1
|
McGeoghegan PB, Lu M, Sleeper LA, Emani SM, Baird CW, Feins EN, Gellis LA, Friedman KG. Cleft closure and other predictors of contemporary outcomes after atrioventricular canal repair in patients with parachute left atrioventricular valve. Interdiscip Cardiovasc Thorac Surg 2024; 38:ivae048. [PMID: 38539038 PMCID: PMC11014788 DOI: 10.1093/icvts/ivae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/17/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVES Parachute left atrioventricular valve (LAVV) complicates atrioventricular septal defect (AVSD) repair. We evaluate outcomes of AVSD patients with parachute LAVV and identify risk factors for adverse outcomes. METHODS We evaluated all patients undergoing repair of AVSD with parachute LAVV from 2012 to 2021. The primary outcome was a composite of time-to-death, LAVV reintervention and development of greater than or equal to moderate LAVV dysfunction (greater than or equal to moderate LAVV stenosis and/or LAVV regurgitation). Event-free survival for the composite outcome was estimated using Kaplan-Meier methodology and competing risks analysis. Cox proportional hazards regression was used to identify predictors of the primary outcome. RESULTS A total of 36 patients were included with a median age at repair of 4 months (interquartile range 2.3-5.5 months). Over a median follow-up of 2.6 years (interquartile range 1.0-5.6 years), 6 (17%) patients underwent LAVV reintervention. All 6 patients who underwent LAVV reintervention had right-dominant AVSD. Sixteen patients (44%) met the composite outcome, and all did so within 2 years of initial repair. Transitional AVSD (versus complete), prior single-ventricle palliation, leaving the cleft completely open and greater than or equal to moderate preoperative LAVV regurgitation were associated with a higher risk of LAVV reintervention in univariate analysis. In multivariate analysis, leaving the cleft completely open was associated with the composite outcome. CONCLUSIONS Repair of AVSD with parachute LAVV remains a challenge with a significant burden of LAVV reintervention and dysfunction in medium-term follow-up. Unbalanced, right-dominant AVSDs are at higher risk for LAVV reintervention. Leaving the cleft completely open might independently predict poor overall outcomes and should be avoided when possible. CLINICAL TRIAL REGISTRATION NUMBER IRB-P00041642.
Collapse
Affiliation(s)
| | - Minmin Lu
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| | - Lynn A Sleeper
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| | - Sitaram M Emani
- Department of Cardiothoracic Surgery, Children’s Hospital Boston, Boston, MA, USA
| | - Christopher W Baird
- Department of Cardiothoracic Surgery, Children’s Hospital Boston, Boston, MA, USA
| | - Eric N Feins
- Department of Cardiothoracic Surgery, Children’s Hospital Boston, Boston, MA, USA
| | - Laura A Gellis
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| |
Collapse
|
2
|
Fernandez-Cisneros A, Staffa SJ, Emani SM, Chávez M, Friedman KG, Hoganson DM, Kaza AK, Del Nido PJ, Baird CW. Association of tetralogy of Fallot and complete atrioventricular canal: a single-centre 40-year experience. Eur J Cardiothorac Surg 2024; 65:ezae037. [PMID: 38310341 DOI: 10.1093/ejcts/ezae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 12/21/2023] [Accepted: 01/31/2024] [Indexed: 02/05/2024] Open
Abstract
OBJECTIVES Outcome data in tetralogy of Fallot (ToF) and complete atrioventricular canal (CAVC) are limited. We report our experience for over 40 years in this patient population. METHODS Single-centre, retrospective analysis of patients who underwent surgical repair with the diagnosis of ToF-CAVC from 1979 to 2022, divided into 2 different periods and compared. RESULTS A total of 116 patients were included: 1979-2007 (n = 61) and 2008-2021 (n = 55). Balanced CAVC (80%) and Rastelli type C CAVC (81%) were most common. Patients in the later era were younger (4 vs 14 months, P < 0.001), fewer had trisomy 21 (60% vs 80%, P = 0.019) and fewer had prior palliative prior procedures (31% vs 43%, P < 0.001). In the earlier era, single-patch technique was more common (62% vs 16%, P < 0.001), and in recent era, double-patch technique was more common (84% vs 33%, P < 0.001). In the earlier era, right ventricular outflow tract was most commonly reconstructed with transannular patch (51%), while in more recent era, valve-sparing repairs were more common (69%) (P < 0.001). In-hospital mortality was 4.3%. The median follow-up was 217 and 74 months for the first and second eras. Survival for earlier and later eras at 2-, 5- and 10-year follow-up was (85.1%, 81.5%, 79.6% vs 94.2%, 94.2%, 94.2% respectively, log-rank test P = 0.03). CONCLUSIONS The surgical approach to ToF-CAVC has evolved over time. More recently, patients tended to receive primary repair at younger ages and had fewer palliative procedures. Improved surgical techniques allowing for earlier and complete repair have shown a decrease in mortality, more valve-sparing procedures without an increase in total reoperations. Presented at the 37th EACTS Annual Meeting, Vienna, Austria.
Collapse
Affiliation(s)
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sitaram M Emani
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mariana Chávez
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin G Friedman
- Cardiology Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David M Hoganson
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Pedro J Del Nido
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher W Baird
- Cardiovascular Surgery Department, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
3
|
Brodeur KE, Liu M, Ibanez D, de Groot MJ, Chen L, Du Y, Seyal E, Laza-Briviesca R, Baker A, Chang JC, Chang MH, Day-Lewis M, Dedeoglu F, Dionne A, de Ferranti SD, Friedman KG, Halyabar O, Lo MS, Meidan E, Sundel RP, Henderson LA, Nigrovic PA, Newburger JW, Son MB, Lee PY. Elevation of IL-17 Cytokines Distinguishes Kawasaki Disease From Other Pediatric Inflammatory Disorders. Arthritis Rheumatol 2024; 76:285-292. [PMID: 37610270 PMCID: PMC10842426 DOI: 10.1002/art.42680] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/26/2023] [Accepted: 08/17/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE Kawasaki disease (KD) is a systemic vasculitis of young children that can lead to development of coronary artery aneurysms. We aimed to identify diagnostic markers to distinguish KD from other pediatric inflammatory diseases. METHODS We used the proximity extension assay to profile proinflammatory mediators in plasma samples from healthy pediatric controls (n = 30), febrile controls (n = 26), and patients with KD (n = 23), multisystem inflammatory syndrome in children (MIS-C; n = 25), macrophage activation syndrome (n = 13), systemic and nonsystemic juvenile idiopathic arthritis (n = 14 and n = 10, respectively), and juvenile dermatomyositis (n = 9). We validated the key findings using serum samples from additional patients with KD (n = 37) and febrile controls (n = 28). RESULTS High-fidelity proteomic profiling revealed distinct patterns of cytokine and chemokine expression across pediatric inflammatory diseases. Although KD and MIS-C exhibited many similarities, KD differed from MIS-C and other febrile diseases in that most patients exhibited elevation in one or more members of the interleukin-17 (IL-17) cytokine family, IL-17A, IL-17C, and IL-17F. IL-17A was particularly sensitive and specific, discriminating KD from febrile controls with an area under the receiver operator characteristic curve of 0.95 (95% confidence interval 0.89-1.00) in the derivation set and 0.91 (0.85-0.98) in the validation set. Elevation of all three IL-17-family cytokines was observed in over 50% of KD patients, including 19 of 20 with coronary artery aneurysms, but was rare in all other comparator groups. CONCLUSION Elevation of IL-17 family cytokines is a hallmark of KD and may help distinguish KD from its clinical mimics.
Collapse
Affiliation(s)
| | - Meng Liu
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Daniel Ibanez
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Mareike J. de Groot
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
- Division of Rheumatology, Department of Medicine V (Hematology, Oncology and Rheumatology), Heidelberg University Hospital, Heidelberg, Germany
| | - Liang Chen
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Yan Du
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Eman Seyal
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Annette Baker
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | - Joyce C. Chang
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Megan Day-Lewis
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | - Olha Halyabar
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Esra Meidan
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Robert P. Sundel
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Peter A. Nigrovic
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | - Mary Beth Son
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Pui Y. Lee
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| |
Collapse
|
4
|
Greene CL, Scully B, Staffa SJ, Chavez M, Friedman KG, del Nido P, Quinonez LG, Emani SM, Baird CW. The Yasui operation: A single institutional experience over 30 years. JTCVS Open 2023; 15:361-367. [PMID: 37808042 PMCID: PMC10556945 DOI: 10.1016/j.xjon.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/02/2023] [Accepted: 06/22/2023] [Indexed: 10/10/2023]
Abstract
Objective The Yasui operation was introduced in 1987 for patients with 2 adequate ventricles, a ventricular septal defect, and aortic atresia or interrupted aortic arch. Despite promising early outcomes, left ventricular outflow tract obstruction (LVOTO) remains a long-term concern. The purpose of this study is to report our institutional experience with the Yasui operation. Methods We retrospectively reviewed all patients undergoing the Yasui operation between 1989 and 2021. Results are reported as median with interquartile range (IQR). Results Twenty-five patients underwent a Yasui operation (19 primary), at 11 days (IQR, 7-218 days) of life and weight of 3 kg (IQR, 2.8-4.1 days). Fundamental diagnosis was ventricular septal defect/interrupted aortic arch in 11 patients and ventricular septal defect/aortic atresia in 14. Follow-up was 96% (24 out of 25) at 5 years (IQR, 1.4-14.7) with 92% survival. Freedom from LVOTO reoperation was 91% at late follow-up with 2 patients requiring baffle revision at 6 and 9 years. Latest echocardiogram showed 100% of patients had normal biventricular function and 87% (20 out of 23) less than mild LVOTO at 5 years (IQR, 2.3-14.9). Diagnosis, aortic valve morphology, and material used were not predictors of LVOTO. Freedom from right ventricle-to-pulmonary artery conduit reoperation was 48% at a median of 5 years (IQR, 1.4-14.7). Conduit type was not a predictor of reintervention. Conclusions The Yasui operation can be performed with low morbidity and mortality in patients with 2 acceptable-size ventricles and aortic atresia or interrupted aortic arch with severe LVOTO. Despite some burden of reoperation, midterm reoperation for LVOTO is not common and ventricular function is preserved.
Collapse
Affiliation(s)
- Christina L. Greene
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Brandi Scully
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Steven J. Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Mariana Chavez
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Pedro del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Luis G. Quinonez
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sitaram M. Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher W. Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| |
Collapse
|
5
|
Dionne A, Friedman KG, Young CC, Newhams MM, Kucukak S, Jackson AM, Fitzgerald JC, Smallcomb LS, Heidemann S, McLaughlin GE, Irby K, Bradford TT, Horwitz SM, Loftis LL, Soma VL, Rowan CM, Kong M, Halasa NB, Tarquinio KM, Schwarz AJ, Hume JR, Gertz SJ, Clouser KN, Carroll CL, Wellnitz K, Cullimore ML, Doymaz S, Levy ER, Typpo KV, Lansell AN, Butler AD, Kuebler JD, Zambrano LD, Campbell AP, Patel MM, Randolph AG, Newburger JW. Tachyarrhythmias During Hospitalization for COVID-19 or Multisystem Inflammatory Syndrome in Children and Adolescents. J Am Heart Assoc 2022; 11:e025915. [PMID: 36250670 PMCID: PMC9673680 DOI: 10.1161/jaha.122.025915] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022]
Abstract
Background Cardiac complications related to COVID-19 in children and adolescents include ventricular dysfunction, myocarditis, coronary artery aneurysm, and bradyarrhythmias, but tachyarrhythmias are less understood. The goal of this study was to evaluate the frequency, characteristics, and outcomes of children and adolescents experiencing tachyarrhythmias while hospitalized for acute severe COVID-19 or multisystem inflammatory syndrome in children. Methods and Results This study involved a case series of 63 patients with tachyarrhythmias reported in a public health surveillance registry of patients aged <21 years hospitalized from March 15, 2020, to December 31, 2021, at 63 US hospitals. Patients with tachyarrhythmias were compared with patients with severe COVID-19-related complications without tachyarrhythmias. Tachyarrhythmias were reported in 22 of 1257 patients (1.8%) with acute COVID-19 and 41 of 2343 (1.7%) patients with multisystem inflammatory syndrome in children. They included supraventricular tachycardia in 28 (44%), accelerated junctional rhythm in 9 (14%), and ventricular tachycardia in 38 (60%); >1 type was reported in 12 (19%). Registry patients with versus without tachyarrhythmia were older (median age, 15.4 [range, 10.4-17.4] versus 10.0 [range, 5.4-14.8] years) and had higher illness severity on hospital admission. Intervention for treatment of tachyarrhythmia was required in 37 (59%) patients and included antiarrhythmic medication (n=31, 49%), electrical cardioversion (n=11, 17%), cardiopulmonary resuscitation (n=8, 13%), and extracorporeal membrane oxygenation (n=9, 14%). Patients with tachyarrhythmias had longer hospital length of stay than those who did not, and 9 (14%) versus 77 (2%) died. Conclusions Tachyarrhythmias were a rare complication of acute severe COVID-19 and multisystem inflammatory syndrome in children and adolescents and were associated with worse clinical outcomes, highlighting the importance of close monitoring, aggressive treatment, and postdischarge care.
Collapse
Affiliation(s)
- Audrey Dionne
- Department of CardiologyBoston Children’s HospitalDepartment of PediatricsHarvard Medical SchoolBostonMA
| | - Kevin G. Friedman
- Department of CardiologyBoston Children’s HospitalDepartment of PediatricsHarvard Medical SchoolBostonMA
| | - Cameron C. Young
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children’s HospitalBostonMA
| | - Margaret M. Newhams
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children’s HospitalBostonMA
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children’s HospitalBostonMA
| | - Ashley M. Jackson
- COVID‐19 Response, Centers for Disease Control and PreventionAtlantaGA
| | - Julie C. Fitzgerald
- Division of Critical CareDepartment of Anesthesiology and Critical CareUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Laura S. Smallcomb
- Department of PediatricsMedical University of South CarolinaCharlestonSC
| | - Sabrina Heidemann
- Division of Pediatric Critical Care Medicine, Department of PediatricsCentral Michigan UniversityDetroitMI
| | - Gwenn E. McLaughlin
- Division of Pediatric Critical Care MedicineDepartment of PediatricsUniversity of Miami Miller School of MedicineMiamiFL
| | - Katherine Irby
- Section of Pediatric Critical CareDepartment of PediatricsArkansas Children’s HospitalLittle RockAR
| | - Tamara T. Bradford
- Division of Cardiology, Department of PediatricsLouisiana State University Health Sciences Center and Children’s Hospital of New OrleansNew OrleansLA
| | - Steven M. Horwitz
- Division of Pediatric Critical Care Medicine, Department of PediatricsRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
| | - Laura L. Loftis
- Section of Critical Care MedicineDepartment of PediatricsTexas Children’s HospitalHoustonTX
| | - Vijaya L. Soma
- Division of Infectious Diseases, Department of PediatricsNew York University Grossman School of Medicine and Hassenfeld Children’s HospitalNew YorkNY
| | - Courtney M. Rowan
- Division of Pediatric Critical Care MedicineDepartment of PediatricsIndiana University School of MedicineRiley Hospital for ChildrenIndianapolisIN
| | - Michele Kong
- Division of Pediatric Critical Care MedicineDepartment of PediatricsUniversity of Alabama at BirminghamBirminghamAL
| | - Natasha B. Halasa
- Division of Pediatric Infectious DiseasesDepartment of PediatricsVanderbilt University Medical CenterNashvilleTN
| | - Keiko M. Tarquinio
- Division of Critical Care MedicineDepartment of PediatricsEmory University School of MedicineChildren’s Healthcare of AtlantaAtlantaGA
| | - Adam J. Schwarz
- Division of Critical Care MedicineCHOC Children’s HospitalOrangeCA
| | - Janet R. Hume
- Division of Pediatric Critical CareUniversity of Minnesota Masonic Children’s HospitalMinneapolisMN
| | - Shira J. Gertz
- Division of Pediatric Critical CareDepartment of PediatricsCooperman Barnabas Medical CenterLivingstonNJ
| | | | | | - Kari Wellnitz
- Division of Pediatric Critical CareStead Family Department of PediatricsUniversity of Iowa Carver College of MedicineIowa CityIA
| | - Melissa L. Cullimore
- Division of Pediatric Critical CareDepartment of Pediatrics, Children’s Hospital and Medical CenterOmahaNE
| | - Sule Doymaz
- Division of Pediatric Critical CareDepartment of PediatricsSUNY Downstate Health Sciences UniversityBrooklynNY
| | - Emily R. Levy
- Divisions of Pediatric Infectious Diseases and Pediatric Critical Care MedicineDepartment of Pediatric and Adolescent Medicine, Mayo ClinicRochesterMN
| | - Katri V. Typpo
- Division of Pediatric Critical CareDepartment of PediatricsUniversity of ArizonaTucsonAZ
| | - Amanda N. Lansell
- Division of Pediatric Hospital MedicineRainbow Babies and Children’s HospitalClevelandOH
| | - Andrew D. Butler
- Division of Pediatric Critical CareSt. Christopher’s Hospital for ChildrenPhiladelphiaPA
| | - Joseph D. Kuebler
- Division of Pediatric Critical CareDepartment of PediatricsGolisano Children’s HospitalUniversity of RochesterRochesterNY
| | - Laura D. Zambrano
- COVID‐19 Response, Centers for Disease Control and PreventionAtlantaGA
| | | | - Manish M. Patel
- COVID‐19 Response, Centers for Disease Control and PreventionAtlantaGA
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children’s HospitalBostonMA
- Departments of Anaesthesia and PediatricsHarvard Medical SchoolBostonMA
| | - Jane W. Newburger
- Department of CardiologyBoston Children’s HospitalDepartment of PediatricsHarvard Medical SchoolBostonMA
| | | |
Collapse
|
6
|
Asrani PP, Gellis LA, Schidlow D, Callahan R, Porras D, Wilkins‐Haug L, Guseh S, Tworetzky W, Friedman KG. Technically Successful Fetal Aortic Valvuloplasty Acutely improves Left Heart Output. Prenat Diagn 2022; 42:1466-1470. [DOI: 10.1002/pd.6240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/30/2022] [Accepted: 09/03/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Priyanka P. Asrani
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Laura A. Gellis
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - David Schidlow
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Ryan Callahan
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Diego Porras
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Louise Wilkins‐Haug
- Department of Obstetrics and Gynecology Boston Children’s Hospital New York United States
- Harvard Medical School Boston MA United States
| | - Stephanie Guseh
- Department of Obstetrics and Gynecology Boston Children’s Hospital New York United States
- Harvard Medical School Boston MA United States
| | - Wayne Tworetzky
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Kevin G. Friedman
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| |
Collapse
|
7
|
Bradford VR, Tworetzky W, Callahan R, Wilkins-Haug LE, Benson CB, Porras D, Guseh SH, Lu M, Sleeper LA, Gellis L, Friedman KG. Hemodynamic and Anatomic Changes after Fetal Aortic Valvuloplasty are associated with Procedural Success and Postnatal Biventricular Circulation. Prenat Diagn 2022; 42:1312-1322. [PMID: 35924422 DOI: 10.1002/pd.6216] [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] [Received: 05/18/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND There are minimal data characterizing the trajectory of left heart growth and hemodynamics following fetal aortic valvuloplasty (FAV). METHODS This retrospective study included patients who underwent FAV between 2000 and 2019 with echocardiograms performed pre-FAV, immediately post-FAV, and in late gestation. RESULTS Of 118 fetuses undergoing FAV, 106 (90%) underwent technically successful FAV, of which 55 (52%) had biventricular circulation. Technically successful FAV was associated with improved aortic valve growth (p<0.001), sustained antegrade aortic arch (AoA) flow (p=0.02), improved mitral valve inflow pattern (p=0.002), and favorable patent foramen ovale (PFO) flow pattern (p=0.004) from pre-FAV to late gestation. Compared to patients with univentricular outcome, patients with biventricular outcome had less decrement in size of the left ventricle (LV) (p<0.001) and aortic valve (p=0.005), as well more physiologic PFO flow (p<0.001) and antegrade AoA flow (p<0.001) from pre-FAV to late gestation. In multivariable analysis, echocardiographic predictors of biventricular outcome were less decline in LV end diastolic dimension (p<0.001), improved PFO flow (p=0.004), and sustained antegrade AoA flow (p=0.002) from pre-FAV to late gestation. CONCLUSION Stabilization of left heart growth and improved hemodynamics following successful FAV through late gestation are associated with postnatal biventricular circulation. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Victoria R Bradford
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Wayne Tworetzky
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Ryan Callahan
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Louise E Wilkins-Haug
- Obstetrics and Gynecology and, Boston, MA, USA.,Obstetrics and Gynecology and, Boston, MA, USA
| | - Carol B Benson
- Radiology, Brigham and Women's Hospital, Department of, Boston, MA, USA.,Radiology, Harvard Medical School, Boston, MA, USA
| | - Diego Porras
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Stephanie H Guseh
- Obstetrics and Gynecology and, Boston, MA, USA.,Obstetrics and Gynecology and, Boston, MA, USA
| | - Minmin Lu
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA
| | - Lynn A Sleeper
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Laura Gellis
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Kevin G Friedman
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| |
Collapse
|
8
|
Friedman KG, McCrindle BW, Runeckles K, Dahdah N, Harahsheh AS, Khoury M, Lang S, Manlhiot C, Tremoulet AH, Raghuveer G, Selamet Tierney ES, Jone PN, Li JS, Szmuszkovicz JR, Norozi K, Jain SS, Yetman AT, Newburger JW. Association of Acute Anti-inflammatory Treatment With Medium-term Outcomes for Coronary Artery Aneurysms in Kawasaki Disease. CJC Pediatr Congenit Heart Dis 2022; 1:174-183. [PMID: 37969928 PMCID: PMC10642124 DOI: 10.1016/j.cjcpc.2022.05.007] [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] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2023]
Abstract
Background The impact of adjunctive anti-inflammatory treatment on outcomes for patients with Kawasaki disease (KD) and coronary artery aneurysms (CAAs) is unknown. Methods Using data from the International KD Registry in patients with ≥ medium CAA we evaluate associations of treatment with outcomes and major adverse cardiac events (MACE). Results Medium or large CAA was present in 527 (32%) patients. All were treated with intravenous immunoglobulin (IVIG), 70% were male, and the median age was 1.3 years (interquartile range: 0.4-4.0 years). The most common acute therapies included single IVIG alone in 243 (46%), multiple IVIG in 100 (19%), multiple IVIG + corticosteroids in 75 (14%), and multiple IVIG + infliximab + corticosteroids in 44 (8%) patients. Patients who received therapy beyond single IVIG had a larger CA z-score at baseline (P < 0.001) and a higher rate of bilateral CAA (P < 0.001). Compared with IVIG alone, early adjunctive treatments (within 3 days of initial IVIG) were not associated with time to CAA regression or MACE, whereas later adjunctive therapy was associated with MACE and longer time to CAA regression. Patients receiving IVIG plus steroids vs IVIG alone had a trend towards shorter time to CAA regression and lower risk of MACE (P = 0.07). A larger CAA z-score at baseline was the strongest predictor of an increase in the CAA z-score over follow-up, lower likelihood of CAA regression, and higher risk of MACE. Conclusions Persistence of CAA and MACE are more strongly associated with baseline severity CAA than with acute adjuvant anti-inflammatory therapy. Patients who received late adjunctive therapy are at higher risk for worse outcomes.
Collapse
Affiliation(s)
- Kevin G. Friedman
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian W. McCrindle
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kyle Runeckles
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nagib Dahdah
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, University of Montreal, Montreal, Québec, Canada
| | - Ashraf S. Harahsheh
- Division of Cardiology, Department of Pediatrics, Children’s National Hospital, the George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Michael Khoury
- Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Alberta, Canada
| | - Sean Lang
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cedric Manlhiot
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Adriana H. Tremoulet
- Department of Pediatrics, Rady Children’s Hospital-San Diego, University of California San Diego, San Diego, California, USA
| | - Geetha Raghuveer
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - Elif Seda Selamet Tierney
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California, USA
| | - Pei-Ni Jone
- Pediatric Cardiology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jennifer S. Li
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Kambiz Norozi
- Division of Cardiology, Department of Pediatrics, University of Western Ontario, London, Ontario, Canada
| | - Supriya S. Jain
- Maria Fareri Children’s Hospital at Westchester Medical Center Health, New York Medical College, Valhalla, New York, USA
| | - Angela T. Yetman
- Department of Pediatrics, Children’s Hospital & Medical Center of Omaha, Omaha, Nebraska, USA
| | - Jane W. Newburger
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Hadley SM, Prakash A, Baker AL, de Ferranti SD, Newburger JW, Friedman KG, Dionne A. Follow-up cardiac magnetic resonance in children with vaccine-associated myocarditis. Eur J Pediatr 2022; 181:2879-2883. [PMID: 35482094 PMCID: PMC9046711 DOI: 10.1007/s00431-022-04482-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/21/2022] [Accepted: 04/16/2022] [Indexed: 12/29/2022]
Abstract
Myocarditis is a rare complication of the COVID-19 mRNA vaccine. We previously reported a case series of 15 adolescents with vaccine-associated myocarditis, 87% of whom had abnormalities on initial cardiac magnetic resonance (CMR), including late gadolinium enhancement (LGE) in 80%. We performed follow-up CMRs to determine the trajectory of myocardial recovery and better understand the natural history of vaccine-associated myocarditis. Case series of patients age < 19 years admitted to Boston Children's Hospital with acute vaccine-associated myocarditis following the BNT162b2 vaccine who had abnormal CMR at the time of initial presentation, and underwent follow-up testing. CMR assessment included left ventricular (LV) ejection fraction, T2-weighted myocardial imaging, LV global native T1, LV global T2, extracellular volume (ECV), and late gadolinium enhancement (LGE). Ten patients (9 male, median age 15 years) with vaccine-associated myocarditis underwent follow-up CMR at a median of 92 days (range 76-119) after hospital discharge. LGE was persistent in 80% of patients, though improved from prior in all cases. Two patients (20%) had abnormal LV global T1 at presentation, which normalized on follow-up. ECV decreased between acute presentation and follow-up in 6/10 patients; it remained elevated at follow-up in 1 patient and borderline in 3 patients. CONCLUSION CMR performed ~3 months after admission for COVID-19 vaccine-associated myocarditis showed improvement of LGE in all patients, but persistent in the majority. Follow-up CMR 6-12 months after acute episode should be considered to better understand the long-term cardiac risks. WHAT IS KNOWN • Myocarditis is a rare side effect of COVID-19 mRNA vaccine. •Late gadolinium enhancement is present on most cardiac magnetic resonance at the time of acute presentation. WHAT IS NEW •Late gadolinium enhancement improved on all repeat cardiac magnetic resonance at 3-month follow-up. •Most patients still had a small amount of late gadolinium enhancement, the clinical significance of which is yet to be determined.
Collapse
Affiliation(s)
- Stephanie M. Hadley
- Department of Medicine, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Ashwin Prakash
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 USA
| | - Annette L. Baker
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 USA
| | - Sarah D. de Ferranti
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 USA
| | - Jane W. Newburger
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 USA
| | - Kevin G. Friedman
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 USA
| | - Audrey Dionne
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 USA
| |
Collapse
|
10
|
Wheeler CR, Vogel ER, Cusano MA, Friedman KG, Callahan R, Porras D, Ibla JC, Levy PT. Definitive Closure of the Patent Ductus Arteriosus in Preterm Infants and Subsequent Short-Term Respiratory Outcomes. Respir Care 2022; 67:594-606. [PMID: 35473850 PMCID: PMC9994254 DOI: 10.4187/respcare.09489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
A persistent patent ductus arteriosus (PDA) can have significant clinical consequences in preterm infants, depending on the degree of left-to-right shunting, its impact on cardiac performance, and associated perinatal risk factors that can mitigate or exacerbate the shunt. Although the best management strategy remains contentious, PDAs that have contraindications to, or have failed medical management have historically undergone surgical ligation. Recently smaller occluder devices and delivery systems have allowed for minimally invasive closure in the catheterization laboratory even in extremely premature infants. The present review summarizes the pathophysiologic manifestations, treatment options and management of hemodynamically significant PDA in preterm infants. Additionally, we review the available literature surrounding the respiratory support and outcomes of preterm infants following definitive PDA closure.
Collapse
Affiliation(s)
- Craig R Wheeler
- Department of Respiratory Care, Boston Children's Hospital, Boston, Massachusetts.
| | - Elizabeth R Vogel
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael A Cusano
- Department of Respiratory Care, Boston Children's Hospital, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Juan C Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| |
Collapse
|
11
|
Sadhwani A, Wypij D, Rofeberg V, Gholipour A, Mittleman M, Rohde J, Velasco-Annis C, Calderon J, Friedman KG, Tworetzky W, Grant PE, Soul JS, Warfield SK, Newburger JW, Ortinau CM, Rollins CK. Fetal Brain Volume Predicts Neurodevelopment in Congenital Heart Disease. Circulation 2022; 145:1108-1119. [PMID: 35143287 PMCID: PMC9007882 DOI: 10.1161/circulationaha.121.056305] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [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 Neurodevelopmental impairment is common in children with congenital heart disease (CHD), but postnatal variables explain only 30% of the variance in outcomes. To explore whether the antecedents for neurodevelopmental disabilities might begin in utero, we analyzed whether fetal brain volume predicted subsequent neurodevelopmental outcome in children with CHD. METHODS Fetuses with isolated CHD and sociodemographically comparable healthy control fetuses underwent fetal brain magnetic resonance imaging and 2-year neurodevelopmental evaluation with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) and the Adaptive Behavior Assessment System, Third Edition (ABAS-3). Hierarchical regression evaluated potential predictors of Bayley-III and ABAS-3 outcomes in the CHD group, including fetal total brain volume adjusted for gestational age and sex, sociodemographic characteristics, birth measures, and medical history. RESULTS The CHD group (n=52) had lower Bayley-III cognitive, language, and motor scores than the control group (n=26), but fetal brain volumes were similar. Within the CHD group, larger fetal total brain volume correlated with higher Bayley-III cognitive, language, and motor scores and ABAS-3 adaptive functioning scores (r=0.32-0.47; all P<0.05), but this was not noted in the control group. Fetal brain volume predicted 10% to 21% of the variance in neurodevelopmental outcome measures in univariate analyses. Multivariable models that also included social class and postnatal factors explained 18% to 45% of the variance in outcome, depending on developmental domain. Moreover, in final multivariable models, fetal brain volume was the most consistent predictor of neurodevelopmental outcome across domains. CONCLUSIONS Small fetal brain volume is a strong independent predictor of 2-year neurodevelopmental outcomes and may be an important imaging biomarker of future neurodevelopmental risk in CHD. Future studies are needed to support this hypothesis. Our findings support inclusion of fetal brain volume in risk stratification models and as a possible outcome in fetal neuroprotective intervention studies.
Collapse
Affiliation(s)
- Anjali Sadhwani
- Department of Psychiatry, Boston Children’s Hospital, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
| | - Ali Gholipour
- Department of Radiology, Boston Children’s Hospital, Boston, MA
- Department of Radiology, Harvard Medical School, Boston, MA
| | | | - Julia Rohde
- Department of Neurology, Boston Children’s Hospital, Boston, MA
| | | | - Johanna Calderon
- Department of Psychiatry, Boston Children’s Hospital, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - P. Ellen Grant
- Department of Radiology, Boston Children’s Hospital, Boston, MA
- Department of Radiology, Harvard Medical School, Boston, MA
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Boston, MA
- Department of Neurology, Harvard Medical School, Boston, MA
| | | | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Caitlin K. Rollins
- Department of Neurology, Boston Children’s Hospital, Boston, MA
- Department of Neurology, Harvard Medical School, Boston, MA
| |
Collapse
|
12
|
Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, Behrens EM, Kernan KF, Schulert GS, Seo P, Son MBF, Tremoulet AH, VanderPluym C, Yeung RSM, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 3. Arthritis Rheumatol 2022; 74:e1-e20. [PMID: 35118829 PMCID: PMC9011620 DOI: 10.1002/art.42062] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of SARS-CoV-2 infection. Recommendations are also provided for children with hyperinflammation during COVID-19, the acute, infectious phase of SARS-CoV-2 infection. METHODS The Task Force is composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting. RESULTS The guidance was approved in June 2020 and updated in November 2020 and October 2021, and consists of 41 final guidance statements accompanied by flow diagrams depicting the diagnostic pathway for MIS-C and recommendations for initial immunomodulatory treatment of MIS-C. CONCLUSION Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.
Collapse
Affiliation(s)
| | - Scott W. Canna
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Kevin G. Friedman
- Boston Children's Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Mark Gorelik
- Morgan Stanley Children’s Hospital and Columbia UniversityNew YorkNew York
| | - Sivia K. Lapidus
- Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center and Hackensack Meridian School of MedicineHackensackNew Jersey
| | - Hamid Bassiri
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Edward M. Behrens
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Kate F. Kernan
- University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Grant S. Schulert
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of MedicineCincinnatiOhio
| | - Philip Seo
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | - Mary Beth F. Son
- Boston Children's Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Adriana H. Tremoulet
- University of California San Diego and Rady Children’s Hospital San DiegoCalifornia
| | | | - Rae S. M. Yeung
- The Hospital for Sick Children and University of TorontoTorontoOntarioCanada
| | | | | | - David R. Karp
- University of Texas Southwestern Medical CenterDallas
| | - Jay J. Mehta
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
13
|
Ross C, Kumar R, Pelland-Marcotte MC, Mehta S, Kleinman ME, Thiagarajan RR, Ghbeis MB, VanderPluym CJ, Friedman KG, Porras D, Fynn-Thompson F, Goldhaber SZ, Brandão LR. Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review. Chest 2022; 161:791-802. [PMID: 34587483 PMCID: PMC8941619 DOI: 10.1016/j.chest.2021.09.019] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/09/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022] Open
Abstract
Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.
Collapse
Affiliation(s)
- Catherine Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Riten Kumar
- Harvard Medical School, Boston, MA,Department of Pediatrics, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | | | - Shivani Mehta
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA,College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY
| | - Monica E. Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Ravi R. Thiagarajan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Muhammad B. Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Christina J. VanderPluym
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Pediatric Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Diego Porras
- Division of Invasive Cardiology, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Samuel Z. Goldhaber
- Harvard Medical School, Boston, MA,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Leonardo R. Brandão
- Department of Paediatrics, Haematology/Oncology Division, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
14
|
Selamet Tierney ES, Runeckles K, Tremoulet AH, Dahdah N, Portman MA, Mackie AS, Harahsheh AS, Lang SM, Choueiter NF, Li JS, Manlhiot C, Low T, Mathew M, Friedman KG, Raghuveer G, Norozi K, Szmuszkovicz JR, McCrindle BW. Variation in Pharmacologic Management of Patients with Kawasaki Disease with Coronary Artery Aneurysms. J Pediatr 2022; 240:164-170.e1. [PMID: 34474088 DOI: 10.1016/j.jpeds.2021.08.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/23/2021] [Accepted: 08/24/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate practice variation in pharmacologic management in the International Kawasaki Disease Registry (IKDR). STUDY DESIGN Practice variation in intravenous immunoglobulin (IVIG) therapy, anti-inflammatory agents, statins, beta-blockers, antiplatelet therapy, and anticoagulation was described. RESULTS We included 1627 patients from 30 IKDR centers with maximum coronary artery aneurysm (CAA) z scores 2.5-4.99 in 848, 5.0-9.99 in 349, and ≥10.0 (large/giant) in 430 patients. All centers reported IVIG and acetylsalicylic acid (ASA) as primary therapy and use of additional IVIG or steroids as needed. In 23 out of 30 centers, (77%) infliximab was also used; 11 of these 23 centers reported using it in <10% of their patients, and 3 centers used it in >20% of patients. Nonsteroidal anti-inflammatory agents were used in >10% of patients in only nine centers. Beta-blocker (8.8%, all patients) and abciximab (3.6%, all patients) were mainly prescribed in patients with large/giant CAAs. Statins (2.7%, all patients) were mostly used in one center and only in patients with large/giant CAAs. ASA was the primary antiplatelet modality for 99% of patients, used in all centers. Clopidogrel (18%, all patients) was used in 24 centers, 11 of which used it in >50% of their patients with large/giant CAAs. CONCLUSIONS In the IKDR, IVIG and ASA therapy as primary therapy is universal with common use of a second dose of IVIG for persistent fever. There is practice variation among centers for adjunctive therapies and anticoagulation strategies, likely reflecting ongoing knowledge gaps. Randomized controlled trials nested in a high-quality collaborative registry may be an efficient strategy to reduce practice variation.
Collapse
Affiliation(s)
- Elif Seda Selamet Tierney
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, School of Medicine, Palo Alto, CA.
| | - Kyle Runeckles
- Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Adriana H Tremoulet
- Department of Pediatrics, University of California San Diego, Rady Children's Hospital-San Diego, San Diego, CA
| | - Nagib Dahdah
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, University of Montreal, Montreal, Quebec, Canada
| | | | | | - Ashraf S Harahsheh
- Pediatrics-Cardiology, Children's National Hospital/George Washington University School of Medicine, Washington, DC
| | - Sean M Lang
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Cedric Manlhiot
- Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tisiana Low
- Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mathew Mathew
- Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Kambiz Norozi
- Department of Pediatrics, Western University, London, Canada
| | | | - Brian W McCrindle
- Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
15
|
Dahdah N, Kung SC, Friedman KG, Marelli A, Gordon JB, Belay ED, Baker AL, Kazi DS, White PH, Tremoulet AH. Falling Through the Cracks: The Current Gap in the Health Care Transition of Patients With Kawasaki Disease: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2021; 10:e023310. [PMID: 34632822 PMCID: PMC8751858 DOI: 10.1161/jaha.121.023310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Health care transition (HCT) is a period of high vulnerability for patients with chronic childhood diseases, particularly when patients shift from a pediatric to an adult care setting. An increasing number of patients with Kawasaki disease (KD) who develop medium and large coronary artery aneurysms (classified by the American Heart Association according to maximal internal coronary artery diameter Z‐scores ≥5 and ≥10, respectively) are becoming adults and thus undergoing an HCT. However, a poor transition to an adult provider represents a risk of loss to follow‐up, which can result in increasing morbidity and mortality. Methods and Results This scientific statement provides a summary of available literature and expert opinion pertaining to KD and HCT of children as they reach adulthood. The statement reviews the existing life‐long risks for patients with KD, explains current guidelines for long‐term care of patients with KD, and offers guidance on assessment and preparation of patients with KD for HCT. The key element to a successful HCT, enabling successful transition outcomes, is having a structured intervention that incorporates the components of planning, transfer, and integration into adult care. This structured intervention can be accomplished by using the Six Core Elements approach that is recommended by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians. Conclusions Formal HCT programs for patients with KD who develop aneurysms should be established to ensure a smooth transition with uninterrupted medical care as these youths become adults.
Collapse
|
16
|
Gellis L, Castellanos DA, Oduor R, Gauvreau K, Dionne A, Newburger J, Friedman KG. Comparison of coronary artery measurements between echocardiograms and cardiac CT in Kawasaki disease patients with aneurysms. J Cardiovasc Comput Tomogr 2021; 16:43-50. [PMID: 34548269 DOI: 10.1016/j.jcct.2021.09.002] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/22/2021] [Accepted: 09/13/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND American Heart Association (AHA) guidelines for management of Kawasaki disease (KD) rely on coronary artery (CA) z-scores from echocardiograms. Compared with echocardiography, cardiac CT (CCT) offers better visualization of distal segments and evaluation for thrombosis and stenosis. Despite increasing use of CCT in KD, CA z-scores for CCT are not available and measurement concordance between imaging modalities is a critical knowledge gap. METHODS We retrospectively reviewed KD patients with CA aneurysms who had concurrent echocardiography and CCT between 2016 and 2020. Patients were included if they had history of CA z-scores of ≥3 on echocardiography during their clinical course. Agreement between CCT and echocardiography was assessed using Bland-Altman analysis. RESULTS Paired CCT and echocardiography studies were available in 18 patients (21 studies). The largest CA aneurysms were large/giant (z-score ≥10) in 14 studies, medium (z-score ≥5, <10) in 3 studies, and small (z score ≥2.5, <5) in 2 studies. Intra- and inter-observer reliability for CCT measurements were high for all CA segments (ICC 99.7% and 98.6%). For the LMCA, proximal LAD and proximal and distal RCA there was high correlation between echocardiogram and CCT absolute measurements with wider variation between modalities for the distal LAD and circumflex. Overall, CCT measurements tended to be smaller than echocardiogram measurements, and led to a lower AHA z-score risk classification in 24% of studies. CONCLUSION CCT and echocardiography have high agreement for absolute measurements of proximal CA segments, but more measurement discrepancy exists for distal CA segments with bias toward lower dimensions on CCT.
Collapse
Affiliation(s)
- Laura Gellis
- Department of Cardiology, Boston Children's Hospital, USA; Department of Pediatrics, Harvard Medical School, Boston, USA.
| | - Daniel A Castellanos
- Department of Cardiology, Boston Children's Hospital, USA; Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Rebecca Oduor
- Department of Cardiology, Boston Children's Hospital, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, USA; Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, USA; Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Jane Newburger
- Department of Cardiology, Boston Children's Hospital, USA; Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, USA; Department of Pediatrics, Harvard Medical School, Boston, USA
| |
Collapse
|
17
|
Lee M, Meidan E, Son M, Dionne A, Newburger JW, Friedman KG. Coronary artery aneurysms in children is not always Kawasaki disease: a case report on Takayasu arteritis. BMC Rheumatol 2021; 5:27. [PMID: 34380576 PMCID: PMC8357446 DOI: 10.1186/s41927-021-00197-0] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 04/28/2021] [Indexed: 12/18/2022] Open
Abstract
Background Coronary artery (CA) aneurysms in children are a rare but potentially life-threatening finding and are highly associated with Kawasaki disease (KD). Case presentation We describe a four-year-old female with a vasculitis and CA aneurysms. She had a prolonged course with recurrent fever and systemic inflammation several times upon discontinuation of steroid treatment. Due in part to the CA aneurysms, she initially was diagnosed with KD but due to the unusual clinical course, further evaluation was performed. Abdominal and chest MRI/A revealed diffuse aortitis suggestive of a large vessel vasculitis, specifically Takayasu arteritis. With treatment targeted for Takayasu arteritis, there was resolution of fever and inflammation and the CA aneurysms improved. Conclusions This case demonstrates the utility in broadening the differential diagnosis in cases of presumed KD with CA involvement in which the clinical course is atypical for KD.
Collapse
Affiliation(s)
- Michelle Lee
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA. .,Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue- Farley 2, Boston, MA, 02115, USA.
| | - Esra Meidan
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Division of Immunology, Boston Children's Hospital, Boston, USA
| | - MaryBeth Son
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Division of Immunology, Boston Children's Hospital, Boston, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue- Farley 2, Boston, MA, 02115, USA.,Division of Immunology, Boston Children's Hospital, Boston, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue- Farley 2, Boston, MA, 02115, USA.,Division of Immunology, Boston Children's Hospital, Boston, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue- Farley 2, Boston, MA, 02115, USA.,Division of Immunology, Boston Children's Hospital, Boston, USA
| |
Collapse
|
18
|
Dionne A, Sperotto F, Chamberlain S, Baker AL, Powell AJ, Prakash A, Castellanos DA, Saleeb SF, de Ferranti SD, Newburger JW, Friedman KG. Association of Myocarditis With BNT162b2 Messenger RNA COVID-19 Vaccine in a Case Series of Children. JAMA Cardiol 2021; 6:1446-1450. [PMID: 34374740 DOI: 10.1001/jamacardio.2021.3471] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance The BNT162b2 (Pfizer-BioNTech) messenger RNA COVID-19 vaccine was authorized on May 10, 2021, for emergency use in children aged 12 years and older. Initial reports showed that the vaccine was well tolerated without serious adverse events; however, cases of myocarditis have been reported since approval. Objective To review results of comprehensive cardiac imaging in children with myocarditis after COVID-19 vaccine. Design, Setting, and Participants This study was a case series of children younger than 19 years hospitalized with myocarditis within 30 days of BNT162b2 messenger RNA COVID-19 vaccine. The setting was a single-center pediatric referral facility, and admissions occurred between May 1 and July 15, 2021. Main Outcomes and Measures All patients underwent cardiac evaluation including an electrocardiogram, echocardiogram, and cardiac magnetic resonance imaging. Results Fifteen patients (14 male patients [93%]; median age, 15 years [range, 12-18 years]) were hospitalized for management of myocarditis after receiving the BNT162b2 (Pfizer) vaccine. Symptoms started 1 to 6 days after receipt of the vaccine and included chest pain in 15 patients (100%), fever in 10 patients (67%), myalgia in 8 patients (53%), and headache in 6 patients (40%). Troponin levels were elevated in all patients at admission (median, 0.25 ng/mL [range, 0.08-3.15 ng/mL]) and peaked 0.1 to 2.3 days after admission. By echocardiographic examination, decreased left ventricular (LV) ejection fraction (EF) was present in 3 patients (20%), and abnormal global longitudinal or circumferential strain was present in 5 patients (33%). No patient had a pericardial effusion. Cardiac magnetic resonance imaging findings were consistent with myocarditis in 13 patients (87%) including late gadolinium enhancement in 12 patients (80%), regional hyperintensity on T2-weighted imaging in 2 patients (13%), elevated extracellular volume fraction in 3 patients (20%), and elevated LV global native T1 in 2 patients (20%). No patient required intensive care unit admission, and median hospital length of stay was 2 days (range 1-5). At follow-up 1 to 13 days after hospital discharge, 11 patients (73%) had resolution of symptoms. One patient (7%) had persistent borderline low LV systolic function on echocardiogram (EF 54%). Troponin levels remained mildly elevated in 3 patients (20%). One patient (7%) had nonsustained ventricular tachycardia on ambulatory monitor. Conclusions and Relevance In this small case series study, myocarditis was diagnosed in children after COVID-19 vaccination, most commonly in boys after the second dose. In this case series, in short-term follow-up, patients were mildly affected. The long-term risks associated with postvaccination myocarditis remain unknown. Larger studies with longer follow-up are needed to inform recommendations for COVID-19 vaccination in this population.
Collapse
Affiliation(s)
- Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Stephanie Chamberlain
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Ashwin Prakash
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Daniel A Castellanos
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Susan F Saleeb
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
19
|
Lo J, Gauvreau K, Baker AL, de Ferranti SD, Friedman KG, Lo MS, Dedeoglu F, Sundel RP, Newburger JW, Son MBF. Multiple Emergency Department Visits for a Diagnosis of Kawasaki Disease: An Examination of Risk Factors and Outcomes. J Pediatr 2021; 232:127-132.e3. [PMID: 33453202 DOI: 10.1016/j.jpeds.2021.01.007] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine predictors of >1 emergency department (ED) visit for a Kawasaki disease diagnosis in a quaternary care pediatric hospital and compare outcomes between patients with 1 vs >1 visit for Kawasaki disease diagnosis. STUDY DESIGN Medical records of patients evaluated for Kawasaki disease between January 2006 and August 2018 at Boston Children's Hospital were abstracted for demographic and clinical data. Predictors of >1 visit were explored using logistic regression and classification and regression tree analysis. RESULTS Of 530 patients diagnosed with Kawasaki disease, 117 (22%) required multiple ED visits for Kawasaki disease diagnosis. Multivariable regression and classification and regression tree analysis identified ≤2 Kawasaki disease criteria (OR 33.9; 95% CI 18.1-63.6), <3 days of fever at the first visit (OR 3.47; 95% CI 1.77-6.84), and non-White race (OR 2.15; 95% CI 1.18-3.95) as predictors of >1 visit. There were no significant differences in duration of hospitalization, day of illness at initial Kawasaki disease treatment, intravenous immunoglobulin resistance, need for adjunctive therapies, or coronary artery outcomes between patients diagnosed with Kawasaki disease at initial visit vs subsequent visits. CONCLUSIONS Incomplete Kawasaki disease criteria, fewer days of fever, and non-White race were significant predictors of multiple ED visits for Kawasaki disease diagnosis in this single institution study. Our findings underscore the importance of maintaining a high index of suspicion for Kawasaki disease in patients with <4 Kawasaki disease criteria. Further research is needed to determine causes for increased healthcare use in non-White patients to receive a Kawasaki disease diagnosis.
Collapse
Affiliation(s)
- Jeffrey Lo
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Robert P Sundel
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Mary Beth F Son
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| |
Collapse
|
20
|
Javalkar K, Robson VK, Gaffney L, Bohling AM, Arya P, Servattalab S, Roberts JE, Campbell JI, Sekhavat S, Newburger JW, de Ferranti SD, Baker AL, Lee PY, Day-Lewis M, Bucholz E, Kobayashi R, Son MB, Henderson LA, Kheir JN, Friedman KG, Dionne A. Socioeconomic and Racial and/or Ethnic Disparities in Multisystem Inflammatory Syndrome. Pediatrics 2021; 147:peds.2020-039933. [PMID: 33602802 PMCID: PMC8086000 DOI: 10.1542/peds.2020-039933] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To characterize the socioeconomic and racial and/or ethnic disparities impacting the diagnosis and outcomes of multisystem inflammatory syndrome in children (MIS-C). METHODS This multicenter retrospective case-control study was conducted at 3 academic centers from January 1 to September 1, 2020. Children with MIS-C were compared with 5 control groups: children with coronavirus disease 2019, children evaluated for MIS-C who did not meet case patient criteria, children hospitalized with febrile illness, children with Kawasaki disease, and children in Massachusetts based on US census data. Neighborhood socioeconomic status (SES) and social vulnerability index (SVI) were measured via a census-based scoring system. Multivariable logistic regression was used to examine associations between SES, SVI, race and ethnicity, and MIS-C diagnosis and clinical severity as outcomes. RESULTS Among 43 patients with MIS-C, 19 (44%) were Hispanic, 11 (26%) were Black, and 12 (28%) were white; 22 (51%) were in the lowest quartile SES, and 23 (53%) were in the highest quartile SVI. SES and SVI were similar between patients with MIS-C and coronavirus disease 2019. In multivariable analysis, lowest SES quartile (odds ratio 2.2 [95% confidence interval 1.1-4.4]), highest SVI quartile (odds ratio 2.8 [95% confidence interval 1.5-5.1]), and racial and/or ethnic minority background were associated with MIS-C diagnosis. Neither SES, SVI, race, nor ethnicity were associated with disease severity. CONCLUSIONS Lower SES or higher SVI, Hispanic ethnicity, and Black race independently increased risk for MIS-C. Additional studies are required to target interventions to improve health equity for children.
Collapse
Affiliation(s)
- Karina Javalkar
- Departments of Medicine and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Department of Pediatrics, Boston University, Boston, Massachusetts;,Contributed equally as co-first authors
| | - Victoria K. Robson
- Departments of Medicine and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Department of Pediatrics, Boston University, Boston, Massachusetts;,Contributed equally as co-first authors
| | - Lukas Gaffney
- Departments of Medicine and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Department of Pediatrics, Boston University, Boston, Massachusetts
| | - Amy M. Bohling
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Puneeta Arya
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Division of Cardiology and
| | - Sarah Servattalab
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Massachusetts General Hospital for Children, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Jordan E. Roberts
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jeffrey I. Campbell
- Infectious Diseases and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sepehr Sekhavat
- Department of Pediatrics, Boston University, Boston, Massachusetts;,Department of Cardiology, Boston Medical Center, Boston, Massachusetts
| | - Jane W. Newburger
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sarah D. de Ferranti
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Annette L. Baker
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Pui Y. Lee
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Megan Day-Lewis
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Emily Bucholz
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Ryan Kobayashi
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mary Beth Son
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lauren A. Henderson
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - John N. Kheir
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Kevin G. Friedman
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Audrey Dionne
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; .,Cardiology, Boston Children's Hospital, Boston, Massachusetts
| |
Collapse
|
21
|
Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, Behrens EM, Ferris A, Kernan KF, Schulert GS, Seo P, Son MBF, Tremoulet AH, Yeung RSM, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 2. Arthritis Rheumatol 2021; 73:e13-e29. [PMID: 33277976 PMCID: PMC8559788 DOI: 10.1002/art.41616] [Citation(s) in RCA: 250] [Impact Index Per Article: 83.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/03/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Recommendations are also provided for children with hyperinflammation during coronavirus disease 2019 (COVID-19), the acute, infectious phase of SARS-CoV-2 infection. METHODS The Task Force was composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting. RESULTS The first version of the guidance was approved in June 2020, and consisted of 40 final guidance statements accompanied by a flow diagram depicting the diagnostic pathway for MIS-C. The document was revised in November 2020, and a new flow diagram with recommendations for initial immunomodulatory treatment of MIS-C was added. CONCLUSION Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.
Collapse
Affiliation(s)
- Lauren A. Henderson
- Lauren A. Henderson, MD, MMSc, Kevin G. Friedman, MD, Mary Beth F. Son, MD: Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott W. Canna
- Scott W. Canna, MD: UPMC Children’s Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kevin G. Friedman
- Lauren A. Henderson, MD, MMSc, Kevin G. Friedman, MD, Mary Beth F. Son, MD: Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mark Gorelik
- Mark Gorelik, MD: Morgan Stanley Children’s Hospital and Columbia University, New York, New York
| | - Sivia K. Lapidus
- Sivia K. Lapidus, MD: Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center and Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Hamid Bassiri
- Hamid Bassiri, MD, PhD, Edward M. Behrens, MD, Jay J. Mehta, MD: Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Edward M. Behrens
- Hamid Bassiri, MD, PhD, Edward M. Behrens, MD, Jay J. Mehta, MD: Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Anne Ferris
- Anne Ferris, MBBS: Columbia University Irving Medical Center, New York, New York
| | - Kate F. Kernan
- Kate F. Kernan, MD: University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Grant S. Schulert
- Grant S. Schulert, MD: Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Philip Seo
- Philip Seo, MD, MHS: Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Beth F. Son
- Lauren A. Henderson, MD, MMSc, Kevin G. Friedman, MD, Mary Beth F. Son, MD: Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Adriana H. Tremoulet
- Adriana H. Tremoulet, MD, MAS: University of California San Diego and Rady Children’s Hospital, San Diego, California
| | - Rae S. M. Yeung
- Rae S. M. Yeung, MD, PhD: The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Amy S. Mudano
- Amy S. Mudano, MPH: University of Alabama at Birmingham
| | - Amy S. Turner
- Amy S. Turner: American College of Rheumatology, Atlanta, Georgia
| | - David R. Karp
- David R. Karp, MD, PhD: University of Texas Southwestern Medical Center, Dallas
| | - Jay J. Mehta
- Hamid Bassiri, MD, PhD, Edward M. Behrens, MD, Jay J. Mehta, MD: Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
22
|
Halyabar O, Friedman KG, Sundel RP, Baker AL, Chang MH, Gould PW, Newburger JW, Son MBF. Cyclophosphamide use in treatment of refractory Kawasaki disease with coronary artery aneurysms. Pediatr Rheumatol Online J 2021; 19:31. [PMID: 33731148 PMCID: PMC7968156 DOI: 10.1186/s12969-021-00526-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/05/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite timely administration of IVIG, some patients with Kawasaki disease (KD) develop rapidly progressive or giant coronary artery aneurysms (CAA). CASE PRESENTATION We describe our experience using cyclophosphamide (CYC) for the treatment of such cases as well as a review of the literature on the use of CYC in KD. Through a retrospective chart review of our KD population, we identified ten children treated for KD with intravenous CYC (10 mg/kg/dose) for one or two doses. Seven patients were male, the median age was 2.0 years (range 4 months - 5 years). All patients received initial IVIG between day 4-10 of illness. Other anti-inflammatory treatments administered before CYC included second IVIG (n = 9), corticosteroids (n = 10), infliximab (n = 4), cyclosporine (n = 2), and anakinra (n = 1). Median illness day at administration of the first CYC dose was 22.5 days (range:10-36 days). The primary indication for treatment with CYC for all patients was large or giant CAA and/or rapid progression of CAA. Three patients received a second dose of CYC (10 mg/kg) for progressively enlarging CAA. CAA did not progress after final CYC treatment. One patient with a history of neutropenia in infancy developed severe neutropenia 9 days after treatment with CYC, which recovered without intervention or complications. No patient developed infections or other serious toxicity from CYC. CONCLUSION In KD patients with severe and progressive enlargement of CAA despite anti-inflammatory therapy, CYC seemed to arrest further dilation and was well-tolerated. Future multicenter studies are needed to confirm our findings in this subgroup of KD patients.
Collapse
Affiliation(s)
- Olha Halyabar
- Division of Immunology, Boston Children's Hospital, 300 Longwood Avenue, Fegan 6, Boston, MA, 02115, USA. .,Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
| | - Kevin G. Friedman
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115 USA ,grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115 USA
| | - Robert P. Sundel
- grid.2515.30000 0004 0378 8438Division of Immunology, Boston Children’s Hospital, 300 Longwood Avenue, Fegan 6, Boston, MA 02115 USA ,Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115 USA
| | - Annette L. Baker
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115 USA ,grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115 USA
| | - Margaret H. Chang
- grid.2515.30000 0004 0378 8438Division of Immunology, Boston Children’s Hospital, 300 Longwood Avenue, Fegan 6, Boston, MA 02115 USA ,Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115 USA
| | - Patrick W. Gould
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115 USA ,grid.25879.310000 0004 1936 8972University of Pennsylvania Medical School, Philadelphia, PA USA
| | - Jane W. Newburger
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115 USA ,grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115 USA
| | - Mary Beth F. Son
- grid.2515.30000 0004 0378 8438Division of Immunology, Boston Children’s Hospital, 300 Longwood Avenue, Fegan 6, Boston, MA 02115 USA ,Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115 USA
| |
Collapse
|
23
|
Feldstein LR, Tenforde MW, Friedman KG, Newhams M, Rose EB, Dapul H, Soma VL, Maddux AB, Mourani PM, Bowens C, Maamari M, Hall MW, Riggs BJ, Giuliano JS, Singh AR, Li S, Kong M, Schuster JE, McLaughlin GE, Schwartz SP, Walker TC, Loftis LL, Hobbs CV, Halasa NB, Doymaz S, Babbitt CJ, Hume JR, Gertz SJ, Irby K, Clouser KN, Cvijanovich NZ, Bradford TT, Smith LS, Heidemann SM, Zackai SP, Wellnitz K, Nofziger RA, Horwitz SM, Carroll RW, Rowan CM, Tarquinio KM, Mack EH, Fitzgerald JC, Coates BM, Jackson AM, Young CC, Son MBF, Patel MM, Newburger JW, Randolph AG. Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA 2021; 325:1074-1087. [PMID: 33625505 PMCID: PMC7905703 DOI: 10.1001/jama.2021.2091] [Citation(s) in RCA: 526] [Impact Index Per Article: 175.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Refinement of criteria for multisystem inflammatory syndrome in children (MIS-C) may inform efforts to improve health outcomes. OBJECTIVE To compare clinical characteristics and outcomes of children and adolescents with MIS-C vs those with severe coronavirus disease 2019 (COVID-19). SETTING, DESIGN, AND PARTICIPANTS Case series of 1116 patients aged younger than 21 years hospitalized between March 15 and October 31, 2020, at 66 US hospitals in 31 states. Final date of follow-up was January 5, 2021. Patients with MIS-C had fever, inflammation, multisystem involvement, and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) or antibody test results or recent exposure with no alternate diagnosis. Patients with COVID-19 had positive RT-PCR test results and severe organ system involvement. EXPOSURE SARS-CoV-2. MAIN OUTCOMES AND MEASURES Presenting symptoms, organ system complications, laboratory biomarkers, interventions, and clinical outcomes. Multivariable regression was used to compute adjusted risk ratios (aRRs) of factors associated with MIS-C vs COVID-19. RESULTS Of 1116 patients (median age, 9.7 years; 45% female), 539 (48%) were diagnosed with MIS-C and 577 (52%) with COVID-19. Compared with patients with COVID-19, patients with MIS-C were more likely to be 6 to 12 years old (40.8% vs 19.4%; absolute risk difference [RD], 21.4% [95% CI, 16.1%-26.7%]; aRR, 1.51 [95% CI, 1.33-1.72] vs 0-5 years) and non-Hispanic Black (32.3% vs 21.5%; RD, 10.8% [95% CI, 5.6%-16.0%]; aRR, 1.43 [95% CI, 1.17-1.76] vs White). Compared with patients with COVID-19, patients with MIS-C were more likely to have cardiorespiratory involvement (56.0% vs 8.8%; RD, 47.2% [95% CI, 42.4%-52.0%]; aRR, 2.99 [95% CI, 2.55-3.50] vs respiratory involvement), cardiovascular without respiratory involvement (10.6% vs 2.9%; RD, 7.7% [95% CI, 4.7%-10.6%]; aRR, 2.49 [95% CI, 2.05-3.02] vs respiratory involvement), and mucocutaneous without cardiorespiratory involvement (7.1% vs 2.3%; RD, 4.8% [95% CI, 2.3%-7.3%]; aRR, 2.29 [95% CI, 1.84-2.85] vs respiratory involvement). Patients with MIS-C had higher neutrophil to lymphocyte ratio (median, 6.4 vs 2.7, P < .001), higher C-reactive protein level (median, 152 mg/L vs 33 mg/L; P < .001), and lower platelet count (<150 ×103 cells/μL [212/523 {41%} vs 84/486 {17%}, P < .001]). A total of 398 patients (73.8%) with MIS-C and 253 (43.8%) with COVID-19 were admitted to the intensive care unit, and 10 (1.9%) with MIS-C and 8 (1.4%) with COVID-19 died during hospitalization. Among patients with MIS-C with reduced left ventricular systolic function (172/503, 34.2%) and coronary artery aneurysm (57/424, 13.4%), an estimated 91.0% (95% CI, 86.0%-94.7%) and 79.1% (95% CI, 67.1%-89.1%), respectively, normalized within 30 days. CONCLUSIONS AND RELEVANCE This case series of patients with MIS-C and with COVID-19 identified patterns of clinical presentation and organ system involvement. These patterns may help differentiate between MIS-C and COVID-19.
Collapse
Affiliation(s)
- Leora R. Feldstein
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Mark W. Tenforde
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Margaret Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Erica Billig Rose
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Heda Dapul
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Vijaya L. Soma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Cindy Bowens
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern, Children’s Medical Center Dallas, Dallas
| | - Mia Maamari
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern, Children’s Medical Center Dallas, Dallas
| | - Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Becky J. Riggs
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - John S. Giuliano
- Division of Critical Care, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Aalok R. Singh
- Pediatric Critical Care Division, Maria Fareri Children’s Hospital at Westchester Medical Center and New York Medical College, Valhalla
| | - Simon Li
- Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children’s Hospital, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Jennifer E. Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Gwenn E. McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Stephanie P. Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children’s Hospital
| | - Tracie C. Walker
- Department of Pediatrics, University of North Carolina at Chapel Hill Children’s Hospital
| | - Laura L. Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Charlotte V. Hobbs
- Division of Infectious Diseases, Department of Pediatrics, Department of Microbiology, University of Mississippi Medical Center, Jackson
| | - Natasha B. Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sule Doymaz
- Division of Pediatric Critical Care, Department of Pediatrics, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Christopher J. Babbitt
- Division of Pediatric Critical Care, Miller Children’s and Women’s Hospital of Long Beach, Long Beach, California
| | - Janet R. Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children’s Hospital, Minneapolis
| | - Shira J. Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children’s Hospital, Little Rock
| | - Katharine N. Clouser
- Division of Hospital Medicine, Department of Pediatrics, Hackensack University Medical Center, Hackensack, New Jersey
| | - Natalie Z. Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children’s Hospital Oakland, Oakland, California
| | - Tamara T. Bradford
- Division of Cardiology, Department of Pediatrics, Louisiana State University Health Sciences Center and Children’s Hospital of New Orleans, New Orleans
| | - Lincoln S. Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle
| | - Sabrina M. Heidemann
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Central Michigan University, Detroit
| | - Sheemon P. Zackai
- Pediatric Critical Care Medicine, Department of Pediatrics, Icahn School of Medicine at the Mount Sinai Kravis Children’s Hospital, New York, New York
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City
| | - Ryan A. Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children’s Hospital, Akron, Ohio
| | - Steven M. Horwitz
- Department of Pediatrics, Division of Critical Care, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ryan W. Carroll
- Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Courtney M. Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Elizabeth H. Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Bria M. Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Ashley M. Jackson
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cameron C. Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Mary Beth F. Son
- Division of Immunology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Manish M. Patel
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Anesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
24
|
Friedman KG, Gauvreau K, Baker A, Son MB, Sundel R, Dionne A, Giorgio T, De Ferranti S, Newburger JW. Primary adjunctive corticosteroid therapy is associated with improved outcomes for patients with Kawasaki disease with coronary artery aneurysms at diagnosis. Arch Dis Child 2021; 106:247-252. [PMID: 32943389 DOI: 10.1136/archdischild-2020-319810] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 06/03/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Patients with Kawasaki disease (KD) with coronary artery enlargement at diagnosis are at the highest risk for persistent coronary artery aneurysms (CAAs) and may benefit from primary adjunctive anti-inflammatory therapy beyond intravenous immunoglobulin (IVIG). We evaluate the effect of primary adjunctive corticosteroid therapy on outcomes in patients with CAA at diagnosis. DESIGN Single-centre, retrospective review. PATIENTS Patients with KD diagnosed within 10 days of fever onset and with baseline CA z-score ≥2.5. INTERVENTIONS Primary treatment with IVIG (n=162) versus IVIG plus corticosteroids (n=48). MAIN OUTCOME MEASURES Treatment resistance (persistent fever >36 hours after initial treatment), CAA regression rate. RESULTS Of the 92 patients with KD who received corticosteroids at our institution from 2012 to 2019, 48 met the inclusion criteria for primary adjunctive therapy. The corticosteroid group was younger and had larger baseline CAAs compared with historical controls. Demographics and laboratory values were otherwise similar between groups. The corticosteroid group had a less treatment resistance (4% vs 30%, p=0.003) and a greater improvement in C reactive protein. After adjusting for baseline CA z-score, age and baseline bilateral versus unilateral CAA, the corticosteroid group had a higher odds of (OR 2.77 (1.04, 7.42), p=0.042) and a shorter time to CAA regression (HR 1.94 (1.27, 2.96), p=0.002). CONCLUSION Primary adjunctive corticosteroid therapy is associated with decreased initial treatment resistance, greater improvement in inflammatory markers and higher likelihood of CAA regression in patients who have CAA at diagnosis. Multi-centre, randomised controlled trials are needed to confirm the benefits of corticosteroids in patients with CAA at diagnosis and to compare corticosteroids with other adjunctive therapies.
Collapse
Affiliation(s)
- Kevin G Friedman
- Boston Children's Hospital-Pediatric Cardiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberlee Gauvreau
- Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Annette Baker
- Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Robert Sundel
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Medicine, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Audrey Dionne
- Boston Children's Hospital, Boston, Massachusetts, USA
| | - Thomas Giorgio
- Boston Children's Hospital-Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Jane W Newburger
- Boston Children's Hospital-Pediatric Cardiology, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
25
|
Kobayashi R, Dionne A, Ferraro A, Harrild D, Newburger J, VanderPluym C, Gauvreau K, Son MB, Lee P, Baker A, de Ferranti S, Friedman KG. Detailed Assessment of Left Ventricular Function in Multisystem Inflammatory Syndrome in Children, Using Strain Analysis. CJC Open 2021; 3:880-887. [PMID: 33649742 PMCID: PMC7905387 DOI: 10.1016/j.cjco.2021.02.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/18/2021] [Indexed: 12/15/2022] Open
Abstract
Background Cardiac manifestations in multisystem inflammatory syndrome in children (MIS-C) occur in ∼80% of patients. Left ventricular (LV) systolic dysfunction is the most frequent cardiac finding. Methods In this single-centre, retrospective cohort study, we report on detailed assessment of LV function in MIS-C patients using strain and strain rate analysis. We compare those with normal peak systolic strain z-scores (both longitudinal and circumferential strain) to those with abnormal peak systolic strain z-scores (decreased circumferential and/or longitudinal strain). Results Among 25 patients, 14 (56%) were male, 20 (80%) were Black or Hispanic, 13 (52%) were overweight/obese, and the median age was 11.4 years (interquartile range: 7.5 to 16). Median ejection fraction (EF) was 55.2% (interquartile range: 48.3% to 58%), with the abnormal strain patients having a lower EF (P < 0.01). Demographics were similar between groups. The abnormal strain patients had more organ systems involved and were more likely to require inotropic support. In a comparison of MIS-C patients with normal EF (n = 15) to controls, MIS-C patients had lower peak systolic strain as well as lower early diastolic strain rates. In patients with initially depressed function, EF normalized in 8 of 10 (80%), but 4 of 11 (36%) patients had persistently abnormal systolic strain after discharge. Conclusions LV systolic dysfunction is common in the acute phase of MIS-C, and detection may be improved with strain imaging. Longitudinal cardiac follow-up is imperative, as some patients may be at risk for persistent LV dysfunction.
Collapse
Affiliation(s)
- Ryan Kobayashi
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Alessandra Ferraro
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - David Harrild
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina VanderPluym
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Kim Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Beth Son
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pui Lee
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Annette Baker
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
26
|
Henderson LA, Friedman KG, Son MBF, Kernan KF, Canna SW, Gorelik M, Lapidus SK, Ferris A, Schulert GS, Seo P, Tremoulet AH, Yeung RSM, Karp DR, Bassiri H, Behrens EM, Mehta JJ. Reply. Arthritis Rheumatol 2021; 73:1342-1343. [PMID: 33586355 DOI: 10.1002/art.41689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 11/07/2022]
Affiliation(s)
| | - Kevin G Friedman
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mary Beth F Son
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Kate F Kernan
- UPMC Children's Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Scott W Canna
- UPMC Children's Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mark Gorelik
- Morgan Stanley Children's Hospital and Columbia University, New York, NY
| | - Sivia K Lapidus
- Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center and Hackensack Meridian School of Medicine, Hackensack, NJ
| | - Anne Ferris
- Columbia University Irving Medical Center, New York, NY
| | - Grant S Schulert
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Philip Seo
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Rae S M Yeung
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - David R Karp
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Hamid Bassiri
- Children's Hospital of Philadelphia and University of Pennsylvania, Perelman School of Medicine
| | - Edward M Behrens
- Children's Hospital of Philadelphia and University of Pennsylvania, Perelman School of Medicine
| | - Jay J Mehta
- Children's Hospital of Philadelphia and University of Pennsylvania, Perelman School of Medicine
| |
Collapse
|
27
|
Beattie MJ, Friedman KG, Sleeper LA, Lu M, Drogosz M, Callahan R, Marshall AC, Prosnitz AR, Lafranchi T, Benson CB, Wilkins-Haug LE, Tworetzky W. Late gestation predictors of a postnatal biventricular circulation after fetal aortic valvuloplasty. Prenat Diagn 2021; 41:479-485. [PMID: 33462820 DOI: 10.1002/pd.5885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Fetal aortic valvuloplasty (FAV) for severe aortic stenosis (AS) has shown promise in averting progression to hypoplastic left heart syndrome. After FAV, predicting which fetuses will achieve a biventricular (BiV) circulation after birth remains challenging. Identifying predictors of postnatal circulation on late gestation echocardiography will improve parental counseling. METHODS Liveborn patients who underwent FAV and had late gestation echocardiography available were included (2000-2017, n = 96). Multivariable logistic regression and classification and regression tree analysis were utilized to identify independent predictors of BiV circulation. RESULTS Among 96 fetuses, 50 (52.1%) had BiV circulation at the time of neonatal discharge. In multivariable analysis, independent predictors of biventricular circulation included left ventricular (LV) long axis z-score (OR 3.2, 95% CI 1.8-5.7, p < 0.001), LV ejection fraction (OR 1.3, 95% CI 1.0-1.8, p = 0.023), anterograde aortic arch flow (OR 5.0, 95% CI 1.2-20.4, p = 0.024), and bidirectional or right-to-left foramen ovale flow (OR 4.6, 95% CI 1.4-15.8, p = 0.015). CONCLUSION Several anatomic and physiologic parameters in late gestation were found to be independent predictors of BiV circulation after FAV. Identifying these predictors adds to our understanding of LV growth and hemodynamics after FAV and may improve parental counseling.
Collapse
Affiliation(s)
- Meaghan J Beattie
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Monika Drogosz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Audrey C Marshall
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - Aaron R Prosnitz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Sanger Heart and Vascular Institute, Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Terra Lafranchi
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Carol B Benson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Louise E Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
28
|
Sperotto F, Friedman KG, Son MBF, VanderPluym CJ, Newburger JW, Dionne A. Cardiac manifestations in SARS-CoV-2-associated multisystem inflammatory syndrome in children: a comprehensive review and proposed clinical approach. Eur J Pediatr 2021; 180:307-322. [PMID: 32803422 PMCID: PMC7429125 DOI: 10.1007/s00431-020-03766-6] [Citation(s) in RCA: 219] [Impact Index Per Article: 73.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/25/2020] [Accepted: 07/30/2020] [Indexed: 01/03/2023]
Abstract
Initial reports on COVID-19 described children as largely spared from severe manifestations, with only 2-6% of children requiring intensive care treatment. However, since mid-April 2020, clusters of pediatric cases of severe systemic hyperinflammation and shock epidemiologically linked with COVID-19 have been reported. This condition was named as SARS-Cov-2-associated multisystem inflammatory syndrome in children and showed similarities to Kawasaki disease. Here, we present a narrative review of cases reported in literature and we discuss the clinical acute and follow-up management of these patients. Patients with SARS-Cov-2-associated multisystem inflammatory syndrome frequently presented with persistent fever, gastrointestinal symptoms, polymorphic rash, conjunctivitis, and mucosal changes. Elevated inflammatory markers and evidence of cytokine storm were frequently observed. A subset of these patients also presented with hypotension and shock (20-100%) from either acute myocardial dysfunction or systemic hyperinflammation/vasodilation. Coronary artery dilation or aneurysms have been described in 6-24%, and arrhythmias in 7-60%. Cardiac support, immunomodulation, and anticoagulation are the key aspects for the management of the acute phase. Long-term structured follow-up of these patients is required due to the unclear prognosis and risk of progression of cardiac manifestations.Conclusion: Multisystem inflammatory syndrome is a novel syndrome related to SARS-CoV-2 infection. Evidence is still scarce but rapidly emerging in the literature. Cardiac manifestations are frequent, including myocardial and coronary involvement, and need to be carefully identified and monitored over time. What is Known: • Multisystem inflammatory syndrome in children (MIS-C) has been described associated with SARS-CoV-2. What is New: • Patients with MIS-C often present with fever, gastrointestinal symptoms, and shock. • Cardiac involvement is found in a high proportion of these patients, including ventricular dysfunction, coronary artery dilation or aneurysm, and arrhythmias. • Management is based on expert consensus and includes cardiac support, immunomodulatory agents, and anticoagulation. • Long-term follow-up is required due to the unclear prognosis and risk of progression of cardiac manifestation.
Collapse
Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Women’s and Children’s Health, University of Padova, Via Giustiniani 2, Padua, Italy
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Mary Beth F. Son
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
- Division of Immunology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Christina J. VanderPluym
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| |
Collapse
|
29
|
Morell E, Miller MK, Lu M, Friedman KG, Breitbart RE, Reichman JR, McDermott J, Sleeper LA, Blume ED. Parent and Physician Understanding of Prognosis in Hospitalized Children With Advanced Heart Disease. J Am Heart Assoc 2021; 10:e018488. [PMID: 33442989 PMCID: PMC7955315 DOI: 10.1161/jaha.120.018488] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background The unpredictable trajectory of pediatric advanced heart disease makes prognostication difficult for physicians and informed decision‐making challenging for families. This study evaluated parent and physician understanding of disease burden and prognosis in hospitalized children with advanced heart disease. Methods and Results A longitudinal survey study of parents and physicians caring for patients with advanced heart disease age 30 days to 19 years admitted for ≥7 days was performed over a 1‐year period (n=160 pairs). Percentage agreement and weighted kappa statistics were used to assess agreement. Median patient age was 1 year (interquartile range, 1–5), 39% had single‐ventricle lesions, and 37% were in the cardiac intensive care unit. Although 92% of parents reported understanding their child's prognosis “extremely well” or “well,” 28% of physicians thought parents understood the prognosis only “a little,” “somewhat,” or “not at all.” Better parent‐reported prognostic understanding was associated with greater preparedness for their child's medical problems (odds ratio, 4.7; 95% CI, 1.4–21.7, P=0.02). There was poor parent–physician agreement in assessing functional class, symptom burden, and likelihood of limitations in physical activity and learning/behavior; on average, parents were more optimistic. Many parents (47%) but few physicians (6%) expected the child to have normal life expectancy. Conclusions Parents and physicians caring for children with advanced heart disease differed in their perspectives regarding prognosis and disease burden. Physicians tended to underestimate the degree of parent‐reported symptom burden. Parents were less likely to expect limitations in physical activity, learning/behavior, and life expectancy. Combined interventions involving patient‐reported outcomes, parent education, and physician communication tools may be beneficial.
Collapse
Affiliation(s)
- Emily Morell
- Division of Cardiology Department of Pediatrics Children's Hospital Los Angeles Los Angeles CA
| | | | - Minmin Lu
- Department of Cardiology Boston Children's Hospital Boston MA
| | | | | | | | - Julie McDermott
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Lynn A Sleeper
- Department of Cardiology Boston Children's Hospital Boston MA
| | | |
Collapse
|
30
|
Meziab O, Marcondes L, Friedman KG, O'Leary ET, Gurvitz M, VanderPluym CJ, Walsh EP, Triedman JK, Mah DY. Difference in the prevalence of intracardiac thrombus on the first presentation of atrial fibrillation versus flutter in the pediatric and congenital heart disease population. J Cardiovasc Electrophysiol 2020; 31:3243-3250. [PMID: 33112018 DOI: 10.1111/jce.14791] [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: 05/25/2020] [Revised: 10/05/2020] [Accepted: 10/21/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Guidelines recommend trans-esophageal echocardiography (TEE) for patients with atrial fibrillation (AF) or atrial flutter (AFL) for >48 h, due to risk of intracardiac thrombus formation. With growing evidence that AFL in adults with structurally normal hearts has less thrombogenic potential compared to AF, and the need for TEE questioned, we compared prevalence of intracardiac thrombus detected by TEE in pediatric and congenital heart disease (CHD) patients presenting in AF and AFL. METHODS/RESULTS Single-center, cross-sectional analysis for unique first-time presentations of patients for either AF, AFL, or intra-atrial reentrant tachycardia (IART) between 2000 and 2019. Patients were categorized by presenting arrhythmia (AF vs. AFL/IART), with the exclusion of other forms of atrial tachycardia, hemodynamic instability, chronic anti-coagulation before TEE, and presentation for a reason other than TEE examination for thrombus. A total of 201 patients had TEE with co-diagnosis of AF or AFL. Of these, 105 patients (29 AF, 76 AFL) met inclusion criteria, with no difference in age between AF (median 24.9 years; IQR 18.6-38.3 years) and AFL/IART (23.3 years; 15.4-38.4 years). The prevalence of thrombus in the entire cohort was 9.5%, with no difference between AF (13.8%) and AFL groups (7.9%), p = .46. Patients with thrombus demonstrated no difference in age, systemic ventricular function, cardiac complexity, or CHADS2/CHA2DS2VASc score at presentation. CONCLUSIONS The risk for intracardiac thrombus is high in the pediatric and CHD population, with no apparent distinguishing factors to warrant a change in the recommendations for TEE, with all levels of cardiac complexity being at risk for clot.
Collapse
Affiliation(s)
- Omar Meziab
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Luciana Marcondes
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina J VanderPluym
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John K Triedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
31
|
Tan CW, Friedman KG, Tworetzky W, del Nido PJ, Baird CW. 1.5-Ventricle Repair Using Left Ventricle as the Subpulmonary Ventricle. Ann Thorac Surg 2020; 110:e529-e530. [DOI: 10.1016/j.athoracsur.2020.04.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 04/18/2020] [Indexed: 11/25/2022]
|
32
|
Lee PY, Day-Lewis M, Henderson LA, Friedman KG, Lo J, Roberts JE, Lo MS, Platt CD, Chou J, Hoyt KJ, Baker AL, Banzon TM, Chang MH, Cohen E, de Ferranti SD, Dionne A, Habiballah S, Halyabar O, Hausmann JS, Hazen MM, Janssen E, Meidan E, Nelson RW, Nguyen AA, Sundel RP, Dedeoglu F, Nigrovic PA, Newburger JW, Son MBF. Distinct clinical and immunological features of SARS-CoV-2-induced multisystem inflammatory syndrome in children. J Clin Invest 2020; 130:5942-5950. [PMID: 32701511 DOI: 10.1172/jci141113] [Citation(s) in RCA: 251] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/22/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUNDPediatric SARS-CoV-2 infection can be complicated by a dangerous hyperinflammatory condition termed multisystem inflammatory syndrome in children (MIS-C). The clinical and immunologic spectrum of MIS-C and its relationship to other inflammatory conditions of childhood have not been studied in detail.METHODSWe retrospectively studied confirmed cases of MIS-C at our institution from March to June 2020. The clinical characteristics, laboratory studies, and treatment response were collected. Data were compared with historic cohorts of Kawasaki disease (KD) and macrophage activation syndrome (MAS).RESULTSTwenty-eight patients fulfilled the case definition of MIS-C. Median age at presentation was 9 years (range: 1 month to 17 years); 50% of patients had preexisting conditions. All patients had laboratory confirmation of SARS-CoV-2 infection. Seventeen patients (61%) required intensive care, including 7 patients (25%) who required inotrope support. Seven patients (25%) met criteria for complete or incomplete KD, and coronary abnormalities were found in 6 cases. Lymphopenia, thrombocytopenia, and elevation in inflammatory markers, D-dimer, B-type natriuretic peptide, IL-6, and IL-10 levels were common but not ubiquitous. Cytopenias distinguished MIS-C from KD and the degree of hyperferritinemia and pattern of cytokine production differed between MIS-C and MAS. Immunomodulatory therapy given to patients with MIS-C included intravenous immune globulin (IVIG) (71%), corticosteroids (61%), and anakinra (18%). Clinical and laboratory improvement were observed in all cases, including 6 cases that did not require immunomodulatory therapy. No mortality was recorded in this cohort.CONCLUSIONMIS-C encompasses a broad phenotypic spectrum with clinical and laboratory features distinct from KD and MAS.FUNDINGThis work was supported by the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases; the National Institute of Allergy and Infectious Diseases; Rheumatology Research Foundation Investigator Awards and Medical Education Award; Boston Children's Hospital Faculty Career Development Awards; the McCance Family Foundation; and the Samara Jan Turkel Center.
Collapse
Affiliation(s)
| | | | | | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | - Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Ezra Cohen
- Division of Immunology and.,Division of Pediatric Rheumatology, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts, USA
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Jonathan S Hausmann
- Division of Immunology and.,Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | - Peter A Nigrovic
- Division of Immunology and.,Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | |
Collapse
|
33
|
Alsaied T, Tremoulet AH, Burns JC, Saidi A, Dionne A, Lang SM, Newburger JW, de Ferranti S, Friedman KG. Review of Cardiac Involvement in Multisystem Inflammatory Syndrome in Children. Circulation 2020; 143:78-88. [PMID: 33166178 DOI: 10.1161/circulationaha.120.049836] [Citation(s) in RCA: 174] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with substantial cardiovascular implications. Although infection with SARS-CoV-2 is usually mild in children, some children later develop a severe inflammatory disease that can have manifestations similar to toxic shock syndrome or Kawasaki disease. This syndrome has been defined by the US Centers for Disease Control and Prevention as multisystem inflammatory syndrome in children. Although the prevalence is unknown, >600 cases have been reported in the literature. Multisystem inflammatory syndrome in children appears to be more common in Black and Hispanic children in the United States. Multisystem inflammatory syndrome in children typically occurs a few weeks after acute infection and the putative etiology is a dysregulated inflammatory response to SARS-CoV-2 infection. Persistent fever and gastrointestinal symptoms are the most common symptoms. Cardiac manifestations are common, including ventricular dysfunction, coronary artery dilation and aneurysms, arrhythmia, and conduction abnormalities. Severe cases can present as vasodilatory or cardiogenic shock requiring fluid resuscitation, inotropic support, and in the most severe cases, mechanical ventilation and extracorporeal membrane oxygenation. Empirical treatments have aimed at reversing the inflammatory response using immunomodulatory medications. Intravenous immunoglobulin, steroids, and other immunomodulatory agents have been used frequently. Most patients recover within days to a couple of weeks and mortality is rare, although the medium- and long-term sequelae, particularly cardiovascular complications, are not yet known. This review describes the published data on multisystem inflammatory syndrome in children, focusing on cardiac complications, and provides clinical considerations for cardiac evaluation and follow-up.
Collapse
Affiliation(s)
- Tarek Alsaied
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, OH(T.A., S.M.L.)
| | - Adriana H Tremoulet
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego and Rady Children's Hospital(A.H.T., J.C.B.)
| | - Jane C Burns
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego and Rady Children's Hospital(A.H.T., J.C.B.)
| | - Arwa Saidi
- Congenital Heart Center, University of Florida, Gainesville (A.S.)
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, MA(A.D., J.W.N., S.d.F., K.G.F.).,Department of Pediatrics, Harvard Medical School, Boston, MA(A.D., J.W.N., S.d.F., K.G.F.)
| | - Sean M Lang
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, OH(T.A., S.M.L.)
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, MA(A.D., J.W.N., S.d.F., K.G.F.).,Department of Pediatrics, Harvard Medical School, Boston, MA(A.D., J.W.N., S.d.F., K.G.F.)
| | - Sarah de Ferranti
- Department of Cardiology, Boston Children's Hospital, MA(A.D., J.W.N., S.d.F., K.G.F.).,Department of Pediatrics, Harvard Medical School, Boston, MA(A.D., J.W.N., S.d.F., K.G.F.)
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, MA(A.D., J.W.N., S.d.F., K.G.F.).,Department of Pediatrics, Harvard Medical School, Boston, MA(A.D., J.W.N., S.d.F., K.G.F.)
| |
Collapse
|
34
|
Rollins CK, Ortinau CM, Stopp C, Friedman KG, Tworetzky W, Gagoski B, Velasco-Annis C, Afacan O, Vasung L, Beaute JI, Rofeberg V, Estroff JA, Grant PE, Soul JS, Yang E, Wypij D, Gholipour A, Warfield SK, Newburger JW. Regional Brain Growth Trajectories in Fetuses with Congenital Heart Disease. Ann Neurol 2020; 89:143-157. [PMID: 33084086 DOI: 10.1002/ana.25940] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Congenital heart disease (CHD) is associated with abnormal brain development in utero. We applied innovative fetal magnetic resonance imaging (MRI) techniques to determine whether reduced fetal cerebral substrate delivery impacts the brain globally, or in a region-specific pattern. Our novel design included two control groups, one with and the other without a family history of CHD, to explore the contribution of shared genes and/or fetal environment to brain development. METHODS From 2014 to 2018, we enrolled 179 pregnant women into 4 groups: "HLHS/TGA" fetuses with hypoplastic left heart syndrome (HLHS) or transposition of the great arteries (TGA), diagnoses with lowest fetal cerebral substrate delivery; "CHD-other," with other CHD diagnoses; "CHD-related," healthy with a CHD family history; and "optimal control," healthy without a family history. Two MRIs were obtained between 18 and 40 weeks gestation. Random effect regression models assessed group differences in brain volumes and relationships to hemodynamic variables. RESULTS HLHS/TGA (n = 24), CHD-other (50), and CHD-related (34) groups each had generally smaller brain volumes than the optimal controls (71). Compared with CHD-related, the HLHS/TGA group had smaller subplate (-13.3% [standard error = 4.3%], p < 0.01) and intermediate (-13.7% [4.3%], p < 0.01) zones, with a similar trend in ventricular zone (-7.1% [1.9%], p = 0.07). These volumetric reductions were associated with lower cerebral substrate delivery. INTERPRETATION Fetuses with CHD, especially those with lowest cerebral substrate delivery, show a region-specific pattern of small brain volumes and impaired brain growth before 32 weeks gestation. The brains of fetuses with CHD were more similar to those of CHD-related than optimal controls, suggesting genetic or environmental factors also contribute. ANN NEUROL 2021;89:143-157.
Collapse
Affiliation(s)
- Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Departments of Neurology, Harvard Medical School, Boston, MA, USA
| | - Cynthia M Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Christian Stopp
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Maternal Fetal Care Center, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Maternal Fetal Care Center, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Borjan Gagoski
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | | | - Onur Afacan
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Lana Vasung
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Jeanette I Beaute
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Judy A Estroff
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA.,Maternal Fetal Care Center, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - P Ellen Grant
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Departments of Neurology, Harvard Medical School, Boston, MA, USA.,Maternal Fetal Care Center, Boston Children's Hospital, Boston, MA, USA
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ali Gholipour
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
35
|
Dionne A, Mah DY, Son MBF, Lee PY, Henderson L, Baker AL, de Ferranti SD, Fulton DR, Newburger JW, Friedman KG. Atrioventricular Block in Children With Multisystem Inflammatory Syndrome. Pediatrics 2020; 146:peds.2020-009704. [PMID: 32855347 DOI: 10.1542/peds.2020-009704] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [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: 08/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Children are at risk for multisystem inflammatory syndrome in children (MIS-C) after infection with severe acute respiratory syndrome coronavirus 2. Cardiovascular complications, including ventricular dysfunction and coronary dilation, are frequent, but there are limited data on arrhythmic complications. METHODS Retrospective cohort study of children and young adults aged ≤21 years admitted with MIS-C. Demographic characteristics, electrocardiogram (ECG) and echocardiogram findings, and hospital course were described. RESULTS Among 25 patients admitted with MIS-C (60% male; median age 9.7 [interquartile range 2.7-15.0] years), ECG anomalies were found in 14 (56%). First-degree atrioventricular block (AVB) was seen in 5 (20%) patients a median of 6 (interquartile range 5-8) days after onset of fever and progressed to second- or third-degree AVB in 4 patients. No patient required intervention for AVB. All patients with AVB were admitted to the ICU (before onset of AVB) and had ventricular dysfunction on echocardiograms. All patients with second- or third-degree AVB had elevated brain natriuretic peptide levels, whereas the patient with first-degree AVB had a normal brain natriuretic peptide level. No patient with AVB had an elevated troponin level. QTc prolongation was seen in 7 patients (28%), and nonspecific ST segment changes were seen in 14 patients (56%). Ectopic atrial tachycardia was observed in 1 patient, and none developed ventricular arrhythmias. CONCLUSIONS Children with MIS-C are at risk for atrioventricular conduction disease, especially those who require ICU admission and have ventricular dysfunction. ECGs should be monitored for evidence of PR prolongation. Continuous telemetry may be required in patients with evidence of first-degree AVB because of risk of progression to high-grade AVB.
Collapse
Affiliation(s)
- Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mary Beth F Son
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Immunology and
| | - Pui Y Lee
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Immunology and
| | - Lauren Henderson
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Immunology and
| | - Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - David R Fulton
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| |
Collapse
|
36
|
Friedman KG, Harrild DM, Newburger JW. Cardiac Dysfunction in Multisystem Inflammatory Syndrome in Children: A Call to Action. J Am Coll Cardiol 2020; 76:1962-1964. [PMID: 33092731 PMCID: PMC7572056 DOI: 10.1016/j.jacc.2020.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | - David M Harrild
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
37
|
Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, Behrens EM, Ferris A, Kernan KF, Schulert GS, Seo P, F Son MB, Tremoulet AH, Yeung RSM, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 1. Arthritis Rheumatol 2020; 72:1791-1805. [PMID: 32705809 PMCID: PMC7405113 DOI: 10.1002/art.41454] [Citation(s) in RCA: 270] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022]
Abstract
Objective To provide guidance on the management of multisystem inflammatory syndrome in children (MIS‐C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of severe acute respiratory syndrome coronavirus 2 (SARS–CoV‐2) infection, and to provide recommendations for children with hyperinflammation during coronavirus disease 2019 (COVID‐19), the acute, infectious phase of SARS–CoV‐2 infection. Methods A multidisciplinary task force was convened by the American College of Rheumatology (ACR) to provide guidance on the management of MIS‐C associated with SARS–CoV‐2 and hyperinflammation in COVID‐19. The task force was composed of 9 pediatric rheumatologists, 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS‐C and hyperinflammation in COVID‐19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved 2 rounds of anonymous voting and 2 webinars. A 9‐point scale was used to determine the appropriateness of each statement (median scores of 1–3 for inappropriate, 4–6 for uncertain, and 7–9 for appropriate), and consensus was rated as low, moderate, or high based on dispersion of the votes along the numeric scale. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, as prespecified prior to voting. Results The ACR task force approved a total of 128 guidance statements addressing the management of MIS‐C and hyperinflammation in pediatric COVID‐19. These statements were refined into 40 final clinical guidance statements, accompanied by a flow diagram depicting the diagnostic pathway for MIS‐C. Conclusion Our understanding of SARS–CoV‐2–related syndromes in the pediatric population continues to evolve. The guidance provided in this “living document” reflects currently available evidence, coupled with expert opinion, and will be revised as further evidence becomes available.
Collapse
Affiliation(s)
- Lauren A Henderson
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott W Canna
- UPMC Children's Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kevin G Friedman
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mark Gorelik
- Morgan Stanley Children's Hospital and Columbia University, New York, New York
| | - Sivia K Lapidus
- Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center and Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Hamid Bassiri
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Edward M Behrens
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Anne Ferris
- Columbia University Irving Medical Center, New York, New York
| | - Kate F Kernan
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Grant S Schulert
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Philip Seo
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Beth F Son
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Rae S M Yeung
- Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - David R Karp
- University of Texas Southwestern Medical Center, Dallas
| | - Jay J Mehta
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
38
|
Abstract
Treatment of Kawasaki disease (KD) with intravenous immunoglobulin (IVIG) administered within the initial 10 days of fever onset decreases the risk of coronary artery aneurysms (CAAs) from ∼ 25% to less than 5%. However, patients with IVIG resistance, young infants, men, highly inflamed patients, and/or those with coronary changes at diagnosis remain at high risk for CAA. High-risk patients may benefit from acute, adjunctive antiinflammatory treatment in addition to IVIG. Optimal therapy remains unknown. This article reviews the acute pharmacologic management of patients with KD, focusing on adjunctive primary therapy options and treatment of patients with IVIG resistance.
Collapse
Affiliation(s)
- Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Pei-Ni Jone
- Department of Pediatrics, Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
39
|
Tan CW, Marathe SP, Kwon MH, Chavez M, Friedman KG, Staffa S, Del Nido P, Baird CW. Ascending Aortoplasty in Pediatric Patients Undergoing Aortic Valve Procedures. Ann Thorac Surg 2020; 112:855-861. [PMID: 32946842 DOI: 10.1016/j.athoracsur.2020.06.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The risks of ascending aortic dilation and indications for intervention in pediatric patients are unclear. Given the concern for aortic size mismatch with growth, larger ascending aortic diameters have been accepted in pediatric patients. The purpose of this study was to evaluate the effectiveness of ascending aortic reduction at the time of aortic valve surgery and its effect on recurrent aortic regurgitation. METHODS A retrospective 8-year observational review (2010-2018) was conducted in pediatric patients with dilated ascending aorta undergoing aortic valve surgery at a single institution. RESULTS Forty-seven patients underwent ascending aortoplasty during aortic valve surgery, of which 39 patients with complete data points had preoperative mean ascending aortic Z-scores of 5.35 ± 1.52 reduced to 1.22 ± 1.63 (P < .001) postoperatively. Ascending aortic Z-scores remained similar at 1.37 ± 1.72 at latest follow-up (P = .306). In contrast our matched control group (n = 39) without ascending aortoplasty had preoperative mean ascending aortic Z-scores of 4.15 ± 1.65 reduced to 3.26 ± 2.0 at the midterm follow-up. This reduction was significantly larger in the aortoplasty group, with an average difference in these changes of 3.12 (95% confidence interval, 2.43-3.8; P < .001). Multivariable logistic regression (controlling for aortic valve intervention type and body surface area) showed a 6.84 odds of moderate to severe aortic regurgitation at follow-up in the control group compared with the aortoplasty group (95% confidence interval, 1.43-32.8; P = .016). There were no complications associated with ascending aortoplasty. CONCLUSIONS Ascending aortoplasty is effective in reducing ascending aortic dimensions and recurrent aortic regurgitation in pediatric patients. Longer-term follow-up is necessary to determine continued rate of growth.
Collapse
Affiliation(s)
- Corinne W Tan
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Supreet P Marathe
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael H Kwon
- Department of Cardiac Surgery, Morgan Stanley Children's Hospital of New York, New York, New York
| | - Mariana Chavez
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Pedro Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
40
|
Kamran A, Friedman KG, Jennings RW, Baird CW. Aortic uncrossing and tracheobronchopexy corrects tracheal compression and tracheobronchomalacia associated with circumflex aortic arch. J Thorac Cardiovasc Surg 2020; 160:796-804. [DOI: 10.1016/j.jtcvs.2020.03.158] [Citation(s) in RCA: 17] [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: 05/20/2019] [Revised: 02/26/2020] [Accepted: 03/07/2020] [Indexed: 11/17/2022]
|
41
|
Son MBF, Gauvreau K, Tremoulet AH, Lo M, Baker AL, de Ferranti S, Dedeoglu F, Sundel RP, Friedman KG, Burns JC, Newburger JW. Risk Model Development and Validation for Prediction of Coronary Artery Aneurysms in Kawasaki Disease in a North American Population. J Am Heart Assoc 2020; 8:e011319. [PMID: 31130036 PMCID: PMC6585355 DOI: 10.1161/jaha.118.011319] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Accurate prediction of coronary artery aneurysms (CAAs) in patients with Kawasaki disease remains challenging in North American cohorts. We sought to develop and validate a risk model for CAA prediction. Methods and Results A binary outcome of CAA was defined as left anterior descending or right coronary artery Z score ≥2.5 at 2 to 8 weeks after fever onset in a development cohort (n=903) and a validation cohort (n=185) of patients with Kawasaki disease. Associations of baseline clinical, laboratory, and echocardiographic variables with later CAA were assessed in the development cohort using logistic regression. Discrimination (c statistic) and calibration (Hosmer‐Lemeshow) of the final model were evaluated. A practical risk score assigning points to each variable in the final model was created based on model coefficients from the development cohort. Predictors of CAAs at 2 to 8 weeks were baseline Z score of left anterior descending or right coronary artery ≥2.0, age <6 months, Asian race, and C‐reactive protein ≥13 mg/dL (c=0.82 in the development cohort, c=0.93 in the validation cohort). The CAA risk score assigned 2 points for baseline Z score of left anterior descending or right coronary artery ≥2.0 and 1 point for each of the other variables, with creation of low‐ (0–1), moderate‐ (2), and high‐ (3–5) risk groups. The odds of CAAs were 16‐fold greater in the high‐ versus the low‐risk groups in the development cohort (odds ratio, 16.4; 95% CI, 9.71–27.7 [P<0.001]), and >40‐fold greater in the validation cohort (odds ratio, 44.0; 95% CI, 10.8–180 [P<0.001]). Conclusions Our risk model for CAA in Kawasaki disease consisting of baseline demographic, laboratory, and echocardiographic variables had excellent predictive utility and should undergo prospective testing.
Collapse
Affiliation(s)
- Mary Beth F Son
- 1 Division of Immunology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | | | - Adriana H Tremoulet
- 4 Department of Pediatrics University of California San Diego School of Medicine La Jolla CA.,5 Department of Pediatrics Rady Children's Hospital San Diego San Diego USA
| | - Mindy Lo
- 1 Division of Immunology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Annette L Baker
- 2 Department of Cardiology Boston Children's Hospital Boston MA
| | - Sarah de Ferranti
- 2 Department of Cardiology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Fatma Dedeoglu
- 1 Division of Immunology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Robert P Sundel
- 1 Division of Immunology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Kevin G Friedman
- 2 Department of Cardiology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Jane C Burns
- 4 Department of Pediatrics University of California San Diego School of Medicine La Jolla CA.,5 Department of Pediatrics Rady Children's Hospital San Diego San Diego USA
| | - Jane W Newburger
- 2 Department of Cardiology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| |
Collapse
|
42
|
Greene CL, Friedman KG, Callahan R, Baird CW. Hybrid approach to neonatal repair of large symptomatic congenital coronary artery fistula. JTCVS Tech 2020; 3:295-297. [PMID: 34317905 PMCID: PMC8305290 DOI: 10.1016/j.xjtc.2020.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Christina L Greene
- Department of Cardiothoracic Surgery, Boston Children's Hospital, Boston, Mass
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Christopher W Baird
- Department of Cardiothoracic Surgery, Boston Children's Hospital, Boston, Mass
| |
Collapse
|
43
|
Affiliation(s)
- Rebecca S. Beroukhim
- Address for correspondence: Dr. Rebecca S. Beroukhim, Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115.
| | | |
Collapse
|
44
|
Jaimes C, Rofeberg V, Stopp C, Ortinau CM, Gholipour A, Friedman KG, Tworetzky W, Estroff J, Newburger JW, Wypij D, Warfield SK, Yang E, Rollins CK. Association of Isolated Congenital Heart Disease with Fetal Brain Maturation. AJNR Am J Neuroradiol 2020; 41:1525-1531. [PMID: 32646947 DOI: 10.3174/ajnr.a6635] [Citation(s) in RCA: 18] [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] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Brain MRI of newborns with congenital heart disease show signs of immaturity relative to healthy controls. Our aim was to determine whether the semiquantitative fetal total maturation score can detect abnormalities in brain maturation in fetuses with congenital heart disease in the second and third trimesters. MATERIALS AND METHODS We analyzed data from a prospective study of fetuses with and without congenital heart disease who underwent fetal MR imaging at 25-35 weeks' gestation. Two independent neuroradiologists blinded to the clinical data reviewed and scored all images using the fetal total maturation score. Interrater reliability was evaluated by the intraclass correlation coefficient using the individual reader scores, which were also used to calculate an average score for each subject. Comparisons of the average and individual reader scores between affected and control fetuses and relationships with clinical variables were evaluated using multivariable linear regression. RESULTS Data from 69 subjects (48 cardiac, 21 controls) were included. High concordance was observed between readers with an intraclass correlation coefficient of 0.98 (95% CI, 0.97-0.99). The affected group had significantly lower fetal total maturation scores than the control group (β-estimate, -0.9 [95% CI, -1.5 to -0.4], P = .002), adjusting for gestational age and sex. Averaged fetal total maturation, germinal matrix, myelination, and superior temporal sulcus scores were significantly delayed in fetuses with congenital heart disease versus controls (P < .05 for each). The fetal total maturation score was not significantly associated with any cardiac, anatomic, or physiologic variables. CONCLUSIONS The fetal total maturation score is sensitive to differences in brain maturation between fetuses with isolated congenital heart disease and healthy controls.
Collapse
Affiliation(s)
- C Jaimes
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - V Rofeberg
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts
| | - C Stopp
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts
| | - C M Ortinau
- Pediatrics (C.M.O.), Washington University in St. Louis, St. Louis, Missouri
| | - A Gholipour
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - K G Friedman
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - W Tworetzky
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - J Estroff
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - J W Newburger
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - D Wypij
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts.,Biostatistics (D.W.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - S K Warfield
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - E Yang
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - C K Rollins
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts .,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
45
|
Chow OS, Hoganson DM, Kaza AK, Chávez M, Altin FH, Marx GR, Friedman KG, Jennings RW, Baird CW. Early Infant Symptomatic Patients With Tetralogy of Fallot With Absent Pulmonary Valve: Pulmonary Artery Management and Airway Stabilization. Ann Thorac Surg 2020; 110:1644-1650. [PMID: 32615094 DOI: 10.1016/j.athoracsur.2020.05.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Tracheobronchomalacia and airway obstruction from severely dilated pulmonary arteries in tetralogy of Fallot with absent pulmonary valve (TOF-APV) has been associated with high rates of respiratory failure and mortality (15% to 25%). It is not known whether aggressive pulmonary artery (PA) or direct airway intervention during early definitive cardiac repair improves outcomes. METHODS A retrospective observational study was made of all patients undergoing surgical repair for TOF-APV at our center between 2006 and 2018. RESULTS Twenty patients underwent repair at a median age of 51 days and PA Z-scores of 8.1. Twelve patients had a valve implanted, 6 of whom required reoperation for valve replacement at a median of 9 months (range, 3 to 28) compared with 8 who had initial transannular patch, and only 1 patient required subsequent valve replacement (P < .05). Seven patients had central PAs replaced with thin-walled Gore-Tex (WL Gore, Flagstaff, AZ) grafts; none of these required PA reoperation during a median follow-up of 26.5 months, whereas 3 of 13 patients who did not have PA replacement with Gore-Tex required subsequent PA reoperation (P < .05). Concomitant airway interventions (eg, tracheobronchopexy/plasty) were performed in 4 patients and none required subsequent airway interventions, whereas 2 patients not having initial airway intervention required subsequent tracheopexy (P < .05). Three patients in the cohort eventually required tracheostomy (15%), and 2 patients died (10%; on postoperative days 30 and 326); none had received initial airway intervention. CONCLUSIONS Pulmonary artery replacement and aggressive direct airway management at initial definitive repair of cardiac TOF-APV can be performed safely with acceptable survival outcomes and low rates of airway and PA reintervention.
Collapse
Affiliation(s)
- Oliver S Chow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Queens, New York, New York
| | - David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mariana Chávez
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Firat H Altin
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gerald R Marx
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
46
|
Baird CW, Chávez M, Friedman KG. Pulmonary Valve Reconstruction Using the Ozaki Leaflet Reconstructive Techniques. Ann Thorac Surg 2020; 111:e19-e21. [PMID: 32511993 DOI: 10.1016/j.athoracsur.2020.04.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 12/01/2022]
Abstract
The aortic valve neocuspidization, or Ozaki procedure, has been shown to be technically reproducible and have acceptable results in the aortic position in adult and pediatric patients. We report a case in which innovative techniques were utilized to create a three-leaflet pulmonary valve using a modified aortic valve neocuspidization technique.
Collapse
Affiliation(s)
- Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Mariana Chávez
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
47
|
Esch JJ, Hellinger A, Friedman KG, VanderPluym CJ. Apixaban for treatment of intracardiac thrombosis in children with congenital heart disease. Interact Cardiovasc Thorac Surg 2020; 30:950-951. [PMID: 32221595 DOI: 10.1093/icvts/ivaa041] [Citation(s) in RCA: 5] [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: 11/27/2019] [Revised: 02/05/2020] [Accepted: 02/10/2020] [Indexed: 11/13/2022] Open
Abstract
Apixaban is well studied in adults; paediatric data are extremely limited. We describe 3 children (age 2-6 years, weight 13-17 kg) with congenital heart disease who developed intracardiac thrombosis, and in whom typical treatments had failed (in 1) or were considered impractical (in 2). All were treated with apixaban 2.5 mg orally twice daily with complete (in 2) or partial (in 1) thrombus resolution and no clinical bleeding events.
Collapse
Affiliation(s)
- Jesse J Esch
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Hellinger
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christina J VanderPluym
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
48
|
Pickard SS, Wong JB, Bucholz EM, Newburger JW, Tworetzky W, Lafranchi T, Benson CB, Wilkins-Haug LE, Porras D, Callahan R, Friedman KG. Fetal Aortic Valvuloplasty for Evolving Hypoplastic Left Heart Syndrome: A Decision Analysis. Circ Cardiovasc Qual Outcomes 2020; 13:e006127. [PMID: 32252549 DOI: 10.1161/circoutcomes.119.006127] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Fetal aortic valvuloplasty (FAV) may prevent progression of midgestation aortic stenosis to hypoplastic left heart syndrome. However, FAV has well-established risks, and its survival benefit remains unknown. Our primary aim was to determine whether FAV for midgestation aortic stenosis increases survival from fetal diagnosis to age 6 years. METHODS AND RESULTS We performed a retrospective analysis of 143 fetuses who underwent FAV from 2000 to 2017 and a secondary analysis of the Pediatric Heart Network Single Ventricle Reconstruction trial. Using these results, we developed a decision model to estimate probability of transplant-free survival from fetal diagnosis to age 6 years and postnatal restricted mean transplant-free survival time. FAV was technically successful in 84% of 143 fetuses with fetal demise in 8%. Biventricular circulation was achieved in 50% of 111 live-born infants with successful FAV but in only 16% of the 19 patients with unsuccessful FAV. The model projected overlapping probabilities of transplant-free survival to age 6 years at 75% (95% CI, 67%-82%) with FAV versus 72% (95% CI, 61%-82%) with expectant fetal management, resulting in a restricted mean transplant-free survival time benefit of 1.2 months. When limiting analyses to the improved FAV experience since 2009 to reflect current practice, (probability of technical success [94%], fetal demise [4%], and biventricular circulation [66%]), the model projected that FAV increased the probability of survival to age 6 years to 82% (95% CI, 73%-89%). Expectant management is favored if risk of fetal demise exceeded 12% or probability of biventricular circulation fell below 26%, but FAV remained favored over plausible recent range of technical success. CONCLUSIONS Our model suggests that FAV provides a modest, medium-term survival benefit over expectant fetal management. Appropriate patient selection and low risk of fetal demise with FAV are critical factors for obtaining a survival benefit.
Collapse
Affiliation(s)
- Sarah S Pickard
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - John B Wong
- Division of Clinical Decision Making, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (J.B.W.)
| | - Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Terra Lafranchi
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.)
| | - Carol B Benson
- Departments of Radiology (C.B.B.), Brigham and Women's Hospital, Boston, MA
| | - Louise E Wilkins-Haug
- Obstetrics and Gynecology (L.E.W.-H.), Brigham and Women's Hospital, Boston, MA.,Obstetrics and Gynecology, (L.E.W.-H.), Harvard Medical School, Boston, MA
| | - Diego Porras
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| |
Collapse
|
49
|
O'Leary ET, Alexander ME, Bezzerides VJ, Drogosz M, Economy KE, Friedman KG, Pickard SS, Tworetzky W, Mah DY. Low mortality in fetal supraventricular tachycardia: Outcomes in a 30-year single-institution experience. J Cardiovasc Electrophysiol 2020; 31:1105-1113. [PMID: 32100356 DOI: 10.1111/jce.14406] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 10/23/2019] [Revised: 01/31/2020] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe a single institutional experience managing fetuses with supraventricular tachycardia (SVT) and to identify associations between patient characteristics and fetal and postnatal outcomes. BACKGROUND Sustained fetal SVT is associated with significant morbidity and mortality if untreated, yet the optimal management strategy remains unclear. METHODS Retrospective cohort study including fetuses diagnosed with sustained SVT (>50% of the diagnostic echocardiogram) between 1985 and 2018. Fetuses with congenital heart disease were excluded. RESULTS Sustained SVT was diagnosed in 65 fetuses at a median gestational age of 30 weeks (range, 14-37). Atrioventricular re-entrant tachycardia and atrial flutter were the most common diagnoses, seen in 41 and 16 cases, respectively. Moderate/severe ventricular dysfunction was present in 20 fetuses, and hydrops fetalis was present in 13. Of the 57 fetuses initiated on transplacental drug therapy, 47 received digoxin first-line, yet 39 of 57 (68%) required advanced therapy with sotalol, flecainide, or amiodarone. Rate or rhythm control was achieved in 47 of 57 treated fetuses. There were no cases of intrauterine fetal demise. Later gestational age at fetal diagnosis (odds ratio [OR], 1.1, 95% confidence interval [CI], 1.01-1.2, P = .02) and moderate/severe fetal ventricular dysfunction (OR, 6.1, 95% CI, 1.7-21.6, P = .005) were associated with postnatal SVT. Two postnatal deaths occurred. CONCLUSIONS Fetuses with structurally normal hearts and sustained SVT can be effectively managed with transplacental drug therapy with minimal risk of intrauterine fetal demise. Treatment requires multiple antiarrhythmic agents in over half of cases. Later gestational age at fetal diagnosis and the presence of depressed fetal ventricular function, but not hydrops, predict postnatal arrhythmia burden.
Collapse
Affiliation(s)
- Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Mark E Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Vassilios J Bezzerides
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Monika Drogosz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Katherine E Economy
- Harvard Medical School, Boston, Massachusetts.,Department of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sarah S Pickard
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
50
|
Guseh SH, Friedman KG, Wilkins-Haug LE. Fetal cardiac intervention-Perspectives from a single center. Prenat Diagn 2020; 40:415-423. [PMID: 31875330 DOI: 10.1002/pd.5631] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/01/2019] [Accepted: 10/18/2019] [Indexed: 12/19/2022]
Abstract
Fetal cardiac intervention was first proposed in the early 1990s to impact cardiac development and survival of fetuses with fetal aortic stenosis and evolving hypoplastic left heart syndrome (HLHS). Although initial attempts of fetal aortic valvuloplasty were unsuccessful and carried a high rate of morbidity and mortality, our collaborative group at the Brigham and Women's Hospital and Boston Children's Hospital have reinvigorated the procedure using improvements in imaging, anesthesia, balloon catheters, and surgical techniques. Two decades of experience have now allowed us to document the safety of in utero intervention and to achieve a better understanding of the impact of midgestation intervention on developing HLHS. Research into underlying genetics, predictive biomarkers, and ways to incorporate stem cell technology will hopefully allow us to further refine the procedure to most benefit children with this historically lethal disease.
Collapse
Affiliation(s)
- Stephanie H Guseh
- Division of Maternal Fetal Medicine, Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Louise E Wilkins-Haug
- Division of Maternal Fetal Medicine, Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|