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Hartje-Dunn C, Blume E, Bastardi H, Clark M, Daly K, Fynn-Thompson F, Gauvreau K, Singh T. Steroid Avoidance in Pediatric Heart Transplant. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.203] [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: 04/05/2023] Open
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Pasqualin G, Misra A, Gauvreau K, Desai AS, Prakash A, Sanders S, Givertz MM, Valente AM. Ventricular-arterial coupling predicts outcomes in adults with a systemic right ventricle. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1539] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Patients with a systemic right ventricle (SRV) and biventricular circulation experience high incidence of cardiovascular morbidities and decreased survival [1]. Non-invasive measures of subclinical ventricular dysfunction are needed to appropriately identify patients at increased risk for adverse outcomes. Ventricular-arterial coupling (VAC), the ratio between the effective arterial elastance (Ea) and ventricular end-systolic elastance (Ees), may predict clinical outcomes in patients with SRV [2].
Objectives
To assess VAC in adults with SRV and evaluate its correlation with clinical outcomes.
Methods
Consecutive cardiovascular magnetic resonance (CMR) examinations of adults with D-loop transposition of great arteries (TGA) after atrial switch operation and L-loop TGA performed at Boston Children's Hospital between 2005 and 2019 were analyzed. VAC was calculated as Ea/Ees (Ea = mean arterial blood pressure (MBP)/ventricular stroke volume; Ees = MBP/end-systolic volume). Global myocardial strain was measured by feature tracking analysis on cine steady-state free precession sequences. Cox proportional hazards regression analysis was performed to assess the association of SRV functional parameters with clinical outcomes. The analysis was adjusted for age, sex, and body mass index. The primary outcome was defined as a composite of death, cardiovascular arrest, hospitalizations for heart failure (HF); the secondary outcome as atrial arrhythmias; the tertiary outcome included other causes of cardiovascular hospitalizations (percutaneous or surgical interventions, device implantation, other cardiovascular disease). Cumulative incidence of the study outcomes was estimated using Kaplan-Meier method.
Results
One hundred sixty-seven adults (mean age 32±10 years, 59% men) with SRV were analyzed. Patients with HF (n=48, 29%) had higher VAC values as compared to those without HF (1.4±0.8 vs. 1.1±0.5, p=0.01). Over a mean follow-up of 6.5±4.2 years, 15 over 139 patients (11%) experienced the primary outcome with an incidence rate of 1.7 per 100 patient-years (95% confidence interval (CI), 1.04–2.85). Higher VAC values were significantly associated with an increased risk of the primary outcome (p for trend = 0.01, Figure 1). VAC was the only functional parameter associated with the primary outcome (hazard ratio (HR) 1.99, 95% CI: 1.06–3.73, p=0.031), secondary outcome (HR 2.33, 95% CI: 1.12–4.82, p=0.023) and tertiary outcome (HR 1.63, 95% CI: 1.09–2.44, p=0.018) in the adjusted analysis (Table 1). Ejection fraction (EF) was not associated with the study outcomes in the adjusted analysis (p>0.05, Table 1) whereas global circumferential and radial strain showed an association limited to the tertiary endpoint (p=0.004, Table 1).
Conclusions
CMR-derived VAC is associated with adverse outcomes in SRV patients and may improve risk stratification of this unique population.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- G Pasqualin
- Boston Children's Hospital, Department of Cardiology , Boston , United States of America
| | - A Misra
- Boston Children's Hospital, Department of Cardiology , Boston , United States of America
| | - K Gauvreau
- Boston Children's Hospital, Department of Cardiology , Boston , United States of America
| | - A S Desai
- Brigham and Women'S Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Department of Medicine , Boston , United States of America
| | - A Prakash
- Boston Children's Hospital, Department of Cardiology , Boston , United States of America
| | - S Sanders
- Boston Children's Hospital, Department of Cardiology , Boston , United States of America
| | - M M Givertz
- Brigham and Women'S Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Department of Medicine , Boston , United States of America
| | - A M Valente
- Boston Children's Hospital, Department of Cardiology , Boston , United States of America
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Williams R, Milligan C, Singh T, Blume E, Lochridge J, Esteso P, Almond C, Gauvreau K, Daly K. A Positive CDC T-cell Crossmatch is Strongly Associated with Allograft Loss and Early Rejection in Pediatric Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.201] [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: 11/27/2022] Open
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4
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Kobayashi R, Przybylski R, Gauvreau K, Esteso P, Nathan M, Thiagarajan R, Fynn-Thompson F, Blume E, Teele S. Contemporary Outcomes of Pediatric Patients with Acute Fulminant Myocarditis Supported with Extracorporeal Membrane Oxygenation. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1282] [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: 10/18/2022] Open
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5
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Connor JA, LaGrasta C, Cerrato B, Porter C, Gauvreau K, Morrill D, Fortkiewicz J, Mechler M, Donnellan A, Kaduc A, Whalen R, Shields A, Bruno M, Jarden A, Dey A, Hickey PA. Measuring Acuity and Pediatric Critical Care Nursing Workload by Using ICU CAMEO III. Am J Crit Care 2022; 31:119-126. [PMID: 35229150 DOI: 10.4037/ajcc2022907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Intensive Care Unit Complexity Assessment and Monitoring to Ensure Optimal Outcomes (ICU CAMEO III) acuity tool measures patient acuity in terms of the complexity of nursing cognitive workload. OBJECTIVE To validate the ICU CAMEO III acuity tool in US children's hospitals. METHODS Using a convenience sample, 9 sites enrolled children admitted to pediatric intensive care units (ICUs). Descriptive statistics were used to summarize patient, nursing, and unit characteristics. Concurrent validity was evaluated by correlating the ICU CAMEO III with the Therapeutic Intervention Scoring System-Children (TISS-C) and the Pediatric Risk of Mortality III (PRISM III). RESULTS Patients (N = 840) were enrolled from 15 units (7 cardiac and 8 mixed pediatric ICUs). The mean number of ICU beds was 23 (range, 12-34). Among the patients, 512 (61%) were diagnosed with cardiac and 328 (39%) with noncardiac conditions; 463 patients (55.1%) were admitted for medical reasons, and 377 patients (44.9%) were surgical. The ICU CAMEO III median score was 99 (range, 59-163). The ICU CAMEO complexity classification was determined for all 840 patients: 60 (7.1%) with level I complexity; 183 (21.8%) with level II; 201 (23.9%), level III; 267 (31.8%), level IV; and 129 (15.4%), level V. Strong correlation was found between ICU CAMEO III and both TISS-C (ρ = .822, P < .001) and PRISM III (ρ = .607, P < .001) scores, and between the CAMEO complexity classifications and the PRISM III categories (ρ = .575, P = .001). CONCLUSION The ICU CAMEO III acuity tool and CAMEO complexity classifications are valid measures of patient acuity and nursing cognitive workload compared with PRISM III and TISS-C in academic children's hospitals.
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Affiliation(s)
- Jean Anne Connor
- Jean Anne Connor is the director of nursing research, Cardiovascular, Critical Care and Peri-operative, Patient Care Operations, Boston Children’s Hospital, Boston, Massachusetts, and an assistant professor of pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Christine LaGrasta
- Christine LaGrasta is a nurse practitioner III, Inpatient Cardiology, Boston Children’s Hospital
| | - Benjamin Cerrato
- Benjamin Cerrato is a project coordinator II, Cardiovascular, Critical Care and Peri-operative, Patient Care Operations, Boston Children’s Hospital
| | - Courtney Porter
- Courtney Porter is a program manager, Center for Healthy Adolescent Transition (CHAT), Clinical Services Education and Research, Children’s Hospital Los Angeles, California
| | - Kimberly Gauvreau
- Kimberly Gauvreau is a senior biostatistician, Department of Cardiology, Boston Children’s Hospital; an associate professor of pediatrics, Harvard Medical School; and an associate professor of biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Diana Morrill
- Diana Morrill is a project coordinator II, Cardiovascular, Critical Care and Peri-operative, Patient Care Operations, Boston Children’s Hospital
| | - Justine Fortkiewicz
- Justine Fortkiewicz is a professional practice specialist, Cardiac Intensive Care Unit (CICU), Children’s National Hospital, Washington, District of Columbia
| | - Mallory Mechler
- Mallory Mechler is the CICU clinical leader, Children’s Hospital New Orleans, Louisiana
| | - Amy Donnellan
- Amy Donnellan is a CICU nurse practitioner, Cincinnati Children’s Hospital, Ohio
| | - Alexandra Kaduc
- Alexandra Kaduc is a nurse educator, Pediatric Cardiac Care Center, Golisano Children’s Hospital, Rochester, New York
| | - Ruby Whalen
- Ruby Whalen is a clinical specialist, Cardiac ICU, Nicklaus Children’s Hospital, Miami, Florida
| | - Ashlee Shields
- Ashlee Shields is a programmatic specialist, UPMC Children’s Hospital of Pittsburgh, and an assistant professor of nursing, Robert Morris University, Pittsburgh, Pennsylvania
| | - Michelle Bruno
- Michelle Bruno is a nurse manager, Pediatric Catheterization Laboratory, Cleveland Clinic Children’s Hospital, Cleveland, Ohio
| | - Angela Jarden
- Angela Jarden is the RN program coordinator for the M43 and M53 Pediatric Intensive Care Units, Cleveland Clinic Children’s Hospital
| | - Anne Dey
- Anne Dey is the director of critical care, Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Patricia A. Hickey
- Patricia A. Hickey is the senior vice president and associate chief nurse, Nursing and Patient Care Operations, Boston Children’s Hospital; and an assistant professor of pediatrics, Harvard Medical School
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6
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El-Assaad I, DeWitt ES, Mah DY, Gauvreau K, Abrams DJ, Alexander ME, Triedman JK, Walsh EP. Accessory pathway ablation in Ebstein anomaly: A challenging substrate. Heart Rhythm 2021; 18:1844-1851. [PMID: 34126268 DOI: 10.1016/j.hrthm.2021.06.1171] [Citation(s) in RCA: 4] [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] [Received: 04/01/2021] [Revised: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Catheter ablation of accessory pathways (APs) in Ebstein anomaly (EA) has been associated with a high recurrence risk. OBJECTIVE The purpose of this study was to compare outcomes of AP ablation in EA in an early (1990-2004) vs a recent (2005-2019) era and identify variables associated with recurrence. METHODS A retrospective review of all catheter ablations for supraventricular tachycardia in EA at our institution was performed. RESULTS We identified 76 patients with median (25th-75th quartiles) age 9 (2.6-13.3) years. Of these patients, 52 had AP alone, 12 had atrial flutter, 3 had atrioventricular nodal reentrant tachycardia, and 9 had AP plus at least 1 additional arrhythmia. Of the 61 patients with APs, a total of 78 separate APs were identified: 40 right-sided, 37 septal, and 1 left-sided. Acute success for AP first procedure was 89% and did not differ between early and recent eras (89% vs 88%; P = .48). However, 19 patients (31%) required repeat procedures (average 1.4 per patient) due to AP recurrence or ablation failure at first attempt. In comparison to early era, recent era ablations had significantly lower recurrence rates at 1 year (62% vs 19%; P = .005). At median follow-up of 2.5 (0.2-7) years, ultimate AP elimination after all procedures was 93%. Younger age at time of electrophysiological study (<2 vs 12-47 years: hazard ratio [HR] 7.3; P = .003) and ablation era (early era vs recent era: HR 3.65; P = .009) predicted recurrence. CONCLUSION Outcomes for AP ablation in patients with EA have improved, but there is still a relatedly high recurrence risk requiring repeat procedures.
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Affiliation(s)
- Iqbal El-Assaad
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth S DeWitt
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Douglas Y Mah
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kimberly Gauvreau
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Dominic J Abrams
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mark E Alexander
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - John K Triedman
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Edward P Walsh
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
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7
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Lunze F, Singh T, Harrild D, Gauvreau K, Molloy M, Narciso R, Goncalves A, Berger F, Blume E, Colan S. Three-Dimensional Speckle Tracking Echocardiography for Assessment of Left Ventricular Function and Myocardial Mechanics after Pediatric Heart Transplantation. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.296] [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] Open
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8
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Singh T, Mehra M, Gauvreau K. Insights from High-Performing Heart Transplant Centers across the Recipient Risk-Spectrum. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.260] [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: 12/01/2022] Open
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9
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Profita E, Gauvreau K, Rycus P, Thiagarajan R, Singh T. Incidence, Predictors and Outcomes of Severe Primary Graft Dysfunction in Pediatric Heart Transplant Recipients. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.227] [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: 10/17/2022] Open
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10
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Lunze F, Colan S, Rifai N, Gauvreau K, Molloy M, Veljkovic K, Kavsak P, Adeli K, Elizabeth D. Blume E, Singh T. Left Atrial Function During the First Year After Pediatric Heart Transplantation. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.268] [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: 12/01/2022] Open
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11
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Friedman KG, Gauvreau K, Hamaoka-Okamoto A, Tang A, Berry E, Tremoulet AH, Mahavadi VS, Baker A, deFerranti SD, Fulton DR, Burns JC, Newburger JW. Coronary Artery Aneurysms in Kawasaki Disease: Risk Factors for Progressive Disease and Adverse Cardiac Events in the US Population. J Am Heart Assoc 2016; 5:JAHA.116.003289. [PMID: 27633390 PMCID: PMC5079009 DOI: 10.1161/jaha.116.003289] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The natural history of coronary artery aneurysms (CAA) after intravenous immunoglobulin (IVIG) treatment in the United States is not well described. We describe the natural history of CAA in US Kawasaki disease (KD) patients and identify factors associated with major adverse cardiac events (MACE) and CAA regression. Methods and Results We evaluated all KD patients with CAA at 2 centers from 1979 to 2014. Factors associated with CAA regression, maximum CA z‐score over time (zMax), and MACE were analyzed. We performed a matched analysis of treatment effect on likelihood of CAA regression. Of 2860 KD patients, 500 (17%) had CAA, including 90 with CAA z‐score >10. Most (91%) received IVIG within 10 days of illness, 32% received >1 IVIG, and 27% received adjunctive anti‐inflammatory medications. CAA regression occurred in 75%. Lack of CAA regression and higher CAA zMax were associated with earlier era, larger CAA z‐score at diagnosis, and bilateral CAA in univariate and multivariable analyses. MACE occurred in 24 (5%) patients and was associated with higher CAA z‐score at diagnosis and lack of IVIG treatment. In a subset of patients (n=132) matched by age at KD and baseline CAA z‐score, those receiving IVIG plus adjunctive medication had a CAA regression rate of 91% compared with 68% for the 3 other groups (IVIG alone, IVIG ≥2 doses, or IVIG ≥2 doses plus adjunctive medication). Conclusions CAA regression occurred in 75% of patients. CAA z‐score at diagnosis was highly predictive of outcomes, which may be improved by early IVIG treatment and adjunctive therapies.
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Affiliation(s)
- Kevin G Friedman
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberly Gauvreau
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Alexander Tang
- Department of Cardiology, Children's Hospital Boston, Boston, MA
| | - Erika Berry
- Department of Pediatrics, University of California San Diego, La Jolla, CA Rady Children's Hospital San Diego, San Diego, CA
| | - Adriana H Tremoulet
- Department of Pediatrics, University of California San Diego, La Jolla, CA Rady Children's Hospital San Diego, San Diego, CA
| | - Vidya S Mahavadi
- Department of Pediatrics, University of California San Diego, La Jolla, CA Rady Children's Hospital San Diego, San Diego, CA
| | - Annette Baker
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sarah D deFerranti
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - David R Fulton
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane C Burns
- Department of Pediatrics, Harvard Medical School, Boston, MA Rady Children's Hospital San Diego, San Diego, CA
| | - Jane W Newburger
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
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12
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Beroukhim RS, Gauvreau K, Benavidez OJ, Baird CW, LaFranchi T, Tworetzky W. Perinatal outcome after prenatal diagnosis of single-ventricle cardiac defects. Ultrasound Obstet Gynecol 2015; 45:657-663. [PMID: 25042627 DOI: 10.1002/uog.14634] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 06/18/2014] [Accepted: 07/07/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To investigate the perinatal outcome of cases with a prenatal diagnosis of single-ventricle cardiac defects, single ventricle being defined as a dominant right ventricle (RV) or left ventricle (LV), in which biventricular circulation was not possible. METHODS We reviewed patients with a prenatal diagnosis of single-ventricle cardiac defects, made at one institution between 1995 and 2008. Cases diagnosed with double-inlet LV, tricuspid atresia, pulmonary atresia with intact ventricular septum and severe RV hypoplasia and those with hypoplastic left heart syndrome (HLHS) were included in the study population. Patients with HLHS were identified prenatally as being standard risk or high risk (HLHS with highly restrictive or intact atrial septum, mitral stenosis with aortic atresia and/or LV coronary artery sinusoids). Patients with an address over 200 miles from the hospital, diagnosed with heterotaxy syndrome or referred for fetal intervention, were excluded. RESULTS We identified 312 cases of single-ventricle cardiac defect (208 dominant RV; 104 dominant LV) that were diagnosed prenatally. Most (96%) patients with a dominant RV had HLHS. Among the total 312 cases there were 98 (31%) elective terminations of pregnancy (TOP), 12 (4%) cases of spontaneous fetal demise, 12 (4%) cases lost to prenatal follow-up and 190 (61%) live births. Among the 199 patients that underwent fetal echocardiography before 24 weeks' gestation, there were 97 (49%) cases of elective TOP. There was no difference in prenatal outcome between those with a dominant RV and those with a dominant LV (P = 0.98). Of the 190 live births, five received comfort care. With an average of 7 years' follow-up (to obtain data on the Fontan procedure), transplantation-free survival was lower in those with a dominant RV than in those with a dominant LV (standard-risk HLHS odds ratio (OR), 3.0 (P = 0.01); high-risk HLHS OR, 8.8 (P < 0.001)). CONCLUSIONS The prenatal outcome of cases with single-ventricle cardiac defects was similar between those with a dominant RV and those with a dominant LV, however postnatal intermediate-term survival favored those with a dominant LV. High-risk HLHS identified prenatally was associated with the lowest transplantation-free survival.
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Affiliation(s)
- R S Beroukhim
- Department of Pediatric/Congenital Cardiology, Massachusetts General Hospital for Children, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - K Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - O J Benavidez
- Department of Pediatric/Congenital Cardiology, Massachusetts General Hospital for Children, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - C W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - T LaFranchi
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - W Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
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13
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Abstract
Background Multicenter studies on idiopathic or viral pericarditis and pericardial effusion (PPE) have not been reported in children. Colchicine use for PPE in adults is supported. We explored epidemiology and management for inpatient hospitalizations for PPE in US children and risk factors for readmission. Methods and Results We analyzed patients in the Pediatric Health Information System database for (1) a code for PPE; (2) absence of codes for underlying systemic disease (eg, neoplastic, cardiac, rheumatologic, renal); (3) age ≥30 days and <21 years; and (4) discharge between January 1, 2007, and December 31, 2012, from 38 hospitals contributing complete data for each year of the study period. Among 11 364 hospitalizations with PPE codes during the study period, 543 (4.8%) met entry criteria for idiopathic or viral PPE. Significantly more boys were noted, especially among adolescents. No temporal trends were noted. Median age was 14.5 years (interquartile range 7.3 to 16.6 years); 78 patients (14.4%) underwent pericardiocentesis, 13 (2.4%) underwent pericardiotomy, and 11 (2.0%) underwent pericardiectomy; 157 (28.9%) had an intensive care unit stay, including 2.0% with tamponade. Median hospitalization was 3 days (interquartile range 2 to 4 days). Medications used at initial admission were nonsteroidal anti‐inflammatory drugs (71.3%), corticosteroids (22.7%), aspirin (7.0%), and colchicine (3.9%). Readmissions within 1 year of initial admission occurred in 46 of 447 patients (10.3%), mostly in the first 3 months. No independent predictors of readmission were noted, but our statistical power was limited. Practice variation was noted in medical management and pericardiocentesis. Conclusions Our report provides the first large multicenter description of idiopathic or viral PPE in children. Idiopathic or viral PPE is most common in male adolescents and is treated infrequently with colchicine.
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Affiliation(s)
- Divya Shakti
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA (D.S., R.H., K.G., J.W.N.)
| | - Rebecca Hehn
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA (D.S., R.H., K.G., J.W.N.)
| | - Kimberly Gauvreau
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA (D.S., R.H., K.G., J.W.N.)
| | - Robert P Sundel
- Department of Rheumatology, Boston Children's Hospital and Harvard Medical School, Boston, MA (R.P.S.)
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA (D.S., R.H., K.G., J.W.N.)
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Hill AC, Brown DW, Colan SD, Gauvreau K, del Nido PJ, Lock JE, Rathod RH. Mixed aortic valve disease in the young: initial observations. Pediatr Cardiol 2014; 35:934-42. [PMID: 24563072 PMCID: PMC6951795 DOI: 10.1007/s00246-014-0878-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 11/01/2013] [Accepted: 02/04/2014] [Indexed: 12/27/2022]
Abstract
The short-term surgical results for mixed aortic valve disease (MAVD) and the long-term effects on the left ventricle (LV) are unknown. Retrospective review identified patients with at least both moderate aortic stenosis (AS) and aortic regurgitation (AR) before surgical intervention. A one-to-one comparison cohort of patients with MAVD not referred for surgical intervention was identified. The 45 patients in this study underwent surgical management for MAVD. A control group of 45 medically managed patients with MAVD also was identified. Both groups had elevated LV end-diastolic volume (EDV), elevated LV mass, a normal LV mass:volume ratio (MVR), and a normal ejection fraction. Both groups had diastolic dysfunction shown by early diastolic pulsed-Doppler mitral inflow/early diastolic tissue Doppler velocity z-score. The LV end-diastolic pressure (EDP) was correlated with age (R = 0.4; p = 0.03) and LV MVR (R = 0.4; p = 0.03) but not with AS, AR, or the score combining gradient and LV size. As shown by 6- to 12-month postoperative echocardiograms, aortic valve gradients and AR significantly improved (gradient 65 ± 17 to 28 ± 18 mmHg, p = 0.01; median regurgitation grade moderate to mild; p < 0.01), LV EDV normalized, and LV mass significantly improved (p < 0.01). Diastolic dysfunction was unchanged. Symptoms did not correlate with any measured parameter, but the preoperative symptoms resolved. In conclusion, despite diastolic dysfunction, systolic function is invariably preserved, and symptoms are not correlated with aortic valve function or LV EDP. Current surgical practice preserves LV mechanics and results in short-term improvement in valve function and symptoms.
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Affiliation(s)
- Allison C. Hill
- Department of Cardiology, Boston Children’s Hospital; Department of Pediatrics, Harvard Medical School, Boston MA
| | - David W. Brown
- Department of Cardiology, Boston Children’s Hospital; Department of Pediatrics, Harvard Medical School, Boston MA
| | - Steven D. Colan
- Department of Cardiology, Boston Children’s Hospital; Department of Pediatrics, Harvard Medical School, Boston MA
| | - Kimberly Gauvreau
- Department of Cardiology, Boston Children’s Hospital; Department of Pediatrics, Harvard Medical School, Boston MA
| | - Pedro J. del Nido
- Department of Cardiac Surgery, Boston Children’s Hospital; Department of Surgery, Harvard Medical School, Boston MA
| | - James E. Lock
- Department of Cardiology, Boston Children’s Hospital; Department of Pediatrics, Harvard Medical School, Boston MA
| | - Rahul H. Rathod
- Department of Cardiology, Boston Children’s Hospital; Department of Pediatrics, Harvard Medical School, Boston MA
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Lunze F, Gauvreau K, Colan S, Dillis S, Blume E, Singh T. Is Doppler Echocardiography Useful for Estimating Ventricular Filling Pressures in Pediatric Heart Transplant Recipients? J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.820] [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: 10/25/2022] Open
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Alexander P, Blume E, Gauvreau K, Kehoe E, Singh T. Risk-Stratification in Children with Advanced Heart Failure Using Hemodynamic Data. J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.813] [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: 10/25/2022] Open
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Alexander P, Blume E, Gauvreau K, Bastardi H, Singh T. The Impact of Right Atrial Pressure on Outcomes in Children with Advanced Heart Failure. J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.822] [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] Open
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Porras D, Brown DW, Rathod R, Friedman K, Gauvreau K, Lock JE, Esch JJ, Bergersen L, Marshall AC. Acute outcomes after introduction of a standardized clinical assessment and management plan (SCAMP) for balloon aortic valvuloplasty in congenital aortic stenosis. CONGENIT HEART DIS 2013; 9:316-25. [PMID: 24127834 DOI: 10.1111/chd.12142] [Citation(s) in RCA: 31] [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] [Accepted: 08/18/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Standardization of care can reduce practice variation, optimize resource utilization, and improve clinical outcomes. We have created a standardized clinical assessment and management plan (SCAMP) for patients having balloon aortic valvuloplasty (BAV) for congenital aortic stenosis (AS). This study compares acute outcomes of BAV at our institution before and after introduction of this SCAMP. METHODS In this retrospective matched cohort study, each SCAMP patient was matched to four historical controls. Outcomes were categorized based on the combination of residual AS and aortic regurgitation (AR) as: (1) Optimal: gradient ≤ 35 mm Hg and trivial or no AR; (2) Adequate: gradient ≤ 35 mm Hg and mild AR; (3) Inadequate: gradient > 35 mm Hg and/or moderate or severe AR. RESULTS All 23 SCAMP patients achieved a residual AS gradient ≤ 35 mm Hg; the median residual AS gradient for the SCAMP group was lower (25 [10-35] mm Hg) than in matched controls (30 [0-65] mm Hg; P = 0.005). The two groups did not differ with regard to degree of AR grade after BAV. Compared with controls, SCAMP patients were more likely to have an optimal result and less likely to have an inadequate result (52% vs. 34% and 17% vs. 45%, respectively; P = 0.02) CONCLUSIONS: A SCAMP for BAV resulted in optimal acute results in half of the initial 23 patients enrolled, and outcomes in this group were better than those of matched historical controls. Whether these improved acute outcomes translate into better long-term outcomes for this patient population remains to be seen.
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Affiliation(s)
- Diego Porras
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA; Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
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Selamet Tierney ES, Gal D, Gauvreau K, Baker AL, Trevey S, O'Neill SR, Jaff MR, de Ferranti S, Fulton DR, Colan SD, Newburger JW. Vascular Health in Kawasaki Disease. J Am Coll Cardiol 2013; 62:1114-1121. [DOI: 10.1016/j.jacc.2013.04.090] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 03/31/2013] [Accepted: 04/23/2013] [Indexed: 01/30/2023]
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Vander Pluym C, Singh T, Gauvreau K, Blume E, Millian B, Fynn-Thompson F, Daly K, Almond C. Pediatric VAD Utilization in Dilated Cardiomyopathy: Does Higher VAD Utilization Lead to Better Waitlist Outcomes? J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.1039] [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: 11/29/2022] Open
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21
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Almond C, Yarlagadda V, Vander Pluym C, Rajagopal S, Millian B, Daly K, Singh T, Fynn-Thompson F, Gauvreau K. US Trends in Pediatric VAD Utilization: Analysis of Organ Procurement and Transplant Network Data. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Almond C, Daly K, Singh T, Piercey G, Gauvreau K. Effect of VAD Use on HLA Sensitization and Risk of Rejection Post-Heart Transplant in US Children with Dilated Cardiomyopathy. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.1038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Selamet Tierney ES, Gal D, Gauvreau K, Zhou J, Soluk Y, McElhinney DB, Colan SD, Geva T. Echocardiographic predictors of left ventricular dysfunction after aortic valve surgery in children with chronic aortic regurgitation. CONGENIT HEART DIS 2012; 8:308-15. [PMID: 23075071 DOI: 10.1111/chd.12009] [Citation(s) in RCA: 8] [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] [Accepted: 08/17/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Postoperative left ventricular dysfunction is associated with poor prognosis in adults with severe chronic aortic regurgitation and published practice guidelines aim to minimize this risk. However, only limited information exists in pediatrics. The goal of this study was to define preoperative risk factors for postoperative left ventricular dysfunction in children with chronic aortic regurgitation. METHODS Patients fulfilling the following criteria were included in this study: (1) age at preoperative echocardiogram ≤18 years; (2) ≥moderate aortic regurgitation; (3) ≤mild aortic valve stenosis; (4) no additional valve disease/shunt; (5) underwent aortic valve surgery for aortic regurgitation; and (6) available preoperative and ≥6-month postoperative echocardiograms with adequate information. Primary outcome was postoperative left ventricular dysfunction defined as ejection fraction z-score < -2. RESULTS Median ages at diagnosis and surgery of the 53 eligible patients were 6.9 (0.04-17.2) and 13 years (1.2-22.4), respectively. Compared with patients whose postoperative left ventricular ejection fraction was normal, those with left ventricular ejection fraction z-score < -2 (n = 10) had significantly higher preoperative left ventricular end-diastolic and systolic volumes and dimensions and lower indices of systolic function. Preoperative left ventricular ejection fraction z-score < -1 was the most sensitive (89%; confidence interval [CI] 52, 100) but least specific (58%; CI 41, 73), whereas left ventricular end-systolic diameter z-score ≥ 5 was the most specific (95%; CI 84, 99) but least sensitive (60%; CI 26, 88) outcome identifier. A combination of shortening fraction z-score < -1 or end-systolic diameter z-score ≥ 5 best identified postoperative left ventricular dysfunction with an area of 0.819 under the receiver-operator characteristic curve. CONCLUSION Lower indices of left ventricular systolic function and severity of dilation identify children at risk for postoperative left ventricular dysfunction after aortic valve surgery. These identifiers are similar to predictors defined in adult patients albeit with different threshold values.
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Affiliation(s)
- Elif Seda Selamet Tierney
- Pediatric Heart Center, Lucile Packard Children’s Hospital, Stanford University School of Medicine, 750 Welch Road, Suite 305, Mail Code: 5731, Palo Alto, CA 94304, USA.
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Roberts AE, Nixon C, Steward CG, Gauvreau K, Maisenbacher M, Fletcher M, Geva J, Byrne BJ, Spencer CT. The Barth Syndrome Registry: distinguishing disease characteristics and growth data from a longitudinal study. Am J Med Genet A 2012; 158A:2726-32. [PMID: 23045169 DOI: 10.1002/ajmg.a.35609] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 07/17/2012] [Indexed: 11/07/2022]
Abstract
Barth syndrome (BTHS); MIM accession # 302060) is a rare X-linked recessive cardioskeletal mitochondrial myopathy with features of cardiomyopathy, neutropenia, and growth abnormalities. The objectives of this study were to further elucidate the natural history, clinical disease presentation, and course, and describe growth characteristics for males with BTHS. Patients with a confirmed genetic diagnosis of BTHS are referred to the BTHS Registry through the Barth Syndrome Foundation, self-referral, or physician referral. This study is based on data obtained from 73 subjects alive at the time of enrollment that provided self-reported and/or medical record abstracted data. The mean age at diagnosis of BTHS was 4.04 ± 5.45 years. While the vast majority of subjects reported a history of cardiac dysfunction, nearly 6% denied any history of cardiomyopathy. Although most subjects had only mildly abnormal cardiac function by echocardiography reports, 70% were recognized as having cardiomyopathy in the first year of life and 12% have required cardiac transplantation. Of the 73 enrolled subjects, there have been five deaths. Growth curves were generated demonstrating a shift down for weight, length, and height versus the normative population with late catch up in height for a significant percentage of cases. This data also confirms a significant number of patients with low birth weight, complications in the newborn period, failure to thrive, neutropenia, developmental delay of motor milestones, and mild learning difficulties. However, it is apparent that the disease manifestations are variable, both over time for an individual patient and across the BTHS population.
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Affiliation(s)
- Amy E Roberts
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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Almond CS, Gauvreau K, Canter CE, Rajagopal SK, Piercey GE, Singh TP. A risk-prediction model for in-hospital mortality after heart transplantation in US children. Am J Transplant 2012; 12:1240-8. [PMID: 22300640 DOI: 10.1111/j.1600-6143.2011.03932.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We sought to develop and validate a quantitative risk-prediction model for predicting the risk of posttransplant in-hospital mortality in pediatric heart transplantation (HT). Children <18 years of age who underwent primary HT in the United States during 1999-2008 (n = 2707) were identified using Organ Procurement and Transplant Network data. A risk-prediction model was developed using two-thirds of the cohort (random sample), internally validated in the remaining one-third, and independently validated in a cohort of 338 children transplanted during 2009-2010. The best predictive model had four categorical variables: hemodynamic support (ECMO, ventilator support, VAD support vs. medical therapy), cardiac diagnosis (repaired congenital heart disease [CHD], unrepaired CHD vs. cardiomyopathy), renal dysfunction (severe, mild-moderate vs. normal) and total bilirubin (≥ 2.0, 0.6 to <2.0 vs. <0.6 mg/dL). The C-statistic (0.78) and the Hosmer-Lemeshow goodness-of-fit (p = 0.89) in the model-development cohort were replicated in the internal validation and independent validation cohorts (C-statistic 0.75, 0.81 and the Hosmer-Lemeshow goodness-of-fit p = 0.49, 0.53, respectively) suggesting acceptable prediction for posttransplant in-hospital mortality. We conclude that this risk-prediction model using four factors at the time of transplant has good prediction characteristics for posttransplant in-hospital mortality in children and may be useful to guide decision-making around patient listing for transplant and timing of mechanical support.
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Affiliation(s)
- C S Almond
- Department of Cardiology, Children's Hospital, Boston, MA, USA.
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Singh T, Almond C, Piercey G, Gauvreau K. 23 Risk-Stratification and Transplant Benefit in Children Listed for Heart Transplant. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.026] [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: 10/28/2022] Open
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Singh TP, Almond CS, Piercey G, Gauvreau K. Trends in wait-list mortality in children listed for heart transplantation in the United States: era effect across racial/ethnic groups. Am J Transplant 2011; 11:2692-9. [PMID: 21883920 PMCID: PMC4243846 DOI: 10.1111/j.1600-6143.2011.03723.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We sought to evaluate trends in overall and race-specific pediatric heart transplant (HT) wait-list mortality in the United States (US) during the last 20 years. We identified all children <18 years old listed for primary HT in the US during 1989-2009 (N = 8096, 62% White, 19% Black, 13% Hispanic and 6% Other) using the Organ Procurement and Transplant Network database. Wait-list mortality was assessed in four successive eras (1989-1994, 1995-1999, 2000-2004 and 2005-2009). Overall wait-list mortality declined in successive eras (26%, 23%, 18% and 13%, respectively). The decline across eras remained significant in adjusted analysis (hazard ratio [HR] 0.70 in successive eras, 95% confidence interval [CI], 0.67-0.74) and was 67% lower for children listed during 2005-2009 versus those listed during 1989-1994 (HR 0.33; CI, 0.28-0.39). In models stratified by race, wait-list mortality decreased in all racial groups in successive eras. In models stratified by era, minority children were not at higher risk of wait-list mortality in the most recent era. We conclude that the risk of wait-list mortality among US children listed for HT has decreased by two-thirds during the last 20 years. Racial gaps in wait-list mortality present variably in the past are not present in the current era.
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Affiliation(s)
- T P Singh
- Department of Cardiology, Children's Hospital Boston, Boston, MA, USA.
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Lunze F, Gauvreau K, Chen M, Perez-Atayde A, Colan S, Blume E, Singh T. 568 Tissue Doppler Imaging Findings Associated with Moderate Rejection in Young Heart Transplant Recipients. J Heart Lung Transplant 2011. [DOI: 10.1016/j.healun.2011.01.580] [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: 11/29/2022] Open
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Singh T, Gauvreau K, Piercey G, Almond C. 368 Development and Validation of a Risk-Prediction Model for In-Hospital Mortality after Heart Transplantation. J Heart Lung Transplant 2011. [DOI: 10.1016/j.healun.2011.01.376] [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: 10/18/2022] Open
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Lunze F, Gauvreau K, Chen M, Perez-Atayde A, Colan S, Blume E, Singh T. 567 Longitudinal Assessment of Allograft Function Using Tissue Doppler Echocardiography after Heart Transplantation. J Heart Lung Transplant 2011. [DOI: 10.1016/j.healun.2011.01.579] [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: 10/18/2022] Open
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Singh TP, Almond CS, Gauvreau K. Improved survival in pediatric heart transplant recipients: have white, black and Hispanic children benefited equally? Am J Transplant 2011; 11:120-8. [PMID: 21199352 PMCID: PMC4248354 DOI: 10.1111/j.1600-6143.2010.03357.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We assessed whether the improvement in posttransplant survival in pediatric heart transplant (HT) recipients during the last two decades has benefited the major racial groups in the United States equally. We analyzed all children <18 years of age who underwent their first HT in the US during 1987-2008. We compared trends in graft loss (death or retransplant) in white, black and Hispanic children in five successive cohorts (1987-1992, 1993-1996, 1997-2000, 2001-2004, 2005-2008). The primary endpoint was early graft loss within 6 months posttransplant. Longer-term survival was assessed in recipients who survived the first 6 months. The improvement in early posttransplant survival was similar (hazard ratio [HR] for successive eras 0.80, 95% confidence interval [CI] 0.7, 0.9, p = 0.24 for black-era interaction, p = 0.22 for Hispanic-era interaction) in adjusted analysis. Longer-term survival was worse in black children (HR 2.2, CI 1.9, 2.5) and did not improve in any group with time (HR 1.0 for successive eras, CI 0.9, 1.1, p = 0.57; p = 0.19 for black-era interaction, p = 0.21 for Hispanic-era interaction). Thus, the improvement in early post-HT survival during the last two decades has benefited white, black and Hispanic children equally. Disparities in longer-term survival have not narrowed with time; the survival remains worse in black recipients.
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Affiliation(s)
- T. P. Singh
- Department of Cardiology, Children’s Hospital Boston, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - C. S. Almond
- Department of Cardiology, Children’s Hospital Boston, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - K. Gauvreau
- Department of Cardiology, Children’s Hospital Boston, Boston, MA,Department of Biostatistics, Harvard School of Public Health, Boston, MA
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Chen M, Ng A, Chu T, Zhou J, Gauvreau K, Mauch P. A Prospective Cardiac Screening Study in Asymptomatic Long-term Survivors of Hodgkin's Lymphoma Treated with Mediastinal Radiation Therapy. Int J Radiat Oncol Biol Phys 2010. [DOI: 10.1016/j.ijrobp.2010.07.1273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Singh T, Almond C, Gauvreau K. 198: White, Black and Hispanic Children Have Benefited Equally from Improvement in Early Post-Transplant Survival in Pediatric Heart Transplantation. J Heart Lung Transplant 2010. [DOI: 10.1016/j.healun.2009.11.208] [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: 10/19/2022] Open
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Singh T, Almond C, Piercey G, Gauvreau K. 109: Improvement in Heart Transplant Survival Across Eras: Have All Racial Groups Benefited Equally? Race-Era Interaction in a Risk-Adjusted Model. J Heart Lung Transplant 2010. [DOI: 10.1016/j.healun.2009.11.118] [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: 10/19/2022] Open
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Chen M, Lunze F, Singh T, Bergersen L, Smoot L, Almond C, Gauvreau K, Geva T, Colan S, Hall K. 521: Evaluation of Safety and Efficacy of Exercise Stress Echocardiography To Screen for Coronary Allograft Vasculopathy in Pediatric Heart Transplant Recipients. J Heart Lung Transplant 2010. [DOI: 10.1016/j.healun.2009.11.538] [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: 10/19/2022] Open
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Singh TP, Gauvreau K, Thiagarajan R, Blume ED, Piercey G, Almond CS. Racial and ethnic differences in mortality in children awaiting heart transplant in the United States. Am J Transplant 2009; 9:2808-15. [PMID: 19845580 PMCID: PMC4254405 DOI: 10.1111/j.1600-6143.2009.02852.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Racial differences in outcomes are well known in children after heart transplant (HT) but not in children awaiting HT. We assessed racial and ethnic differences in wait-list mortality in children <18 years old listed for primary HT in the United States during 1999-2006 using multivariable Cox models. Of 3299 listed children, 58% were listed as white, 20% as black, 16% as Hispanic, 3% as Asian and 3% were defined as 'Other'. Mortality on the wait-list was 14%, 19%, 21%, 17% and 27% for white, black, Hispanic, Asian and Other children, respectively. Black (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.3, 1.9), Hispanic (HR 1.5, CI 1.2, 1.9), Asian (HR, 2.0, CI 1.3, 3.3) and Other children (HR 2.3, CI 1.5, 3.4) were all at higher risk of wait-list death compared to white children after controlling for age, listing status, cardiac diagnosis, hemodyamic support, renal function and blood group. After adjusting additionally for medical insurance and area household income, the risk remained higher for all minorities. We conclude that minority children listed for HT have significantly higher wait-list mortality compared to white children. Socioeconomic variables appear to explain a small fraction of this increased risk.
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Affiliation(s)
- T P Singh
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA.
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Almond C, Singh T, Gauvreau K, Bartlett R, Rykus P, Fynn-Thompson F, Thiagarajan R. 163: Safety and Efficacy of Extra-Corporeal Membrane Oxygenation for Bridge-to-Heart Transplantation in Children: Analysis of Data from the Extra-Corporeal Life Support (ELSO) Registry. J Heart Lung Transplant 2009. [DOI: 10.1016/j.healun.2008.11.170] [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] Open
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Vida VL, Bacha EA, Larrazabal A, Gauvreau K, Dorfman AL, Marx G, Geva T, Marshall AC, Pigula FA, Mayer JE, del Nido PJ, Fynn-Thompson F. Surgical outcome for patients with the mitral stenosis–aortic atresia variant of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2008; 135:339-46. [DOI: 10.1016/j.jtcvs.2007.09.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 08/30/2007] [Accepted: 09/14/2007] [Indexed: 10/22/2022]
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Singh T, Gauvreau K, Blume E, Bastardi H, Mayer J. 192: Socioeconomic Position and Graft Failure in Pediatric Heart Transplant Recipients. J Heart Lung Transplant 2008. [DOI: 10.1016/j.healun.2007.11.199] [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: 10/22/2022] Open
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Vida VL, Bacha EA, Larrazabal A, Gauvreau K, Thiagaragan R, Fynn-Thompson F, Pigula FA, Mayer JE, del Nido PJ, Tworetzky W, Lock JE, Marshall AC. Hypoplastic Left Heart Syndrome With Intact or Highly Restrictive Atrial Septum: Surgical Experience From a Single Center. Ann Thorac Surg 2007; 84:581-5; discussion 586. [PMID: 17643639 DOI: 10.1016/j.athoracsur.2007.04.017] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Revised: 03/30/2007] [Accepted: 04/02/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND The presence of an intact or highly restrictive atrial septum (I/HRAS) has long been recognized as a predictor of poor outcome among patients with hypoplastic left heart syndrome (HLHS), although the rarity of this condition has precluded conclusive study. The purpose of this review is to summarize recent surgical outcomes for these patients at our center and to identify predictors. METHODS We retrospectively identified all neonates with a diagnosis of HLHS and I/HRAS who underwent stage I palliation at Children's Hospital Boston between January 2001 and December 2006. Chart review enabled analysis of patient and procedural variables. RESULTS All 32 patients underwent left atrial decompression in utero or postnatally before surgery. Fourteen patients (44%) underwent fetal intervention, either atrial septoplasty (n = 9) or aortic valvuloplasty (n = 5). Twenty-nine of the 32 patients had postnatal left atrial hypertension and underwent transcatheter atrial septoplasty as neonates before surgery; 3 did not require postnatal atrial septoplasty after successful fetal atrial septoplasty. After stage I, hospital survival was 69% (22 of 32). Need for shunt revision (p = 0.02) and for extracorporeal membrane oxygenation use (p < 0.001) were associated with hospital mortality. Survival at 6 months was 69% for patients who had fetal intervention, and 38% for those who were treated only postnatally (p = 0.2). CONCLUSIONS Surgical outcome for patients with HLHS and I/HRAS continues to improve. Prenatal decompression of the left atrium may be associated with greater hospital survival. Proposed effects of fetal intervention on lung pathology and longer-term survival are subjects for future study in this unique group of patients.
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Affiliation(s)
- Vladimiro L Vida
- Department of Cardiac Surgery, Children's Hospital Boston, Boston, Massachusetts 02115, USA
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Singh T, Rhodes J, Gauvreau K, Blume E. 174: Longitudinal changes in chronotropic response to exercise and heart rate recovery in pediatric heart transplant recipients. J Heart Lung Transplant 2007. [DOI: 10.1016/j.healun.2006.11.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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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Knauth AL, Gauvreau K, Powell AJ, Landzberg MJ, Walsh EP, Lock JE, del Nido PJ, Geva T. Ventricular size and function assessed by cardiac MRI predict major adverse clinical outcomes late after tetralogy of Fallot repair. Heart 2006; 94:211-6. [PMID: 17135219 DOI: 10.1136/hrt.2006.104745] [Citation(s) in RCA: 347] [Impact Index Per Article: 19.3] [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: 11/04/2022] Open
Abstract
BACKGROUND Factors associated with impaired clinical status in a cross-sectional study of patients with repaired tetralogy of Fallot (TOF) have been reported previously. OBJECTIVES To determine independent predictors of major adverse clinical outcomes late after TOF repair in the same cohort during follow-up evaluated by cardiac magnetic resonance (CMR). METHODS Clinical status at latest follow-up was ascertained in 88 patients (median time from TOF repair to baseline evaluation 20.7 years; median follow-up from baseline evaluation to most recent follow-up 4.2 years). Major adverse outcomes included (a) death; (b) sustained ventricular tachycardia; and (c) increase in NYHA class to grade III or IV. RESULTS 22 major adverse outcomes occurred in 18 patients (20.5%): death in 4, sustained ventricular tachycardia in 8, and increase in NYHA class in 10. Multivariate analysis identified right ventricular (RV) end-diastolic volume Z >or=7 (odds ratio (OR) = 4.55, 95% confidence interval (CI) 1.10 to 18.8, p = 0.037) and left ventricular (LV) ejection fraction <55% (OR = 8.05, 95% CI 2.14 to 30.2, p = 0.002) as independent predictors of outcome with an area under the receiver operator characteristic curve of 0.850. LV ejection fraction could be replaced by RV ejection fraction <45% in the multivariate model. QRS duration >or=180 ms also predicted major adverse events but correlated with RV size. CONCLUSIONS In this cohort, severe RV dilatation and either LV or RV dysfunction assessed by CMR predicted major adverse clinical events. This information may guide risk stratification and therapeutic interventions.
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Affiliation(s)
- A L Knauth
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
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Abstract
Our objective was to assess risk-adjusted racial and ethnic disparities in mortality following congenital heart surgery. We studied 8483 congenital heart surgical cases from the Kids' Inpatient Database 2000. Black sub-analysis was performed using predetermined regional categories. For our Hispanic sub-analyses, we categorized Hispanics into state groups according to a state's predominant Hispanic group: West (Mexican-American), Southeast (Cuban-American), Northeast (Puerto Rican), and Mixed/Heterogeneous. Risk adjustment was performed using the Risk Adjustment for Congenital Heart Surgery method. Multivariate analyses assessed the effect of race/ethnicity and Hispanic state group on mortality and explored the effects of gender, income, insurance type, and region. Black children had a higher risk for death than Whites odds ratio (OR), [1.65; p = 0.003]. Hispanics and the Cuban-American state group showed a trend toward a higher death risk (Hispanic: OR, 1.24; p = 0.16; Southeast Cuban-American: OR 1.55; p = 0.08). Disparities were not influenced by insurance. Among Blacks, disparities were greatest in the Northeast region (OR, 2.25; p = 0.007). After adjusting for gender, income, and region, Blacks (OR, 1.76; p = 0.002) and Hispanics (OR, 1.34; p = 0.05) had a higher death risk. Racial and ethnic disparities in risk-adjusted mortality following congenital heart disease exist for Blacks and Hispanics. These disparities are not due to insurance but are partially explained by gender and region.
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Affiliation(s)
- O J Benavidez
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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44
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Abstract
The objective of this study was to evaluate the safety and efficacy of carvedilol in pediatric patients with stable moderate heart failure. We performed a single-arm prospective drug trial at three academic medical centers and the results were compared to historical controls. Patients were 3 months to 17 years old with an ejection fraction <40% in the systemic ventricle for at least 3 months on maximal medical therapy including ACE inhibitors. Treated patients were started on 0.1 mg/kg/day and uptitrated to 0.8 mg/kg/day or the maximal tolerated dose. Echocardiographic parameters of function were prospectively measured at entry and at 6 months. Two composite endpoints were recorded: severe decline in status and significant clinical change. Adverse events were reviewed by a safety committee. Data were also collected from untreated controls with dilated cardiomyopathy meeting entry criteria, assessed over a similar time frame. Twenty patients [12 dilated cardiomyopathy (DCM) and 8 congenital] with a median age of 8.4 years (range, 8 months to 17.8 years) were treated with carvedilol. Three patients discontinued the drug during the study. At entry, there was no statistical difference in age, weight, or ejection fraction between the treated group and controls. The ejection fraction of the treated DCM group improved significantly from entry to 6 months (median, 31 to 40%, p = 0.04), with no significant change in ejection fraction in the control group [median, 29 to 27%, p = not significant (NS)]. The median increase in ejection fraction was larger for the treated DCM group than for the untreated DCM controls (7 vs 0%, p = 0.05). By Kaplan-Meier analysis, time to death or transplant tended to be longer in treated patients (p = 0.07). The difference in the proportion of patients with severe decline in status or significant clinical change in the treated group was not significant compared to the controls (5 vs 12%, p = NS). We conclude that in this prospective protocol of pediatric patients, the use of adjunct carvedilol in the DCM group improved ejection fraction compared to untreated controls and trended toward delaying time to transplant or death.
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Affiliation(s)
- E D Blume
- Department of Cardiology, Children's Hospital, Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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45
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Abstract
Our purpose was to evaluate the impact of suspicion or confirmation of heart disease on the physical and psychosocial health of children. We utilized the Child Health Questionnaire (CHQ PF-50). Children ages 5 to 18 years attending a general cardiology clinic were eligible. Those with primary noncardiac diagnoses unrelated to heart disease were excluded. Children with similar conditions were grouped together for analysis. Group and subgroup means were compared to a U.S. population normative sample using the two-sample t test. The CHQ was administered to 321 patients (median age, 10.6 years). Overall, parents reported mean Physical and Psychosocial Summary Scores comparable to those for the normative sample (mean, 51.5 vs 53.0, p = 0.04; mean, 52.3 vs 51.2, p = 0.10). There was a trend toward worse physical health in most subgroups, especially those with cardiomyopathy (CM) (46.5; p = 0.01), and a comparable trend toward better psychosocial health except in those requiring major interventions. In subscale analyses, most subgroups reported worse Physical Functioning than the normative sample, especially CM (85.1 vs 96.1; p = 0.02). Parents of children with CM (53.2 vs 73.0; p = 0.002) and the intervention subgroups (except minor) reported worse General Health Perceptions. Parents experienced increased Parental Impact-Emotional, especially parents of children undergoing evaluations for chest pain (62.5 vs 80.3; p = 0.007). Most parents reported comparable or better health for the Family Cohesion and Bodily Pain subscales. Generally, parents of children attending a cardiology clinic report physical and psychosocial health comparable to that for the general U.S. population. However, diagnosis or confirmation of heart disease resulted in worse physical functioning and health perceptions and a significant negative emotional impact on parents.
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Affiliation(s)
- R E Walker
- Department of Cardiology, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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DeMone JA, Gonzalez PC, Gauvreau K, Piercey GE, Jenkins KJ. Risk of death for Medicaid recipients undergoing congenital heart surgery. Pediatr Cardiol 2003; 24:97-102. [PMID: 12360394 DOI: 10.1007/s00246-002-0243-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [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] [Received: 12/03/2001] [Accepted: 03/14/2002] [Indexed: 10/27/2022]
Abstract
The objective of this study was to explore the effect of insurance type on mortality for congenital heart surgery. We performed a population-based retrospective cohort study using hospital discharge abstract data from five states in 1992 and 1996. The outcome measure was risk-adjusted in-hospital mortality. Cases of pediatric congenital heart surgery were identified and placed into six risk categories using the Risk Adjustment in Congenital Heart Surgery method. Multivariate analyses were used to determine the effect of insurance type on risk-adjusted mortality; regional effects were explored. Using standardized mortality ratios, institutions were grouped by outcome; within and between group differences were examined. Of 11,636 cases, 9656 (83%) were placed in a risk group for analysis. In 1996, children with Medicaid had a higher risk of death than those with commercial or managed care in both unadjusted (p = 0.002) and adjusted (p < 0.001) analyses. Overall mortality rates decreased between 1992 and 1996 (p = 0.001). However, improvement was not consistent among insurance groups. Differences were present within and between low, average, and high-mortality hospitals, suggesting that the adverse effect of Medicaid may be due to both differential referral and other differences in care among patients treated at similar institutions. Children with Medicaid insurance have a higher risk of dying after congenital heart surgery than those with commercial and some managed care insurance. Barriers to access go beyond differences in referral patterns.
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Affiliation(s)
- J A DeMone
- Department of Cardiology, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Gonzalez PC, Gauvreau K, Demone JA, Piercey GE, Jenkins KJ. Regional racial and ethnic differences in mortality for congenital heart surgery in children may reflect unequal access to care. Pediatr Cardiol 2003; 24:103-8. [PMID: 12360393 DOI: 10.1007/s00246-002-0244-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [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] [Received: 12/03/2001] [Accepted: 03/24/2002] [Indexed: 10/27/2022]
Abstract
The objective of this study was to explore racial differences in mortality for congenital heart surgery. We performed a population-based retrospective cohort study using hospital discharge abstract data from four states in 1996. The outcome measure was risk-adjusted in-hospital mortality. Cases of pediatric congenital heart surgery were classified into six risk categories using the Risk Adjustment in Congenital Heart Surgery method. Differences in risk-adjusted in-hospital mortality among racial groups were explored. Analyses stratified by state were used to identify regional differences. Of 5791 cases, 4822 (83%) were assigned to a risk group for analysis. Surgical mortality differed for whites compared to non-whites (3.7 vs 5.1%, p = 0.02). Among non-white groups, unadjusted mortality rates varied: Asian, 5.3%; black, 4.1%; Hispanic 4.9%; other, 7.3%; and missing, 7.6% (p = 0.008). Adjusted mortality also differed by race but was inconsistent across regions, making explanatory factors based solely on biology implausible. For example, compared to whites, blacks had a higher risk of dying in Massachusetts [odds ratio (OR) = 6.39, p = 0.08] but lower in Pennsylvania (OR = 0.41, p = 0.009). Adding insurance type to models did not eliminate racial differences. In risk-adjusted analyses, non-white groups had a higher risk of dying after congenital heart surgery than whites. Inconsistent effects among regions suggest that differential mortality is due to unequal access to care rather than biology.
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Affiliation(s)
- P C Gonzalez
- Department of Cardiology, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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48
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Affiliation(s)
- A J Powell
- Department of Cardiology, Children's Hospital, Boston, Masschusetts 02115, USA.
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Kreutzer J, Ryan CA, Gauvreau K, Van Praagh R, Anderson JM, Jenkins KJ. Healing response to the Clamshell device for closure of intracardiac defects in humans. Catheter Cardiovasc Interv 2001; 54:101-11. [PMID: 11553959 DOI: 10.1002/ccd.1248] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The healing response to intracardiac devices in humans is largely unknown. During regulatory trials using the Clamshell device in over 800 patients, attempts were made to perform histopathological evaluation of all explanted devices. We reviewed all those with complete histopathological examination (n = 12) from Fontan baffles (n = 4), ventricular septal defects (n = 2), and atrial septal defects (ASD; n = 6), explanted at 2.7 months to 3.6 years (median, 1.6 years), at autopsy (n = 1) or surgery (n = 11), performed for residual defects (n = 5), atrial masses (n = 3), or Fontan revision (n = 3). All but one were nearly (n = 3) or completely (n = 8) covered by pseudointima, composed of fibroelastic tissue, predominantly collagen, with focal foreign body reaction in contact with fabric, without acute inflammation or infection. Atrial masses of granulation tissue were present in three cases (ASD), opposite to protruding fractured arms. No associations were identified between coverage and closure status, position, arm fractures, or implant period. In conclusion, the healing response to transcatheter Clamshell implantation in humans is characterized by a relatively rapid development of a nonthrombotic pseudointima composed of fibroelastic tissue with minimal foreign body reaction. Cathet Cardiovasc Intervent 2001;54:101-111.
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Affiliation(s)
- J Kreutzer
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, 19104, USA.
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50
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Abstract
BACKGROUND Decisions regarding surgical strategy in patients with multiple left heart obstructive or hypoplastic lesions often must be made in the newborn period and are seldom reversible. Predictors of outcome of biventricular repair have not been well defined in this heterogeneous group of patients, and risk factors described for critical aortic valve stenosis have been shown to be inapplicable to patients with other left heart obstructive lesions. The goal of this study was to identify echocardiographic predictors of outcome of biventricular repair for infants with multiple left heart obstructive lesions. METHODS AND RESULTS Patients with >/=2 areas of left heart obstruction or hypoplasia, diagnosed at </=3 months of age, who had not previously undergone surgical or catheter intervention and maintained biventricular physiology were included (n=72). Failure of biventricular repair was defined as takedown to a univentricular repair, cardiac transplantation, and/or death (n=14; 19%). This group was compared with the patients who survived a biventricular approach (n=58). Multiple categorical, morphometric and calculated variables were examined on the basis of the initial echocardiograms. By multivariate analysis, predictors of failure included moderate/large ventricular septal defect (OR=22, P=0.001), unicommissural aortic valve (OR=16, P=0.006), and lower mitral valve dimension z-score (OR=2.2, P=0.02) or lower left ventricular end-diastolic volume z-score (OR=1.9, P=0.03). CONCLUSIONS Moderate/large ventricular septal defect, unicommissural aortic valve, and hypoplastic mitral valve or left ventricle are independent risk factors for failure of biventricular repair for infants with multiple left heart obstructive lesions. Combinations of these risk factors may be useful in selecting surgical strategy.
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Affiliation(s)
- M L Schwartz
- Department of Cardiology, Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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