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Newland DM, Palmer MM, Knorr LR, Pak JL, Albers EL, Friedland-Little JM, Hong BJ, Law YM, Spencer KL, Kemna MS. Analysis of Platelet Function Testing in Children Receiving Aspirin for Antiplatelet Effects. Pediatr Cardiol 2024; 45:614-622. [PMID: 38153548 DOI: 10.1007/s00246-023-03377-6] [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: 07/23/2023] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Abstract
Aspirin (ASA) remains the most common antiplatelet agent used in children. VerifyNow Aspirin Test® (VN) assesses platelet response to ASA, with therapeutic effect defined by the manufacturer as ≤ 549 aspirin reaction units (ARU). Single-center, observational, analysis of 195 children (< 18 years-old) who underwent first VN between 2015 and 2020. Primary outcome was proportion of patients with ASA biochemical resistance (> 549 ARU). Secondary outcomes included incidence of new clinical thrombotic and bleeding events during ≤ 6 months from VN in those who received ASA monotherapy (n = 113). Median age was 1.8 years. Common indications for ASA included cardiac anomalies or dysfunction (74.8%) and ischemic stroke (22.6%). Median ASA dose before VN was 4.6 mg/kg/day. Mean VN was 471 ARU. ASA biochemical resistance was detected in 14.4% (n = 28). Of 113 patients receiving ASA monotherapy, 14 (12.4%) had a thrombotic event and 2 (1.8%) had a bleeding event. Mean VN was significantly higher at initial testing in patients experiencing thrombotic event compared to those without thrombosis (516 vs 465 ARU, [95% CI: 9.8, 92.2], p = 0.02). Multivariable analysis identified initial VN ASA result ≥ 500 ARU at initial testing as the only significant independent risk factor for thrombosis (p < 0.01). VN testing identifies ASA biochemical resistance in 14.4% of children. VN ASA ≥ 500 ARU rather than ≥ 550 ARU at initial testing was independently associated with increased odds of thrombosis. Designated cut-off of 550 ARU for detecting platelet dysfunction by ASA may need reconsideration in children.
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Affiliation(s)
- David M Newland
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA.
- School of Pharmacy, University of Washington, Seattle, WA, USA.
| | - Michelle M Palmer
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Lisa R Knorr
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Jennifer L Pak
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Erin L Albers
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Joshua M Friedland-Little
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Borah J Hong
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Yuk M Law
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Mariska S Kemna
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
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2
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Newland DM, Pak JL, Ali R, Herzog T, Nemeth TL, Tressel W, Kronmal RA, Knorr LR, Albers EL, Friedland-Little JM, Ahmed H, Kemna MS, Hong BJ, Spencer K, Law YM. Mycophenolic acid therapeutic drug monitoring using area under the curve in pediatric heart transplant recipients. Clin Transplant 2023; 37:e15087. [PMID: 37526562 DOI: 10.1111/ctr.15087] [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] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/10/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Pharmacokinetics of mycophenolic acid (MPA) display substantial interpatient variability, with up to 10-fold difference of exposure in individual patients under a fixed-dose regimen. MPA trough level (C0) monitoring is common in clinical practice but has not proven sufficiently informative in predicting MPA exposure or patient outcomes, especially in children. No limited sampling strategies (LSSs) have been generated from pediatric heart transplant (HTx) recipients to estimate MPA AUC. METHODS Single-center, observational analysis of 135 de novo pediatric HTx recipients ≤21 years old who underwent MPA AUC between 2011 and 2021. RESULTS Median age was 4 years (IQR .6-12.1). Median time from transplant to MPA AUC sampling was 15 days (IQR 11-19). MMF doses (mg or mg/day) had low, negative Pearson correlation coefficients (r) while doses adjusted for weight or body surface area had low correlation with Trapezoidal MPA AUC0-24 h (r = .3 and .383, respectively). MPA C0 had weak association (r = .451) with Trapezoidal MPA AUC0-24 h . LSS with two pharmacokinetic sampling time points at 90 (C3 ) and 360 (C5 ) min after MMF administration (estimated AUC0-24 h = 32.82 + 4.12 × C3 + 11.53 × C5 ) showed strong correlation with Trapezoidal MPA AUC0-24 h (r = .87). CONCLUSION MMF at fixed or weight-adjusted doses, as well as MPA trough levels, correlate poorly with MPA AUC0-24 h . We developed novel LSSs to estimate Trapezoidal MPA AUC from a large cohort of pediatric HTx recipients. Validation of our LSSs should be completed in a separate cohort of pediatric HTx recipients.
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Affiliation(s)
- David M Newland
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Jennifer L Pak
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Reda Ali
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | | | - Thomas L Nemeth
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - William Tressel
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Richard A Kronmal
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Lisa R Knorr
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Erin L Albers
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Joshua M Friedland-Little
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Humera Ahmed
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Mariska S Kemna
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Borah J Hong
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kathryn Spencer
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Yuk M Law
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
- School of Medicine, University of Washington, Seattle, Washington, USA
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3
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Clark JD, Albers EL, Albert JE, Berkman ER, Englund JA, Farris RWD, Johnson BA, Lewis‐Newby M, McGuire J, Rogers M, Thompson HM, Wagner TA, Wells C, Yanay O, Zerr DM, Limaye AP. SARS-CoV-2 RNA positive pediatric organ donors: A case report. Pediatr Transplant 2023; 27:e14452. [PMID: 36518025 PMCID: PMC9878170 DOI: 10.1111/petr.14452] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/23/2022] [Accepted: 10/24/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Preliminary evidence suggests that non-lung organ donation from resolved, asymptomatic or mildly symptomatic SARS-CoV-2 infected adults may be safe. However, several biological aspects of SARS-CoV-2 infection differ in children and the risk for transmission and outcomes of recipients from pediatric donors with SARS-CoV-2 infection are not well described. METHODS We report two unvaccinated asymptomatic pediatric non-lung organ deceased donors who tested positive for SARS-CoV-2 RNA by RT-PCR. Donor One unexpectedly had SARS-CoV-2 RNA detected in nasopharyngeal swab and plasma specimens at autopsy despite several negative tests (upper and lower respiratory tract) in the days prior to organ recovery. Donor Two had SARS-CoV- 2 RNA detected in multiple nasopharyngeal swabs but not lower respiratory tract specimens (endotracheal aspirate and bronchoalveolar lavage) during routine surveillance prior to organ recovery and was managed with remdesivir and monoclonal antibodies prior to organ recovery. RESULTS Two hearts, two livers and four kidneys were successfully transplanted into seven recipients. No donor to recipient transmission of SARS-CoV-2 was observed and graft function of all organs has remained excellent for up to 7 months of followup. CONCLUSIONS Due to the persistent gap between organ availability and the number of children waiting for transplants, deceased pediatric patients with non-disseminated SARS-CoV-2 infection, isolated to upper and/or lower respiratory tract, should be considered as potential non-lung organ donors.
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Affiliation(s)
- Jonna D. Clark
- Division of Bioethics and Palliative Care, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
- Treuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteSeattleWashingtonUSA
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Erin L. Albers
- Division of Pediatric CardiologyUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Jesselle E. Albert
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Emily R. Berkman
- Division of Bioethics and Palliative Care, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
- Treuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteSeattleWashingtonUSA
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Janet A. Englund
- Division of Pediatric Infectious DiseasesUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Reid W. D. Farris
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | | | - Mithya Lewis‐Newby
- Division of Bioethics and Palliative Care, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
- Treuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteSeattleWashingtonUSA
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - John McGuire
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | | | | | - Thor A. Wagner
- Division of Pediatric Infectious DiseasesUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | | | - Ofer Yanay
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Danielle M. Zerr
- Division of Pediatric Infectious DiseasesUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Ajit P. Limaye
- Department of Medicine, Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWashingtonUSA
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Newland DM, Rosete BE, Law YM, Kemna MS, Albers EL, Hong BJ, Ahmed H, Spencer KL, Friedland-Little JM. Assessment of the adverse effects of sirolimus versus everolimus in pediatric heart transplant recipients. Pediatr Transplant 2023; 27:e14487. [PMID: 36869621 DOI: 10.1111/petr.14487] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Literature is limited comparing adverse effects (AEs) of the proliferation signal inhibitors (PSIs) sirolimus (SRL) and everolimus (EVL) in pediatric heart transplant (HTx) recipients. METHODS Single-center, observational cohort analysis assessing first use of SRL or EVL in pediatric HTx recipients <21 years of age with up to 2 years follow-up between 2009 and 2020. RESULTS Eighty-seven patients were included, with 52 (59.8%) receiving EVL and 35 (40.2%) receiving SRL. Tacrolimus with PSI was the most common regimen. Intergroup comparison revealed lower baseline estimated glomerular filtration rate (eGFR) and greater increase in eGFR from baseline to 6 months and latest follow-up in SRL cohort compared to EVL cohort. There was greater increase in HDL cholesterol in SRL cohort compared to EVL cohort. Intragroup analysis revealed eGFR and HDL cholesterol increased significantly within SRL cohort, triglycerides and glycosylated hemoglobin increased in EVL cohort, and LDL cholesterol and total cholesterol increased in both cohorts (all p < .05). There were no differences in hematological indices or rates of aphthous ulcers, effusions, or infections between cohorts. Incidence of proteinuria was not significantly different among those screened within cohorts. Of those included in our analysis, one patient in SRL cohort (2.9%) and two in EVL cohort (3.8%) had PSI withdrawn due to AE. CONCLUSION Low-dose PSIs in calcineurin inhibitor minimization regimens appear well-tolerated with low withdrawal rate secondary to AE in pediatric HTx recipients. While incidence of most AE was similar between PSI, our results suggest EVL may be associated with less favorable metabolic impact than SRL in this population.
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Affiliation(s)
- David M Newland
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA.,School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Beatrice E Rosete
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA.,School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Humera Ahmed
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kathryn L Spencer
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joshua M Friedland-Little
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
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5
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Newland DM, Law YM, Albers EL, Friedland-Little JM, Ahmed H, Kemna MS, Hong BJ. Early Clinical Experience with Dapagliflozin in Children with Heart Failure. Pediatr Cardiol 2023; 44:146-152. [PMID: 35948644 DOI: 10.1007/s00246-022-02983-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 03/20/2022] [Accepted: 07/25/2022] [Indexed: 01/24/2023]
Abstract
Pediatric heart failure (HF) is associated with significant morbidity and mortality. Medical treatment for pediatric HF is largely derived from adult studies. Previously, there has been no described use of dapagliflozin in pediatric HF patients. We describe our single-center experience using dapagliflozin in addition to standard HF medical therapy in 38 pediatric HF patients since January 2020. Median age was 12.2 years (interquartile range 6.2-17.5). Majority of patients had dilated cardiomyopathy (68.4%) and reduced left ventricular ejection fraction (LVEF) of 40% or less (65.8%). HF regimens commonly included sacubitril/valsartan, beta-blocker, mineralocorticoid receptor antagonist, and loop diuretic. Median follow-up from dapagliflozin initiation for the whole cohort was 130 days (IQR 76-332). Median B-type natriuretic peptide decreased significantly from 222 to 166 pg/mL at latest clinical follow-up (P = .04). Estimated glomerular filtration rate trended lower at latest follow-up but was not significant from baseline. There were no clinically significant changes in blood chemistries or vital signs after initiation of dapagliflozin. No patients experienced symptomatic hypoglycemia or hypovolemia. Six patients (15.8%) experienced a symptomatic urinary tract infection necessitating antibiotic treatment. In a separate analysis of 16 patients with dilated cardiomyopathy who received dapagliflozin for a median of 313 days (IQR 191-414), median LVEF increased significantly from 32 to 37.2% (P = .006). Dapagliflozin, when added to a background of guideline-directed medical therapy, appears well tolerated in children with HF. Larger studies are needed to evaluate safety and efficacy of dapagliflozin in this population.
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Affiliation(s)
- David M Newland
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA. .,School of Pharmacy, University of Washington, Seattle, WA, USA.
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Joshua M Friedland-Little
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Humera Ahmed
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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6
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Frandsen EL, Banker KA, Mazor RL, McMullan DM, Law YM, Kemna MS, Albers EL, Hong BJ, Friedland-Little JM. Waitlist and posttransplant outcomes of critically ill infants awaiting heart transplantation managed without ventricular assist device support. Pediatr Transplant 2022; 26:e14308. [PMID: 35587026 DOI: 10.1111/petr.14308] [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: 01/03/2022] [Revised: 04/14/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Infants listed for heart transplant are at high risk for waitlist mortality. While waitlist mortality for children has decreased in the current era of increased ventricular assist device use, outcomes for small infants supported by ventricular assist device remain suboptimal. We evaluated morbidity and survival in critically ill infants listed for heart transplant and managed without ventricular assist device support. METHODS Critically ill infants (requiring ≥1 inotrope and mechanical ventilation or ≥2 inotropes without mechanical ventilation) listed between 2008 and 2019 were included. During the study period, infants were managed primarily medically. Mechanical circulatory support, specifically extracorporeal membrane oxygenation, was utilized as "rescue therapy" for decompensating patients. RESULTS Thirty-two infants were listed 1A, 66% with congenital heart disease. Median age and weight at listing were 2.2 months and 4.4 kg, with 69% weighing <5 kg. At listing, 97% were mechanically ventilated, 41% on ≥2 inotropes, and 25% under neuromuscular blockade. Five patients were supported by ECMO after listing. A favorable outcome (transplant or recovery) was observed in 84%. One-year posttransplant survival was 92%. Infection was the most common waitlist complication occurring in 75%. Stroke was rare, occurring in one patient who was supported on ECMO. Renal function improved from listing to transplant, death, or recovery (eGFR 70 vs 87 ml/min/1.73m2 , p = .001). CONCLUSION A strategy incorporating a high threshold for mechanical circulatory support and acceptance of prolonged mechanical ventilation and neuromuscular blockade can achieve good survival and morbidity outcomes for critically ill infants listed for heart transplant.
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Affiliation(s)
- Erik L Frandsen
- Pediatric Cardiology, Loma Linda University Children's Hospital, Loma Linda, California, United States
| | - Katherine A Banker
- Division of Critical Care, Seattle Children's Hospital, Seattle, Washington, USA
| | - Robert L Mazor
- Division of Critical Care, Seattle Children's Hospital, Seattle, Washington, USA
| | - D Michael McMullan
- Division of Pediatric Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
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7
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Rabbani N, Kronmal RA, Wagner T, Kemna M, Albers EL, Hong B, Friedland-Little J, Spencer K, Law YM. Association Between Cytomegalovirus Serostatus, Antiviral Therapy, and Allograft Survival in Pediatric Heart Transplantation. Transpl Int 2022; 35:10121. [PMID: 35368645 PMCID: PMC8964945 DOI: 10.3389/ti.2022.10121] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
Background: Cytomegalovirus (CMV) is an important complication of heart transplantation and has been associated with graft loss in adults. The data in pediatric transplantation, however, is limited and conflicting. We conducted a large-scale cohort study to better characterize the relationship between CMV serostatus, CMV antiviral use, and graft survival in pediatric heart transplantation. Methods: 4,968 pediatric recipients of solitary heart transplants from the Scientific Registry of Transplant Recipients were stratified into three groups based on donor or recipient seropositivity and antiviral use: CMV seronegative (CMV-) transplants, CMV seropositive (CMV+) transplants without antiviral therapy, and CMV+ transplants with antiviral therapy. The primary endpoint was retransplantation or death. Results: CMV+ transplants without antiviral therapy experienced worse graft survival than CMV+ transplants with antiviral therapy (10-year: 57 vs 65%). CMV+ transplants with antiviral therapy experienced similar survival as CMV- transplants. Compared to CMV seronegativity, CMV seropositivity without antiviral therapy had a hazard ratio of 1.21 (1.07–1.37 95% CI, p-value = .003). Amongst CMV+ transplants, antiviral therapy had a hazard ratio of .82 (0.74–.92 95% CI, p-value < .001). During the first year after transplantation, these hazard ratios were 1.32 (1.06–1.64 95% CI, p-value .014) and .59 (.48–.73 95% CI, p-value < .001), respectively. Conclusions: CMV seropositivity is associated with an increased risk of graft loss in pediatric heart transplant recipients, which occurs early after transplantation and may be mitigated by antiviral therapy.
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Affiliation(s)
- Naveed Rabbani
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | - Richard A Kronmal
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Thor Wagner
- Division of Pediatric Infectious Diseases, Seattle Children's Hospital, Seattle, WA, United States
| | - Mariska Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | - Borah Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | | | - Kathryn Spencer
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
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8
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Albers EL, Friedland-Little JM, Hong BJ, Kemna MS, Warner P, Law YM. Human leukocyte antigen eplet mismatching is associated with increased risk of graft loss and rejection after pediatric heart transplant. Pediatr Transplant 2022; 26:e14126. [PMID: 34476876 DOI: 10.1111/petr.14126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 04/22/2021] [Revised: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND While mismatching between donor and recipient human leukocyte antigen (HLA) alleles has been associated with increased graft loss in pediatric heart recipients, it is actually the surface amino acid structures, termed eplets, which determine the antigenicity of each HLA molecule. We hypothesized that HLA eplet mismatch analysis is a better predictor of adverse outcomes after pediatric heart transplant than conventional allele mismatch comparison. METHODS A retrospective review of the Pediatric Heart Transplant Society database identified pediatric heart recipients (<18 years at listing) with complete donor and recipient HLA typing (A, B, and DR). Imputed high-resolution HLA genotypes were entered into HLAMatchmaker software which then calculated the number of eplet mismatches between each donor-recipient pair. Multivariable Cox regression analysis was used to examine associations between allele or eplet mismatching and adverse outcomes. RESULTS Compared to those with <20 HLA class I eplet mismatches, recipients with 20 or more HLA class I eplet mismatches had an increased risk of graft loss (HR 1.46 [1.01-2.12], p = .049). HLA class I eplet mismatching was also associated with rejection (>20 mismatches: HR 1.30 [1.03-1.65], p = .030), while HLA class II eplet mismatching was associated with specified antibody-mediated rejection (10-20 mismatches: HR 1.57 [1.06-2.34], p = .025; >20 mismatches: HR 3.14 [1.72-5.71], p < .001). Neither HLA class I nor class II allele mismatching was significantly associated with graft loss or rejection. CONCLUSION Eplet mismatch analysis was more predictive of adverse post-transplant outcomes (including graft loss and rejection) than allele mismatch comparison. Further study, including prospective high-resolution HLA typing, is warranted.
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Affiliation(s)
- Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Paul Warner
- Immunogenetics/HLA Laboratory, Bloodworks Northwest, Seattle, WA, USA
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
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9
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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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10
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Berkman E, Wightman A, Friedland-Little JM, Albers EL, Diekema D, Lewis-Newby M. An ethical analysis of obesity as a determinant of pediatric heart transplant candidacy. Pediatr Transplant 2021; 25:e13913. [PMID: 33179426 DOI: 10.1111/petr.13913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 08/04/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Inclusion of BMI as criterion in the determination of heart transplant candidacy in children is a clinical and ethical challenge. Childhood obesity is increasing and children with heart disease are not spared. Currently, many adult heart transplant centers consider class II obesity and higher (BMI > 35 kg/m2 ) to be a relative contraindication for transplantation due to risk of poor outcome after transplant. No national guidelines exist regarding consideration of BMI in pediatric heart transplant and outcomes data are limited. This leaves decisions about transplant candidacy in obese pediatric patients to individual institutions or on a case-by-case basis, allowing for bias and inequity. METHODS We review (a) the prevalence of childhood obesity, including among heart transplant candidates, (b) the lack of existing BMI guidelines, and (c) relevant literature on BMI and pediatric heart transplant outcomes. We discuss the ethical considerations of using obesity as a criterion using the principles of utility, justice, and respect for persons. RESULTS Existing transplant outcomes data do not show that obese children have different or poor enough outcomes compared to non-obese children to warrant exclusion. Moreover, obesity in the United States is unequally distributed by race and socioeconomic status. Children already suffering from health disparities are therefore doubly penalized if obesity denies them access to life-saving transplant. CONCLUSION Insufficient data exist to support using any BMI cutoff as an absolute contraindication for heart transplant in children. Attention should be paid to health equity issues when considering excluding a patient for transplant based on obesity.
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Affiliation(s)
- Emily Berkman
- Division of Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA
| | - Aaron Wightman
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.,Division of Pediatric Nephrology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Joshua M Friedland-Little
- Division of Pediatric Cardiology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Douglas Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.,Division of Pediatric Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Mithya Lewis-Newby
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.,Division of Pediatric Cardiac Critical Care, University of Washington School of Medicine Ι Seattle Children's Hospital, Seattle, WA, USA
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11
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Frandsen EL, Otero J, Rutledge JC, Kemna MS, Albers EL, Hong BJ, Law YM, Friedland-Little JM. A fatal case of bortezomib-induced lung toxicity in a young adult heart transplant recipient. Pediatr Transplant 2020; 24:e13628. [PMID: 31815325 DOI: 10.1111/petr.13628] [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: 09/26/2019] [Revised: 10/22/2019] [Accepted: 10/27/2019] [Indexed: 11/28/2022]
Abstract
Bortezomib is approved for the treatment of multiple myeloma but increasingly used in heart transplant (HTx) recipients with antibody-mediated rejection (AMR). Severe pulmonary toxicity is a rare complication in multiple myeloma patients treated with bortezomib, but has not been described in a solid organ transplant recipient. A 20-year-old man 7 years post-HTx presented with acute rejection with hemodynamic compromise. Endomyocardial biopsy showed mixed rejection (ISHLT grade 2R-3R acute cellular rejection (ACR) and pAMR 1 (I+) with diffuse C4d staining). Two new high MFI circulating MHC class-II donor-specific antibodies (DSA) were detected. Treatment included corticosteroids, antithymocyte globulin, plasmapheresis, IVIG, rituximab, and bortezomib (1.3 mg/m2 ). Due to rebound in DSA, a second course of bortezomib was started. Thrombocytopenia and peripheral neuropathy prompted a 50% dose reduction during the 2nd course. Shortly after the 3rd reduced dose, the patient developed hypoxemic respiratory failure. Bronchoscopy revealed pulmonary hemorrhage with negative infectious studies. Chest CT showed bilateral parenchymal disease with bronchiectasis and alveolar bleeding. Despite treatment with high-dose steroids, severe ARDS ensued with multisystem organ failure. The patient expired 23 days after the final dose of bortezomib. Post-mortem lung histology revealed diffuse alveolar damage, pulmonary fibrosis, and hemorrhage. Cardiac histology showed resolving/residual ACR 1R and pAMR 1 (I+). While rare, bortezomib-induced lung toxicity (BILT) can occur in HTx recipients and can carry a high risk of mortality. Drug reaction and immediate drug withdrawal should be considered in patients who develop respiratory symptoms, though optimal management of BILT is unclear.
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Affiliation(s)
| | - Jessica Otero
- Clinical Pharmacy Services, Seattle Children's Hospital, Seattle, WA, USA
| | - Joe C Rutledge
- Department of Pathology, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Erin L Albers
- Heart Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Borah J Hong
- Heart Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Yuk M Law
- Heart Center, Seattle Children's Hospital, Seattle, WA, USA
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12
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Kerr SM, Jorgensen NW, Hong BJ, Friedland-Little JM, Albers EL, Newland DM, Law YM, Kemna MS. Assessment of rejection risk following subtherapeutic calcineurin inhibitor levels after pediatric heart transplantation. Pediatr Transplant 2020; 24:e13616. [PMID: 31820529 DOI: 10.1111/petr.13616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Received: 03/08/2019] [Revised: 09/24/2019] [Accepted: 10/22/2019] [Indexed: 11/29/2022]
Abstract
CNIs are the mainstay of immunosuppressive therapy after pediatric HTx. While regular laboratory surveillance is performed to ensure blood levels are within targeted range, the risk of acute rejection associated with subtherapeutic CNI levels has never been quantified. This is a retrospective single-center review of 8413 CNI trough levels in 138 pediatric HTx recipients who survived >1 year after HTx. Subtherapeutic CNI levels were defined as <50% of the lower limit of target range. The risk of acute, late (>12 months post-transplant) rejection following recipients' subtherapeutic CNI levels was assessed using time-varying multivariable Cox proportional hazards analysis. We found that 79 of 138 recipients (57%) had at least one subtherapeutic CNI level on routine surveillance laboratories during a mean follow-up of 5.5 ± 3.6 years. Following an episode of subtherapeutic levels, 17 recipients (22%) had biopsy-proven rejection within the next 3 months; the majority (9/17) within the first 2 weeks. After presenting with subtherapeutic CNI levels, recipients incurred a 6.1 times increased risk of acute rejection in the following 3 months (HR = 6.11 [2.41, 15.51], P = <.001). Age at HTx, HLA sensitization, or positive crossmatch were not associated with acute late rejection, but rejection in the first post-transplant year was (HR 2.61 [1.27, 5.35], P = .009). Thus, maintaining therapeutic CNI levels is the most important factor in preventing acute rejection in recipients who are >12 months after pediatric HTx. Recipients who present with subtherapeutic CNI levels on surveillance monitoring are 6.1 times more likely to develop rejection in the following 3 months.
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Affiliation(s)
- Sarah M Kerr
- School of Medicine, University of Washington, Seattle, Washington
| | - Neal W Jorgensen
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Joshua M Friedland-Little
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - David M Newland
- Pharmacy, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
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13
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Abstract
Despite advancements in transplant immunosuppression and techniques for managing critically ill patients awaiting heart transplantation, children who are immunologically sensitized to human leukocyte antigen remain at increased risk for morbidity and mortality, both while awaiting and after heart transplant. In this review we will discuss the epidemiology of sensitization, review the immunologic basis and methods of human leukocyte antigen antibody detection, describe outcomes for sensitized pediatric transplant candidates, and consider both pre- and post-transplant management options for sensitized patients.
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Affiliation(s)
- Erik L Frandsen
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
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14
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Chen CY, Warner P, Albers EL, Kemna MS, Delaney M, Hong BJ, Law YM. Donor-specific anti-HLA antibody production following pediatric ABO-incompatible heart transplantation. Pediatr Transplant 2019; 23:e13332. [PMID: 30515928 DOI: 10.1111/petr.13332] [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: 05/11/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Abstract
ABO-i heart transplantation can be performed in infants with end-stage heart failure to increase organ availability. The development of newly detected DSAs is associated with decreased cardiac graft survival, and the effect of ABO-i transplantation on DSA production is unknown. We examined DSA production and rejection frequency in infant recipients of ABO-i and ABO-c heart transplants via a retrospective cohort study of infant heart transplant recipients transplanted at a single pediatric center between January 2004 and November 2014. Patients were included if they were less than 1 year of age at transplant and had a minimum of 6 months follow-up. DSA positivity was examined under two categories, either the lowest level detectable (MFI > 500) or a level presumed to have clinical relevance in our immunogenetics laboratory (MFI > 5000). Of 52 patients, 36 received ABO-c transplants and 16 received ABO-i transplants. Compared to ABO-c recipients, the ABO-i group showed a consistent but statistically non-significant finding of less frequent ndDSA positivity (69.4% ABO-c vs 43.8% ABO-i with MFI >500, P = 0.122; 41.7% ABO-c vs 25% ABO-i with MFI >5000, P = 0.353). Additionally, ABO-i patients were less likely to have any form of rejection (12.5% vs 47.2%, P = 0.027) or acute cellular rejection (6.3% vs 38.9%, P = 0.021). Our data suggest that infants receiving ABO-i heart transplants may be less likely to develop ndDSAs or have rejection compared to same age ABO-c recipients. Larger multicenter studies are needed to confirm results from this single center study.
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Affiliation(s)
- Chiu-Yu Chen
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Paul Warner
- Immunogenetics/HLA Laboratory, Bloodworks Northwest, Seattle, Washington
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Meghan Delaney
- Pathology and Laboratory Medicine Division, Children's National Health System, Washington, D.C.,Departments of Pathology and Pediatrics, George Washington University, Washington, D.C
| | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
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15
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Morray BH, Albers EL, Jones TK, Kemna MS, Permut LC, Law YM. Hybrid stage 1 palliation as a bridge to cardiac transplantation in patients with high-risk single ventricle physiology. Pediatr Transplant 2018; 22:e13307. [PMID: 30338630 DOI: 10.1111/petr.13307] [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] [Received: 04/19/2018] [Revised: 09/14/2018] [Accepted: 09/19/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The hybrid stage 1 palliation for hypoplastic left heart syndrome (HLHS) was first described in 1993 as a bridge to heart transplant for HLHS. There are limited data on this strategy as primary heart transplantation for HLHS has become less common. METHODS This is an observational, single-center study comparing pre- and post-transplant outcomes of patients listed for transplant following hybrid palliation with those following surgical stage 1 palliation. RESULTS From 2004 to 2017, 21 patients underwent hybrid palliation as a bridge to heart transplant and 28 patients were listed for transplant following surgical stage 1 palliation or aortic arch repair and pulmonary artery band placement. Premature birth and the presence of genetic or anatomic abnormalities were more common in the hybrid group. Need for extracorporeal membrane oxygenation (ECMO) support and ventricular dysfunction was more common in the surgical group. There was a trend toward shorter waitlist times in the surgical cohort (36 days vs 70 days, P = 0.06). There was no difference in waitlist mortality (19% vs 21%, P = 0.61). Survival at 1 and 5 years post-transplant was similar for the hybrid and surgical cohorts (5-year survival, 80% vs 85%, P = 0.94, respectively). There was no difference in the number of post-transplant interventions. CONCLUSIONS Although the hybrid patients represented a higher risk cohort and demonstrated longer wait times, the waitlist and post-transplant mortality was equivalent between the two groups. For high-risk patients, the hybrid palliation as a bridge to transplant appears to be a reasonable strategy.
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Affiliation(s)
- Brian H Morray
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Thomas K Jones
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Lester C Permut
- Division of Pediatric Cardiothoracic Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
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16
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Wisotzkey BL, Soriano BD, Albers EL, Ferguson M, Buddhe S. Diagnostic role of strain imaging in atypical myocarditis by echocardiography and cardiac MRI. Pediatr Radiol 2018; 48:835-842. [PMID: 29651605 DOI: 10.1007/s00247-017-4061-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 04/28/2017] [Revised: 08/25/2017] [Accepted: 12/18/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND The diagnosis of myocarditis presenting as isolated acute chest pain with elevated troponins but normal systolic function is challenging with significant drawbacks even for the gold-standard endomyocardial biopsy. OBJECTIVE This study aimed to evaluate the diagnostic role of strain imaging by echocardiography and cardiac MRI in these patients. MATERIALS AND METHODS This was a retrospective review of children with cardiac MRI for acute chest pain with elevated troponins compared to normal controls. Echocardiographic fractional shortening, ejection fraction, speckle-tracking-derived peak longitudinal, radial, and circumferential strain were compared to cardiac MRI ejection fraction, T2 imaging, late gadolinium enhancement, speckle-tracking-derived peak longitudinal strain, radial strain, and circumferential strain. RESULTS Group 1 included 10 subjects diagnosed with myocarditis, 9 (90%) males with a median age of 15.5 years (range: 14-17 years) compared with 10 age-matched controls in group 2. All subjects in group 1 had late gadolinium enhancement consistent with myocarditis and troponin ranged from 2.5 to >30 ng/ml. Electrocardiogram changes included ST segment elevation in 6 and abnormal Q waves in 1. Qualitative echocardiographic function was normal in both groups and mean fractional shortening was similar (35±6% in group 1 vs. 34±4% in group 2, P=0.70). Left ventricle ejection fraction by cardiac MRI, however, was lower in group 1 (52±9%) compared to group 2 at (59±4%) (P=0.03). Cardiac MRI derived strain was lower in group 1 vs. group 2 for speckle-tracking-derived peak longitudinal strain (-12.8±2.8% vs. -17.1±1.5%, P=0.001), circumferential strain (-12.3±3.8% vs. -15.8±1.2%, P=0.020) and radial strain (13.6±3.7% vs. 17.2±3.2%, P=0.040). Echocardiography derived strain was also lower in group 1 vs. group 2 for speckle-tracking-derived peak longitudinal strain (-15.6±3.9% vs. -20.8±2.2%, P<0.002), circumferential strain (-16±3% vs. -19.8±1.9%, P<0.003) and radial strain (17.3±6.1% vs. 24.8±6.3%, P=0.010). CONCLUSION In previously asymptomatic children, myocarditis can present with symptoms of acute chest pain suspicious for coronary ischemia. Cardiac MRI and echocardiographic strain imaging are noninvasive, radiation-free tests of immense diagnostic utility in these situations. Long-term studies are needed to assess prognostic significance of these findings.
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Affiliation(s)
- Bethany L Wisotzkey
- Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, 501 Sixth Avenue South, St. Petersburg, FL, 33701, USA.
| | - Brian D Soriano
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Mark Ferguson
- Division of Radiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Sujatha Buddhe
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
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17
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Albers EL, Bradford MC, Friedland-Little JM, Hong BJ, Kemna MS, Chen JM, Law YM. Diastolic pressure indices offer a novel approach to predicting risk of graft loss after pediatric heart transplant. Pediatr Transplant 2018; 22. [PMID: 29396892 DOI: 10.1111/petr.13126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 12/19/2017] [Indexed: 11/28/2022]
Abstract
PH is a risk factor for GL after HTx. However, traditional parameters are not reliable predictors of risk in children. We hypothesized that DPI (dPAP and DPG) are predictive of GL in pediatric HTx recipients. The UNOS/SRTR database was reviewed to identify pediatric HTx recipients (age <18 years) between 1994 and 2013. Recipients with pretransplant hemodynamic data were grouped by diagnosis (CMP or CHD), and the groups were analyzed separately. Bivariate Cox regression analysis examined the association between hemodynamic variables and GL. DPI showed the strongest association with early GL in recipients with CMP (dPAP: HR = 1.25 [1.09-1.42]; DPG: 1.24 [1.11-1.38]). Among CHD recipients, DPI were associated with early GL in those with preexisting PH (dPAP: HR = 1.16 [1.01-1.33]; DPG: HR = 1.10 [1.00-1.21]). No cutoff values for "high-risk" DPI were identified, but a continuous relationship between higher DPI and risk of early GL was observed. DPI are associated with early GL in select pediatric HTx recipients. Our findings suggest that DPI should be considered as part of routine hemodynamic assessment for pediatric HTx candidates.
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Affiliation(s)
- Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | | | | | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Jonathan M Chen
- Division of Pediatric Cardiothoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
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18
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Vaughn GR, Jorgensen NW, Law YM, Albers EL, Hong BJ, Friedland-Little JM, Kemna MS. Outcome of antibody-mediated rejection compared to acute cellular rejection after pediatric heart transplantation. Pediatr Transplant 2018; 22. [PMID: 29222866 DOI: 10.1111/petr.13092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 11/08/2017] [Indexed: 01/28/2023]
Abstract
Outcomes of ACR after pediatric HTx have been well described, but less has been reported on outcomes of AMR. We compared the clinical characteristics and cardiovascular outcomes (composite end-point of death, retransplantation, or allograft vasculopathy) of pediatric HTx recipients with AMR, ACR, and no rejection in a retrospective single-center study of 104 recipients. Twenty were treated for AMR; 15 were treated for ACR. Recipients with AMR had an increased frequency of congenital heart disease (90% vs ACR 67% vs no rejection 59%, P = .03), homograft (68% vs 7% vs 18%, P < .001), HLA sensitization (45% vs 13% vs 13%, P = .008), and positive cross-match (30% vs 7% vs 9%, P = .046). AMR caused hemodynamic compromise more often than ACR (39% vs 4%, P = .02). AMR recipients had worse cardiovascular outcome than recipients with ACR or no rejection (40% vs 20% vs 8.6%, P = .003). In bivariate Cox analysis, AMR (HR 4.1, CI 1.4-12.0, P = .009) and ischemic time (HR 1.6, CI 1.1-2.3, P = .02) were associated with worse cardiovascular outcome; ACR was not. In summary, pediatric HTx recipients who develop AMR have worse cardiovascular outcome than recipients who develop only ACR or experience no rejection at all.
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Affiliation(s)
- Gabrielle R Vaughn
- Division of Pediatric Cardiology, Rady Children's Hospital, San Diego, CA, USA
| | - Neal W Jorgensen
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Joshua M Friedland-Little
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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19
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Wisotzkey BL, Jorgensen NW, Albers EL, Kemna MS, Boucek RJ, Kronmal RA, Law YM, Bhat AH. Feasibility and interpretation of global longitudinal strain imaging in pediatric heart transplant recipients. Pediatr Transplant 2017; 21. [PMID: 28295946 DOI: 10.1111/petr.12909] [Citation(s) in RCA: 10] [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] [Accepted: 12/15/2016] [Indexed: 01/07/2023]
Abstract
Evaluation of myocardial mechanics after heart transplant is important in monitoring allograft function and identifying rejection. Speckle tracking global longitudinal strain (GLS) may be more sensitive to early regional changes from rejection. This study aimed to determine feasibility of GLS in pediatric hearts during surveillance echocardiograms, compare their GLS to published norms (-18% to -22%), and assess association of GLS with other indices of graft function. Retrospective review of transplant echocardiograms from 2013 to 2014. Philips QLAB was used for post-acquisition GLS analysis. Multiple linear regression was used to assess the association of GLS with echocardiographic/catheterization indices, and B-type natriuretic peptide (BNP). Forty-seven patients (84 studies) were included. Calculation of GLS was feasible in 82 studies (97%) with inter- and intra-observer variability of 0.71 and 0.69. Patients (n=9) with rejection had GLS of -16.4% (SD=3.5%) compared to those without [-16.8% (SD=3.7%)]. GLS worsened linearly with increasing Ln(BNP) (P=<.001), left ventricular volume in diastole (P=<.001), septal a' wave (P=<.001), and pulmonary capillary wedge pressure (P=<.001). Speckle tracking-based GLS is feasible and reproducible in pediatric heart recipients and is reduced at baseline. The role of GLS and BNP in detecting early systolic dysfunction warrants further investigation.
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Affiliation(s)
- Bethany L Wisotzkey
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Neal W Jorgensen
- Division of Biostatistics, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Robert J Boucek
- Division of Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Richard A Kronmal
- Division of Biostatistics, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Yuk M Law
- Division of Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Aarti H Bhat
- Division of Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
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20
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Moore JP, Wang S, Albers EL, Salerno JC, Stephenson EA, Shah MJ, Pflaumer A, Czosek RJ, Garnreiter JM, Collins K, Papez AL, Sanatani S, Cain NB, Kannankeril PJ, Perry JC, Mandapati R, Silva JN, Balaji S, Shannon KM. A Clinical Risk Score to Improve the Diagnosis of Tachycardia-Induced Cardiomyopathy in Childhood. Am J Cardiol 2016; 118:1074-80. [PMID: 27515893 DOI: 10.1016/j.amjcard.2016.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/05/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022]
Abstract
Tachycardia-induced cardiomyopathy (TIC) is a treatable cause of heart failure in children, but there is little information as to which clinical variables best discriminate TIC from other forms of cardiomyopathy. TIC cases with dilated cardiomyopathy (DC) from 16 participating centers were identified and compared with controls with other forms of DC. Presenting clinical, echocardiographic, and electrocardiographic characteristics were collected. Heart rate (HR) percentile was defined as HR/median HR for age, and PR index as the PR/RR interval. P-wave morphology (PWM) was defined as possible sinus or nonsinus based on a predefined algorithm. Eighty TIC cases and 135 controls were identified. Cases demonstrated lower LV end-diastolic diameter and LV end-systolic diameter than DC controls (4.3 vs 6.5, p <0.001; 7.4 vs 10.9, p <0.001) and were less likely to receive inotropic medication at presentation (p <0.001 for both). Multivariable logistic regression identified HR percentile (OR 2.1 per 10% increase, CI 1.3 to 4.6; p = 0.014), PR index (OR 1.2, CI 1.1 to 1.4; p = 0.004), and nonsinus PWM (OR 104.9, CI 15.2 to 1,659.8; p <0.001) as predictive of TIC status. A risk score using HR percentile >130%, PR index >30%, and nonsinus PWM was associated with a sensitivity of 100% and specificity of 87% for the diagnosis of TIC. Model training and validation area under the curves were similar at 0.97 and 0.94, respectively. In conclusion, pediatric TIC may be accurately discriminated from other forms of DC using simple electrocardiographic parameters. This may allow for rapid diagnosis and early treatment of this condition.
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21
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Latham GJ, Jefferis Kirk C, Falconer A, Dickey R, Albers EL, McMullan DM. Challenging Argatroban Management of a Child on Extracorporeal Support and Subsequent Heart Transplant. Semin Cardiothorac Vasc Anesth 2015; 20:168-74. [DOI: 10.1177/1089253215624766] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
A 6-year-old child developed heparin-induced thrombocytopenia while on extracorporeal life support. Hours after a difficult transition from heparin to argatroban for anticoagulation therapy, the child underwent heart transplantation. Intraoperative management was plagued with circuit thrombus formation while on cardiopulmonary bypass and subsequent massive hemorrhage after bypass. We review the child’s anticoagulation management, clinical challenges encountered, and review current literature related to the use of argatroban in pediatric cardiac surgery.
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Affiliation(s)
- Gregory J. Latham
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | | | | | | | - Erin L. Albers
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - David Michael McMullan
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
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22
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Moore JP, Patel PA, Shannon KM, Albers EL, Salerno JC, Stein MA, Stephenson EA, Mohan S, Shah MJ, Asakai H, Pflaumer A, Czosek RJ, Everitt MD, Garnreiter JM, McCanta AC, Papez AL, Escudero C, Sanatani S, Cain NB, Kannankeril PJ, Bratincsak A, Mandapati R, Silva JNA, Knecht KR, Balaji S. Predictors of myocardial recovery in pediatric tachycardia-induced cardiomyopathy. Heart Rhythm 2014; 11:1163-9. [PMID: 24751393 DOI: 10.1016/j.hrthm.2014.04.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [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: 02/04/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Tachycardia-induced cardiomyopathy (TIC) carries significant risk of morbidity and mortality, although full recovery is possible. Little is known about the myocardial recovery pattern. OBJECTIVE The purpose of this study was to determine the time course and predictors of myocardial recovery in pediatric TIC. METHODS An international multicenter study of pediatric TIC was conducted. Children ≤18 years with incessant tachyarrhythmia, cardiac dysfunction (left ventricular ejection fraction [LVEF] <50%), and left ventricular (LV) dilation (left ventricular end-diastolic dimension [LVEDD] z-score ≥2) were included. Children with congenital heart disease or suspected primary cardiomyopathy were excluded. Primary end-points were time to LV systolic functional recovery (LVEF ≥55%) and normal LV size (LVEDD z-score <2). RESULTS Eighty-one children from 17 centers met inclusion criteria: median age 4.0 years (range 0.0-17.5 years) and baseline LVEF 28% (interquartile range 19-39). The most common arrhythmias were ectopic atrial tachycardia (59%), permanent junctional reciprocating tachycardia (23%), and ventricular tachycardia (7%). Thirteen required extracorporeal membrane oxygenation (n = 11) or ventricular assist device (n = 2) support. Median time to recovery was 51 days for LVEF and 71 days for LVEDD. Two (4%) underwent heart transplantation, and 1 died (1%). Multivariate predictors of LV systolic functional recovery were age (hazard ratio [HR] 0.61, P = .040), standardized tachycardia rate (HR 1.16, P = .015), mechanical circulatory support (HR 2.61, P = .044), and LVEF (HR 1.33 per 10% increase, p=0.005). For normalization of LV size, only baseline LVEDD (HR 0.86, P = .008) was predictive. CONCLUSION Pediatric TIC resolves in a predictable fashion. Factors associated with faster recovery include younger age, higher presenting heart rate, use of mechanical circulatory support, and higher LVEF, whereas only smaller baseline LV size predicts reverse remodeling. This knowledge may be useful for clinical evaluation and follow-up of affected children.
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Affiliation(s)
- Jeremy P Moore
- Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California.
| | - Payal A Patel
- Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California
| | - Kevin M Shannon
- Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California
| | - Erin L Albers
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Jack C Salerno
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Maya A Stein
- Division of Cardiology, The Hospital for Sick Children/University of Toronto, Toronto, Canada
| | - Elizabeth A Stephenson
- Division of Cardiology, The Hospital for Sick Children/University of Toronto, Toronto, Canada
| | - Shaun Mohan
- Department of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maully J Shah
- Department of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hiroko Asakai
- The Royal Children's Hospital, MCRI and University of Melbourne, Melbourne, Australia
| | - Andreas Pflaumer
- The Royal Children's Hospital, MCRI and University of Melbourne, Melbourne, Australia
| | - Richard J Czosek
- The Heart Center, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Melanie D Everitt
- Division of Pediatric Cardiology, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
| | - Jason M Garnreiter
- Division of Pediatric Cardiology, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
| | - Anthony C McCanta
- University of Colorado Denver/Children's Hospital Colorado, Denver, Colorado
| | - Andrew L Papez
- Arizona Pediatric Cardiology/Phoenix Children's Hospital, Phoenix, Arizona
| | - Carolina Escudero
- Division of Pediatric Cardiology, University of British Columbia, British Columbia, Canada
| | - Shubhayan Sanatani
- Division of Pediatric Cardiology, University of British Columbia, British Columbia, Canada
| | - Nicole B Cain
- Department of Pediatric Cardiology, Medical University of South Carolina, Charelston, South Carolina
| | - Prince J Kannankeril
- Department of Pediatrics, Division of Cardiology, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | | | - Ravi Mandapati
- Division of Pediatric Cardiology, Loma Linda University Children's Hospital, Loma Linda, California
| | - Jennifer N A Silva
- Department of Pediatric Cardiology, Washington University School of Medicine/St. Louis Children's Hospital, St. Louis, Missouri
| | - Kenneth R Knecht
- Department of Pediatric Cardiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Seshadri Balaji
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
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23
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Mouledoux JH, Albers EL, Lu Z, Saville BR, Moore DJ, Dodd DA. Clinical predictors of autoimmune and severe atopic disease in pediatric heart transplant recipients. Pediatr Transplant 2014; 18:197-203. [PMID: 24372990 PMCID: PMC3988248 DOI: 10.1111/petr.12205] [Citation(s) in RCA: 14] [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] [Accepted: 11/15/2013] [Indexed: 11/28/2022]
Abstract
Autoimmune and allergic diseases cause morbidity and diminished quality of life in pediatric organ transplant recipients. We hypothesize that younger age at transplantation and immunosuppression regimen play a role in the development of immune-mediated disease following heart transplant. A single institution retrospective review identified all patients undergoing heart transplant at ≤18 yr of age from 1987 to 2010 who survived ≥1 yr. Using medical record and database review, patients were evaluated for development of autoimmune or severe allergic disease. Of 129 patients who met criteria, seven patients (5.4%) with autoimmune or severe atopic disease were identified. Immune-mediated diseases included inflammatory bowel disease (n = 3), eosinophilic esophagitis/colitis (n = 4), and chronic bullous disease of childhood (n = 1). Patients <1 yr of age at transplant were at greater risk of developing autoimmune disease than patients 1-18 yr at transplant (OR = 9.3, 95% CI 1.1-79.2, p = 0.02). All affected patients underwent thymectomy at <1 yr of age (7/71 vs. 0/58, p = 0.02). In our experience, heart transplantation in infancy is associated with the development of immune-mediated gastrointestinal and dermatologic diseases. Further study is needed to determine risk factors for the development of immune-mediated disease to identify best practices to decrease incidence.
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Affiliation(s)
- Jessica H. Mouledoux
- Vanderbilt University Medical Center Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital
| | - Erin L. Albers
- University of Washington Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital
| | - Zengqi Lu
- Department of Biostatistics, Seattle Children's Hospital
| | | | - Daniel J. Moore
- Department of Pediatrics, Division of Pediatric Endocrinology, Seattle Children's Hospital,Department of Pathology, Microbiology, and Immunology, Seattle Children's Hospital
| | - Debra A. Dodd
- Vanderbilt University Medical Center Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital
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24
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Albers EL, Bichell DP, Dodd DA. Left main coronary artery compression by a dilated pulmonary artery after heart transplantation in an infant with complex congenital heart disease. J Heart Lung Transplant 2013; 32:470-2. [PMID: 23375751 DOI: 10.1016/j.healun.2012.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/18/2012] [Accepted: 12/18/2012] [Indexed: 11/29/2022] Open
Affiliation(s)
- Erin L Albers
- Division of Pediatric Cardiology, Seattle Children’s Hospital, Seattle, Washington, USA
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Hill KD, Fleming G, Curt Fudge J, Albers EL, Doyle TP, Rhodes JF. Percutaneous interventions in high-risk patients following Mustard repair of transposition of the great arteries. Catheter Cardiovasc Interv 2012; 80:905-14. [PMID: 22419517 DOI: 10.1002/ccd.23470] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [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] [Received: 03/11/2011] [Accepted: 10/31/2011] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To assess safety, efficacy, and intermediate term outcomes of percutaneous interventions in Mustard patients. BACKGROUND Baffle leaks and obstruction are present in 20% of Mustard survivors. Surgical reintervention is associated with high mortality. METHODS Retrospective review of percutaneous interventions performed at three adult congenital catheterization programs. RESULTS Overall, 26 catheterizations and 29 interventions were performed in 22 patients (mean age 32.4 ± 8.3 years). Previous laser pacemaker lead extraction was successful in seven of seven procedures where the lead was at risk. Stent placement was successful in all 18 patients with systemic venous baffle (SVB) obstruction (mean gradient: 6.2 ± 3.4-0.6 ± 1.0 mm Hg; P < 0.01, narrowest diameter 4.5 ± 4.5-17.1 ± 3.9 mm; P < 0.01). Balloon angioplasty was performed in two patients for pulmonary venous baffle (PVB) obstruction with mixed results. Baffle leak interventions included device occlusion (n = 6), coil occlusion (n = 1), and covered stent occlusion (n = 3). Postprocedural residual leaks were demonstrated in three of eight. In two of the three the residual leak was not appreciable at 1-year follow-up. No patient experienced leak or obstruction related symptom recurrence (mean follow-up: 33.4 ± 29.5 months). Complications included one death secondary to ventricular arrhythmia 2 days after PVB angioplasty and device related inferior SVB obstruction with resolution following stent placement. CONCLUSIONS Stent placement for SVB obstruction following Mustard repair is effective and likely safer than surgical intervention. Baffle leak occlusion can be safely accomplished but residual leaks are common in the short term.
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Affiliation(s)
- Kevin D Hill
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Albers EL, Pugh ME, Hill KD, Wang L, Loyd JE, Doyle TP. Percutaneous vascular stent implantation as treatment for central vascular obstruction due to fibrosing mediastinitis. Circulation 2011; 123:1391-9. [PMID: 21422386 DOI: 10.1161/circulationaha.110.949180] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [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: 12/15/2022]
Abstract
BACKGROUND Fibrosing Mediastinitis (FM) is a rare complication of infection with Histoplasma capsulatum that can lead to obstruction of pulmonary and systemic vasculature and large airways, often resulting in significant morbidity and mortality. Medical therapy is ineffective, and surgical intervention is often not feasible. Stent implantation offers a potential treatment for vascular obstruction due to FM, but this has not been well studied. METHODS AND RESULTS We conducted a retrospective review of all patients undergoing cardiac catheterization for FM. Anatomic site of stenosis and hemodynamic information before and after intervention, as well as clinical presentation and follow-up data, were recorded. From 1996 to 2008, 58 patients underwent cardiac catheterization for FM, with intervention performed in 40 (69%). A total of 77 stents were used to relieve 59 lesions (pulmonary artery=26, pulmonary vein=21, and superior vena cava=12). Significant reduction in pressure gradients (P<0.001) and increase in vessel caliber (P<0.001) were seen at all locations. Symptomatic recurrent stenosis requiring further intervention occurred in 11 patients (28%). Median time to recurrence was 115 months. Thirty-two (87%) of 37 patients for whom follow-up was available reported symptomatic improvement after stent placement. PROCEDURE related complications occurred in 14 patients (24%). Overall mortality was 19%, with the majority of deaths in patients with bilateral disease. Among patients with bilateral disease, intervention was associated with improved survival at 5 years. CONCLUSION Percutaneous vascular stent implantation is an effective therapy for central vascular obstruction due to FM, providing significant relief of anatomic obstruction and sustained clinical improvement.
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Affiliation(s)
- Erin L Albers
- Vanderbilt University Medical Center, Division of Pediatric Cardiology, 2200 Children's Way, Ste 5230, Nashville, TN 37232-6602, USA.
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27
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Abstract
Advances in surgical techniques and perioperative management have led to dramatic improvements in outcomes for children with complex congenital heart disease (CHD). As the number of survivors continues to grow, clinicians are becoming increasingly aware that adverse neurodevelopmental outcomes after surgical repair of CHD represent a significant cause of morbidity, with widespread neuropsychologic deficits in as many as 50% of these children by the time they reach school age. Modifications of intraoperative management have yet to measurably impact long-term neurologic outcomes. However, exciting advances in our understanding of the underlying mechanisms of cellular injury and of the events that mediate endogenous cellular protection have provided a variety of new potential targets for the assessment, prevention, and treatment of neurologic injury in patients with CHD. In this review, we will discuss the unique challenges to developing neuroprotective strategies in children with CHD and consider how multisystem approaches to neuroprotection, such as ischemic preconditioning, will be the focus of ongoing efforts to develop new diagnostic tools and therapies. Although significant challenges remain, tremendous opportunity exists for the development of diagnostic and therapeutic interventions that can serve to limit neurologic injury and ultimately improve outcomes for infants and children with CHD.
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Affiliation(s)
- Erin L Albers
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee 37323, USA
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