO
| | - Joanne Lee
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Lynsey M Barkoff
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Selena Gonzales
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Gloria Klein
- Department of Cardiology, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin P Daly
- Department of Cardiology, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA
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Lubert AM, Cedars A, Almond CS, Amdani S, Conway J, Friedland-Little JM, Gajarski RJ, Kindel SJ, Lorts A, Morales DLS, O'Connor MJ, Peng DM, Rosenthal DN, Smyth L, Sutcliffe DL, Schumacher KR. Considerations for Advanced Heart Failure Consultation in Individuals With Fontan Circulation: Recommendations From ACTION. Circ Heart Fail 2023; 16:e010123. [PMID: 36786204 DOI: 10.1161/circheartfailure.122.010123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Individuals with Fontan circulation are at risk of late mortality from both cardiac and noncardiac causes. Despite the known risk of mortality, referral indications for advanced heart failure care vary between centers, and many individuals die from Fontan circulation-related complications either after late consideration for advanced heart failure therapies or having never seen a heart failure specialist. There is a critical need for guidelines to direct appropriately timed referral for advanced heart failure consultation. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Fontan Committee has developed recommended thresholds for advanced heart failure referral to guide primary cardiologists. These recommendations are divided into 4 categories of clinical Fontan circulatory dysfunction including (1) cardiac/systemic ventricular dysfunction, (2) Fontan pathway dysfunction, (3) lymphatic dysfunction, and (4) extracardiac dysfunction.
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Affiliation(s)
- Adam M Lubert
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, OH (A.M.L., A.L., D.L.S.M., L.S.)
| | - Ari Cedars
- Johns Hopkins University, Baltimore, MD (A.C.)
| | - Christopher S Almond
- Stanford University School of Medicine (Pediatrics) and Stanford Children's Health, Palo Alto, CA (C.S.A., D.N.R.)
| | | | - Jennifer Conway
- Stollery Children's Hospital, Edmonton, Alberta, Canada (J.C.)
| | | | | | - Steven J Kindel
- Children's Hospital of Wisconsin and Herma Heart Institute, Medical College of Wisconsin, Milwaukee (S.J.K.)
| | - Angela Lorts
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, OH (A.M.L., A.L., D.L.S.M., L.S.)
| | - David L S Morales
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, OH (A.M.L., A.L., D.L.S.M., L.S.)
| | | | - David M Peng
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor (D.M.P., K.R.S.)
| | - David N Rosenthal
- Stanford University School of Medicine (Pediatrics) and Stanford Children's Health, Palo Alto, CA (C.S.A., D.N.R.)
| | - Lauren Smyth
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, OH (A.M.L., A.L., D.L.S.M., L.S.)
| | | | - Kurt R Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor (D.M.P., K.R.S.)
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Nasirov T, Dykes JC, Hollander SA, Almond CS, Reinhartz O, Maeda K, Martin E, Murray J, Chen S, Chen CY, Kaufman BD, Bernstein D, Profita EL, Rosenthal DN, Ma M. PEDS3: Twenty Years of Pediatric Ventricular Assist Device Support at a Single Institution. ASAIO J 2022. [DOI: 10.1097/01.mat.0000841104.02767.6a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Levy JH, Faraoni D, Almond CS, Baumann-Kreuziger L, Bembea MM, Connors JM, Dalton HJ, Davies R, Dumont LJ, Griselli M, Karkouti K, Massicotte MP, Teruya J, Thiagarajan RR, Spinella PC, Steiner ME. Consensus Statement: Hemostasis Trial Outcomes in Cardiac Surgery and Mechanical Support. Ann Thorac Surg 2022; 113:1026-1035. [PMID: 34826386 DOI: 10.1016/j.athoracsur.2021.09.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/08/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Research evaluating hemostatic agents for the treatment of clinically significant bleeding has been hampered by inconsistency and lack of standardized primary clinical trial outcomes. Clinical trials of hemostatic agents in both cardiac surgery and mechanical circulatory support, such as extracorporeal membrane oxygenation and ventricular assist devices, are examples of studies that lack implementation of universally accepted outcomes. METHODS A subgroup of experts convened by the National Heart, Lung, and Blood Institute and the US Department of Defense developed consensus recommendations for primary outcomes in cardiac surgery and mechanical circulatory support. RESULTS For cardiac surgery the primary efficacy endpoint of total allogeneic blood products (units vs mL/kg for pediatric patients) administered intraoperatively and postoperatively through day 5 or hospital discharge is recommended. For mechanical circulatory support outside the perioperative period the recommended primary outcome for extracorporeal membrane oxygenation is a 5-point ordinal score of thrombosis and bleeding severity adapted from the Common Terminology Criteria for Adverse Events version 5.0. The recommended primary endpoint for ventricular assist device is freedom from disabling stroke (Common Terminology Criteria for Adverse Events AE ≥ grade 3) through day 180. CONCLUSIONS The proposed composite risk scores could impact the design of upcoming clinical trials and enable comparability of future investigations. Harmonizing and disseminating global consensus definitions and management guidelines can also reduce patient heterogeneity that would confound standardized primary outcomes in future research.
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Affiliation(s)
- Jerrold H Levy
- Division Cardiothoracic Anesthesiology and Critical Care, Departments of Anesthesiology and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina.
| | - David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Almond
- Heart Failure Service, Cardiac Anticoagulation Service, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California
| | | | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heidi J Dalton
- INOVA Heart and Vascular Institute; Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, Virginia
| | - Ryan Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Larry J Dumont
- Vitalant Research Institute, Denver, Colorado; Department of Pathology, University of Colorado Medical School, Denver, Colorado; Department of Pathology and Laboratory Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Massimo Griselli
- Division of Pediatric Cardiovascular Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Keyvan Karkouti
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Patricia Massicotte
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Department of Pathology and Immunology, Pediatrics and Medicine, Texan Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ravi R Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Marie E Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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10
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Spinella PC, Kassar NE, Cap AP, Kindzelski AL, Almond CS, Barkun A, Gernsheimer TB, Goldstein JN, Holcomb JB, Iorio A, Jensen DM, Key NS, Levy JH, Mayer SA, Moore EE, Stanworth SJ, Lewis RJ, Steiner ME. Recommended primary outcomes for clinical trials evaluating hemostatic blood products and agents in patients with bleeding: Proceedings of a National Heart Lung and Blood Institute and US Department of Defense Consensus Conference. J Trauma Acute Care Surg 2021; 91:S19-S25. [PMID: 34039915 PMCID: PMC9032809 DOI: 10.1097/ta.0000000000003300] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
ABSTRACT High-quality evidence guiding optimal transfusion and other supportive therapies to reduce bleeding is needed to improve outcomes for patients with either severe bleeding or hemostatic disorders that are associated with poor outcomes. Alongside challenges in performing high-quality clinical trials in patient populations who are at risk of bleeding or who are actively bleeding, the interpretation of research evaluating hemostatic agents has been limited by inconsistency in the choice of primary trial outcomes. This lack of standardization of primary endpoints or outcomes decreases the ability of clinicians to assess the validity of endpoints and compare research results across studies, impairs meta-analytic efforts, and, ultimately, delays the translation of research results into clinical practice. To address this challenge, an international panel of experts was convened by the National Heart Lung and Blood Institute and the US Department of Defense on September 23 and 24, 2019, to develop expert opinion, consensus-based recommendations for primary clinical trial outcomes for pivotal trials in pediatric and adult patients with six categories in various clinical settings. This publication documents the conference proceedings from the workshop funded by the National Heart Lung and Blood Institute and the US Department of Defense that consolidated expert opinion regarding clinically meaningful outcomes across a wide range of disciplines to provide guidance for outcomes of future trials of hemostatic products and agents for patients with active bleeding.
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Affiliation(s)
- Philip C. Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Andrew P. Cap
- US Army Institute of Surgical Research, Ft Sam Houston, TX
| | | | | | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre Montréal, Québec, Canada
| | | | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John B. Holcomb
- Department of Surgery, Center for Injury Science, Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Alfonso Iorio
- Division of Hematology and Thromboembolism, Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton Ontario L8S 4K Canada
| | - Dennis M. Jensen
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095
| | - Nigel S. Key
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599
| | - Jerrold H. Levy
- Department of Anesthesiology and Critical Care, Duke University Medical Center, Durham, NC 27710 USA
| | - Stephan A. Mayer
- Departments of Neurology and Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla NY 10595
| | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, University of Colorado Denver, Denver, Colorado 80204 USA
| | - Simon J. Stanworth
- Oxford University, Oxford, United Kingdom, The John Radcliffe Hospital, Oxford, GBR NHSBT, Oxford, United Kingdom
| | - Roger J. Lewis
- Berry Consultants LLC, Austin TX 78746
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles California 90095 USA
| | - Marie E. Steiner
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Division of Pediatric Critical Care Medicine, University of Minnesota Medical School, Minneapolis, MN 55455 USA
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11
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Dykes JC, Rosenthal DN, Bernstein D, McElhinney DB, Chrisant MRK, Daly KP, Ameduri RK, Knecht K, Richmond ME, Lin KY, Urschel S, Simmonds J, Simpson KE, Albers EL, Khan A, Schumacher K, Almond CS, Chen S. Clinical and hemodynamic characteristics of the pediatric failing Fontan. J Heart Lung Transplant 2021; 40:1529-1539. [PMID: 34412962 DOI: 10.1016/j.healun.2021.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 07/02/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022] Open
Abstract
AIM To describe the clinical and hemodynamic characteristics of Fontan failure in children listed for heart transplant. METHODS In a nested study of the Pediatric Heart Transplant Society, 16 centers contributed information on Fontan patients listed for heart transplant between 2005and 2013. Patients were classified into four mutually exclusive phenotypes: Fontan with abnormal lymphatics (FAL), Fontan with reduced systolic function (FRF), Fontan with preserved systolic function (FPF), and Fontan with "normal" hearts (FNH). Primary outcome was waitlist and post-transplant mortality. RESULTS 177 children listed for transplant were followed over a median 13 (IQR 4-31) months, 84 (47%) were FAL, 57 (32%) FRF, 22 (12%) FNH, and 14 (8%) FPF. Hemodynamic characteristics differed between the 4 groups: Fontan pressure (FP) was most elevated with FPF (median 22, IQR 18-23, mmHg) and lowest with FAL (16, 14-20, mmHg); cardiac index (CI) was lowest with FRF (2.8, 2.3-3.4, L/min/m2). In the entire cohort, 66% had FP >15 mmHg, 21% had FP >20 mmHg, and 10% had CI <2.2 L/min/m2. FRF had the highest risk of waitlist mortality (21%) and FNH had the highest risk of post-transplant mortality (36%). CONCLUSIONS Elevated Fontan pressure is more common than low cardiac output in pediatric failing Fontan patients listed for transplant. Subtle hemodynamic differences exist between the various phenotypes of pediatric Fontan failure. Waitlist and post-transplant mortality risks differ by phenotype.
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Affiliation(s)
- John C Dykes
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University.
| | - David N Rosenthal
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University
| | - Daniel Bernstein
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University
| | - Doff B McElhinney
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University; Department of Cardiovascular Surgery, Stanford University
| | | | - Kevin P Daly
- Boston Children's Hospital, Harvard Medical School
| | | | - Kenneth Knecht
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences
| | - Marc E Richmond
- Morgan Stanley Children's Hospital, Columbia University College of Physicians & Surgeons
| | - Kimberly Y Lin
- Children's Hospital of Philadelphia, University of Pennsylvania
| | | | | | | | - Erin L Albers
- Seattle Children's Hospital, University of Washington
| | - Asma Khan
- Ann and Robert H Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | | | - Christopher S Almond
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University
| | - Sharon Chen
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Almond CS, Chen S, Dykes JC, Kwong J, Burstein DS, Rosenthal DN, Kipps AK, Teuteberg J, Murray JM, Kaufman BD, Hollander SA, Profita E, Yarlagadda VY, Sacks LD, Chen CY. The Stanford acute heart failure symptom score for patients hospitalized with heart failure. J Heart Lung Transplant 2020; 39:1250-1259. [DOI: 10.1016/j.healun.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/24/2020] [Accepted: 08/02/2020] [Indexed: 11/17/2022] Open
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14
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Chen CY, Chen SF, Hollander SA, Rosenthal D, Maeda K, Burgart A, Almond CS, Chen S. Donor heart selection during the COVID-19 pandemic: A case study. J Heart Lung Transplant 2020; 39:497-498. [PMID: 32362395 PMCID: PMC7193142 DOI: 10.1016/j.healun.2020.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/21/2020] [Accepted: 03/21/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Chiu-Yu Chen
- Department of Pediatrics, Divisions of Pediatric Cardiology
| | | | | | | | | | - Alyssa Burgart
- Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California
| | | | - Sharon Chen
- Department of Pediatrics, Divisions of Pediatric Cardiology
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15
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Chubb H, Rosenthal DN, Almond CS, Ceresnak SR, Motonaga KS, Arunamata AA, Long J, Trela AV, Hanisch D, McElhinney DB, Dubin AM. Impact of Cardiac Resynchronization Therapy on Heart Transplant-Free Survival in Pediatric and Congenital Heart Disease Patients. Circ Arrhythm Electrophysiol 2020; 13:e007925. [PMID: 32202126 DOI: 10.1161/circep.119.007925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) studies in pediatric or congenital heart disease patients have shown an improvement in ejection fraction and heart failure symptoms. However, a survival benefit of CRT in this population has not been established. This study aimed to evaluate the impact of CRT upon heart transplant-free survival in pediatric and congenital heart disease patients, using a propensity score-matched (PSM) analysis. METHODS This single-center study compared CRT patients (implant date, 2004-2017) and controls, matched by 1:1 PSM using 21 comprehensive baseline indices for risk stratification. CRT patients were <21 years of age or had congenital heart disease, had systemic ventricular ejection fraction <45%, symptomatic heart failure, and had significant electrical dyssynchrony, all before CRT implant. Controls were screened from nonselective imaging and ECG databases. Controls were retrospectively enrolled when they achieved the same inclusion criteria at an outpatient clinical encounter, within the same time period. RESULTS Of 133 patients who received CRT during the study period, 84 met all study inclusion criteria. One hundred thirty-three controls met all criteria at an outpatient encounter. Following PSM, 63 matched CRT-control pairs were identified with no significant difference between groups across all baseline indices. Heart transplant or death occurred in 12 (19%) PSM-CRT subjects and 37 (59%) PSM-controls with a median follow-up of 2.7 years (quartiles, 0.8-6.1 years). CRT was associated with markedly reduced risk of heart transplant or death (hazard ratio, 0.24 [95% CI, 0.12-0.46]; P<0.001). There was no CRT procedural mortality and 1 system infection at 54 months post-implant. CONCLUSIONS In pediatric and congenital heart disease patients with symptomatic systolic heart failure and electrical dyssynchrony, CRT was associated with improved heart transplant-free survival. Visual Overview: A visual overview is available for this article.
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Affiliation(s)
- Henry Chubb
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA.,Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery (H.C., D.B.M.), Stanford University, CA
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Christopher S Almond
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Scott R Ceresnak
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Kara S Motonaga
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Alisa A Arunamata
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Jin Long
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
| | - Anthony V Trela
- Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford, Palo Alto, CA (A.V.T., D.H.)
| | - Debra Hanisch
- Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford, Palo Alto, CA (A.V.T., D.H.)
| | - Doff B McElhinney
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA.,Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery (H.C., D.B.M.), Stanford University, CA
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics (H.C., D.N.R., C.S.A., S.R.C., K.S.M., A.A.A., J.L., D.B.M., A.M.D.), Stanford University, CA
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16
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Power A, Schultz L, Dennis K, Rizzuto S, Hollander AM, Rosenthal DN, Almond CS, Hollander SA. Growth stunting in single ventricle patients after heart transplantation. Pediatr Transplant 2020; 24:e13634. [PMID: 31845499 DOI: 10.1111/petr.13634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/09/2019] [Accepted: 11/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Malnutrition is common among children with single ventricle (SV) congenital heart disease (CHD). The impact of heart transplantation (HT) on nutritional status in SV patients is understudied. Our aim was to evaluate anthropometric changes in SV patients after HT, compared with those transplanted for cardiomyopathy (CM). METHODS We performed a single-center retrospective chart review of SV and CM patients < 18 years who underwent HT from January 01, 2010 to December 05, 2017. Wasting and stunting were defined as z-scores for weight-for-age or height-for-age ≤-2, respectively. Changes in these indices between HT and 3 years post-HT were analyzed. RESULTS Of 86 eligible patients, 28 (33%) had SV CHD and 58 (67%) had CM. Data were available at 3 years post-HT for 57 patients. At transplant, wasting was equally present in SV versus CM patients (7/28, 25% vs. 9/58, 16%, P = .22), which remained true at 3 years post-HT (2/16, 13% vs. 3/41, 7%, P = .61). At transplant, stunting was more common in SV than CM patients (17/28, 61% vs. 8/58, 14%, P < .001). At 3 years post-HT, 6 of 16 (38%) SV patients and 3 of 41 (7%) CM patients remained stunted (P = .01). Among all patients, wasting decreased from transplant to end-point (19% vs. 9%, P = .05), but stunting did not (29% vs. 16%, P = .2), such that wasting and stunting were associated at transplant (P < .001) but not at end-point (P = .17). CONCLUSIONS Longitudinal growth remains impaired for several years after HT in SV patients, even when weight gain is achieved, suggesting that some factors contributing to growth impairment persist despite resolution of SV physiology.
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Affiliation(s)
- Alyssa Power
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Lisa Schultz
- Nutrition Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Katelin Dennis
- Nutrition Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Sandra Rizzuto
- Rehabilitation Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Amanda M Hollander
- Rehabilitation Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | | | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
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17
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Amodeo A, Filippelli S, Perri G, Iacobelli R, Adorisio R, Iodice F, Rizza A, Massicotte MP, Baldwin JT, Almond CS. First human implantation of a miniaturized axial flow ventricular assist device in a child with end-stage heart failure. J Heart Lung Transplant 2020; 39:83-87. [DOI: 10.1016/j.healun.2019.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/09/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022] Open
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18
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Knoll C, Chen S, Murray JM, Dykes JC, Yarlagadda VV, Rosenthal DN, Almond CS, Maeda K, Shin AY. A Quality Bundle to Support High-Risk Pediatric Ventricular Assist Device Implantation. Pediatr Cardiol 2019; 40:1159-1164. [PMID: 31087144 DOI: 10.1007/s00246-019-02123-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/03/2019] [Indexed: 11/27/2022]
Abstract
Pediatric ventricular assist device (VAD) implantation outcomes are increasingly promising for children with dilated cardiomyopathy and advanced decompensated heart failure (ADHF). VAD placement in patients with clinical features such as complex congenital cardiac anatomy, small body size, or major comorbidities remains problematic. These comorbidities have been traditionally prohibitive for VAD consideration leaving these children as a treatment-orphaned population. Here we describe the quality bundle surrounding these patients with ADHF considered high risk for VAD implantation at our institution. Over a 7-year period, a quality bundle aimed at the peri-operative care for children with high-risk features undergoing VAD implantation was incrementally implemented at a tertiary children's hospital. Patients were considered high risk if they were neonates (< 30 days), had single-ventricle physiology, non-dilated cardiomyopathy, biventricular dysfunction, or significant comorbidities. The quality improvement bundle evolved to include (1) structured team-based peri-operative evaluation, (2) weekly VAD rounds addressing post-operative device performance, (3) standardized anticoagulation strategies, and (4) a multidisciplinary system for management challenges. These measures aimed to improve communication, standardize management, allow for ongoing process improvement, and incorporate principles of a high-reliability organization. Between January 2010 and December 2017, 98 patients underwent VAD implantation, 48 (49%) of which had high-risk comorbidities and a resultant cohort survival-to-transplant rate of 65%. We report on the evolution of a quality improvement program to expand the scope of VAD implantation to patients with high-risk clinical profiles. This quality bundle can serve as a template for future large-scale collaborations to improve outcomes in these treatment-orphaned subgroups.
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Affiliation(s)
- Christopher Knoll
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
| | - Sharon Chen
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Jenna M Murray
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - John C Dykes
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Vamsi V Yarlagadda
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - David N Rosenthal
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Christopher S Almond
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Andrew Y Shin
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
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19
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May LJ, Liu X, Tesoro T, Yang J, Lo C, Chen S, Murray J, Rosenthal DN, Massicotte P, Michelson AD, Almond CS. Usefulness of anti-platelet therapy testing in children supported with a ventricular assist device. J Heart Lung Transplant 2019; 38:781-783. [DOI: 10.1016/j.healun.2019.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 03/30/2019] [Accepted: 03/30/2019] [Indexed: 11/16/2022] Open
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20
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Kaufman BD, Hollander SA, Zhang Y, Chen S, Bernstein D, Rosenthal DN, Almond CS, Murray JM, Burgart AM, Cohen HJ, Kirkpatrick JN, Blume ED. Compassionate deactivation of ventricular assist devices in children: A survey of pediatric ventricular assist device clinicians' perspectives and practices. Pediatr Transplant 2019; 23:e13359. [PMID: 30734422 DOI: 10.1111/petr.13359] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/29/2018] [Accepted: 01/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study's objective was to investigate compassionate ventricular assist device deactivation (VADdeact) in children from the perspective of the pediatric heart failure provider. BACKGROUND Pediatric VAD use is a standard therapy for advanced heart failure. Serious adverse events may affect relative benefit of continued support, leading to consideration of VADdeact. Perspectives and practices regarding VADdeact have been studied in adults but not in children. METHODS A web-based anonymous survey of clinicians for pediatric VAD patients (<18 years) was sent to list-serves for the ISHLT Pediatric Council, the International Consortium of Circulatory Assist Clinicians Pediatric Taskforce, and the Pediatric Cardiac Intensivist Society. RESULTS A total of 106 respondents met inclusion criteria of caring for pediatric VAD patients. Annual VAD volume per clinician ranged from <4 (33%) to >9 (20%). Seventy percent of respondents had performed VADdeact of a child. Response varied to VADdeact requests by parent or patient and was influenced by professional degree and region of practice. Except for the scenario of intractable suffering, no consensus on VADdeact appropriateness was reported. Age of child thought capable of making informed requests for VADdeact varied by subspecialty. The majority of respondents (62%) do not feel fully informed of relevant legal issues; 84% reported that professional society supported guidelines for VADdeact in children had utility. CONCLUSION There is limited consensus regarding indications for VADdeact in children reported by pediatric VAD provider survey respondents. Knowledge gaps related to legal issues are evident; therefore, professional guidelines and educational resources related to pediatric VADdeact are needed.
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Affiliation(s)
- Beth D Kaufman
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Yulin Zhang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sharon Chen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Daniel Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Christopher S Almond
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jenna M Murray
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Alyssa M Burgart
- Anesthesiology, Perioperative and Pain Medicine, Stanford Center for Biomedical Ethics, Stanford University, Palo Alto, California
| | - Harvey J Cohen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - James N Kirkpatrick
- Division of Cardiology, Department of Bioethics and Humanities, University of Washington Medical Center, Seattle, Washington
| | - Elizabeth D Blume
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
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Burstein DS, Shamszad P, Dai D, Almond CS, Price JF, Lin KY, O’Connor MJ, Shaddy RE, Mascio CE, Rossano JW. Significant mortality, morbidity and resource utilization associated with advanced heart failure in congenital heart disease in children and young adults. Am Heart J 2019; 209:9-19. [PMID: 30639612 DOI: 10.1016/j.ahj.2018.11.010] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/27/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children with congenital heart disease (CHD) are at risk for advanced heart failure (AHF). We sought to define the mortality and resource utilization in CHD-related AHF in children and young adults. METHODS All hospitalizations in the Pediatric Health Information System database involving patients ≤21 years old with a CHD diagnosis and heart failure requiring at least 7 days of continuous inotropic support between 2004 and 2015 were included. Hospitalizations including CHD surgery were excluded. RESULTS Of 465,482 CHD hospitalizations, AHF was present in 2,712 (0.6%) [58% infant, 55% male, 30% single ventricle]. AHF therapies frequently used included extracorporeal membrane oxygenation (ECMO) (15%) and cardiac transplant (16%). Ventricular assist device (VAD) support was rare (3%), although VAD use significantly increased from 2004 to 2015 (P < .0010). Hospital mortality in CHD with AHF was 26%, with higher mortality associated with single ventricle heart disease (OR 1.64, 95% CI 1.23-2.19; P = .0009), infancy (OR 1.71, 95% CI 1.17-2.5; P = .0057), non-white race (OR 1.28, 95% CI 1.04-1.59; p=0.0234), and chronic complex comorbidities (OR 1.76, 95% CI 1.34-2.30; P < .0001). Over the 11-year study period, despite the significant increase in CHD-related AHF hospitalizations (P < .0001), hospital mortality improved (P = .0011). Median hospital costs were $252,000, a 6-fold increase above those without AHF, and was primarily driven by hospital length of stay (P < .0001). CONCLUSION AHF in children with CHD in uncommon but increasing and is associated with significant morbidity, mortality and resource utilization. Approximately 1 in 5 children do not survive to hospital discharge. Many risk factors for mortality may not be modifiable, and further study is needed to identify modifiable risk factors and improve care for this complex population.
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22
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Hollander SA, Schultz LM, Dennis K, Hollander AM, Rizzuto S, Murray JM, Rosenthal DN, Almond CS. Impact of ventricular assist device implantation on the nutritional status of children awaiting heart transplantation. Pediatr Transplant 2019; 23:e13351. [PMID: 30628144 DOI: 10.1111/petr.13351] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Malnutrition is common in pediatric heart failure and is associated with mortality. The effect of VAD support on malnutrition in children is unknown. We sought to compare the prevalence and severity of malnutrition at HT in children on VAD support vs OMT to inform decisions regarding support strategies. METHODS Retrospective chart review involving all patients <18 years who underwent HT at Stanford between 1/1/2011 and 3/1/2018. Malnutrition diagnosis and severity were defined by ASPEN guidelines using the lowest age-adjusted z-score for weight (WAZ), height (HAZ), and BMI (BMIZ) when the patient was euvolemic. Changes in z-scores from baseline to HT and across groups were analyzed. RESULTS A total of 104 patients (52 in each group) were included. Among all patients, WAZ (-0.9 vs 0.3, P < 0.001) and BMIZ (0 vs 0.6, P < 0.001) improved while HAZ (-0.9 vs -0.9, P = 0.4) did not. Compared to children on OMT, children on VAD experienced greater increases in WAZ (0.8 vs 0.3, P < 0.001) and BMIZ (0.7 vs 0.2, P < 0.003) at HT. The prevalence of moderate-to-severe malnutrition decreased in VAD patients (40% to 19%, P < 0.001) and increased in OMT patients (37% to 46%, P < 0.001), leading to a lower prevalence of moderate-to-severe malnutrition at HT (19% vs 46%, P = 0.003). CONCLUSIONS Malnutrition is common in pediatric HT candidates. Compared to children on OMT, children on VAD support had greater improvement in nutritional status while awaiting HT, and a lower prevalence of malnutrition at HT.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Lisa M Schultz
- Nutrition Services, Lucile Packard Children's Hospital, Stanford, California
| | - Katelin Dennis
- Nutrition Services, Lucile Packard Children's Hospital, Stanford, California
| | - Amanda M Hollander
- Rehabilitation Services, Lucile Packard Children's Hospital, Stanford, California
| | - Sandra Rizzuto
- Rehabilitation Services, Lucile Packard Children's Hospital, Stanford, California
| | - Jenna M Murray
- Solid Organ Transplant Services, Lucile Packard Children's Hospital, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Christopher S Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
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23
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Peng DM, Ding VY, Hollander SA, Khalapyan T, Dykes JC, Rosenthal DN, Almond CS, Sakarovitch C, Desai M, McElhinney DB. Long-term surveillance biopsy: Is it necessary after pediatric heart transplant? Pediatr Transplant 2019; 23:e13330. [PMID: 30506612 PMCID: PMC8063536 DOI: 10.1111/petr.13330] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/15/2018] [Accepted: 11/02/2018] [Indexed: 12/16/2022]
Abstract
Due to limited and conflicting data in pediatric patients, long-term routine surveillance endomyocardial biopsy (RSB) in pediatric heart transplant (HT) remains controversial. We sought to characterize the rate of positive RSB and determine factors associated with RSB-detected rejection. Records of patients transplanted at a single institution from 1995 to 2015 with >2 year of post-HT biopsy data were reviewed for RSB-detected rejections occurring >2 year post-HT. We illustrated the trajectory of significant rejections (ISHLT Grade ≥3A/2R) among total RSB performed over time and used multivariable logistic regression to model the association between time and risk of rejection. We estimated Kaplan-Meier freedom from rejection rates by patient characteristics and used the log-rank test to assess differences in rejection probabilities. We identified the best-fitting Cox proportional hazards regression model. In 140 patients, 86% did not have any episodes of significant RSB-detected rejection >2 year post-HT. The overall empirical rate of RSB-detected rejection >2 year post-HT was 2.9/100 patient-years. The percentage of rejection among 815 RSB was 2.6% and remained stable over time. Years since transplant remained unassociated with rejection risk after adjusting for patient characteristics (OR = 0.98; 95% CI 0.78-1.23; P = 0.86). Older age at HT was the only factor that remained significantly associated with risk of RSB-detected rejection under multivariable Cox analysis (P = 0.008). Most pediatric patients did not have RSB-detected rejection beyond 2 years post-HT, and the majority of those who did were older at time of HT. Indiscriminate long-term RSB in pediatric heart transplant should be reconsidered given the low rate of detected rejection.
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Affiliation(s)
- David M. Peng
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - Victoria Y. Ding
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Seth A. Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - Tigran Khalapyan
- Clinical and Translational Research Program, Palo Alto, California
| | - John C. Dykes
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - David N. Rosenthal
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - Christopher S. Almond
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California,Clinical and Translational Research Program, Palo Alto, California
| | - Charlotte Sakarovitch
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Manisha Desai
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Doff B. McElhinney
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California,Clinical and Translational Research Program, Palo Alto, California,Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
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Hollander SA, Peng DM, Mills M, Berry GJ, Fedrigo M, McElhinney DB, Almond CS, Rosenthal DN. Pathological antibody-mediated rejection in pediatric heart transplant recipients: Immunologic risk factors, hemodynamic significance, and outcomes. Pediatr Transplant 2018; 22:e13197. [PMID: 29729067 DOI: 10.1111/petr.13197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 12/31/2022]
Abstract
Biopsy-diagnosed pAMR has been observed in over half of pediatric HT recipients within 6 years of transplantation. We report the incidence and outcomes of pAMR at our center. All endomyocardial biopsies for all HT recipients transplanted between 2010 and 2015 were reviewed and classified using contemporary ISHLT guidelines. Graft dysfunction was defined as a qualitative decrement in systolic function by echocardiogram or an increase of ≥3 mm Hg in atrial filling pressure by direct measurement. Among 96 patients, pAMR2 occurred in 7 (7%) over a median follow-up period of 3.1 years, while no cases of pAMR3 occurred. A history of CHD, DSA at transplant, and elevated filling pressures were associated with pAMR2. Five-sixths (83%) of patients developed new C1q+ DSA at the time of pAMR diagnosis. There was a trend toward reduced survival, with 43% of patients dying within 2.3 years of pAMR diagnosis.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - David M Peng
- Department of Pediatrics (Cardiology), University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Marcos Mills
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Gerald J Berry
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Marny Fedrigo
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, LPCH Heart Center Clinical and Translational Research Program, Stanford University, Stanford, CA, USA
| | - Christopher S Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
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25
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Chen S, Dykes JC, McElhinney DB, Gajarski RJ, Shin AY, Hollander SA, Everitt ME, Price JF, Thiagarajan RR, Kindel SJ, Rossano JW, Kaufman BD, May LJ, Pruitt E, Rosenthal DN, Almond CS. Haemodynamic profiles of children with end-stage heart failure. Eur Heart J 2018; 38:2900-2909. [PMID: 29019615 DOI: 10.1093/eurheartj/ehx456] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/18/2017] [Indexed: 01/31/2023] Open
Abstract
Aims To evaluate associations between haemodynamic profiles and symptoms, end-organ function and outcome in children listed for heart transplantation. Methods and results Children <18 years listed for heart transplant between 1993 and 2013 with cardiac catheterization data [pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), and cardiac index (CI)] in the Pediatric Heart Transplant Study database were included. Outcomes were New York Heart Association (NYHA)/Ross classification, renal and hepatic dysfunction, and death or clinical deterioration while on waitlist. Among 1059 children analysed, median age was 6.9 years and 46% had dilated cardiomyopathy. Overall, 58% had congestion (PCWP >15 mmHg), 28% had severe congestion (PCWP >22 mmHg), and 22% low cardiac output (CI < 2.2 L/min/m2). Twenty-one per cent met the primary outcome of death (9%) or clinical deterioration (12%). In multivariable analysis, worse NYHA/Ross classification was associated with increased PCWP [odds ratio (OR) 1.03, 95% confidence interval (95% CI) 1.01-1.07, P = 0.01], renal dysfunction with increased RAP (OR 1.04, 95% CI 1.01-1.08, P = 0.007), and hepatic dysfunction with both increased PCWP (OR 1.03, 95% CI 1.01-1.06, P < 0.001) and increased RAP (OR 1.09, 95% CI 1.06-1.12, P < 0.001). There were no associations with low output. Death or clinical deterioration was associated with severe congestion (OR 1.6, 95% CI 1.2-2.2, P = 0.002), but not with CI alone. However, children with both low output and severe congestion were at highest risk (OR 1.9, 95% CI 1.1-3.5, P = 0.03). Conclusion Congestion is more common than low cardiac output in children with end-stage heart failure and correlates with NYHA/Ross classification and end-organ dysfunction. Children with both congestion and low output have the highest risk of death or clinical deterioration.
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Affiliation(s)
- Sharon Chen
- Stanford University, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
| | - John C Dykes
- Stanford University, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
| | - Doff B McElhinney
- Stanford University, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
| | | | - Andrew Y Shin
- Stanford University, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
| | - Seth A Hollander
- Stanford University, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
| | | | | | | | | | | | - Beth D Kaufman
- Stanford University, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
| | - Lindsay J May
- Primary Children's Hospital, Salt Lake City, UT, USA
| | - Elizabeth Pruitt
- The Pediatric Heart Transplant Study Group, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - David N Rosenthal
- Stanford University, 750 Welch Road, Suite 305, Palo Alto, CA 94304, USA
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Almond CS, Hoen H, Rossano JW, Castleberry C, Auerbach SR, Yang L, Lal AK, Everitt MD, Fenton M, Hollander SA, Pahl E, Pruitt E, Rosenthal DN, McElhinney DB, Daly KP, Desai M. Development and validation of a major adverse transplant event (MATE) score to predict late graft loss in pediatric heart transplantation. J Heart Lung Transplant 2018; 37:441-450. [DOI: 10.1016/j.healun.2017.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 02/22/2017] [Accepted: 03/22/2017] [Indexed: 12/21/2022] Open
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27
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Morales DL, Zafar F, Almond CS, Canter C, Fynn-Thompson F, Conway J, Adachi I, Lorts A. Berlin Heart EXCOR use in patients with congenital heart disease. J Heart Lung Transplant 2017; 36:1209-1216. [DOI: 10.1016/j.healun.2017.02.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/05/2017] [Accepted: 02/01/2017] [Indexed: 10/20/2022] Open
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28
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Baker AL, Vanderpluym C, Gauvreau KA, Fulton DR, de Ferranti SD, Friedman KG, Murray JM, Brown LD, Almond CS, Evans-Langhorst M, Newburger JW. Safety and Efficacy of Warfarin Therapy in Kawasaki Disease. J Pediatr 2017; 189:61-65. [PMID: 28552449 DOI: 10.1016/j.jpeds.2017.04.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/30/2017] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe the safety and efficacy of warfarin for patients with Kawasaki disease and giant coronary artery aneurysms (CAAs, ≥8 mm). Giant aneurysms are managed with combined anticoagulation and antiplatelet therapies, heightening risk of bleeding complications. STUDY DESIGN We reviewed the time in therapeutic range; percentage of international normalization ratios (INRs) in range (%); bleeding events, clotting events; INRs ≥6; INRs ≥5 and <6; and INRs <1.5. RESULTS In 9 patients (5 male), median age 14.4 years (range 7.1-22.8 years), INR testing was prescribed weekly to monthly and was done by home monitor (n = 5) or laboratory (n = 3) or combined (1). Median length of warfarin therapy was 7.2 years (2.3-13.3 years). Goal INR was 2.0-3.0 (n = 6) or 2.5-3.5 (n = 3), based on CAA size and history of CAA thrombosis. All patients were treated with aspirin; 1 was on dual antiplatelet therapy and warfarin. The median time in therapeutic range was 59% (37%-85%), and median percentage of INRs in range was 68% (52%-87%). INR >6 occurred in 3 patients (4 events); INRs ≥5 <6 in 7 patients (12 events); and INR <1.5 in 5 patients (28 events). The incidence of major bleeding events and clinically relevant nonmajor bleeding events were each 4.3 per 100 patient-years (95% CI 0.9-12.6). New asymptomatic coronary thrombosis was detected by imaging in 2 patients. CONCLUSIONS Bleeding and clotting complications are common in patients with Kawasaki disease on warfarin and aspirin, with INRs in range only two-thirds of the time. Future studies should evaluate the use of direct oral anticoagulants in children as an alternative to warfarin.
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Affiliation(s)
- Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Christina Vanderpluym
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberly A Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - David R Fulton
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jenna M Murray
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Loren D Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Christopher S Almond
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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Yarlagadda VV, Maeda K, Zhang Y, Chen S, Dykes JC, Gowen MA, Shuttleworth P, Murray JM, Shin AY, Reinhartz O, Rosenthal DN, McElhinney DB, Almond CS. Temporary Circulatory Support in U.S. Children Awaiting Heart Transplantation. J Am Coll Cardiol 2017; 70:2250-2260. [DOI: 10.1016/j.jacc.2017.08.072] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/29/2017] [Accepted: 08/29/2017] [Indexed: 10/18/2022]
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30
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Dykes JC, Reinhartz O, Almond CS, Yarlagadda V, Murray J, Rosenthal DN, Maeda K. Alternative Strategy for Biventricular Assist Device in an Infant With Hypertrophic Cardiomyopathy. Ann Thorac Surg 2017; 104:e185-e186. [DOI: 10.1016/j.athoracsur.2017.02.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 02/19/2017] [Indexed: 11/29/2022]
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Peng DM, Qu Q, McDonald N, Hollander SA, Bernstein D, Maeda K, Kaufman BD, Rosenthal DN, McElhinney DB, Almond CS. Impact of the 18th birthday on waitlist outcomes among young adults listed for heart transplant: A regression discontinuity analysis. J Heart Lung Transplant 2017; 36:1185-1191. [PMID: 28712678 DOI: 10.1016/j.healun.2017.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 05/12/2017] [Accepted: 05/17/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Patients listed for heart transplant after their 18th birthday purportedly wait longer to receive a donor heart compared with patients listed before their 18th birthday. It is unclear whether there is an actual difference in wait times and whether any difference in wait time is associated with lower likelihood of transplant and/or higher risk of mortality. METHODS Organ procurement and transplant network data were used to identify all patients listed for heart transplant between 2006 and 2014 within a 1-year period before and after their 18th birthday. The primary study end-point was the waiting time to receive a donor heart. Secondary end-points included the probability of transplant and waitlist mortality. Regression discontinuity analysis was used to analyze the effect of age on either side of the sharp cut-off value of age 18 years (6,574 days of life), when allocation of donor hearts transitions from the pediatric to adult allocation system. RESULTS A total of 360 patients met the study inclusion criteria, including 207 (57.5%) listed during the 12-month period before their 18th birthday under the pediatric allocation system, and 153 (42.5%) listed during the 12 months after their 18th birthday under the adult allocation system. The pediatric cohort was more likely to be listed Status 1A. Otherwise, the 2 groups shared similar baseline characteristics. Overall, patients listed after their 18th birthday waited 8.5 months longer to receive a transplant than adolescents listed before their 18th birthday (p = 0.01) and had a 47% lower probability of receiving a transplant (p = 0.001), but there was no difference in waitlist mortality (p = 0.37). CONCLUSIONS Patients listed for heart transplant shortly after their 18th birthday have significantly longer wait-times compared with patients listed shortly before their 18th birthday and a lower probability of transplant, but no significant difference in waitlist mortality. For medically fragile adolescents at high risk of death, birth date may be a relevant factor in the timing of heart transplant listing.
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Affiliation(s)
- David M Peng
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA; Heart Center and the Clinical and Translational Research Unit, The Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Qiuying Qu
- Department of Economics, Columbia University, New York, New York, USA
| | - Nancy McDonald
- Heart Center and the Clinical and Translational Research Unit, The Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA; Heart Center and the Clinical and Translational Research Unit, The Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Daniel Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA; Heart Center and the Clinical and Translational Research Unit, The Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Katsuhide Maeda
- Heart Center and the Clinical and Translational Research Unit, The Lucile Packard Children's Hospital, Palo Alto, California, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Beth D Kaufman
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA; Heart Center and the Clinical and Translational Research Unit, The Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA; Heart Center and the Clinical and Translational Research Unit, The Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Doff B McElhinney
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA; Heart Center and the Clinical and Translational Research Unit, The Lucile Packard Children's Hospital, Palo Alto, California, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Christopher S Almond
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA; Heart Center and the Clinical and Translational Research Unit, The Lucile Packard Children's Hospital, Palo Alto, California, USA.
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Dimas VV, Morray BH, Kim DW, Almond CS, Shahanavaz S, Tume SC, Peng LF, McElhinney DB, Justino H. A multicenter study of the impella device for mechanical support of the systemic circulation in pediatric and adolescent patients. Catheter Cardiovasc Interv 2017; 90:124-129. [PMID: 28295963 DOI: 10.1002/ccd.26973] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/23/2016] [Accepted: 01/16/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The objective was to review the use of Impella devices (Abiomed Inc, Danvers, MA) for temporary circulatory support in pediatric and adolescent patients (age ≤ 21 yrs). BACKGROUND Options for minimally invasive circulatory support in children are limited, and published data are confined to case reports and small case series. METHODS This was a retrospective, multicenter review of Impella implants in pediatric and adolescent patients from 2009-15, using standardized data collection and INTERMACS definitions. RESULTS A total of 39 implants were performed in 38 patients from 16 centers. Median age and weight were 16 yrs (4-21 yrs) and 62 kg (15-134 kg). The primary indication for implant was cardiogenic shock in 28 patients (72%). Cardiac allograft rejection, myocarditis, or cardiomyopathy were the underlying diagnosis in 23 patients (59%); 11 patients had congenital heart disease. The median duration of support was 45 hr (1-1224 hr). Indications for explant included ventricular recovery in 16 patients, transition to another device in 12, death in 5, and transplant in 1. Survival was 85% at 7 days and 68% at 30 days. Major adverse events occurred in 8 patients: hemolysis in 3, bleeding in 2, stroke in 1 (unclear if related to Impella), sepsis in 1, and critical leg ischemia in 1. An increase in aortic regurgitation was noted in three patients, with no evidence of valve injury. CONCLUSION Temporary circulatory support with Impella devices is feasible in pediatric and adolescent patients, with acceptable risk profiles. More experience and follow up is needed to improve technical performance and patient selection. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- V Vivian Dimas
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Brian H Morray
- Division of Cardiology, Seattle Children's Hospital, Seattle, WA
| | - Dennis W Kim
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Christopher S Almond
- Division of Pediatric Cardiology, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA
| | - Shabana Shahanavaz
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, MO
| | - Sebastian C Tume
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lynn F Peng
- Division of Pediatric Cardiology, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA
| | - Henri Justino
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Zafar F, Jaquiss RD, Almond CS, Lorts A, Chin C, Rizwan R, Bryant R, Tweddell JS, Morales DLS. Pediatric Heart Donor Assessment Tool (PH-DAT): A novel donor risk scoring system to predict 1-year mortality in pediatric heart transplantation. J Heart Lung Transplant 2017; 37:332-339. [PMID: 28365178 DOI: 10.1016/j.healun.2017.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 03/01/2017] [Accepted: 03/03/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In this study we sought to quantify hazards associated with various donor factors into a cumulative risk scoring system (the Pediatric Heart Donor Assessment Tool, or PH-DAT) to predict 1-year mortality after pediatric heart transplantation (PHT). METHODS PHT data with complete donor information (5,732) were randomly divided into a derivation cohort and a validation cohort (3:1). From the derivation cohort, donor-specific variables associated with 1-year mortality (exploratory p-value < 0.2) were incorporated into a multivariate logistic regression model. Scores were assigned to independent predictors (p < 0.05) based on relative odds ratios (ORs). RESULTS The final model had an acceptable predictive value (c-statistic = 0.62). The significant 5 variables (ischemic time, stroke as the cause of death, donor-to-recipient height ratio, donor left ventricular ejection fraction, glomerular filtration rate) were used for the scoring system. The validation cohort demonstrated a strong correlation between the observed and expected rates of 1-year mortality (r = 0.87). The risk of 1-year mortality increases by 11% (OR 1.11 [1.08 to 1.14]; p < 0.001) in the derivation cohort and 9% (OR 1.09 [1.04 to 1.14]; p = 0.001) in the validation cohort with an increase of 1-point in score. Mortality risk increased 5 times from the lowest to the highest donor score in this cohort. Based on this model, a donor score range of 10 to 28 predicted 1-year recipient mortality of 11% to 31%. CONCLUSION This novel pediatric-specific, donor risk scoring system appears capable of predicting post-transplant mortality. Although the PH-DAT may benefit organ allocation and assessment of recipient risk while controlling for donor risk, prospective validation of this model is warranted.
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Affiliation(s)
- Farhan Zafar
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
| | | | | | - Angela Lorts
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Clifford Chin
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Raheel Rizwan
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Roosevelt Bryant
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James S Tweddell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David L S Morales
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Bulic A, Maeda K, Zhang Y, Chen S, McElhinney DB, Dykes JC, Hollander AM, Hollander SA, Murray J, Reinhartz O, Gowan MA, Rosenthal DN, Almond CS. Functional status of United States children supported with a left ventricular assist device at heart transplantation. J Heart Lung Transplant 2017; 36:890-896. [PMID: 28363739 DOI: 10.1016/j.healun.2017.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 02/03/2017] [Accepted: 02/24/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND As survival with pediatric left ventricular assist devices (LVADs) has improved, decisions regarding the optimal support strategy may depend more on quality of life and functional status (FS) rather than mortality alone. Limited data are available regarding the FS of children supported with LVADs. We sought to compare the FS of children supported with LVADs vs vasoactive infusions to inform decision making around support strategies. METHODS Organ Procurement and Transplant Network data were used to identify all United States children aged between 1 and 21 years at heart transplant (HT) between 2006 and 2015 for dilated cardiomyopathy and supported with an LVAD or vasoactive infusions alone at HT. FS was measured using the 10-point Karnofsky and Lansky scale. RESULTS Of 701 children who met the inclusion criteria, 430 (61%) were supported with vasoactive infusions, and 271 (39%) were supported with an LVAD at HT. Children in the LVAD group had higher median FS scores at HT than children in the vasoactive infusion group (6 vs 5, p < 0.001) but lower FS scores at listing (4 vs 6, p < 0.001). The effect persisted regardless of patient location at HT (home, hospital, intensive care) or device type. Discharge by HT occurred in 46% of children in the LVAD group compared with 26% of children in the vasoactive infusion cohort (p = 0.001). Stroke was reported at HT in 3% of children in the LVAD cohort and in 1% in the vasoactive infusion cohort (p = 0.04). CONCLUSIONS Among children with dilated cardiomyopathy undergoing HT, children supported with LVADs at HT have higher FS than children supported with vasoactive infusions at HT, regardless of device type or hospitalization status. Children supported with LVADs at HT were more likely to be discharged from the hospital but had a higher prevalence of stroke at HT.
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Affiliation(s)
- Anica Bulic
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; The Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Katsuhide Maeda
- The Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Yulin Zhang
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; The Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Sharon Chen
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; The Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Doff B McElhinney
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; The Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; The Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - John C Dykes
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; The Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Amanda M Hollander
- Department of Rehabilitation Services, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Seth A Hollander
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; The Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Jenna Murray
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Olaf Reinhartz
- The Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Mary Alice Gowan
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - David N Rosenthal
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; The Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Christopher S Almond
- Division of Pediatric Cardiology and The Heart Center Clinical and Translational Research Program, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California.
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Hollander SA, McElhinney DB, Almond CS, McDonald N, Chen S, Kaufman BD, Bernstein D, Rosenthal DN. Rehospitalization after pediatric heart transplantation: Incidence, indications, and outcomes. Pediatr Transplant 2017; 21. [PMID: 27891727 DOI: 10.1111/petr.12857] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2016] [Indexed: 12/20/2022]
Abstract
We report the patterns of rehospitalization after pediatric heart transplant (Htx) at a single center. Retrospective review of 107 consecutive pediatric Htx recipients between January 22, 2007, and August 28, 2014, who survived their initial transplant hospitalization. The frequency, duration, and indications for all hospitalizations between transplant hospitalization discharge and September 30, 2015, were analyzed. A total of 444 hospitalization episodes occurred in 90 of 107 (84%) patients. The median time to first rehospitalization was 59.5 (range 1-1526) days, and the median length of stay was 2.5 (range 0-81) days. There were an average of two hospitalizations per patient in the first year following transplant hospitalization, declining to about 0.8 per patient per year starting at 3 years post-transplant. Admissions for viral infections were most common, occurring in 93 of 386 (24%), followed by rule out sepsis in 61 of 386 (16%). Admissions for suspected or confirmed rejection were less frequent, accounting for 41 of 386 (11%) and 31 of 386 (8%) of all admissions, respectively. Survival to discharge after rehospitalization was 97%. Hospitalization is common after pediatric Htx, particularly in the first post-transplant year, with the most frequent indications for hospitalization being viral illness and rule out sepsis. After the first post-transplant year, the risk for readmission falls significantly but remains constant for several years.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, LPCH Heart Center Clinical and Translational Research Program, Palo Alto, CA, USA
| | - Christopher S Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Nancy McDonald
- Solid Organ Transplant Services, Lucile Packard Children's Hospital, Stanford, Palo Alto, CA, USA
| | - Sharon Chen
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
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Rosenthal DN, Almond CS, Jaquiss RD, Peyton CE, Auerbach SR, Morales DR, Epstein DJ, Cantor RS, Kormos RL, Naftel DC, Butts RJ, Ghanayem NS, Kirklin JK, Blume ED. Adverse events in children implanted with ventricular assist devices in the United States: Data from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS). J Heart Lung Transplant 2016; 35:569-77. [PMID: 27197775 DOI: 10.1016/j.healun.2016.03.005] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 02/25/2016] [Accepted: 03/11/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Ventricular assist devices (VADs) have been used in children on an increasing basis in recent years. One-year survival rates are now >80% in multiple reports. In this report we describe adverse events experienced by children with durable ventricular assist devices, using a national-level registry (PediMACS, a component of INTERMACS) METHODS: PediMACS is a national registry that contains clinical data on patients who are <19 years of age at the time of VAD implantation. Data collection concludes at the time of VAD explantation. All FDA-approved devices are included. PediMACS was launched on September 1, 2012, and this report includes all data from launch until August 2014. Adverse events were coded with a uniform, pre-specified set of definitions. RESULTS This report comprises data from 200 patients with a median age of 11 years (range 11 days to 18 years), and total follow-up of 783 patient-months. The diagnoses were cardiomyopathy (n = 146, 73%), myocarditis (n = 17, 9%), congenital heart disease (n = 35, 18%) and other (n = 2, 1%). Pulsatile-flow devices were used in 91 patients (45%) and continuous-flow devices in 109 patients (55%). Actuarial survival was 81% at 6 months. There were 418 adverse events reported. The most frequent events were device malfunction (n = 79), infection (n = 78), neurologic dysfunction (n = 52) and bleeding (n = 68). Together, these accounted for 277 events, 66% of the total. Although 38% of patients had no reported adverse event and 16% of patients had ≥5 adverse events. Adverse events occurred at all time-points after implantation, but were most likely to occur in the first 30 days. For continuous-flow devices, there were broad similarities in adverse event rates between this cohort and historic rates from the INTERMACS population. CONCLUSIONS In this study cohort, the overall rate of early adverse events (within 90 days of implantation) was 86.3 events per 100 patient-months, and of late adverse events it was 20.4 events per 100 patient-months. The most common adverse events in recipients of pulsatile VADs were device malfunction, neurologic dysfunction, bleeding and infection. For continuous-flow VADs, the most common adverse events were infection, bleeding, cardiac arrhythmia, neurologic dysfunction and respiratory failure. Compared with an adult INTERMACS cohort, the overall rate and distribution of adverse events appears similar.
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Affiliation(s)
- David N Rosenthal
- Department of Pediatric (Cardiology), Stanford University, Palo Alto, California, USA.
| | - Christopher S Almond
- Department of Pediatric (Cardiology), Stanford University, Palo Alto, California, USA
| | - Robert D Jaquiss
- Department of Pediatric Cardiac Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christine E Peyton
- Children's Hospital Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Scott R Auerbach
- Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - David R Morales
- Department of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Deirdre J Epstein
- Department of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan S Cantor
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Robert L Kormos
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David C Naftel
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryan J Butts
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nancy S Ghanayem
- Department of Pediatrics (Critical Care Section), Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - James K Kirklin
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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Elbers J, Lee EJ, Yarlagadda VV, Lo C, Hanisch D, Lin A, Almond CS, Shin AY. Abstract WMP99: Major Causes of Stroke in Children With Congenital and Acquired Heart Disease. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.wmp99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Heart disease is the leading cause of stroke in children; however, little is known about the distribution of cardiac conditions associated with stroke.
Hypothesis:
We assessed the hypothesis that patients requiring cardiac surgery, catheterization, or mechanical support account for the majority of strokes in children with heart disease.
Methods:
All patients admitted to Lucile Packard Children’s Hospital at Stanford were included. A new diagnosis of stroke was identified using hospital data. Descriptive statistics were used to evaluate the characteristics of the population and tabulate common causes of stroke and stroke sub-types.
Results:
Between September 1, 2009 and February 1, 2014, a total of 36 patients with congenital or acquired heart disease had a new diagnosis of stroke. The median age was 4.18 years (IQR 0.32 - 10.6 years); 64% were male. Overall, 50% of strokes were arterial ischemic, 17% hemorrhagic and 25% had both ischemic and hemorrhagic components. Transient ischemic attacks accounted for the remaining 8%. Patients on mechanical support accounted for the majority of strokes (33%; ECMO 22%, ventricular assist device 11%) followed by left-sided cardiac catheterization (22%). Single-ventricle palliation procedures (Norwood or Glenn) accounted for 11% and septal defect repair 8%. Associated cardiac conditions included cardiomyopathy (28%), single-ventricle physiology (28%), septal defects (14%), myo/endocarditis (11%), heart transplantation (6%), and left-sided valvular disease (5%). Overall, 47.2% of patients were receiving anticoagulant therapy at the time of their stroke. Among those patients, 32% with arterial ischemic strokes and 60% with hemorrhagic strokes were within goal anticoagulation levels.
Conclusions:
Mechanical circulatory support, cardiac catheterizations and single-ventricle palliation procedures account for two-thirds of strokes observed in patients with cardiac disease. Many strokes occur in patients receiving anticoagulant therapy in accordance with contemporary anticoagulation guidelines. Re-evaluation of these guidelines and studies to reduce the risk of strokes in vulnerable sub-groups of cardiac patients is warranted.
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Affiliation(s)
- Jorina Elbers
- Child Neurology, Lucile Packard Children's Hosp, Palo Alto, CA
| | - Esther J Lee
- Stanford Cardiovascular Institute, Lucile Packard Children's Hosp, Palo Alto, CA
| | - Vamsi V Yarlagadda
- Stanford Cardiovascular Institute, Lucile Packard Children's Hosp, Palo Alto, CA
| | - Clara Lo
- Pediatric Hematology/Oncology/Stem Cell Transplantation, Lucile Packard Children's Hosp, Palo Alto, CA
| | - Debra Hanisch
- Stanford Cardiovascular Institute, Lucile Packard Children's Hosp, Palo Alto, CA
| | - Aileen Lin
- Stanford Cardiovascular Institute, Lucile Packard Children's Hosp, Palo Alto, CA
| | - Christopher S Almond
- Stanford Cardiovascular Institute, Lucile Packard Children's Hosp, Palo Alto, CA
| | - Andrew Y Shin
- Stanford Cardiovascular Institute, Lucile Packard Children's Hosp, Palo Alto, CA
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Stein ML, Dao DT, Doan LN, Reinhartz O, Maeda K, Hollander SA, Yeh J, Kaufman BD, Almond CS, Rosenthal DN. Ventricular assist devices in a contemporary pediatric cohort: Morbidity, functional recovery, and survival. J Heart Lung Transplant 2016. [DOI: 10.1016/j.healun.2015.06.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Massicotte MP, Bauman ME, Murray J, Almond CS. Antithrombotic therapy for ventricular assist devices in children: do we really know what to do? J Thromb Haemost 2015; 13 Suppl 1:S343-50. [PMID: 26149046 DOI: 10.1111/jth.12928] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
The use of ventricular assist devices (VADs) in children is increasing. Stroke and device-related thromboembolism remain the most feared complications associated with VAD therapy in children. The presence of a VAD causes dysregulation of hemostasis due to the presence of foreign materials and sheer forces intrinsic to the device resulting in hypercoagulability and potentially life-threatening thrombosis. The use of antithrombotic therapy in adults with VADs modulates this disruption in hemostasis, decreasing the risk of thrombosis. Yet, differences in hemostasis in children (developmental hemostasis) may result in variances in dysregulation by these devices and preclude the use of adult guidelines. Consequently, pediatric device studies must include safety and efficacy estimates of device-specific antithrombotic therapy guidelines. This review will discuss mechanisms of hemostatic dysregulation as it pertains to VADs, goals of VAD antithrombotic therapy for children and adults, and emerging antithrombotic strategies for VAD use in children.
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Affiliation(s)
- M P Massicotte
- KIDCLOT Pediatric Thrombosis, Stollery Children's Hospital, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - M E Bauman
- KIDCLOT Pediatric Thrombosis, Stollery Children's Hospital, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - J Murray
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA
- Stanford University, Stanford, CA, USA
| | - C S Almond
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA
- Stanford University, Stanford, CA, USA
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Singh TP, Milliren CE, Almond CS, Graham D. Survival Benefit From Transplantation in Patients Listed for Heart Transplantation in the United States. J Am Coll Cardiol 2014; 63:1169-1178. [DOI: 10.1016/j.jacc.2013.11.045] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/17/2013] [Accepted: 11/19/2013] [Indexed: 11/29/2022]
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VanderPluym C, Graham DA, Almond CS, Blume ED, Milliren CE, Singh TP. Survival in patients removed from the heart transplant waiting list before receiving a transplant. J Heart Lung Transplant 2014; 33:261-9. [DOI: 10.1016/j.healun.2013.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/31/2013] [Accepted: 12/11/2013] [Indexed: 11/30/2022] Open
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Daly KP, Chandler SF, Almond CS, Singh TP, Mah H, Milford E, Matte GS, Bastardi HJ, Mayer JE, Fynn-Thompson F, Blume ED. Antibody depletion for the treatment of crossmatch-positive pediatric heart transplant recipients. Pediatr Transplant 2013; 17:661-9. [PMID: 23919762 PMCID: PMC3843490 DOI: 10.1111/petr.12131] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 11/29/2022]
Abstract
Sensitization to HLA is a risk factor for adverse outcomes after heart transplantation. Requiring a negative prospective CM results in longer waiting times and increased waitlist mortality. We report outcomes in a cohort of sensitized children who underwent transplant despite a positive CDC CM+ using a protocol of antibody depletion at time of transplant, followed by serial IVIG administration. All patients <21 yrs old who underwent heart transplantation at Boston Children's Hospital from 1/1998 to 1/2011 were included. We compared freedom from allograft loss, allograft rejection, and serious infection between CM+ and CM- recipients. Of 134 patients in the cohort, 33 (25%) were sensitized prior to transplantation and 12 (9%) received a CM+ heart transplant. Serious infection in the first post-transplant year was more prevalent in the CM+ patients compared with CM- patients (50% vs. 16%; p = 0.005), as was HD-AMR (50% vs. 2%; p < 0.001). There was no difference in freedom from allograft loss or any rejection. At our center, children transplanted despite a positive CM had acceptable allograft survival and risk of any rejection, but a higher risk of HD-AMR and serious infection.
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Affiliation(s)
- Kevin P. Daly
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, 02115
| | | | | | - Tajinder P. Singh
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, 02115
| | - Helen Mah
- Tissue Typing Laboratory, Brigham & Women's Hospital, Boston, MA, 02115
| | - Edgar Milford
- Tissue Typing Laboratory, Brigham & Women's Hospital, Boston, MA, 02115
| | - Gregory S. Matte
- Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, MA, 02115
| | | | - John E. Mayer
- Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, MA, 02115
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Affiliation(s)
- Tajinder P. Singh
- From the Department of Cardiology, Boston Children’s Hospital, Boston, MA (T.P.S., C.S.A., G.P., K.G.); Department of Pediatrics, Harvard Medical School, Boston, MA (T.P.S., C.S.A.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Christopher S. Almond
- From the Department of Cardiology, Boston Children’s Hospital, Boston, MA (T.P.S., C.S.A., G.P., K.G.); Department of Pediatrics, Harvard Medical School, Boston, MA (T.P.S., C.S.A.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Gary Piercey
- From the Department of Cardiology, Boston Children’s Hospital, Boston, MA (T.P.S., C.S.A., G.P., K.G.); Department of Pediatrics, Harvard Medical School, Boston, MA (T.P.S., C.S.A.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Kimberlee Gauvreau
- From the Department of Cardiology, Boston Children’s Hospital, Boston, MA (T.P.S., C.S.A., G.P., K.G.); Department of Pediatrics, Harvard Medical School, Boston, MA (T.P.S., C.S.A.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
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Almond CS, Morales DL, Blackstone EH, Turrentine MW, Imamura M, Massicotte MP, Jordan LC, Devaney EJ, Ravishankar C, Kanter KR, Holman W, Kroslowitz R, Tjossem C, Thuita L, Cohen GA, Buchholz H, St Louis JD, Nguyen K, Niebler RA, Walters HL, Reemtsen B, Wearden PD, Reinhartz O, Guleserian KJ, Mitchell MB, Bleiweis MS, Canter CE, Humpl T. Berlin Heart EXCOR pediatric ventricular assist device for bridge to heart transplantation in US children. Circulation 2013; 127:1702-11. [PMID: 23538380 DOI: 10.1161/circulationaha.112.000685] [Citation(s) in RCA: 329] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent data suggest that the Berlin Heart EXCOR Pediatric ventricular assist device is superior to extracorporeal membrane oxygenation for bridge to heart transplantation. Published data are limited to 1 in 4 children who received the device as part of the US clinical trial. We analyzed outcomes for all US children who received the EXCOR to characterize device outcomes in an unselected cohort and to identify risk factors for mortality to facilitate patient selection. METHODS AND RESULTS This multicenter, prospective cohort study involved all children implanted with the Berlin Heart EXCOR Pediatric ventricular assist device at 47 centers from May 2007 through December 2010. Multiphase nonproportional hazards modeling was used to identify risk factors for early (<2 months) and late mortality. Of 204 children supported with the EXCOR, the median duration of support was 40 days (range, 1-435 days). Survival at 12 months was 75%, including 64% who reached transplantation, 6% who recovered, and 5% who were alive on the device. Multivariable analysis identified lower weight, biventricular assist device support, and elevated bilirubin as risk factors for early mortality and bilirubin extremes and renal dysfunction as risk factors for late mortality. Neurological dysfunction occurred in 29% and was the leading cause of death. CONCLUSIONS Use of the Berlin Heart EXCOR has risen dramatically over the past decade. The EXCOR has emerged as a new treatment standard in the United States for pediatric bridge to transplantation. Three-quarters of children survived to transplantation or recovery; an important fraction experienced neurological dysfunction. Smaller patient size, renal dysfunction, hepatic dysfunction, and biventricular assist device use were associated with mortality, whereas extracorporeal membrane oxygenation before implantation and congenital heart disease were not.
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Affiliation(s)
- Christopher S Almond
- The Heart Center, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA.
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Gossett JG, Almond CS, Kirk R, Zangwill S, Richmond ME, Kantor PF, Tresler MA, Lenderman SM, Naftel DC, Matthews KL, Pahl E. Outcomes of Cardiac Transplantation in Single-Ventricle Patients With Plastic Bronchitis: A Multicenter Study. J Am Coll Cardiol 2013; 61:985-6. [DOI: 10.1016/j.jacc.2012.10.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 10/06/2012] [Accepted: 10/23/2012] [Indexed: 10/27/2022]
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Abstract
Background—
Previous studies have reported worse outcomes in children with nondilated cardiomyopathy (CMP) listed for heart transplant compared with children with dilated CMP. We sought to compare wait-list and posttransplant outcomes in these groups in the current era.
Methods and Results—
We analyzed all children <18 years of age with a diagnosis of CMP listed for heart transplant in the United States between July 2004 and December 2010. Multivariable risk factors for death on the wait-list (or becoming too sick to transplant) and posttransplant graft loss (median follow-up 2 years) were assessed using Cox models. Of the 1436 children analyzed, 1197 (83%) had dilated CMP and 239 (17%) had nondilated CMP (167 restrictive CMP, 72 hypertrophic CMP). In adjusted analysis, children with nondilated CMP were at higher risk of wait-list mortality only if they were on a ventilator support at listing (hazard ratio, 2.3; CI, 1.2–4.5). The risk was similar among children not on a ventilator support (hazard ratio, 0.6; CI, 0.3–1.1). Posttransplant 30-day and 1-year survival was 98% and 94%, respectively, in children with dilated CMP versus 95% and 89%, respectively, in children with nondilated CMP (
P
=0.17, log-rank test). In adjusted analysis, the risk of posttransplant graft loss was higher in nondilated CMP (hazard ratio, 1.8; CI, 1.2–2.7) versus dilated CMP.
Conclusions—
The increased risk of wait-list mortality in children with nondilated CMP is limited to those on ventilator support at listing. Although the risk of graft loss is modestly higher in children with nondilated forms of CMP, their short-term transplant outcomes are good.
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Affiliation(s)
- Tajinder P. Singh
- From the Department of Cardiology, Boston Children’s Hospital, Boston, MA (T.P.S., C.A., G.P., K.G.); Department of Pediatrics, Harvard Medical School, Boston, MA (T.P.S., C.A.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Christopher S. Almond
- From the Department of Cardiology, Boston Children’s Hospital, Boston, MA (T.P.S., C.A., G.P., K.G.); Department of Pediatrics, Harvard Medical School, Boston, MA (T.P.S., C.A.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Gary Piercey
- From the Department of Cardiology, Boston Children’s Hospital, Boston, MA (T.P.S., C.A., G.P., K.G.); Department of Pediatrics, Harvard Medical School, Boston, MA (T.P.S., C.A.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Kimberlee Gauvreau
- From the Department of Cardiology, Boston Children’s Hospital, Boston, MA (T.P.S., C.A., G.P., K.G.); Department of Pediatrics, Harvard Medical School, Boston, MA (T.P.S., C.A.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
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47
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Barrett CS, Jaggers JJ, Cook EF, Graham DA, Rajagopal SK, Almond CS, Seeger JD, Rycus PT, Thiagarajan RR. Outcomes of neonates undergoing extracorporeal membrane oxygenation support using centrifugal versus roller blood pumps. Ann Thorac Surg 2012; 94:1635-41. [PMID: 22921236 DOI: 10.1016/j.athoracsur.2012.06.061] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 06/25/2012] [Accepted: 06/26/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Advances in centrifugal blood pump technology have led to increased use of centrifugal pumps in extracorporeal membrane oxygenation (ECMO) circuits. Their efficacy and safety in critically ill neonates remains unknown. Blood cell trauma leading to hemolysis may result in end-organ injury in critically ill neonates receiving centrifugal pump ECMO. We hypothesized that neonates undergoing ECMO support using centrifugal pumps were at increased odds of hemolysis and subsequent end-organ injury. METHODS Children 30 days of age or younger who received support with venoarterial ECMO and were reported to the Extracorporeal Life Support Registry during 2007 to 2009 underwent propensity score matching (Greedy matching 1:1) using pre-ECMO support characteristics. RESULTS A total of 1,592 neonates receiving ECMO (centrifugal pump = 163 and roller pump = 1,492) were identified. Significant differences in demographic, presupport, and cannulation variables were present before matching. One hundred seventy-six neonates who were supported using either centrifugal (n = 88) or roller pumps (n = 88) were matched using propensity scoring. No significant differences in demographic, presupport, or cannulation variables were present after matching. Neonates undergoing support using centrifugal pumps had increased odds of hemolysis (odds ratio [OR], 7.7 [2.8-21.2]), hyperbilirubinemia (OR, 20.8 [2.7-160.4]), hypertension (OR, 3.2 [1.3-8.0]), and acute renal failure (OR, 2.4 [1.1-5.6]). Survival to discharge was not different between pump types. CONCLUSIONS Use of ECMO using centrifugal pumps is associated with increased odds of hemolysis that likely contributes to other end-organ injury. Research into the optimal use of centrifugal pumps and strategies to prevent support-related complications need to be investigated.
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Affiliation(s)
- Cindy S Barrett
- Department of Cardiology, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado.
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Fraser CD, Jaquiss RDB, Rosenthal DN, Humpl T, Canter CE, Blackstone EH, Naftel DC, Ichord RN, Bomgaars L, Tweddell JS, Massicotte MP, Turrentine MW, Cohen GA, Devaney EJ, Pearce FB, Carberry KE, Kroslowitz R, Almond CS. Prospective trial of a pediatric ventricular assist device. N Engl J Med 2012; 367:532-41. [PMID: 22873533 DOI: 10.1056/nejmoa1014164] [Citation(s) in RCA: 353] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Options for mechanical circulatory support as a bridge to heart transplantation in children with severe heart failure are limited. METHODS We conducted a prospective, single-group trial of a ventricular assist device designed specifically for children as a bridge to heart transplantation. Patients 16 years of age or younger were divided into two cohorts according to body-surface area (cohort 1, <0.7 m(2); cohort 2, 0.7 to <1.5 m(2)), with 24 patients in each group. Survival in the two cohorts receiving mechanical support (with data censored at the time of transplantation or weaning from the device owing to recovery) was compared with survival in two propensity-score-matched historical control groups (one for each cohort) undergoing extracorporeal membrane oxygenation (ECMO). RESULTS For participants in cohort 1, the median survival time had not been reached at 174 days, whereas in the matched ECMO group, the median survival was 13 days (P<0.001 by the log-rank test). For participants in cohort 2 and the matched ECMO group, the median survival was 144 days and 10 days, respectively (P<0.001 by the log-rank test). Serious adverse events in cohort 1 and cohort 2 included major bleeding (in 42% and 50% of patients, respectively), infection (in 63% and 50%), and stroke (in 29% and 29%). CONCLUSIONS Our trial showed that survival rates were significantly higher with the ventricular assist device than with ECMO. Serious adverse events, including infection, stroke, and bleeding, occurred in a majority of study participants. (Funded by Berlin Heart and the Food and Drug Administration Office of Orphan Product Development; ClinicalTrials.gov number, NCT00583661.).
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Affiliation(s)
- Charles D Fraser
- Texas Children's Hospital and Baylor College of Medicine, Houston, Texas 77030, USA.
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Smoot LB, VanderPluym C, Oliva M, Rosenthal DN, Bastardi H, Singh TP, Gauvreau K, Almond CS. Risk Factors for Cognitive Impairment in Children Undergoing Pediatric Heart Transplant. J Card Fail 2012. [DOI: 10.1016/j.cardfail.2012.06.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Singh TP, Almond CS, Taylor DO, Milliren CE, Graham DA. Racial and ethnic differences in wait-list outcomes in patients listed for heart transplantation in the United States. Circulation 2012; 125:3022-30. [PMID: 22589383 DOI: 10.1161/circulationaha.112.092643] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Racial differences in long-term survival after heart transplant (HT) are well known. We sought to assess racial/ethnic differences in wait-list outcomes among patients listed for HT in the United States in the current era. METHODS AND RESULTS We compared wait-list and posttransplant in-hospital mortality among white, black, and Hispanic patients ≥ 18 years of age listed for their primary HT in the United States between July 2006 and September 2010. Of 10 377 patients analyzed, 71% were white, 21% were black, and 8% were Hispanic. Black and Hispanic patients were more likely to be listed with higher urgency (listing status 1A/1B) in comparison with white patients (P<0.001). Overall, 10.5% of white, 11.6% of black, and 13.4% of Hispanic candidates died on the wait-list or became too sick for a transplant within 1 year of listing. After adjusting for baseline risk factors, Hispanic patients were at higher risk of wait-list mortality (hazard ratio 1.51, 95% CI 1.23, 1.85) in comparison with white patients, but not black patients (hazard ratio 1.13, 95% CI 0.97, 1.31). In comparison with white HT recipients, posttransplant in-hospital mortality was higher in black recipients (odds ratio 1.53, 95% CI 1.15, 2.03) but was not different in Hispanic recipients (odds ratio 0.78, 95% CI 0.48, 1.29). CONCLUSIONS Hispanic patients listed for HT in the United States appear to be at higher risk of dying on the wait-list or becoming too sick for a transplant in comparison with white patients. Black patients are not at higher risk of wait-list mortality, but they have higher early posttransplant mortality.
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Affiliation(s)
- Tajinder P Singh
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
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