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Meadows JJ, Bauser-Heaton H, Petit CJ, Goldstein BH, Qureshi AM, McCracken CE, Kelleman MS, Nicholson GT, Law MA, Zampi JD, Shahanavaz S, Chai PJ, Romano JC, Batlivala SP, Maskatia SA, Asztalos IB, Eilers L, Kamsheh AM, Healan SJ, Smith JD, Ligon RA, Dailey-Schwartz A, Pettus JA, Pajk AL, Glatz AC, Mascio CE. Comparison of treatment strategies for neonates with tetralogy of Fallot and pulmonary atresia. J Thorac Cardiovasc Surg 2023; 166:916-925.e6. [PMID: 36828672 DOI: 10.1016/j.jtcvs.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Neonates with tetralogy of Fallot and pulmonary atresia (TOF/PA) but no major aorta-pulmonary collaterals are dependent on the arterial duct for pulmonary blood flow and require early intervention, either by primary (PR) or staged repair (SR) with initial palliation (IP) followed by complete repair (CR). The optimal approach has not been established. METHODS Neonates with TOF/PA who underwent PR or SR were retrospectively reviewed from the Congenital Cardiac Research Collaborative. Outcomes were compared between PR and SR (IP + CR) strategies. Propensity scoring was used to adjust for baseline differences. The primary outcome was mortality. Secondary outcomes included complications, length of stay, cardiopulmonary bypass and anesthesia times, reintervention (RI), and pulmonary artery (PA) growth. RESULTS Of 282 neonates, 106 underwent PR and 176 underwent SR (IP: 144 surgical, 32 transcatheter). Patients who underwent SR were more likely to have DiGeorge syndrome and greater rates of mechanical ventilation before the initial intervention. Mortality was not significantly different. Duration of mechanical ventilation, inotrope use, and complication rates were similar. Cumulative length of stay, cardiopulmonary bypass, and anesthesia times favored PR (P ≤ .001). Early RI was more common in patients who underwent SR (rate ratio, 1.42; P = .003) but was similar after CR (P = .837). Conduit size at the time of CR was larger with SR. Right PA growth was greater with PR. CONCLUSIONS In neonates with TOF/PA, SR is more common in greater-risk patients. Accounting for this, SR and PR strategies have similar mortality. Perioperative morbidities, RI, and right PA growth generally favor PR, whereas SR allows for larger initial conduit implantation.
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Affiliation(s)
- Jeffery J Meadows
- Department of Pediatrics, University of California, San Francisco, San Francisco, Calif; Benioff Children's Hospital, San Francisco, Calif.
| | - Holly Bauser-Heaton
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga; Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Christopher J Petit
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga; Division of Cardiology, Morgan Stanley Children's Hospital of New York, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Bryan H Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati School of Medicine, Cincinnati, Ohio; Department of Pediatrics, Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Athar M Qureshi
- Lillie Frank Abercrombie Section on Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Courtney E McCracken
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Michael S Kelleman
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - George T Nicholson
- Division of Cardiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Mark A Law
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Ala
| | - Jeffrey D Zampi
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Mich
| | - Shabana Shahanavaz
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Paul J Chai
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Jennifer C Romano
- Section of Pediatric Cardiothoracic Surgery, Department of Cardiac Surgery, CS Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, Mich
| | - Sarosh P Batlivala
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Shiraz A Maskatia
- Moore Children's Heart Center, Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, Calif
| | - Ivor B Asztalos
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Lindsay Eilers
- Lillie Frank Abercrombie Section on Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Alicia M Kamsheh
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Steven J Healan
- Division of Cardiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Justin D Smith
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Mich
| | - R Allen Ligon
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Andrew Dailey-Schwartz
- Lillie Frank Abercrombie Section on Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Joelle A Pettus
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Amy L Pajk
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Andrew C Glatz
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Washington University Heart Center at St Louis Children's Hospital, St. Louis, Mo
| | - Christopher E Mascio
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WVa
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Nicholson GT, Goldstein BH, Petit CJ, Qureshi AM, Glatz AC, McCracken CE, Kelleman MS, Meadows JJ, Zampi JD, Shahanavaz S, Mascio CE, Chai PJ, Romano JC, Healan SJ, Pettus JA, Batlivala SP, Raulston JEB, Hock KM, Maskatia SA, Beshish A, Law MA. Impact of Management Strategy on Feeding and Somatic Growth in Neonates with Symptomatic Tetralogy of Fallot: Results from the Congenital Cardiac Research Collaborative. J Pediatr 2022; 250:22-28.e4. [PMID: 35772511 DOI: 10.1016/j.jpeds.2022.06.024] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/10/2022] [Accepted: 06/22/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate early growth following primary or staged repair of neonatal symptomatic tetralogy of Fallot (sTOF). STUDY DESIGN We performed a retrospective, multicenter cohort study of consecutive infants with sTOF who underwent initial intervention at age ≤30 days, from 2005 to 2017. Management strategies were either primary repair or staged repair (ie, initial palliation followed by complete repair). The primary outcome was change in weight-for-age z-score (ΔWAZ) from the initial intervention to age 6 ± 2 months. Secondary outcomes included method and mode of feeding, feeding-related medications, and feeding-related readmissions. Propensity score adjustment was used to account for baseline differences between groups. A secondary analysis was performed comparing patients stratified by the presence of adequate growth (6-month ΔWAZ > -0.5) or inadequate growth (6-month ΔWAZ ≤ -0.5), independent of treatment strategy. RESULTS The study cohort included 143 primary repair subjects and 240 staged repair subjects. Prematurity was more common in the staged repair group. After adjustment, median ΔWAZ did not differ between treatment groups over the first 6 months of life (primary: -0.43 [IQR, -1.17 to 0.50]; staged: -0.31 [IQR, -1.31 to 0.71]; P = .55). For the entire cohort, ΔWAZ was negative (-0.36; IQR, -1.21 to 0.63). There were no between-group differences in the secondary outcomes. Secondary analysis revealed that the subjects with adequate growth were more likely to be orally fed at initial hospital discharge (P = .04). CONCLUSIONS In neonates with sTOF, growth trajectory over the first 6 months of life was substandard, irrespective of treatment strategy. Those patients with adequate growth were more likely to be discharged from the index procedure on oral feeds.
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Affiliation(s)
- George T Nicholson
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.
| | - Bryan H Goldstein
- The Heart Institute, Cincinnati Children's Hospital Medical Center and Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, OH; Heart Institute, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christopher J Petit
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA; Morgan Stanley Children's Hospital, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Athar M Qureshi
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Andrew C Glatz
- The Cardiac Center, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Courtney E McCracken
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Michael S Kelleman
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Jeffery J Meadows
- Division of Cardiology, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA
| | - Jeffrey D Zampi
- Division of Cardiology, Department of Pediatrics, CS Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI
| | - Shabana Shahanavaz
- The Heart Institute, Cincinnati Children's Hospital Medical Center and Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, OH; Section of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Christopher E Mascio
- The Cardiac Center, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV
| | - Paul J Chai
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Jennifer C Romano
- Section of Pediatric Cardiothoracic Surgery, Department of Cardiac Surgery, CS Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI
| | - Steven J Healan
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Joelle A Pettus
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Sarosh P Batlivala
- The Heart Institute, Cincinnati Children's Hospital Medical Center and Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - James E B Raulston
- Division of Pediatric Cardiology, Department of Pediatrics, Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL
| | - Kristal M Hock
- Division of Pediatric Cardiology, Department of Pediatrics, Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL
| | - Shiraz A Maskatia
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Asaad Beshish
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Mark A Law
- Division of Pediatric Cardiology, Department of Pediatrics, Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL
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Law MA, Glatz AC, Romano JC, Chai PJ, Mascio CE, Petit CJ, McCracken CE, Kelleman MS, Nicholson GT, Meadows JJ, Zampi JD, Shahanavaz S, Batlivala SP, Pettus J, Pajk AL, Hock KM, Goldstein BH, Qureshi AM. Palliation Strategy to Achieve Complete Repair in Symptomatic Neonates with Tetralogy of Fallot. Pediatr Cardiol 2022; 43:1587-1598. [PMID: 35381860 DOI: 10.1007/s00246-022-02886-0] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022]
Abstract
Neonates with symptomatic tetralogy of Fallot (sTOF) may undergo palliations with varying physiology, namely systemic to pulmonary artery connections (SPC) or right ventricular outflow tract interventions (RVOTI). A comparison of palliative strategies based on the physiology created is lacking. Consecutive sTOF neonates undergoing SPC or RVOTI from 2005-2017 were reviewed from the Congenital Cardiac Research Collaborative. The primary outcome was survival with successful complete repair (CR) by 18 months. A variety of secondary outcomes were assessed including overall survival, hospitalization-related comorbidities, and interstage reinterventions. Propensity score adjustment was utilized to compare treatment strategies. The cohort included 252 SPC (surgical shunt = 226, ductus arteriosus stent = 26) and 68 RVOTI (balloon pulmonary valvuloplasty = 48, RVOT stent = 11, RVOT patch = 9) patients. Genetic syndrome (29 [42.6%] v 75 [29.8%], p = 0.04), weight < 2.5 kg (28 [41.2%] v 68 [27.0%], p = 0.023), bilateral pulmonary artery Z-score < - 2 (19 [28.0%] v 36 [14.3%], p = 0.008), and pre-intervention antegrade flow (48 [70.6%] v 104 [41.3%], p < 0.001) were more common in RVOTI. Significant center differences were noted (p < 0.001). Adjusted survival to CR by 18 months (HR = 0.87, 95% CI = 0.63-1.21, p = 0.41) and overall survival (HR = 2.08, 95% CI = 0.93-4.65, p = 0.074) were similar. RVOTI had increased interstage reintervention (HR = 2.15, 95% CI = 1.36-3.99, p = 0.001). Total anesthesia (243 [213, 277] v 328 [308, 351] minutes, p < 0.001) and cardiopulmonary bypass times (117 [103, 132] v 151 [143, 160] minutes, p < 0.001) favored RVOTI. In this multicenter comparison of physiologic palliation strategies for sTOF, survival to successful CR and overall survival were similar; however, reintervention burden was significantly higher in RVOTI.
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Affiliation(s)
- Mark A Law
- Department of Pediatrics, University of Alabama at Birmingham, 1700 6th Ave S, Suite 9100, Birmingham, AL, 35233, USA.
| | - Andrew C Glatz
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer C Romano
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, Atlanta, USA
| | - Paul J Chai
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Christopher E Mascio
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Courtney E McCracken
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael S Kelleman
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - George T Nicholson
- Division of Cardiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jeffery J Meadows
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey D Zampi
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, Atlanta, USA
| | - Shabana Shahanavaz
- Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Sarosh P Batlivala
- Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Joelle Pettus
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Amy L Pajk
- Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Kristal M Hock
- Department of Pediatrics, University of Alabama at Birmingham, 1700 6th Ave S, Suite 9100, Birmingham, AL, 35233, USA
| | - Bryan H Goldstein
- Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Department of Pediatrics, The Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburg School of Medicine, Pittsburgh, PA, USA
| | - Athar M Qureshi
- Department of Pediatrics, Lillie Frank Abercrombie Section on Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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4
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Villacis-Nunez DS, Jones K, Jabbar A, Fan L, Moore W, Peter AS, Henderson M, Xiang Y, Kelleman MS, Sherry W, Chandrakasan S, Oster ME, Jaggi P, Prahalad S. Short-term Outcomes of Corticosteroid Monotherapy in Multisystem Inflammatory Syndrome in Children. JAMA Pediatr 2022; 176:576-584. [PMID: 35344042 PMCID: PMC8961405 DOI: 10.1001/jamapediatrics.2022.0292] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Optimal agents and duration of primary treatment for multisystem inflammatory syndrome in children (MIS-C) remain unclear. OBJECTIVE To compare short-term patient outcomes based on initial treatment with corticosteroids, intravenous immunoglobulin (IVIG), or both. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients in a tertiary-care pediatric hospital system who had MIS-C per the Centers for Disease Control and Prevention case definition during the period March 2020 to February 2021. EXPOSURES Immunomodulatory therapy within the first 24 hours (patients in the intensive care unit [ICU]) or 48 hours (non-ICU patients): corticosteroids alone, IVIG alone, and IVIG plus corticosteroids. MAIN OUTCOMES AND MEASURES Primary outcome was failure of initial therapy, defined as therapy escalation due to fever or worsening or lack of improvement of laboratory, cardiac, or noncardiac clinical factors after 24 hours (ICU patients) or 48 hours (non-ICU patients) from time of therapy initiation, per clinician assessment. Secondary outcomes included presence of complications, cardiovascular outcomes, fever duration, length of hospital and ICU stays, corticosteroid use duration, and need for readmission. RESULTS Among 228 eligible patients, 215 patients were included in the univariate analysis; median age was 8 years, and 135 (62.8%) were boys. There were 69 patients in the corticosteroids group, 31 patients in the IVIG group, and 115 patients in the IVIG plus corticosteroids group. Patients in the corticosteroids group had milder disease at presentation. After propensity score weighting including 179 patients (68 in the corticosteroids group and 111 in the IVIG plus corticosteroids group), rates of initial treatment failure were similar between groups. Among patients whose initial treatment failed, treatment failure in the IVIG plus corticosteroids group was more likely to be based on laboratory parameters (odds ratio [OR], 1.96; 95% CI, 1.07-3.60) and less likely to be based on cardiovascular markers (OR, 0.39; 95% CI, 0.2-0.76), per clinician assessment. Patients in the IVIG plus corticosteroids group had a longer median inpatient stay (6 vs 5 days; P = .001) and longer median corticosteroid course duration (10 vs 5 days; P = .04) compared with the corticosteroids group. Forty-nine patients (71% of 69 in the corticosteroids group) recovered after receiving corticosteroid monotherapy for 10 days or less. CONCLUSIONS AND RELEVANCE Corticosteroid monotherapy is a reasonable management option for a subset of patients with MIS-C, particularly those with mild disease.
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Affiliation(s)
- D. Sofia Villacis-Nunez
- Division of Pediatric Rheumatology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia,Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Aysha Jabbar
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Lucie Fan
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Andrew S. Peter
- Children’s Healthcare of Atlanta, Atlanta, Georgia,Emory University School of Medicine, Atlanta, Georgia,Sibley Heart Center, Atlanta, Georgia
| | - Michaela Henderson
- Children’s Healthcare of Atlanta, Atlanta, Georgia,Emory University School of Medicine, Atlanta, Georgia,Sibley Heart Center, Atlanta, Georgia
| | - Yijin Xiang
- Emory University School of Medicine, Atlanta, Georgia,Pediatrics Biostatistics Core, Atlanta, Georgia
| | - Michael S. Kelleman
- Emory University School of Medicine, Atlanta, Georgia,Pediatrics Biostatistics Core, Atlanta, Georgia
| | - Whitney Sherry
- Children’s Healthcare of Atlanta, Atlanta, Georgia,Division of Hospital Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Shanmuganathan Chandrakasan
- Children’s Healthcare of Atlanta, Atlanta, Georgia,Division of Hematology, Oncology and BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew E. Oster
- Children’s Healthcare of Atlanta, Atlanta, Georgia,Emory University School of Medicine, Atlanta, Georgia,Sibley Heart Center, Atlanta, Georgia
| | - Preeti Jaggi
- Children’s Healthcare of Atlanta, Atlanta, Georgia,Division of Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Sampath Prahalad
- Division of Pediatric Rheumatology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia,Children’s Healthcare of Atlanta, Atlanta, Georgia,Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
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5
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O'Byrne ML, Glatz AC, Huang YSV, Kelleman MS, Petit CJ, Qureshi AM, Shahanavaz S, Nicholson GT, Batlivala S, Meadows JJ, Zampi JD, Law MA, Romano JC, Mascio CE, Chai PJ, Maskatia S, Asztalos IB, Beshish A, Pettus J, Pajk AL, Healan SJ, Eilers LF, Merritt T, McCracken CE, Goldstein BH. Comparative Costs of Management Strategies for Neonates With Symptomatic Tetralogy of Fallot. J Am Coll Cardiol 2022; 79:1170-1180. [PMID: 35331412 DOI: 10.1016/j.jacc.2021.12.036] [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: 10/07/2021] [Revised: 11/22/2021] [Accepted: 12/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recent data have demonstrated that overall mortality and adverse events are not significantly different for primary repair (PR) and staged repair (SR) approaches to management of neonates with symptomatic tetralogy of Fallot (sTOF). Cost data can be used to compare the relative value (cost for similar outcomes) of these approaches and are a potentially more sensitive measure of morbidity. OBJECTIVES This study sought to compare the economic costs associated with PR and SR in neonates with sTOF. METHODS Data from a multicenter retrospective cohort study of neonates with sTOF were merged with administrative data to compare total costs and cost per day alive over the first 18 months of life in a propensity score-adjusted analysis. A secondary analysis evaluated differences in department-level costs. RESULTS In total, 324 subjects from 6 centers from January 2011 to November 2017 were studied (40% PR). The 18-month cumulative mortality (P = 0.18), procedural complications (P = 0.10), hospital complications (P = 0.94), and reinterventions (P = 0.22) did not differ between PR and SR. Total 18-month costs for PR (median $179,494 [IQR: $121,760-$310,721]) were less than for SR (median: $222,799 [IQR: $167,581-$327,113]) (P < 0.001). Cost per day alive (P = 0.005) and department-level costs were also all lower for PR. In propensity score-adjusted analyses, PR was associated with lower total cost (cost ratio: 0.73; P < 0.001) and lower department-level costs. CONCLUSIONS In this multicenter study of neonates with sTOF, PR was associated with lower costs. Given similar overall mortality between treatment strategies, this finding suggests that PR provides superior value.
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Affiliation(s)
- Michael L O'Byrne
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center For Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Andrew C Glatz
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center For Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yuan-Shung V Huang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael S Kelleman
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher J Petit
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA; Division of Cardiology, Morgan Stanley Children's Hospital of New York, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Athar M Qureshi
- Lillie Frank Abercrombie Section on Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Shabana Shahanavaz
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA; Heart Center, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - George T Nicholson
- Division of Cardiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Shawn Batlivala
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Jeffery J Meadows
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jeffrey D Zampi
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark A Law
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jennifer C Romano
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher E Mascio
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul J Chai
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shiraz Maskatia
- Betty Irene Moore Children's Heart Center, Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ivor B Asztalos
- Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Asaad Beshish
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joelle Pettus
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amy L Pajk
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Steven J Healan
- Division of Cardiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lindsay F Eilers
- Lillie Frank Abercrombie Section on Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Taylor Merritt
- Heart Center, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Courtney E McCracken
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Bryan H Goldstein
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA; Heart Institute, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Beshish AG, Fundora MP, Aronoff E, Rao N, Kelleman MS, Shaw FR, Maher KO, Wolf M. Prevalence, Risk Factors, and Etiology of Extubation Failure in Pediatric Patients After Cardiac Surgery. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0041-1742253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractIn this article, our primary objective was to investigate the prevalence and etiology of extubation failure (EF) in patients following cardiac surgery for congenital heart disease. Secondarily, we examined the association of different risk factors with EF. This was single-center retrospective study in a 27-bed cardiac intensive care unit at a quaternary children's hospital. All patients between 0 and 18 years of age who underwent congenital cardiac surgery from January 2008 to September 2019 were included. During the study period, among 8,750 surgical encounters, 257 (2.9%) failed extubation, defined as reintubation within 48 hours from extubation. EF patients were younger, smaller, more likely to have genetic syndromes, higher Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery (STAT) mortality scores, single-ventricle physiology, longer cardiopulmonary bypass (CPB) and cross-clamp (XC) times, longer mechanical ventilation (MV) duration, and higher mortality (p <0.05). In a univariate analysis, EF patients when compared to matched controls by age, gender, and STAT score, and genetic syndrome, particularly heterotaxy, were associated with increased odds of EF (p <0.05). In a multivariable logistic regression of the entire cohort, the presence of any genetic syndrome was associated with higher odds of EF (p <0.05). In a subgroup of neonates, a univariate analysis was performed and multivariable analysis was attempted, but both did not achieve statistical significance. In summary, EF after congenital cardiac surgery is associated with younger age, lower weight, single-ventricle physiology, longer CPB and XC times, longer duration of MV, and genetic syndromes. Patients failing extubation have increased morbidity and mortality. Recognition of these risk factors may provide clinicians the ability to identify patients at high risk allowing for timely intervention to limit adverse outcomes.
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Affiliation(s)
- Asaad G. Beshish
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Michael P. Fundora
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Elizabeth Aronoff
- Emory University School of Medicine, Atlanta, Georgia, United States
| | - Nikita Rao
- Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Michael S. Kelleman
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Fawwaz R. Shaw
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Kevin O. Maher
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Michael Wolf
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
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7
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Shahanavaz S, Qureshi AM, Petit CJ, Goldstein BH, Glatz AC, Bauser-Heaton HD, McCracken CE, Kelleman MS, Law MA, Nicholson GT, Zampi JD, Pettus J, Meadows J. Factors Influencing Reintervention Following Ductal Artery Stent Implantation for Ductal-Dependent Pulmonary Blood Flow: Results From the Congenital Cardiac Research Collaborative. Circ Cardiovasc Interv 2021; 14:e010086. [PMID: 34789017 DOI: 10.1161/circinterventions.120.010086] [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] [Indexed: 12/17/2022]
Abstract
BACKGROUND Stenting of the patent ductus arteriosus (PDA) is an established palliative option for infants with ductal-dependent pulmonary blood flow. Following initial palliation, reintervention on the PDA stent is common, but risk factors have not been characterized. METHODS Infants with ductal-dependent pulmonary blood flow palliated with PDA stent between 2008 and 2015 were reviewed within the Congenital Cardiac Research Collaborative. Rates and risk factors for reintervention were analyzed. RESULTS Among 105 infants who underwent successful PDA stenting, 41 patients (39%) underwent a total of 53 reinterventions on the PDA stent, with all but one occurring within 6 months of the initial intervention. Stent redilation constituted the majority of reintervention (n=35; 66%) followed by additional stent placement (n=11; 21%) and surgical shunt placement (n=7; 13%). The majority of reintervention was nonurgent, and there were no deaths during the reintervention procedure. All but one reintervention occurred within 6 months of the initial procedure. On univariate analysis, risk factors for reintervention included anticipated single-ventricle physiology, lack of prior balloon pulmonary valvuloplasty, use of drug-eluting stent, and increased ductal tortuosity. CONCLUSIONS In infants with ductal-dependent pulmonary blood flow palliated with PDA stent implantation, reintervention is common, can be performed safely, and is associated with both anatomic/procedural factors and anticipated final physiology.
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Affiliation(s)
- Shabana Shahanavaz
- Division of Cardiology, Department of Pediatrics, Washington University in St. Louis School of Medicine, MO (S.S.).,The Heart Institute, Cincinnati Children's Hospital Medical Center, OH (S.S., B.H.G.)
| | - Athar M Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston (A.M.Q.)
| | - Christopher J Petit
- Emory University School of Medicine, Children's Healthcare of Atlanta, GA (C.J.P., H.D.B.-H., J.P.).,Division of Pediatric Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York Presbyterian Hospital (C.J.P.)
| | - Bryan H Goldstein
- The Heart Institute, Cincinnati Children's Hospital Medical Center, OH (S.S., B.H.G.).,Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, PA (B.H.G.)
| | - Andrew C Glatz
- Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia (A.C.G.)
| | - Holly D Bauser-Heaton
- Emory University School of Medicine, Children's Healthcare of Atlanta, GA (C.J.P., H.D.B.-H., J.P.)
| | - Courtney E McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (C.E.M., M.S.K.)
| | - Michael S Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (C.E.M., M.S.K.)
| | - Mark A Law
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alabama at Birmingham (M.A.L.)
| | - George T Nicholson
- Division of Pediatric Cardiology, Department of Pediatrics at the Ann and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN (G.T.N.)
| | - Jeffrey D Zampi
- Department of Pediatrics, Division of Cardiology, University of Michigan, Ann Arbor (J.D.Z.)
| | - Joelle Pettus
- Emory University School of Medicine, Children's Healthcare of Atlanta, GA (C.J.P., H.D.B.-H., J.P.)
| | - Jeffery Meadows
- Division of Pediatric Cardiology, University of California, San Francisco (J.M.)
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8
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Butto A, Mao CY, Wright L, Wetzel M, Kelleman MS, Carboni MP, Dipchand AI, Knecht KR, Reinhardt Z, Sparks JD, Villa C, Mahle WT. Relationship of ventricular assist device support duration with pediatric heart transplant outcomes. J Heart Lung Transplant 2021; 41:61-69. [PMID: 34688547 DOI: 10.1016/j.healun.2021.09.011] [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] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is wide variability in the timing of heart transplant (HTx) after pediatric VAD implant. While some centers wait months before listing for HTx, others accept donor heart offers within days of VAD surgery. We sought to determine if HTx within 30 days versus ≥ 30 after VAD impacts post-HTx outcomes. METHODS Children on VAD pre-HTx were extracted from the Pediatric Heart Transplant Study database. The primary endpoints were post-HTx length of hospital stay (LOS) and one-year survival. Confounding was addressed by propensity score weighting using inverse probability of treatment. Propensity scores were calculated based on age, blood type, primary cardiac diagnosis, decade, VAD type, and allosensitization status. RESULTS A total of 1064 children underwent VAD prior to HTx between 2000 to 2018. Most underwent HTx ≥ 30 days post-VAD (70%). Infants made up 22% of both groups. Patients ≥ 12 years old were 42% of the < 30 days group and children 1 to 11 years comprised 47% of the ≥ 30 days group (p < 0.001). There was no difference in the prevalence of congenital heart disease vs. cardiomyopathy (p = 0.8) or high allosensitization status (p = 0.9) between groups. Post-HTx LOS was similar between groups (p = 0.11). One-year survival was lower in the < 30 days group (adjusted mortality HR 1.76, 95% CI 1.11-2.78, p = 0.016). CONCLUSIONS A longer duration of VAD support prior to HTx is associated with a one-year survival benefit in children, although questions of patient complexity, post-VAD complications and the impact on causality remain. Additional studies using linked databases to understand these factors will be needed to fully assess the optimal timing for post-VAD HTx.
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Affiliation(s)
- Arene Butto
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Chad Y Mao
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lydia Wright
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Martha Wetzel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Michael S Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | | | - Anne I Dipchand
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kenneth R Knecht
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Zdenka Reinhardt
- Freeman Hospital, Thew Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, England
| | | | - Chet Villa
- Cincinnati Children's Hospital, Cincinnati, Ohio
| | - William T Mahle
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
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9
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Bharath A, Sathian U, Zmitrovich A, Shane AL, Escoffery C, Kelleman MS, Gandrakota N, Aguilera-Navarro C, Jaggi P. Pediatric Caregiver Behaviors Related to Oral Antibiotic Use. J Pediatric Infect Dis Soc 2021:piab020. [PMID: 34363082 DOI: 10.1093/jpids/piab020] [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: 10/04/2020] [Accepted: 03/18/2021] [Indexed: 11/13/2022]
Abstract
In a survey of 396 caregivers of children, 119 (30%) reported requesting antibiotics from clinicians and 65 (16%) had stored antibiotics at home. In addition, 47 (12%) reported past or intended nonprescription antibiotic administration; this finding was associated with household income of ≥$75 000 annually (odds ratio 2.042, 95% confidence interval 1.01-4.14, P = .048).
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Affiliation(s)
- Anita Bharath
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Usha Sathian
- Division of Pediatric Urgent Care, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - April Zmitrovich
- Division of Pediatric Urgent Care, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Andi L Shane
- Division Pediatric Infectious Disease, Department of Pediatrics, Emory School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Cam Escoffery
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Michael S Kelleman
- Research Biostatistics Core, Emory+Children's Pediatric Institute, Atlanta, Georgia, USA
| | - Nikhila Gandrakota
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Preeti Jaggi
- Division Pediatric Infectious Disease, Department of Pediatrics, Emory School of Medicine, Emory University, Atlanta, Georgia, USA
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10
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Goldstein BH, Qureshi AM, Meadows JJ, Nicholson GT, Bauser-Heaton H, Petit CJ, Pater C, Kelleman MS, Morales DLS, Mery CM, Shashidharan S, Mascio CE, Mozumdar N, Aggarwal V, Agrawal H, Ligon RA, Christensen J, McCracken CE, Glatz AC. Impact of Treatment Strategy on Outcomes in Isolated Pulmonary Artery of Ductal Origin. Pediatr Cardiol 2021; 42:533-542. [PMID: 33394118 DOI: 10.1007/s00246-020-02511-y] [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: 09/01/2020] [Accepted: 11/17/2020] [Indexed: 11/30/2022]
Abstract
Isolated pulmonary artery (PA) of ductal origin (IPADO) is a rare cardiac defect which requires surgical repair, with or without preceding palliation. We sought to determine the impact of treatment strategy on outcomes. Retrospective study of consecutive patients with IPADO that underwent staged or primary repair from 1/05 to 9/16 at 6 Congenital Cardiac Research Collaborative centers. Patients with single ventricle physiology, major aortopulmonary collaterals, or bilateral IPADO were excluded. Primary outcome was isolated PA z-score at late follow-up. Secondary outcomes included PA symmetry index (isolated:confluent PA diameter) and reintervention burden. Propensity score adjustment was used to account for baseline differences. Of 60 patients in the study cohort, 26 (43%) underwent staged and 34 (57%) primary repair. The staged and primary repair groups differed in weight at diagnosis and presence of other heart disease but not in baseline PA dimensions. Staged patients underwent ductal stent (n = 16) or surgical shunt (n = 10) placement followed by repair at 210 vs. 21 days in the primary repair group (p < 0.001). At median follow-up of 4.5 years post-repair, after adjustment, isolated PA z-score (- 0.74 [- 1.75, - 0.26] vs. - 1.95 [- 2.91, - 1.59], p = 0.012) and PA symmetry index (0.81 [0.49, 1.0] vs. 0.55 [0.48, 0.69], p = 0.042) significantly favored the staged repair group. Freedom from PA reintervention was not different between groups (adjusted HR 0.78 [0.41, 1.48]; p = 0.445). A staged approach to repair of IPADO is associated with superior isolated PA size and symmetry at late follow-up. Consideration should be given to initial palliation in IPADO patients, when feasible.
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Affiliation(s)
- Bryan H Goldstein
- Heart Institute, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA.
| | - Athar M Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | | | | | | | | | - Colleen Pater
- The Heart Institute, Cincinnati Children's Hospital, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, Dell Medical School/Dell Children's Medical Center, University of Texas, Austin, TX, USA
| | | | | | | | - Varun Aggarwal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Hitesh Agrawal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | | | | | | | - Andrew C Glatz
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
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11
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Qureshi AM, Caldarone CA, Romano JC, Chai PJ, Mascio CE, Glatz AC, Petit CJ, McCracken CE, Kelleman MS, Nicholson GT, Meadows JJ, Zampi JD, Shahanavaz S, Law MA, Batlivala SP, Goldstein BH. Comparison of management strategies for neonates with symptomatic tetralogy of Fallot and weight <2.5 kg. J Thorac Cardiovasc Surg 2021; 163:192-207.e3. [PMID: 33726912 DOI: 10.1016/j.jtcvs.2021.01.100] [Citation(s) in RCA: 15] [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: 07/16/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare management strategies for neonates <2.5 kg with tetralogy of Fallot and symptomatic cyanosis who either undergo staged repair (SR) (initial palliation followed by later complete repair) or primary repair (PR). METHODS Consecutive neonates with tetralogy of Fallot and symptomatic cyanosis weighing <2.5 kg at initial intervention and between 2005 and 2017 were retrospectively reviewed from the Congenital Cardiac Research Collaborative. Primary outcome was mortality and secondary outcomes included component (eg, initial palliation, complete repair, or primary repair) and cumulative (SR: initial palliation followed by later complete repair) hospital and intensive care unit lengths of stay, durations of ventilation, inotrope use, cardiopulmonary bypass time, procedural complications, and reintervention. Outcomes were compared with propensity score adjustments with PR as the reference group. RESULTS The cohort included 76 SR (initial palliation: 53 surgical and 23 transcatheter) and 44 PR patients. The observed risk of overall mortality was similar between SR and PR groups (15.8% vs 18.2%: P = .735). The adjusted hazard of mortality remained similar between groups overall (hazard ratio, 0.59; 95% confidence interval, 0.26-1.36; P = .214), as well as during short-term (<4 months: hazard ratio, 0.37; 95% confidence interval, 0.13-1.09; P = .071) and midterm (>4 months: hazard ratio, 1.32; 95% confidence interval, 0.30-5.79; P = .717) follow-up. Reintervention in the first 18 months was common in both groups (53.2% vs 48.4%; hazard ratio, 1.69; 95% confidence interval, 0.96-2.28; P = .072). Adjusted procedural complications and neonatal morbidity burden were overall lower in the SR group. Cumulative secondary outcome burdens largely favored the PR group. CONCLUSIONS In this study comparing SR and PR treatment strategies for neonates with tetralogy of Fallot and symptomatic cyanosis and weight <2.5 kg, mortality and reintervention burden was highly independent of treatment strategy. Other potential advantages were observed with each approach.
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Affiliation(s)
- Athar M Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Houston, Tex; Department of Pediatrics, Baylor College of Medicine, Houston, Tex.
| | - Christopher A Caldarone
- Congenital Heart Surgery, Texas Children's Hospital, Houston, Tex; Department of Surgery, Baylor College of Medicine, Houston, Tex
| | | | - Paul J Chai
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | | | - Andrew C Glatz
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Christopher J Petit
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Courtney E McCracken
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Michael S Kelleman
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | | | | | | | | | - Mark A Law
- University of Alabama at Birmingham, Birmingham, Ala
| | - Sarosh P Batlivala
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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12
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Gaitonde M, Ziebell D, Kelleman MS, Cox DE, Lipinski J, Border WL, Sachdeva R. COVID-19-Related Multisystem Inflammatory Syndrome in Children Affects Left Ventricular Function and Global Strain Compared with Kawasaki Disease. J Am Soc Echocardiogr 2020; 33:1285-1287. [PMID: 33010854 PMCID: PMC7832547 DOI: 10.1016/j.echo.2020.07.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Mansi Gaitonde
- Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center, Atlanta, Georgia
| | - Daniel Ziebell
- Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center, Atlanta, Georgia
| | | | - David E Cox
- Children's Healthcare of Atlanta Sibley Heart Center, Atlanta, Georgia
| | - Joan Lipinski
- Children's Healthcare of Atlanta Sibley Heart Center, Atlanta, Georgia
| | - William L Border
- Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center, Atlanta, Georgia
| | - Ritu Sachdeva
- Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center, Atlanta, Georgia
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13
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Meadows JJ, Qureshi AM, Goldstein BH, Petit CJ, McCracken CE, Kelleman MS, Aggarwal V, Bauser-Heaton H, Combs CS, Gartenberg AJ, Ligon RA, Nicholson GT, Glatz AC. Comparison of Outcomes at Time of Superior Cavopulmonary Connection Between Single Ventricle Patients With Ductal-Dependent Pulmonary Blood Flow Initially Palliated With Either Blalock-Taussig Shunt or Ductus Arteriosus Stent: Results From the Congenital Catheterization Research Collaborative. Circ Cardiovasc Interv 2019; 12:e008110. [PMID: 31607156 DOI: 10.1161/circinterventions.119.008110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with single ventricle anatomy and ductal-dependent pulmonary blood flow may be initially palliated with either modified Blalock-Taussig shunt (BTS) or ductus arteriosus stent (DAS). Comparisons of outcomes during the interstage period and at the time of superior cavopulmonary connection (SCPC) are lacking and may differ between palliation strategies. METHODS Infants with single ventricle anatomy and ductal-dependent pulmonary blood flow palliated with either DAS or BTS from 2008 to 2015 were reviewed across 4 centers. Interstage outcomes, and for those who had SCPC, anatomy, hemodynamics, and perioperative clinical outcomes were compared. Thirty-five patients with DAS and 136 patients with BTS were included. RESULTS At initial palliation, demographic, clinical variables, and pulmonary artery size were similar. Interstage death, transplant, or unplanned reintervention to treat cyanosis occurred in 25.7% of DAS and 35.8% of BTS, P=0.27. Reintervention was more common with DAS (48.6% versus 2.2%; P<0.001). Twenty-three DAS patients and 111 BTS patients underwent SCPC. Preoperative hemodynamics and overall pulmonary atresia growth were similar, although right pulmonary artery growth was better with DAS (change in z-score: 1.57 versus 0.65, P=0.026). SCPC intraoperative and postoperative courses were similar. CONCLUSIONS In patients with single-ventricle anatomy and ductal-dependent pulmonary blood flow, interstage outcomes, hemodynamics before SCPC, and acute postoperative outcomes were similar. Overall reintervention was more common in the DAS group, driven by more frequent planned reintervention. Unplanned reintervention, death, and transplant were similar. Both groups demonstrated good pulmonary atresia growth. DAS is a reasonable initial palliative alternative to BTS in select patients.
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Affiliation(s)
| | | | | | | | | | - Michael S Kelleman
- Children's Healthcare of Atlanta (C.J.P., C.E.M., M.S.K., H.B.-H., R.A.L.)
| | | | | | | | | | - R Allen Ligon
- Children's Healthcare of Atlanta (C.J.P., C.E.M., M.S.K., H.B.-H., R.A.L.)
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14
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Goldstein BH, O’Byrne ML, Petit CJ, Qureshi AM, Dai D, Griffis HM, France A, Kelleman MS, McCracken CE, Mascio CE, Shashidharan S, Ligon RA, Whiteside W, Wallen WJ, Agrawal H, Aggarwal V, Glatz AC. Differences in Cost of Care by Palliation Strategy for Infants With Ductal-Dependent Pulmonary Blood Flow. Circ Cardiovasc Interv 2019; 12:e007232. [PMID: 30998390 PMCID: PMC6546294 DOI: 10.1161/circinterventions.118.007232] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In infants with ductal-dependent pulmonary blood flow, initial palliation with patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt have comparable mortality but discrepant length of stay, procedural complication rates and reintervention burdens, which may influence cost. The relative economic impact of these palliation strategies is unknown. METHODS AND RESULTS Retrospective study of infants with ductal-dependent pulmonary blood flow palliated with PDA stent (n=104) or BT shunt (n=251) from 2008 to 2015 at 4 centers of the Congenital Catheterization Research Collaborative. Inflation-adjusted inpatient hospital costs were calculated for first year of life using Pediatric Health Information System data. Costs derived from outpatient catheterizations not in Pediatric Health Information System were imputed. Costs were compared using propensity score-adjusted multivariable models, to account for baseline differences between groups. After propensity score adjustment, first year of life costs were significantly lower in PDA stent ($215 825 [190 644-244 333]) than BT shunt ($249 855 [230 693-270 609]) patients ( P=0.05). After addition of imputed costs, first year of life costs were not significantly different between PDA stent ($226 403 [200 274-255 941]) and BT shunt ($252 072 [232 955-272 759]) groups ( P=0.15). Patient characteristics associated with higher costs included: younger gestational age, genetic syndrome, noncardiac diagnoses, procedural complications, extracorporeal membrane oxygenation, duration of ventilation, intensive care unit and hospital length of stay and reintervention ( P≤0.02 for all). CONCLUSIONS In this first multicenter comparative cost study of PDA stent or BT shunt as palliation for infants with ductal-dependent pulmonary blood flow, adjusted for baseline differences, PDA stent was associated with lower to equivalent costs over the first year of life. Combined with previous evidence suggesting clinical noninferiority, these findings suggest that PDA stent provides competitive health care value.
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Affiliation(s)
| | - Michael L. O’Byrne
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | | | - Athar M. Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Dingwei Dai
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Heather M. Griffis
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Ashton France
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | | | | | - Christopher E. Mascio
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Subi Shashidharan
- Children’s Healthcare of Atlanta, Emory University School of Medicine
| | - R. Allen Ligon
- Children’s Healthcare of Atlanta, Emory University School of Medicine
| | - Wendy Whiteside
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | - W. Jack Wallen
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | - Hitesh Agrawal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Varun Aggarwal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Andrew C. Glatz
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
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15
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Winterberg PD, Robertson JM, Kelleman MS, George RP, Ford ML. T Cells Play a Causal Role in Diastolic Dysfunction during Uremic Cardiomyopathy. J Am Soc Nephrol 2019; 30:407-420. [PMID: 30728178 PMCID: PMC6405145 DOI: 10.1681/asn.2017101138] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 12/24/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Uremic cardiomyopathy, characterized by left ventricular hypertrophy, diastolic dysfunction, and impaired myocardial strain, contributes to increased cardiovascular mortality in patients with CKD. Emerging evidence suggests a pathogenic role for T cells during chronic heart failure. METHODS To determine whether T cells contribute to uremic cardiomyopathy pathogenesis, we modeled this condition by inducing CKD via 5/6th nephrectomy in mice. We used flow cytometry to assess expression of markers of T cell memory or activation by lymphocytes from CKD mice and controls, as well as lymphocyte capacity for cytokine production. Flow cytometry was also used to quantify immune cells isolated from heart tissue. To test effects of T cell depletion on cardiac function, we gave CKD mice anti-CD3 antibody injections to deplete T cells and compared heart function (assessed by echocardiography) with that of controls. Finally, we correlated T cell phenotypes with structural and functional measures on clinically acquired echocardiograms in children with CKD. RESULTS Mice with CKD accumulated T cells bearing markers of memory differentiation (CD44hi) and activation (PD-1, KLRG1, OX40), as reported previously in human CKD. In addition, mice with CKD showed T cells infiltrating the heart. T cell depletion significantly improved both diastolic function and myocardial strain in CKD mice without altering hypertension or degree of renal dysfunction. In children with CKD, increasing frequency of T cells bearing activation markers PD-1 and/or CD57 was associated with worsening diastolic function on echocardiogram. CONCLUSIONS CKD results in an accumulation of proinflammatory T cells that appears to contribute to myocardial dysfunction.
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Affiliation(s)
- Pamela D Winterberg
- Division of Pediatric Nephrology, Department of Pediatrics,
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Michael S Kelleman
- Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and
| | - Roshan P George
- Division of Pediatric Nephrology, Department of Pediatrics
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mandy L Ford
- Emory Transplant Center, Department of Surgery, and
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16
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Zaki NC, Kelleman MS, James Parks W, Slesnick TC, McConnell ME, Oster ME. The utility of cardiac magnetic resonance imaging in post-Fontan surveillance. CONGENIT HEART DIS 2018; 14:140-146. [PMID: 30378262 DOI: 10.1111/chd.12692] [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] [Received: 04/24/2018] [Revised: 07/17/2018] [Accepted: 08/28/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Gated cardiac MRI offers the most detailed and accurate noninvasive method of assessing cardiac anatomy, particularly in patients with complex congenital heart disease. The proposed benefits of using cMRI as a routine screening tool in the Fontan population include early recognition of asymptomatic, postoperative anatomic and physiologic changes. In 2011, we therefore instituted at our center a recommended practice of cMRI screening in patients with Fontan physiology at 3 and 8 years post-Fontan operation. The purpose of this study was to determine the impact of this standardized practice of cMRI screening on the clinical management of a Fontan population. DESIGN We retrospectively reviewed charts from our institutional Fontan database to determine which patients were eligible for cMRI under the current guidelines and who underwent imaging from November 2002 to June 2015. We reviewed the frequency of cMRI and number of changes in management based on the results. Statistical significance was determined using a chi-square test. RESULTS There were 141 cMRIs performed on 121 patients who met inclusion criteria. The odds of a change in management were significantly greater after clinically indicated cMRI compared to screening cMRI (OR = 3.79, 95% CI: 1.48-9.66, P = .004). There were near significant odds of change in management if the cMRI occurred <8 years after Fontan regardless of whether it was for screening or clinically indicated purposes (OR = 2.43, 95% CI: 0.97-6.08, P = .052). The most frequent change in management was referral for catheterization with pulmonary artery angioplasty. CONCLUSIONS There is an important role for cMRI in routine surveillance of post-Fontan patients. Screening cMRI performed less than 8 years after Fontan palliation offers increased utility compared to studies performed later. The optimal timing of such imaging after Fontan palliation remains unclear.
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Affiliation(s)
- Neil C Zaki
- Emory University School of Medicine, Atlanta, Georgia.,Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - W James Parks
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Timothy C Slesnick
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael E McConnell
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Matthew E Oster
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
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17
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Abstract
Neutropenia has been reported in pediatric heart transplant recipients, but its association with infectious morbidity and mortality is unknown. We sought to determine neutropenia's prevalence and impact on infection, rejection, and survival. A retrospective analysis of pediatric heart transplant recipients from March 2005 to August 2015 was performed. Demographics, medications, infection, and rejection data were collected. Of 142 pediatric heart transplant recipients, 77 (54.2%) developed neutropenia within 4.7 months [3.3-12.1 months] of transplant. In all patients, the adjusted 5-year cumulative incidence of neutropenia was 30.2%. Fifty-one patients (66.2%) had recurrent neutropenia. Six of 14 tested had positive antineutrophil antibodies. Medications associated with neutropenia were decreased in 15 (19.5%) and discontinued in 42 (54.4%) patients with no change in 1-year rejection rates compared to published data. Fifteen patients developed infection within 30 days of neutropenia and two from 30 days to 1 year, with an infection rate similar to the non-neutropenic group. There was no significant difference in survival, ANC, rate of rejection or PTLD in neutropenic patients with and without infection at median follow-up (5.5 years). Neutropenia is common in pediatric heart transplant recipients. Neutropenia had <20% risk of associated infection, similar to non-neutropenic patients. Infection in neutropenic patients did not increase mortality.
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Affiliation(s)
- Kirsten Rose-Felker
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Ayesha Mukhtar
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Michael S Kelleman
- Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Shriprasad R Deshpande
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - William T Mahle
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA, USA
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18
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Diller CL, Kelleman MS, Kupke KG, Quary SC, Kochilas LK, Oster ME. A Modified Algorithm for Critical Congenital Heart Disease Screening Using Pulse Oximetry. Pediatrics 2018; 141:peds.2017-4065. [PMID: 29691284 DOI: 10.1542/peds.2017-4065] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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] [Accepted: 02/21/2018] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5727212367001PEDS-VA_2017-4065Video Abstract OBJECTIVES: Determine the performance of the American Academy of Pediatrics (AAP) critical congenital heart disease (CCHD) newborn screening algorithm and the impact of an alternative algorithm. METHODS Screening was performed on term infants without a known CCHD diagnosis at or near 24 hours of age at a tertiary birth hospital by using the AAP algorithm from 2013 to 2016. Retrospective review from the birth hospital and the area's sole pediatric cardiac center identified true- and false-positives and true- and false-negatives. A simulation study modeled the results of a modified screening algorithm with a single repeat pulse oximetry test instead of 2. RESULTS Screening results were collected on 77 148 newborns . By using the current AAP algorithm, 77 114 (99.96%) infants passed screening, 18 infants failed for an initial saturation of <90%, and 16 failed after not attaining a passing pulse oximetry level after 3 tests. There was 1 true-positive (total anomalous pulmonary venous return), 33 false-positives, and 6 false-negatives, yielding an overall specificity of 99.96%, a sensitivity of 14.3%, and a false-positive rate of 0.043%. Among false-positives, 10 (31.3%) had significant non-CCHD disease. Simulating the modified algorithm, sensitivity remained at 14.3%, and the false-positive rate increased to 0.054%. CONCLUSIONS Although CCHD screening in a tertiary care birth hospital may not detect many new cases of CCHD, it can detect other important diseases in newborns. Modifying the screening algorithm to 1 repeat pulse oximetry test instead of 2 may detect additional infants with significant disease without a substantial increase in the false-positive rate.
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Affiliation(s)
- Christina L Diller
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia; and
| | - Michael S Kelleman
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
| | | | | | - Lazaros K Kochilas
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia; and
| | - Matthew E Oster
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia; .,Children's Healthcare of Atlanta, Atlanta, Georgia; and
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19
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Glatz AC, Petit CJ, Goldstein BH, Kelleman MS, McCracken CE, McDonnell A, Buckey T, Mascio CE, Shashidharan S, Ligon RA, Ao J, Whiteside W, Wallen WJ, Metcalf CM, Aggarwal V, Agrawal H, Qureshi AM. Comparison Between Patent Ductus Arteriosus Stent and Modified Blalock-Taussig Shunt as Palliation for Infants With Ductal-Dependent Pulmonary Blood Flow. Circulation 2018; 137:589-601. [DOI: 10.1161/circulationaha.117.029987] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [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: 06/16/2017] [Accepted: 10/10/2017] [Indexed: 12/17/2022]
Abstract
Background:
Infants with ductal-dependent pulmonary blood flow may undergo palliation with either a patent ductus arteriosus (PDA) stent or a modified Blalock-Taussig (BT) shunt. A balanced multicenter comparison of these 2 approaches is lacking.
Methods:
Infants with ductal-dependent pulmonary blood flow palliated with either a PDA stent or a BT shunt from January 2008 to November 2015 were reviewed from the 4 member centers of the Congenital Catheterization Research Collaborative. Outcomes were compared by use of propensity score adjustment to account for baseline differences between groups.
Results:
One hundred six patients with a PDA stent and 251 patients with a BT shunt were included. The groups differed in underlying anatomy (expected 2-ventricle circulation in 60% of PDA stents versus 45% of BT shunts;
P
=0.001) and presence of antegrade pulmonary blood flow (61% of PDA stents versus 38% of BT shunts;
P
<0.001). After propensity score adjustment, there was no difference in the hazard of the primary composite outcome of death or unplanned reintervention to treat cyanosis (hazard ratio, 0.8; 95% confidence interval [CI], 0.52–1.23;
P
=0.31). Other reinterventions were more common in the PDA stent group (hazard ratio, 29.8; 95% CI, 9.8–91.1;
P
<0.001). However, the PDA stent group had a lower adjusted intensive care unit length of stay (5.3 days [95% CI, 4.2–6.7] versus 9.19 days [95% CI, 7.9–10.6];
P
<0.001), a lower risk of diuretic use at discharge (odds ratio, 0.4; 95% CI, 0.25–0.64;
P
<0.001) and procedural complications (odds ratio, 0.4; 95% CI, 0.2–0.77;
P
=0.006), and larger (152 mm
2
/m
2
[95% CI, 132–176] versus 125 mm
2
/m
2
[95% CI, 113–138];
P
=0.029) and more symmetrical (symmetry index, 0.84 [95% CI, 0.8–0.89] versus 0.77 [95% CI, 0.75–0.8];
P
=0.008] pulmonary arteries at the time of subsequent surgical repair or last follow-up.
Conclusions:
In this multicenter comparison of palliative PDA stent and BT shunt for infants with ductal-dependent pulmonary blood flow adjusted for differences in patient factors, there was no difference in the primary end point, death or unplanned reintervention to treat cyanosis. However, other markers of morbidity and pulmonary artery size favored the PDA stent group, supporting PDA stent as a reasonable alternative to BT shunt in select patients.
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Affiliation(s)
- Andrew C. Glatz
- Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine (A.C.G., A.M., T.B., C.E.M.)
| | - Christopher J. Petit
- Children’s Healthcare of Atlanta, Emory University School of Medicine, GA (C.J.P., M.S.K., C.E.M., S.S., R.A.L., J.A.)
| | - Bryan H. Goldstein
- Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, OH (B.H.G., W.W., W.J.W., C.M.M.)
| | - Michael S. Kelleman
- Children’s Healthcare of Atlanta, Emory University School of Medicine, GA (C.J.P., M.S.K., C.E.M., S.S., R.A.L., J.A.)
| | - Courtney E. McCracken
- Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine (A.C.G., A.M., T.B., C.E.M.)
| | - Alicia McDonnell
- Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine (A.C.G., A.M., T.B., C.E.M.)
| | - Timothy Buckey
- Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine (A.C.G., A.M., T.B., C.E.M.)
| | - Christopher E. Mascio
- Children’s Healthcare of Atlanta, Emory University School of Medicine, GA (C.J.P., M.S.K., C.E.M., S.S., R.A.L., J.A.)
| | - Subi Shashidharan
- Children’s Healthcare of Atlanta, Emory University School of Medicine, GA (C.J.P., M.S.K., C.E.M., S.S., R.A.L., J.A.)
| | - R. Allen Ligon
- Children’s Healthcare of Atlanta, Emory University School of Medicine, GA (C.J.P., M.S.K., C.E.M., S.S., R.A.L., J.A.)
| | - Jingning Ao
- Children’s Healthcare of Atlanta, Emory University School of Medicine, GA (C.J.P., M.S.K., C.E.M., S.S., R.A.L., J.A.)
| | - Wendy Whiteside
- Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, OH (B.H.G., W.W., W.J.W., C.M.M.)
| | - W. Jack Wallen
- Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, OH (B.H.G., W.W., W.J.W., C.M.M.)
| | - Christina M. Metcalf
- Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, OH (B.H.G., W.W., W.J.W., C.M.M.)
| | - Varun Aggarwal
- Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston (V.A., H.A., A.M.Q.)
| | - Hitesh Agrawal
- Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston (V.A., H.A., A.M.Q.)
| | - Athar M. Qureshi
- Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston (V.A., H.A., A.M.Q.)
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20
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Sachdeva R, Kelleman MS, McCracken CE, Campbell RM, Lai WW, Lopez L, Stern KW, Welch E, Douglas PS. Physician Attitudes toward the First Pediatric Appropriate Use Criteria and Engagement With Educational Intervention to Improve the Appropriateness of Outpatient Echocardiography. J Am Soc Echocardiogr 2017; 30:926-931.e2. [DOI: 10.1016/j.echo.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Indexed: 01/12/2023]
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21
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Cory MJ, Ooi YK, Kelleman MS, Vincent RN, Kim DW, Petit CJ. Reintervention Is Associated With Improved Survival in Pediatric Patients With Pulmonary Vein Stenosis. JACC Cardiovasc Interv 2017; 10:1788-1798. [PMID: 28823777 DOI: 10.1016/j.jcin.2017.05.052] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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: 02/21/2017] [Revised: 05/24/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate survival following catheter intervention in pediatric patients with pulmonary vein stenosis (PVS). BACKGROUND Despite aggressive surgical and catheter intervention on PVS in children, recurrence and progression of stenosis can lead to right heart failure and death. Clinicians continue to seek effective treatment options for PVS. METHODS A single-center, retrospective study was performed including all patients <18 years of age who underwent catheter intervention (balloon angioplasty and bare-metal stent and drug-eluting stent insertion) on PVS. Endpoints included death, vein loss, and rate of reintervention. RESULTS Thirty patients underwent intervention (balloon angioplasty, n = 9; bare-metal stent, n = 5; drug-eluting stent, n = 16) at a median age of 6.4 months (4.3 to 9.9 months). Median follow-up duration was 30.6 months (77 days to 10.5 years). Fourteen patients (47%) died at a median of 2.0 months (0.4 to 3.2 months) following intervention. There was no association between DES placement and survival (p = 0.067). Reintervention (catheter or surgical) was associated with improved survival (p = 0.001), with a 1-year survival rate of 84% compared with 25% for no reintervention. Vein loss occurred in 34 of 58 (59%) veins at a median of 3.3 months (1.0 to 5.0 months). One-year vein survival was higher with DES implantation (p = 0.031) and with reintervention (p < 0.001). CONCLUSIONS DES implantation at first catheter intervention appears to be associated with improved vein survival but may not result in improved patient survival. However, reintervention appears to be associated with improved patient survival and vein patency, suggesting that despite mode of treatment, frequent surveillance is important in the care of these patients.
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Affiliation(s)
- Melinda J Cory
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Sibley Heart Center, Emory University School of Medicine, Atlanta, Georgia
| | - Yinn K Ooi
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Sibley Heart Center, Emory University School of Medicine, Atlanta, Georgia
| | - Michael S Kelleman
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Sibley Heart Center, Emory University School of Medicine, Atlanta, Georgia
| | - Robert N Vincent
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Sibley Heart Center, Emory University School of Medicine, Atlanta, Georgia
| | - Dennis W Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Sibley Heart Center, Emory University School of Medicine, Atlanta, Georgia
| | - Christopher J Petit
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Sibley Heart Center, Emory University School of Medicine, Atlanta, Georgia.
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22
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Rose-Felker K, Kelleman MS, Campbell RM, Sachdeva R. Appropriateness of Outpatient Echocardiograms Ordered by Pediatric Cardiologists or Other Clinicians. J Pediatr 2017; 184:137-142. [PMID: 28238480 DOI: 10.1016/j.jpeds.2017.01.073] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 01/12/2017] [Accepted: 01/31/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess the appropriateness and diagnostic yield of TTEs ordered by various pediatric providers according to the pediatric appropriate use criteria (AUC) for outpatient transthoracic echocardiography (TTE) before its release. STUDY DESIGN Clinic notes of patients aged ≤18 years who underwent initial outpatient TTE between April and September 2014 were reviewed to determine the AUC indication, and appropriateness was assigned based on the AUC document. Ordering physicians were categorized into cardiologists, primary care physicians (PCPs; including pediatricians and family practitioners [FPs]), and noncardiology subspecialists. RESULTS Of the 1921 TTEs ordered during the study period, 84.6% were by cardiologists, 9.2% by pediatricians, 3.4% by FPs, and 2.8% by noncardiology subspecialists. The appropriateness rate for cardiologists was higher than that for PCPs (86% vs 64%; P < .001) but not noncardiology subspecialist (86% vs 87%; P = .80). PCPs had a significantly higher proportion of studies that could not be classified compared with cardiologists (35% vs 5%; P < .001) and noncardiology subspecialists (35% vs 11%; P < .001), owing primarily to a lack of adequate clinical information. The likelihood of an abnormal finding was higher in TTEs ordered by a cardiologist vs those ordered by a noncardiologist (OR, 4.8; 95% CI, 2.1-10.9; P < .001). CONCLUSIONS Compared with PCPs, cardiologists ordered more TTEs, had the highest yield of abnormal findings, and had greater appropriateness of TTE orders. A large proportion of TTEs ordered by PCPs were unclassifiable owing to insufficient information. This study lays a framework for provider education and improvement in the TTE order intake process.
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Affiliation(s)
- Kirsten Rose-Felker
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA.
| | - Michael S Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Robert M Campbell
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA
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23
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Jones NE, Kelleman MS, Simon HK, Stockwell JA, McCracken C, Mallory MD, Kamat PP. Evaluation of methohexital as an alternative to propofol in a high volume outpatient pediatric sedation service. Am J Emerg Med 2017; 35:1101-1105. [PMID: 28330689 DOI: 10.1016/j.ajem.2017.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 03/02/2017] [Accepted: 03/07/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Propofol is a preferred agent for many pediatric sedation providers because of its rapid onset and short duration of action. It allows for quick turn around times and enhanced throughput. Occasionally, intravenous (IV) methohexital (MHX), an ultra-short acting barbiturate is utilized instead of propofol. OBJECTIVE Describe the experience with MHX in a primarily propofol driven outpatient sedation program and to see if it serves as an acceptable alternative when propofol is not the preferred pharmacologic option. METHODS Retrospective chart review from 2012 to 2015 of patients receiving IV MHX as their primary sedation agent. Data collected included demographics, reason for methohexital use, dosing, type of procedure, success rate, adverse events (AE), duration of the procedure, and time to discharge. RESULTS Methohexital was used in 240 patient encounters. Median age was 4years (IQR 2-7), 71.8% were male, and 80.4% were ASA-PS I or II. Indications for MHX use: egg+soy/peanut allergy in 93 (38.8%) and mitochondrial disorder 9 (3.8%). Median induction bolus was 2.1mg/kg (IQR, 1.9-2.8), median maintenance infusion was 4.5mg/kg/h (IQR, 3.0-6.0). Hiccups 15 (6.3%), secretions requiring intervention 14 (5.8%), and cough 12 (5.0%) were the most commonly occurring minor AEs. Airway obstruction was seen in 28 (11.6%). Overall success rate was 94%. Median time to discharge after procedure completion was 40.5min (IQR 28-57). CONCLUSION Methohexital can be used with a high success rate and AEs that are not inconsistent with propofol administration. Methohexital should be considered when propofol is not a preferred option.
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Affiliation(s)
- Nicholas E Jones
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
| | - Michael S Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
| | - Harold K Simon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, Atlanta, GA, United States.
| | - Jana A Stockwell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, Atlanta, GA, United States.
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
| | - Michael D Mallory
- Pediatric Emergency Medicine Associates, Atlanta, GA, United States.
| | - Pradip P Kamat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, Atlanta, GA, United States.
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24
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Sachdeva R, Douglas PS, Kelleman MS, McCracken CE, Lopez L, Stern KW, Eidem BW, Benavidez OJ, Weiner RB, Welch E, Campbell RM, Lai WW. Educational intervention for improving the appropriateness of transthoracic echocardiograms ordered by pediatric cardiologists. CONGENIT HEART DIS 2017; 12:373-381. [DOI: 10.1111/chd.12455] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/06/2016] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ritu Sachdeva
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | | | - Michael S. Kelleman
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | - Courtney E. McCracken
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | - Leo Lopez
- Nicklaus Children's Hospital; Miami Florida USA
| | | | | | | | - Rory B. Weiner
- Massachusetts General Hospital; Boston Massachusetts USA
| | | | - Robert M. Campbell
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | - Wyman W. Lai
- NewYork-Presbyterian, Morgan Stanley Children's Hospital; New York New York USA
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25
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Phelps HM, Kelleman MS, McCracken CE, Benavidez OJ, Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Stern KWD, Welch E, Sachdeva R. Application of pediatric appropriate use criteria for initial outpatient evaluation of syncope. Echocardiography 2017; 34:441-445. [PMID: 28177138 DOI: 10.1111/echo.13475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Syncope is a common reason for outpatient transthoracic echocardiography (TTE). We studied the applicability of pediatric appropriate use criteria (AUC) on initial outpatient evaluation of children (≤18 years) with syncope. METHODS Data were obtained before (Phase I, April-September 2014) and after (Phase II, January-April 2015) the release of the AUC document from six participating pediatric cardiology centers. Site investigators determined the indication for TTE and assigned appropriateness rating based on the AUC document: Appropriate (A), May Be Appropriate (M), Rarely Appropriate (R), or "unclassifiable" (U) if it did not fit any scenario in the AUC document. RESULTS Of the total 4562 TTEs, 310 (6.8%) were performed for syncope: 174/2655 (6.6%) Phase I and 136/1907 (7.1%) Phase II, P=.44. Overall, 168 (50.5%) were for indications rated A, 63 (18.9%) for M, 79 (23.7%) for R, and 23 (6.9%) for U. Release of AUC did not change the appropriateness of TTEs [A=51.6% vs 49.0%, P=.63, R=20.2% vs 28.3%, P=.09]. Overall syncope-related R indications formed 15.7% of R indications for all the echocardiograms performed in the entire Pediatric Appropriate Use (PAUSE) study (11.9% Phase I and 22.4% Phase II, P=.002). TTEs were normal in majority of the patients except 7 that had incidental findings. CONCLUSIONS In conclusion, syncope is a common reason for indications rated R and release of the AUC document did not improve appropriate utilization of TTE in syncope. Targeted educational interventions are needed to reduce unnecessary TTEs in children with syncope.
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Affiliation(s)
| | | | | | | | | | | | | | - Wyman W Lai
- Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY, USA
| | - Leo Lopez
- Nicklaus Children's Hospital, Miami, FL, USA
| | | | | | - Ritu Sachdeva
- Emory University School of Medicine, Atlanta, GA, USA
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Sachdeva R, Douglas PS, Kelleman MS, McCracken CE, Lopez L, Stern KWD, Eidem BW, Benavidez OJ, Weiner RB, Welch E, Campbell RM, Lai WW. Effect of Release of the First Pediatric Appropriate Use Criteria on Transthoracic Echocardiogram Ordering Practice. Am J Cardiol 2016; 118:1545-1551. [PMID: 27639687 DOI: 10.1016/j.amjcard.2016.08.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [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: 05/10/2016] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 11/17/2022]
Abstract
Pediatric appropriate use criteria (AUC) were recently published for initial outpatient transthoracic echocardiography (TTE). The purpose of this study was to determine the effect of AUC publication on TTE ordering patterns of pediatric cardiologists. Data were prospectively collected on patients who had initial outpatient TTE ordered before (phase I, April to September 2014) and 3 months after (phase II, January to April 2015) AUC document publication at 6 centers. Site investigators assessed each study's indication and assigned AUC appropriateness as "appropriate" (A), "may be appropriate" (M), "rarely appropriate" (R), or "unclassifiable." One hundred three physicians ordered 4,562 TTEs (2,655 phase I and 1,907 phase II). Overall, there was no statistically significant change in the proportion of A, M, or unclassifiable, but R decreased (12.0% to 9.6%, p = 0.01). There was significant variability among the centers in the percentage of studies for indications rated R (4.9% to 34.8%). There was no significant change in any of the appropriateness ratings at 4 centers, a decrease in R and an increase in A at 1 and a decrease in R and increase in unclassifiable at another. The first pediatric AUC document had only a small impact on physician ordering behavior for initial TTEs, including a small decrease in R. There was a significant variability in appropriateness of studies among centers. These data suggest that active educational interventions are required to substantially improve the appropriate use of pediatric TTE in the outpatient setting.
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Affiliation(s)
- Ritu Sachdeva
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia.
| | - Pamela S Douglas
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Michael S Kelleman
- Department of Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney E McCracken
- Department of Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia
| | - Leo Lopez
- Division of Cardiology, Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Kenan W D Stern
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital at Montefiore, New York, New York
| | - Benjamin W Eidem
- Division of Pediatric Cardiology, Department of Pediatrics, Mayo Clinic Rochester, Rochester, Minnesota
| | - Oscar J Benavidez
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rory B Weiner
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth Welch
- Division of Cardiology, Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Robert M Campbell
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia
| | - Wyman W Lai
- Division of Pediatric Cardiology, NewYork-Presbyterian, Morgan Stanley Children's Hospital, New York, New York
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Tandon A, Hashemi S, Parks WJ, Kelleman MS, Sallee D, Slesnick TC. Improved high-resolution pediatric vascular cardiovascular magnetic resonance with gadofosveset-enhanced 3D respiratory navigated, inversion recovery prepared gradient echo readout imaging compared to 3D balanced steady-state free precession readout imaging. J Cardiovasc Magn Reson 2016; 18:74. [PMID: 27802802 PMCID: PMC5090984 DOI: 10.1186/s12968-016-0296-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/14/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Improved delineation of vascular structures is a common indication for cardiovascular magnetic resonance (CMR) in children and requires high spatial resolution. Currently, pre-contrast 3D, respiratory navigated, T2-prepared, fat saturated imaging with a bSSFP readout (3D bSSFP) is commonly used; however, these images can be limited by blood pool inhomogeneity and exaggeration of metal artifact. We compared image quality of pediatric vasculature obtained using standard 3D bSSFP to 3D, respiratory navigated, inversion recovery prepared imaging with a gradient echo readout (3D IR GRE) performed after administration of gadofosveset trisodium (GT), a blood pool contrast agent. METHODS For both sequences, VCG triggering was used with acquisition during a quiescent period of the cardiac cycle. 3D bSSFP imaging was performed pre-contrast, and 3D IR GRE imaging was performed 5 min after GT administration. We devised a vascular imaging quality score (VIQS) with subscores for coronary arteries, pulmonary arteries and veins, blood pool homogeneity, and metal artifact. Scoring was performed on axial reconstructions of isotropic datasets by two independent readers and differences were adjudicated. Signal- and contrast-to-noise (SNR and CNR) calculations were performed on each dataset. RESULTS Thirty-five patients had both 3D bSSFP and 3D IR GRE imaging performed. 3D IR GRE imaging showed improved overall vascular imaging compared to 3D bSSFP when comparing all-patient VIQS scores (n = 35, median 14 (IQR 11-15), vs 6 (4-10), p < 0.0001), and when analyzing the subset of patients with intrathoracic metal (n = 17, 16 (14-17) vs. 5 (2-9), p < 0.0001). 3D IR GRE showed significantly improved VIQS subscores for imaging the RCA, pulmonary arteries, pulmonary veins, and blood pool homogeneity. In addition, 3D IR GRE imaging showed reduced variability in both all-patient and metal VIQS scores compared to 3D bSSFP (p < 0.05). SNR and CNR were higher with 3D IR GRE in the left ventricle and left atrium, but not the pulmonary arteries. CONCLUSIONS Respiratory navigated 3D IR GRE imaging after GT administration provides improved vascular CMR in pediatric patients compared to pre-contrast 3D bSSFP imaging, as well as improved imaging in patients with intrathoracic metal. It is an excellent alternative in this challenging patient population when high spatial resolution vascular imaging is needed.
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Affiliation(s)
- Animesh Tandon
- Departments of Pediatrics, Radiology, and Biomedical Engineering, University of Texas Southwestern Medical School, Dallas, TX USA
- Children’s Medical Center Dallas, Dallas, TX USA
| | | | - W. James Parks
- Children’s Healthcare of Atlanta, Atlanta, GA USA
- Emory University School of Medicine, Atlanta, GA USA
| | | | - Denver Sallee
- Children’s Healthcare of Atlanta, Atlanta, GA USA
- Emory University School of Medicine, Atlanta, GA USA
| | - Timothy C. Slesnick
- Children’s Healthcare of Atlanta, Atlanta, GA USA
- Emory University School of Medicine, Atlanta, GA USA
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Knutson S, Kelleman MS, Kochilas L. Implementation of Developmental Screening Guidelines for Children with Congenital Heart Disease. J Pediatr 2016; 176:135-141.e2. [PMID: 27301570 DOI: 10.1016/j.jpeds.2016.05.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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: 01/13/2016] [Revised: 04/27/2016] [Accepted: 05/10/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To assess awareness and implementation among pediatric primary care providers of the 2012 American Heart Association (AHA) guidelines for the evaluation and management of developmental abnormalities in children with congenital heart disease (CHD). We hypothesized that children with CHD are not being provided neurodevelopmental screening and support according to the AHA guidelines. STUDY DESIGN An online survey was administered to licensed pediatric primary care providers in Minnesota (pediatricians = 530, family physicians = 1469) to evaluate awareness of the AHA guidelines, current screening practices, and barriers to implementation of these guidelines. RESULTS A total of 326 providers (17% of 1911 successful e-mails) responded to the survey, which included 148 pediatricians (29% of 518 successful e-mails) and 178 family physicians (13% of 1393 successful e-mails). Overall, 202 providers (62%) reported caring for children with CHD. Among those caring for children with CHD, the most commonly reported reasons for neurodevelopmental referral were nonspecific to CHD. Presence of risks specific to children with CHD, such as history of cyanotic heart disease or open heart surgery as an infant, accounted for only 25% and 22% of the referrals, respectively. Only 21% of providers were aware of the guidelines, and only 7% received guidance from a pediatric cardiologist regarding neurodevelopmental screening in children with CHD. CONCLUSION There is need for further education of primary care providers on the developmental risks associated with CHD as well as increased involvement by the pediatric cardiology community to enhance the developmental outcomes of children with CHD.
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Affiliation(s)
- Stacie Knutson
- Division of Cardiology, Department of Pediatrics, University of Minnesota, Minneapolis, MN.
| | - Michael S Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Lazaros Kochilas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
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Gauthier TW, Guidot DM, Kelleman MS, McCracken CE, Brown LAS. Maternal Alcohol Use During Pregnancy and Associated Morbidities in Very Low Birth Weight Newborns. Am J Med Sci 2016; 352:368-375. [PMID: 27776718 DOI: 10.1016/j.amjms.2016.06.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 02/23/2016] [Revised: 06/09/2016] [Accepted: 06/28/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND We hypothesized that maternal alcohol use occurs in pregnancies that end prematurely and that in utero alcohol exposure is associated with an increased risk of morbidities of premature newborns. METHODS In an observational study of mothers who delivered very low birth weight newborns (VLBW) ≤1,500 g, maternal alcohol use was determined via a standardized administered questionnaire. We compared the effect of maternal drinking on the odds of developing late-onset sepsis (LOS), bronchopulmonary dysplasia (BPD), death, BPD or death, days on oxygen or any morbidity (either LOS, BPD or death). The effect of drinking amounts (light versus heavy) was also evaluated. RESULTS A total of 129 subjects who delivered 143 VLBW newborns were enrolled. Approximately 1 in 3 (34%) subjects reported drinking alcohol during the first trimester ("exposed"). Within the exposed group, 15% reported drinking ≥7drinks/week ("heavy") and 85% of the subjects reported drinking <7drinks/week ("light"). When controlling for maternal age, drug or tobacco use during pregnancy and neonatal gestational age, any drinking increased the odds of BPD or death and any morbidity. Furthermore, light or heavy drinking increased the odds of BPD or death and any morbidity, whereas heavy drinking increased the odds of LOS. CONCLUSIONS In utero alcohol exposure during the first trimester occurred in 34% of VLBW newborns. Maternal drinking in the first trimester was associated with significantly increased odds of neonatal morbidity. Further studies are warranted to determine the full effect of in utero alcohol exposure on the adverse outcomes of VLBW premature newborns.
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Affiliation(s)
| | - David M Guidot
- Department of Medicine, Emory University, Atlanta, Georgia; Atlanta VA Medical Center, Decatur, Georgia
| | | | | | - Lou Ann S Brown
- Department of Pediatrics, Emory University, Atlanta, Georgia
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Rose-Felker K, Kelleman MS, Campbell RM, Oster ME, Sachdeva R. Appropriate Use and Clinical Impact of Echocardiographic “Evaluation of Murmur” in Pediatric Patients. CONGENIT HEART DIS 2016; 11:721-726. [DOI: 10.1111/chd.12379] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Kirsten Rose-Felker
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Michael S. Kelleman
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Robert M. Campbell
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Matthew E. Oster
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Ritu Sachdeva
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
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Abarbanell GL, Morrow G, Kelleman MS, Kanter KR, Border WL, Sachdeva R. Echocardiographic Predictors of Left Ventricular Outflow Tract Obstruction following Repair of Atrioventricular Septal Defect. CONGENIT HEART DIS 2016; 11:554-561. [DOI: 10.1111/chd.12370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/08/2016] [Accepted: 03/18/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Ginnie L. Abarbanell
- Division of Pediatric Cardiology, Department of Pediatrics; Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology; Atlanta Ga USA
| | - Gemma Morrow
- Division of Pediatric Cardiology, Department of Pediatrics; Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology; Atlanta Ga USA
| | - Michael S. Kelleman
- Division of Pediatric Cardiology, Department of Pediatrics; Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology; Atlanta Ga USA
| | - Kirk R. Kanter
- Division of Pediatric Cardiology, Department of Pediatrics; Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology; Atlanta Ga USA
| | - William L. Border
- Division of Pediatric Cardiology, Department of Pediatrics; Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology; Atlanta Ga USA
| | - Ritu Sachdeva
- Division of Pediatric Cardiology, Department of Pediatrics; Emory University School of Medicine, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology; Atlanta Ga USA
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Sachdeva R, Kelleman MS, Allen J, Benavidez O, Campbell R, Douglas P, Eidem B, Gold L, Lopez L, McCracken C, Stern K, Weiner R, Welch E, Lai W. EDUCATIONAL INTERVENTION FOR IMPROVING THE APPROPRIATENESS OF TRANSTHORACIC ECHOCARDIOGRAMS ORDERED BY PEDIATRIC CARDIOLOGISTS. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)31009-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ramamurthy S, Kelleman MS, McGaughy F, Sachdeva R. Semiautomatic Evaluation of Tricuspid Annular Plane Systolic Excursion from Two Dimensional Echocardiographic Images. Echocardiography 2016; 33:674-80. [PMID: 26751037 DOI: 10.1111/echo.13166] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Tricuspid annular plane systolic excursion (TAPSE) has emerged as a reliable marker of right ventricular (RV) systolic function. Recently, TAPSE derived using 2D images (2D-TAPSE) was shown to correlate with M-mode TAPSE (MM-TAPSE). We have developed a novel technique for semiautomatic evaluation of TAPSE (SA-TAPSE). The purpose of this study was to determine the accuracy of this novel technique and validate it on normal hearts and pulmonary hypertension (PH). METHODS A total of 110 patients (56 with normal heart and 54 with PH) were retrospectively identified for analysis. The semiautomatic algorithm tracked the lateral tricuspid valve hinge point (TVHP) and the apex in the apical 4-chamber view. SA-TAPSE was calculated as displacement of the TVHP in end-diastole (ED) and end-systole (ES). The same points were manually identified to derive 2D-TAPSE. RESULTS The system was able to accurately identify ED and ES in 304/330 heartbeats within three cardiac frames. The automatically identified TVHP points were within 1.2 ± 0.7 mm from the manually identified points. Intra-class correlation between SA-TAPSE and 2D-TAPSE was 0.96 (95% CI 0.93-0.98) for normal hearts and 0.92 (95% CI 0.87-0.96) for those with PH. Bland-Altman analysis showed a strong agreement between SA-TAPSE and 2D-TAPSE for normal hearts and those with PH. CONCLUSION Using the novel custom-made software, SA-TAPSE could be measured in majority of our patients and was accurate when applied to normal hearts and those with PH. Future work will focus on fully automating the system for a rapid retrospective analysis of TAPSE.
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Affiliation(s)
| | | | | | - Ritu Sachdeva
- Children's Healthcare of Atlanta, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia.,Sibley Heart Center Cardiology, Atlanta, Georgia
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Sachdeva R, Allen J, Benavidez OJ, Campbell RM, Douglas PS, Eidem BW, Gold L, Kelleman MS, Lopez L, McCracken CE, Stern KW, Weiner RB, Welch E, Lai WW. Pediatric Appropriate Use Criteria Implementation Project. J Am Coll Cardiol 2015; 66:1132-40. [DOI: 10.1016/j.jacc.2015.06.1327] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/16/2015] [Accepted: 06/22/2015] [Indexed: 11/30/2022]
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