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Hollander SA. Partial heart transplantation: A procedure still finding its place. Pediatr Transplant 2024; 28:e14745. [PMID: 38623883 DOI: 10.1111/petr.14745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 04/17/2024]
Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
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Idrovo A, Hollander SA, Neumayr TM, Bell C, Munoz G, Choudhry S, Price J, Adachi I, Srivaths P, Sutherland S, Akcan-Arikan A. Long-term kidney outcomes in pediatric continuous-flow ventricular assist device patients. Pediatr Nephrol 2024; 39:1289-1300. [PMID: 37971519 DOI: 10.1007/s00467-023-06190-8] [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: 05/26/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Continuous-flow ventricular assist devices (CF-VADs) are used increasingly in pediatric end-stage heart failure (ESHF) patients. Alongside common risk factors like oxidant injury from hemolysis, non-pulsatile flow constitutes a unique circulatory stress on kidneys. Post-implantation recovery after acute kidney injury (AKI) is commonly reported, but long-term kidney outcomes or factors implicated in the evolution of chronic kidney disease (CKD) with prolonged CF-VAD support are unknown. METHODS We studied ESHF patients supported > 90 days on CF-VAD from 2008 to 2018. The primary outcome was CKD (per Kidney Disease Improving Global Outcomes (KDIGO) criteria). Secondary outcomes included AKI incidence post-implantation and CKD evolution in the 6-12 months of CF-VAD support. RESULTS We enrolled 134 patients; 84/134 (63%) were male, median age was 13 [IQR 9.9, 15.9] years, 72/134 (54%) had preexisting CKD at implantation, and 85/134 (63%) had AKI. At 3 months, of the 91/134 (68%) still on a CF-VAD, 34/91 (37%) never had CKD, 13/91 (14%) developed de novo CKD, while CKD persisted or worsened in 49% (44/91). Etiology of heart failure, extracorporeal membrane oxygenation use, duration of CF-VAD, AKI history, and kidney replacement therapy were not associated with different CKD outcomes. Mortality was higher in those with AKI or preexisting CKD. CONCLUSIONS In the first multicenter study to focus on kidney outcomes for pediatric long-term CF-VAD patients, preimplantation CKD and peri-implantation AKI were common. Both de novo CKD and worsening CKD can happen on prolonged CF-VAD support. Proactive kidney function monitoring and targeted follow-up are important to optimize outcomes.
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Affiliation(s)
- Alexandra Idrovo
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA.
- Renal Section, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Seth A Hollander
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tara M Neumayr
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School, St. Louis, MO, USA
- Division of Nephrology, Department of Pediatrics, Washington University School, St. Louis, MO, USA
| | - Cynthia Bell
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Genevieve Munoz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School, St. Louis, MO, USA
| | - Swati Choudhry
- Pediatrics, Cardiology Section, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Jack Price
- Pediatrics, Cardiology Section, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Department of Pediatrics, Baylor College of Medicine/Texas Children's, Houston, TX, USA
| | - Poyyapakkam Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA
| | - Scott Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ayse Akcan-Arikan
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's, Houston, TX, USA
- Department of Pediatrics Critical Care Section, Baylor College of Medicine, Texas Children's, Houston, TX, USA
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Hollander SA, Chung S, Reddy S, Zook N, Yang J, Vella T, Navaratnam M, Price E, Sutherland SM, Algaze CA. Intraoperative and Postoperative Hemodynamic Predictors of Acute Kidney Injury in Pediatric Heart Transplant Recipients. J Pediatr Intensive Care 2024; 13:37-45. [PMID: 38571984 PMCID: PMC10987224 DOI: 10.1055/s-0041-1736336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/28/2021] [Indexed: 10/20/2022] Open
Abstract
Acute kidney injury (AKI) is common after pediatric heart transplantation (HT) and is associated with inferior patient outcomes. Hemodynamic risk factors for pediatric heart transplant recipients who experience AKI are not well described. We performed a retrospective review of 99 pediatric heart transplant patients at Lucile Packard Children's Hospital Stanford from January 1, 2015, to December 31, 2019, in which clinical and demographic characteristics, intraoperative perfusion data, and hemodynamic measurements in the first 48 postoperative hours were analyzed as risk factors for severe AKI (Kidney Disease: Improving Global Outcomes [KDIGO] stage ≥ 2). Univariate analysis was conducted using Fisher's exact test, Chi-square test, and the Wilcoxon rank-sum test, as appropriate. Multivariable analysis was conducted using logistic regression. Thirty-five patients (35%) experienced severe AKI which was associated with lower intraoperative cardiac index ( p = 0.001), higher hematocrit ( p < 0.001), lower body temperature ( p < 0.001), lower renal near-infrared spectroscopy ( p = 0.001), lower postoperative mean arterial blood pressure (MAP: p = 0.001), and higher central venous pressure (CVP; p < 0.001). In multivariable analysis, postoperative CVP >12 mm Hg (odds ratio [OR] = 4.27; 95% confidence interval [CI]: 1.48-12.3, p = 0.007) and MAP <65 mm Hg (OR = 4.9; 95% CI: 1.07-22.5, p = 0.04) were associated with early severe AKI. Children with severe AKI experienced longer ventilator, intensive care, and posttransplant hospital days and inferior survival ( p = 0.01). Lower MAP and higher CVP are associated with severe AKI in pediatric HT recipients. Patients, who experienced AKI, experienced increased intensive care unit (ICU) morbidity and inferior survival. These data may guide the development of perioperative renal protective management strategies to reduce AKI incidence and improve patient outcomes.
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Affiliation(s)
- Seth A. Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, United States
| | - Sukyung Chung
- Quantitative Sciences Unit, Stanford University, Stanford, California, United States
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, United States
| | - Nina Zook
- Department of Pediatrics, Stanford University, Stanford, California, United States
| | - Jeffrey Yang
- Department of Pediatrics, Stanford University, Stanford, California, United States
| | - Tristan Vella
- Perfusion Services, Lucile Packard Children's Hospital Stanford, Palo Alto, California, United States
| | - Manchula Navaratnam
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California, United States
| | - Elizabeth Price
- Patient Care Services, Cardiovascular Intensive Care Unit, Lucile Packard Children's Hospital Stanford, Palo Alto, California, United States
| | - Scott M. Sutherland
- Department of Pediatrics (Nephrology), Scott M Sutherland, Stanford University School of Medicine, Stanford, California, United States
| | - Claudia A. Algaze
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, United States
- Center for Pediatric and Maternal Value, Stanford University, Palo Alto, California, Unites States
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Armstrong A, Liang JW, Char D, Hollander SA, Pyke-Grimm KA. The effect of socioeconomic status on pediatric heart transplant outcomes at a single institution between 2013 and 2022. Pediatr Transplant 2024; 28:e14695. [PMID: 38433565 DOI: 10.1111/petr.14695] [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: 10/11/2023] [Revised: 12/06/2023] [Accepted: 01/05/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Disparities in pediatric heart transplant outcomes based on socioeconomic status (SES) have been previously observed. However, there is a need to reevaluate these associations in contemporary settings with advancements in transplant therapies and increased awareness of health disparities. This retrospective study aims to investigate the relationship between SES and outcomes for pediatric heart transplant patients. METHODS Data were collected through a chart review of 176 pediatric patients who underwent first orthotopic heart transplantation (OHT) at a single center from 2013 to 2021. The Area Deprivation Index (ADI), a composite score based on U.S. census data, was used to quantify SES. Cox proportional hazards models and generalized linear models were employed to analyze the association between SES and graft failure, rejection rates, and hospitalization rates. RESULTS The analysis revealed no statistically significant differences in graft failure rates, rejection rates, or hospitalization rates between low-SES and high-SES pediatric heart transplant patients for our single-center study. CONCLUSION There may be patient education, policies, and social resources that can help mitigate SES-based healthcare disparities. Additional multi-center research is needed to identify post-transplant care that promotes patient equity.
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Affiliation(s)
- Allison Armstrong
- Department of Cardiology, Lucile Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Jane W Liang
- Quantitative Sciences Unit, Stanford University of Medicine, Palo Alto, California, USA
| | - Danton Char
- Department of Cardiology, Lucile Packard Children's Hospital/Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Cardiology, Lucile Packard Children's Hospital/Stanford University School of Medicine, Palo Alto, California, USA
| | - Kimberly A Pyke-Grimm
- Center for Nursing Excellence, Bass Center for Childhood Cancer and Blood Diseases, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
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Ybarra AM, Kamsheh AM, O'Connor MJ, Hollander SA, Bano M, Ploutz M, Vaughn G, Lambert A, Wallendorf M, Kirklin J, Canter CE. Survival does not differ by annual center transplant volume-A Pediatric Heart Transplant Society Registry study. Pediatr Transplant 2024; 28:e14720. [PMID: 38433570 DOI: 10.1111/petr.14720] [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: 12/20/2023] [Accepted: 02/08/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND There are conflicting data regarding the relationship between center volume and outcomes in pediatric heart transplantation. Previous studies have not fully accounted for differences in case mix, particularly in high-risk congenital heart disease (CHD) groups. We aimed to evaluate the relationship between center volume and outcomes using the Pediatric Heart Transplant Society (PHTS) Registry and explore how case mix may affect outcomes. METHODS A retrospective cohort study of all pediatric patients in the PHTS Registry who received a heart transplant from 2009 to 2018 was performed. Centers were divided into 5 groups based on average yearly transplant volume. The primary outcome was time to death or graft loss and outcomes were compared using Kaplan-Meier analysis. RESULTS There were 4583 cases among 55 centers included. There was no difference in time to death or graft loss by center volume in the entire cohort (p = .75), in patients with CHD (p = .79) or in patients with cardiomyopathy (p = .23). There was also no difference in time to death or graft loss by center size in patients undergoing transplant after Norwood, Glenn or Fontan (log rank p = .17, p = .31, and p = .10 respectively). There was a statistically significant difference in outcomes by center size in the positive crossmatch group (p < .0001), though no discernible pattern related to high or low center volume. CONCLUSIONS Outcomes are similar among transplant centers of all sizes, including for high-risk patient groups with CHD. Future work is needed to understand how patient-specific risk factors may vary among centers of various sizes and whether this influences patient outcomes.
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Affiliation(s)
- A Marion Ybarra
- Department of Pediatrics, Division of Pediatric Cardiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alicia M Kamsheh
- Department of Pediatrics, Division of Pediatric Cardiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Matthew J O'Connor
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Seth A Hollander
- Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Maria Bano
- Department of Pediatrics, UT Southwestern, Dallas, Texas, USA
| | - Michelle Ploutz
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Gabrielle Vaughn
- Department of Pediatrics, University of California San Diego, San Diego, California, USA
| | - Andrea Lambert
- University of Louisville and Norton Children's Hospital, Louisville, Kentucky, USA
| | - Michael Wallendorf
- Department of Biostatistics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - James Kirklin
- Division of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles E Canter
- Department of Pediatrics, Division of Pediatric Cardiology, Washington University in St. Louis, St. Louis, Missouri, USA
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Bansal N, Jeewa A, Watanabe K, Richmond ME, Alzubi A, D'Souza N, Bano M, Lorts A, Rosenthal DN, Taylor K, O'Shea C, Smyth L, Koehl D, Zhao H, Hollander SA. Reducing donor acceptance practice variation - Learnings from a discussion forum. Pediatr Transplant 2024; 28:e14635. [PMID: 37957127 DOI: 10.1111/petr.14635] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/26/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE Although waitlist mortality is unacceptably high, nearly half of donor heart offers are rejected by pediatric heart transplant centers. The Advanced Cardiac Therapy Improving Outcome Network (ACTION) and Pediatric Heart Transplant Society (PHTS) convened a multi-institutional donor decision discussion forum (DDDF) aimed at assessing donor acceptance practices and reducing practice variation. METHODS A 1-h-long virtual DDDF for providers across North America, the United Kingdom, and Brazil was held monthly. Each session typically included two case presentations posing a real-world donor decision challenge. Attendees were polled before the presenting center's decision was revealed. Group discussion followed, including a review of relevant literature and PHTS data. Metrics of participation, participant agreement with presenting center decisions, and impact on future decision-making were collected and analyzed. RESULTS Over 2 years, 41 cases were discussed. Approximately 50 clinicians attended each call. Risk factors influencing decision-making included donor quality (10), size discrepancy (8), and COVID-19 (8). Donor characteristics influenced 63% of decisions, recipient factors 35%. Participants agreed with the decision made by the presenting center only 49% of the time. Post-presentation discussion resulted in 25% of participants changing their original decision. Survey conducted reported that 50% respondents changed their donor acceptance practices. CONCLUSION DDDF identified significant variation in pediatric donor decision-making among centers. DDDF may be an effective format to reduce practice variation, provide education to decision-makers, and ultimately increase donor utilization.
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Affiliation(s)
- Neha Bansal
- Icahn School of Medicine at Mount Sinai, Mount Sinai Kravis Children's Hospital, New York, New York, USA
| | - Aamir Jeewa
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kae Watanabe
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Marc E Richmond
- Division of Pediatric Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Anaam Alzubi
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nikita D'Souza
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Maria Bano
- Department of Pediatric Cardiology, UT Southwestern, Dallas, Texas, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | - Lauren Smyth
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Hong Zhao
- Kirklin Solutions, Hoover, Alabama, USA
| | - Seth A Hollander
- Stanford University School of Medicine, Palo Alto, California, USA
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Hollander SA. Improving pediatric donor heart utilization: The less we change, the more things will stay the same. Pediatr Transplant 2024; 28:e14668. [PMID: 38058192 DOI: 10.1111/petr.14668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, USA
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Torpoco Rivera DM, Hollander SA, Almond C, Profita E, Dykes JC, Raissadati A, Lee J, Sacks LD, Kleiman ZI, Lee E, Rosenthal A, Rosenthal DN, Nasirov T, Ma M, Martin E, Chen S. An integrated program to expand donor utilization in pediatric heart transplantation: Case report of successful transplant with multiple donor risk factors. Pediatr Transplant 2024; 28:e14584. [PMID: 37470130 DOI: 10.1111/petr.14584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/20/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Pediatric heart transplantation (HT) continues to be limited by the shortage of donor organs, distance constraints, and the number of potential donor offers that are declined due to the presence of multiple risk factors. METHODS We report a case of successful pediatric HT in which multiple risk factors were mitigated through a combination of innovative donor utilization improvement strategies. RESULTS An 11-year-old, 25-kilogram child with cardiomyopathy and pulmonary hypertension, on chronic milrinone therapy and anticoagulated with apixaban, was transplanted with a heart from a Hepatitis C virus positive donor and an increased donor-to-recipient weight ratio. Due to extended geographic distance, an extracorporeal heart preservation system (TransMedics™ OCS Heart) was used for procurement. No significant bleeding was observed post-operatively, and she was discharged by post-operative day 15 with normal biventricular systolic function. Post-transplant Hepatitis C virus seroconversion was successfully treated. CONCLUSIONS Heart transplantation in donors with multiple risk factor can be achieved with an integrative team approach and should be taken into consideration when evaluating marginal donors in order to expand the current limited donor pool in pediatric patients.
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Affiliation(s)
- Diana M Torpoco Rivera
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christopher Almond
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth Profita
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - John C Dykes
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Alireza Raissadati
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Joanne Lee
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Loren D Sacks
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Zachary I Kleiman
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ellen Lee
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ayelet Rosenthal
- Department of Pediatrics, Division of Infectious Disease, Stanford University School of Medicine, Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Teimour Nasirov
- Department of Cardiothoracic Surgery, Division of Pediatric Heart Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Division of Pediatric Heart Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elisabeth Martin
- Department of Cardiothoracic Surgery, Division of Pediatric Heart Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sharon Chen
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
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Zook N, Schultz L, Rizzuto S, Aufdermauer A, Hollander AM, Almond CS, Hollander SA. Supplemental nutrition, feeding disorders, and renourishment in pediatric heart failure through transplantation. Pediatr Transplant 2023; 27:e14601. [PMID: 37706571 DOI: 10.1111/petr.14601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Tube feeds are used commonly in children listed for heart transplant; however, rates of renourishment and development of feeding disorders are not sufficiently characterized. METHODS Retrospective review of pediatric heart transplant recipients from January 1, 2014, to January 3, 2021. Demographics, anthropometric, and nutritional data were collected from heart transplant listing through 3 years post-transplant. Renourishment rates, presence of a feeding disorder, and need for a gastric feeding tube were analyzed. Multivariable analysis was conducted to identify risks for poor nutritional outcomes. RESULTS Of 104 patients, 35 (34%) and 36 (35%) were malnourished at heart transplant listing and transplant, respectively, persisting in 21/91 (23%) 1 year postheart transplant. Forty (38%) received tube feeds at listing, 42 (40%) at heart transplant, and 18/90 (20%) 1 year post-transplant. Rates of feeding disorders fell from 23% at transplantation to 10% 1 year post-transplant. Feeding disorders were associated with younger age at heart transplant (p < .001) and congenital heart disease (p = .03). Forty-six percent of infants required a gastric feeding tube. Renourishment occurred in 20% during listing and was associated with ventricular assist device support (p = .03) and noncalorically dense feeds (p = .03). Malnutrition at transplant was associated with inferior post-transplant survival (6/36 (17%) vs. 2/68 (3%); p = .02). CONCLUSIONS Malnourishment requiring tube feeds is common in pediatric heart transplant candidates; however, most patients who eventually survive to transplant remain malnourished at time of transplantation and 1 year later. While some children develop feeding disorders, they generally resolve by 1 year post-transplant.
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Affiliation(s)
- Nina Zook
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Lisa Schultz
- Department of Nutrition Services, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Sandra Rizzuto
- Department of Occupational Therapy, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Amanda Aufdermauer
- Department of Nutrition Services, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Amanda M Hollander
- Department of Physical Therapy, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Christopher S Almond
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
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Mai DH, Sutherland S, Blinder J, Hollander SA. A novel acute kidney injury scoring system for renal and clinical outcomes in pediatric heart transplant patients. Pediatr Transplant 2023; 27:e14565. [PMID: 37409513 DOI: 10.1111/petr.14565] [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: 04/18/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND The development of acute kidney injury (AKI) has been associated with worse outcomes in children after heart transplantation. Our study compares the application of a cumulative six-point Kidney Diseases Improving Global Outcomes (KDIGO) AKI scoring system, utilizing both creatinine and urine output criteria that we term as the AKI-6 criteria, to traditional AKI staging as a predictor for clinical and renal outcomes in the pediatric heart transplant recipients. METHODS We conducted a retrospective single-center chart review on 155 pediatric patients who underwent heart transplantation from May 2014 to December 2021. The primary independent variable was the presence of severe AKI. Severe AKI by KDIGO was defined as Stage ≥2, whereas severe AKI by AKI-6 was defined as cumulative scores ≥4 or Stage 3 AKI based on either KDIGO criterion alone. Primary outcomes included actuarial survival and renal dysfunction by 1-year post-transplant, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2 . RESULTS In total, 140 (90%) patients developed AKI; 98 (63%) patients developed severe AKI by KDIGO, and 60 (39%) by AKI-6. Severe AKI by AKI-6 was associated with worse actuarial survival following heart transplantation compared with KDIGO (p = 0.01). Of the 143 patients with 1-year creatinine data, 6 (11%) patients out of 54 with severe AKI by AKI-6 had evidence of renal dysfunction (p = 0.01), compared with 6 (7%) patients out of 88 by KDIGO (p = 0.3). CONCLUSIONS AKI-6 scoring provides greater prognostic utility for actuarial survival and renal dysfunction by 1-year post-heart transplantation in pediatric patients than traditional KDIGO staging.
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Affiliation(s)
- Daniel H Mai
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Scott Sutherland
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Joshua Blinder
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Stanford University School of Medicine, Palo Alto, California, USA
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Almond CS, Sleeper LA, Rossano JW, Bock MJ, Pahl E, Auerbach S, Lal A, Hollander SA, Miyamoto SD, Castleberry C, Lee J, Barkoff LM, Gonzales S, Klein G, Daly KP. The teammate trial: Study design and rationale tacrolimus and everolimus against tacrolimus and MMF in pediatric heart transplantation using the major adverse transplant event (MATE) score. Am Heart J 2023; 260:100-112. [PMID: 36828201 DOI: 10.1016/j.ahj.2023.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Currently there are no immunosuppression regimens FDA-approved to prevent rejection in pediatric heart transplantation (HT). In recent years, everolimus (EVL) has emerged as a potential alternative to standard tacrolimus (TAC) as the primary immunosuppressant to prevent rejection that may also reduce the risk of cardiac allograft vasculopathy (CAV), chronic kidney disease (CKD) and cytomegalovirus (CMV) infection. However, the 2 regimens have never been compared head-to-head in a randomized trial. The study design and rationale are reviewed in light of the challenges inherent in rare disease research. METHODS The TEAMMATE trial (IND 127980) is the first multicenter randomized clinical trial (RCT) in pediatric HT. The primary purpose is to evaluate the safety and efficacy of EVL and low-dose TAC (LD-TAC) compared to standard-dose TAC and mycophenolate mofetil (MMF). Children aged <21 years at HT were randomized (1:1 ratio) at 6 months post-HT to either regimen, and followed for 30 months. Children with recurrent rejection, multi-organ transplant recipients, and those with an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m2 were excluded. The primary efficacy hypothesis is that, compared to TAC/MMF, EVL/LD-TAC is more effective in preventing 3 MATEs: acute cellular rejection (ACR), CKD and CAV. The primary safety hypothesis is that EVL/LD-TAC does not have a higher cumulative burden of 6 MATEs (antibody mediated rejection [AMR], infection, and post-transplant lymphoproliferative disorder [PTLD] in addition to the 3 above). The primary endpoint is the MATE score, a composite, ordinal surrogate endpoint reflecting the frequency and severity of MATEs that is validated against graft loss. The study had a target sample size of 210 patients across 25 sites and is powered to demonstrate superior efficacy of EVL/LD-TAC. Trial enrollment is complete and participant follow-up will be completed in 2023. CONCLUSION The TEAMMATE trial is the first multicenter RCT in pediatric HT. It is anticipated that the study will provide important information about the safety and efficacy of everolimus vs tacrolimus-based regimens and will provide valuable lessons into the design and conduct of future trials in pediatric HT.
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Affiliation(s)
- Christopher S Almond
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA.
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Joseph W Rossano
- Department of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Matthew J Bock
- Division of Pediatric Cardiology, Loma Linda University Children's Hospital, Loma Linda University School of Medicine, Loma Linda, CA
| | - Elfriede Pahl
- Department of Pediatrics, Lurie Children's Hospital, Northwestern School of Medicine, Chicago, IL
| | - Scott Auerbach
- Children's Hospital Colorado Heart Institute, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Ashwin Lal
- Department of Pediatrics Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Seth A Hollander
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Shelley D Miyamoto
- Children's Hospital Colorado Heart Institute, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Chesney Castleberry
- Departments of Pediatrics, St. Louis Children's Hospital, Washington University in Saint Louis, Saint Louis, MO
| | - Joanne Lee
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Lynsey M Barkoff
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Selena Gonzales
- Departments of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA
| | - Gloria Klein
- Department of Cardiology, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin P Daly
- Department of Cardiology, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA
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Giacone HM, Chubb H, Dubin AM, Motonaga KS, Ceresnak SR, Goodyer WR, Hanish D, Trela AV, Boramanand N, Lencioni E, Boothroyd D, Graber-Naidich A, Wright G, Haeffele C, Hollander SA, McElhinney DB, Ma M, Hanley FL, Chen S. Outcomes After Development of Ventricular Arrhythmias in Single Ventricular Heart Disease Patients With Fontan Palliation. Circ Arrhythm Electrophysiol 2023:e011143. [PMID: 37254747 DOI: 10.1161/circep.122.011143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND With the advent of more intensive rhythm monitoring strategies, ventricular arrhythmias (VAs) are increasingly detected in Fontan patients. However, the prognostic implications of VA are poorly understood. We assessed the incidence of VA in Fontan patients and the implications on transplant-free survival. METHODS Medical records of Fontan patients seen at a single center between 2002 and 2019 were reviewed to identify post-Fontan VA (nonsustained ventricular tachycardia >4 beats or sustained >30 seconds). Patients with preFontan VA were excluded. Hemodynamically unstable VA was defined as malignant VA. The primary outcome was death or heart transplantation. Death with censoring at transplant was a secondary outcome. RESULTS Of 431 Fontan patients, transplant-free survival was 82% at 15 years post-Fontan with 64 (15%) meeting primary outcome of either death (n=16, 3.7%), at a median 4.6 (0.4-10.2) years post-Fontan, or transplant (n=48, 11%), at a median of 11.1 (5.9-16.2) years post-Fontan. Forty-eight (11%) patients were diagnosed with VA (90% nonsustained ventricular tachycardia, 10% sustained ventricular tachycardia). Malignant VA (n=9, 2.0%) was associated with younger age, worse systolic function, and valvular regurgitation. Risk for VA increased with time from Fontan, 2.4% at 10 years to 19% at 20 years. History of Stage 1 surgery with right ventricular to pulmonary artery conduit and older age at Fontan were significant risk factors for VA. VA was strongly associated with an increased risk of transplant or death (HR, 9.2 [95% CI, 4.5-18.7]; P<0.001), with a transplant-free survival of 48% at 5-year post-VA diagnosis. CONCLUSIONS Ventricular arrhythmias occurred in 11% of Fontan patients and was highly associated with transplant or death, with a transplant-free survival of <50% at 5-year post-VA diagnosis. Risk factors for VA included older age at Fontan and history of right ventricular to pulmonary artery conduit. A diagnosis of VA in Fontan patients should prompt increased clinical surveillance.
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Affiliation(s)
- Heather M Giacone
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine. (H.M.G., H.C., A.M.D., K.S.M., S.R.C., W.R.G., C.H., S.A.H., S.C.)
| | - Henry Chubb
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine. (H.M.G., H.C., A.M.D., K.S.M., S.R.C., W.R.G., C.H., S.A.H., S.C.)
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine. (H.M.G., H.C., A.M.D., K.S.M., S.R.C., W.R.G., C.H., S.A.H., S.C.)
| | - Kara S Motonaga
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine. (H.M.G., H.C., A.M.D., K.S.M., S.R.C., W.R.G., C.H., S.A.H., S.C.)
| | - Scott R Ceresnak
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine. (H.M.G., H.C., A.M.D., K.S.M., S.R.C., W.R.G., C.H., S.A.H., S.C.)
| | - William R Goodyer
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine. (H.M.G., H.C., A.M.D., K.S.M., S.R.C., W.R.G., C.H., S.A.H., S.C.)
| | - Deb Hanish
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital (D.H., A.V.T., N.B., E.L. )
| | - Anthony V Trela
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital (D.H., A.V.T., N.B., E.L. )
| | - Nicole Boramanand
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital (D.H., A.V.T., N.B., E.L. )
| | - Erin Lencioni
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital (D.H., A.V.T., N.B., E.L. )
| | - Derek Boothroyd
- Quantitative Science Unit, Biomedical Informatics Research Division, Stanford University, Palo Alto (D.B., A.G.-N.)
| | - Anna Graber-Naidich
- Quantitative Science Unit, Biomedical Informatics Research Division, Stanford University, Palo Alto (D.B., A.G.-N.)
| | - Gail Wright
- Department of Pediatric Cardiology, Santa Clara Valley Medical Center, San Jose, CA (G.W.)
| | - Christiane Haeffele
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine. (H.M.G., H.C., A.M.D., K.S.M., S.R.C., W.R.G., C.H., S.A.H., S.C.)
| | - Seth A Hollander
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine. (H.M.G., H.C., A.M.D., K.S.M., S.R.C., W.R.G., C.H., S.A.H., S.C.)
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. (D.B.M., M.M., F.L.H.)
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. (D.B.M., M.M., F.L.H.)
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. (D.B.M., M.M., F.L.H.)
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine. (H.M.G., H.C., A.M.D., K.S.M., S.R.C., W.R.G., C.H., S.A.H., S.C.)
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13
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Hopper RK, van der Have O, Hollander SA, Dipchand AI, Perez de Sa V, Feinstein JA, Tran-Lundmark K. International practice heterogeneity in pre-transplant management of pulmonary hypertension related to pediatric left heart disease. Pediatr Transplant 2023; 27:e14461. [PMID: 36593638 DOI: 10.1111/petr.14461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Elevated pulmonary vascular resistance (PVR) in the setting of left heart failure may contribute to poor outcomes after pediatric heart transplant (HTx), but peri-transplant management is variable. METHODS We sought to characterize international practice by surveying physicians at pediatric HTx centers. RESULTS We received 49 complete responses from 39 centers in 16 countries. Most respondents are pediatric cardiologists (90%), practice at centers offering heart (86%) and lung (55%) transplant, and perform pre-HTx acute vasoreactivity testing (AVT, 88%) in patients with elevated PVR. Half (51%) reported defining a PVR cutoff for HTx eligibility as ≤6 WU m2 (56%) post-AVT (84%). The highest post-AVT PVR ever accepted for HTx ranged from 3-14.4 (median 6) WU m2 . To treat elevated pre-transplant PVR, phosphodiesterase type 5 inhibitors are most common (65%) followed by oxygen (31%), nitric oxide (14%), endothelin receptor antagonists (11%), and prostacyclins (6%). Nearly a third (31%) do not routinely use pulmonary vasodilators without implantation of a left ventricular assist device (LVAD). Case scenarios highlight treatment variability: in a restrictive cardiomyopathy scenario, HTx listing with post-transplant vasodilator therapy was favored, whereas in a Shone's complex patient with fixed PVR, LVAD ± pulmonary vasodilators followed by repeat catheterization was most common. Management of dilated cardiomyopathy with reactive PVR was variable. Most continue vasodilator therapy until HTx (16%), PVR normalizes (16%) or ≤6 months. CONCLUSIONS Management of elevated PVR in children awaiting HTx is heterogenous. Evidence-based guidelines are needed to allow for longitudinal determination of optimal outcomes and standardized care.
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Affiliation(s)
- Rachel K Hopper
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Oscar van der Have
- Department of Experimental Medical Science, Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Anne I Dipchand
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Valeria Perez de Sa
- Department of Clinical Sciences, Anesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Karin Tran-Lundmark
- Department of Experimental Medical Science, Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
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14
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Hollander SA, Wujcik K, Schmidt J, Liu E, Lin A, Dykes J, Good J, Brown M, Rosenthal D. Home Milrinone in Pediatric Hospice Care of Children with Heart Failure. J Pain Symptom Manage 2023; 65:216-221. [PMID: 36417945 DOI: 10.1016/j.jpainsymman.2022.11.014] [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: 08/04/2022] [Revised: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT The symptom profile of children dying from cardiac disease, especially heart failure, differs from those with cancer and other non-cardiac conditions. Treatment with vasoactive infusions at home may be a superior therapy for symptom control for these patients, rather than traditional pain and anxiety management with morphine and benzodiazepines. OBJECTIVES We report our experience using outpatient milrinone in children receiving hospice care for end-stage heart failure. METHODS Retrospective review of a contemporary cohort of all patients at Lucile Packard Children's Hospital, Stanford who were discharged on intravenous milrinone and hospice care between 2008 and 2021. Clinical data, including cardiac diagnosis, milrinone dose and route of administration, total milrinone days, symptoms reported, rehospitalization rates, concurrent therapies and complications were analyzed. RESULTS Among 8 patients, median duration of home milrinone infusion was 191 (33, 572) days with the longest support duration 1,054 days. All (100%) patients were also receiving diuretics at the time of death. Five (63%) were receiving no other pain control medications until the active phase of dying. From milrinone initiation to last outpatient assessment, a reduction in the number of patients reporting respiratory discomfort, abdominal pain, weight loss/lack of appetite, and fatigue was observed. Six (75%) died at home. CONCLUSION We used milrinone with oral diuretics effectively for symptom control in children with heart failure on palliative care. Our experience was that this combination can be used safely in the outpatient setting for long-term use without the addition of opiates, benzodiazepines, or supplemental oxygen in most cases.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA.
| | - Kari Wujcik
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Julie Schmidt
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Esther Liu
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Aileen Lin
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - John Dykes
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Julie Good
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Michelle Brown
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - David Rosenthal
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
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Ahmed H, Lee J, Bernstein D, Rosenthal D, Dykes J, Lee D, Barkoff L, Weinberg K, Hollander SA, Chen S. Increased risk of infections in pediatric Fontan patients after heart transplantation. Pediatr Transplant 2023; 27:e14421. [PMID: 36303275 DOI: 10.1111/petr.14421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Infectious complications are a major cause of morbidity and mortality after HT. Fontan patients may be more susceptible to post-HT infections. METHODS This was a single-center, retrospective cohort analysis of pediatric patients undergoing HT for FF physiology or DCM, who underwent induction with ATG. The primary endpoint was an infection in the first 180 days post-HT, defined as positive (1) blood/urine/respiratory culture; (2) viral PCR; (3) skin or wound infection; and/or (4) culture-negative infection if ≥5 days of antibiotics were completed. Secondary endpoints included (1) cell counts after ATG; (2) PTLD; and (3) rejection (≥Grade 2R ACR or pAMR2) in the first 180 days post-HT. RESULTS A total of 59 patients (26 FF, 33 DCM) underwent HT at 14.7 (IQR 10.6, 19.5) and 11.7 (IQR 1.4, 13.6) years of age, respectively. The median total ATG received was 7.4 (IQR 4.9, 7.7) vs 7.5 (IQR 7.3, 7.6) mg/kg (p = NS) for FF and DCM patients, respectively. Twenty-three patients (39%) developed an infection 180 days post-HT, with a higher rate of infection in FF patients (54% vs 27%, p = .03). Adjusted for pre-transplant absolute lymphocyte count, FF patients had a higher risk of infection at 30 days post-HT (OR 7.62, 95% CI 1.13-51.48, p = .04). There was no difference in the incidence of PTLD (12% vs 0%; p = .08) or rejection (12% vs 21%; p = .49). CONCLUSION Compared to DCM patients, FF patients have a higher risk of infection. Modifications to induction therapy for FF patients should be considered.
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Affiliation(s)
- Humera Ahmed
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Joanne Lee
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Daniel Bernstein
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - David Rosenthal
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - John Dykes
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Donna Lee
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Lynsey Barkoff
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kenneth Weinberg
- Division of Hematology-Oncology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
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16
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Sekhon R, Foshaug RR, Kantor PF, Mansukhani G, Mackie AS, Hollander SA, Lewis K, Conway J. Incidence and impact of malnutrition in patients with Fontan physiology. JPEN J Parenter Enteral Nutr 2023; 47:59-66. [PMID: 35932247 DOI: 10.1002/jpen.2437] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/21/2022] [Accepted: 08/02/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Single-ventricle patients require a series of surgeries, with the final stage being the Fontan. This form of circulation results in several long-term complications, but the impact and consequences of nutrition status remain unclear. We sought to evaluate the incidence of malnutrition in Fontan patients and the impact on outcomes. METHODS This study was a retrospective cohort study of children who underwent Fontan surgery between 1997 and 2018. Clinical, demographic, and nutrition data were collected, including weight, height, body mass index (BMI), and their respective z scores (z score for weight-for-age [WAZ], z score for height-for-age [HAZ], and z score for BMI-for-age [BMIZ]) pre-Fontan, at discharge, 6 months, and 1, 5, and 10 years post-Fontan. Malnutrition status was categorized using the American Society for Parenteral and Enteral Nutrition guidelines and the Michigan MTool. Fontan failure was defined as listing for heart transplant or death. RESULTS Of the 69 patients, moderate-severe malnutrition occurred at any time point in 11% (n = 8) by WAZ, 16% (n = 11) by HAZ, and 6% (n = 4) by BMIZ. Moderate-severe malnutrition persisted in 6.5%-12.9% at 10 years post-Fontan. Compared with the pre-Fontan period, there was no change in these parameters over time. There was no statistically significant difference in Fontan failure between degrees of pre-Fontan malnutrition. CONCLUSION There is a 6%-16% incidence of moderate-severe malnutrition in Fontan patients. Malnutrition is a condition that remains present in follow-up. There was no association with anthropometric parameters and transplant-free survival. A prospective multi-institutional study is needed to understand the impact of malnutrition on long-term outcomes.
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Affiliation(s)
- Ravneet Sekhon
- Department of Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Rae R Foshaug
- Department of Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Paul F Kantor
- Department of Pediatric Cardiology, Keck School of Medicine of USC, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Gitanjali Mansukhani
- Division of Pediatric Cardiology, Department of Pediatrics, LHSC Children's Hospital, Western University, London, Ontario, Canada
| | - Andrew S Mackie
- Department of Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Seth A Hollander
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California, USA
| | - Kylie Lewis
- Department of Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Conway
- Department of Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
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Hollander SA, Pyke-Grimm KA, Shezad MF, Zafar F, Cousino MK, Feudtner C, Char DS. End-of-Life in Pediatric Patients Supported by Ventricular Assist Devices: A Network Database Cohort Study. Pediatr Crit Care Med 2023; 24:41-50. [PMID: 36398973 DOI: 10.1097/pcc.0000000000003115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Most pediatric patients on ventricular assist device (VAD) survive to transplantation. Approximately 15% will die on VAD support, and the circumstances at the end-of-life are not well understood. We, therefore, sought to characterize patient location and invasive interventions used at the time of death. DESIGN Retrospective database study of a cohort meeting inclusion criteria. SETTING Thirty-six centers participating in the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Registry. PATIENTS Children who died on VAD therapy in the period March 2012 to September 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 117 of 721 patients (16%) who died on VAD, the median (interquartile range) age was 5 years (1-16 yr) at 43 days (17-91 d) postimplant. Initial goals of therapy were bridge to consideration for candidacy for transplantation in 60 of 117 (51%), bridge to transplantation in 44 of 117 (38%), bridge to recovery 11 of 117 (9%), or destination therapy (i.e., VAD as the endpoint) in two of 117 (2%). The most common cause of death was multiple organ failure in 35 of 117 (30%), followed by infection in 12 of 117 (10%). Eighty-five of 92 (92%) died with a functioning device in place. Most patients were receiving invasive interventions (mechanical ventilation, vasoactive infusions, etc.) at the end of life. Twelve patients (10%) died at home. CONCLUSIONS One-in-six pediatric VAD patients die while receiving device support, with death occurring soon after implant and usually from noncardiac causes. Aggressive interventions are common at the end-of-life. The ACTION Registry data should inform future practices to promote informed patient/family and clinician decision-making to hopefully reduce suffering at the end-of-life.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA
| | - Kimberly A Pyke-Grimm
- Departments of Pediatrics (Hematology/Oncology), and Nursing Research and Evidence-Based Practice, Stanford University, Palo Alto, CA
| | - Muhammad F Shezad
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Melissa K Cousino
- Departments of Pediatrics and Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Chris Feudtner
- Department of Pediatrics (General Pediatrics), Children's Hospital of Philadelphia, Philadelphia, PA
| | - Danton S Char
- Department of Anesthesia (Pediatric Cardiac), Stanford University, Palo Alto, CA
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18
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Mai DH, Sedler J, Weinberg K, Bernstein D, Schroeder A, Mathew R, Chen S, Lee D, Dykes JC, Hollander SA. Fatal nocardiosis infection in a pediatric patient with an immunodeficiency after heart re-transplantation. Pediatr Transplant 2022; 26:e14344. [PMID: 35726843 DOI: 10.1111/petr.14344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/05/2022] [Accepted: 06/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nocardia infections are rare opportunistic infections in SOT recipients, with few reported pediatric cases. Pediatric patients with single ventricle congenital heart defects requiring HT may be more susceptible to opportunistic infections due to a decreased T-cell repertoire from early thymectomy and potential immunodeficiencies related to their congenital heart disease. Other risk factors in SOT recipients include the use of immunosuppressive medications and the development of persistent lymphopenia, delayed count recovery and/or lymphocyte dysfunction. METHODS We report the case of a patient with hypoplastic left heart syndrome who underwent neonatal congenital heart surgery (with thymectomy) prior to palliative surgery and 2 HTs. RESULTS After developing respiratory and neurological symptoms, the patient was found to be positive for Nocardia farcinica by BAL culture and cerebrospinal fluid PCR. Immune cell phenotyping demonstrated an attenuated T and B-cell repertoire. Despite antibiotic and immunoglobulin therapy, his symptoms worsened and he was subsequently discharged with hospice care. CONCLUSION Pediatric patients with a history of congenital heart defects who undergo neonatal thymectomy prior to heart transplantation and a long-term history of immunosuppression should undergo routine immune system profiling to evaluate for T- and B-cell deficiency as risk factors for opportunistic infection. Such patients could benefit from long-term therapy with TMP/SMX for optimal antimicrobial prophylaxis, with desensitization as needed for allergies. Disseminated nocardiosis should be considered when evaluating acutely ill SOT recipients, especially those with persistent lymphopenia and known or suspected secondary immunodeficiencies.
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Affiliation(s)
- Daniel H Mai
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer Sedler
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Kenneth Weinberg
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Daniel Bernstein
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Alan Schroeder
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Roshni Mathew
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Sharon Chen
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Donna Lee
- Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - John C Dykes
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Stanford University School of Medicine, Palo Alto, California, USA
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19
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Adachi I, Peng DM, Hollander SA, Simpson KE, Davies RR, Jacobs JP, VanderPluym CJ, Fynn-Thompson F, Wells DA, Law SP, Amdani S, Cantor R, Koehl D, Kirklin JK, Morales DL, Rossano JW. Sixth Annual Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report. Ann Thorac Surg 2022; 115:1098-1108. [PMID: 36402175 DOI: 10.1016/j.athoracsur.2022.10.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/16/2022] [Accepted: 10/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs), supported by The Society of Thoracic Surgeons, provides detailed information on pediatric patients supported with ventricular assist devices (VADs). METHODS From September 19, 2012, to December 31, 2021, there were 1355 devices in 1109 patients (<19 years) from 42 North American Hospitals. RESULTS Cardiomyopathy was the most common underlying cause (59%), followed by congenital heart disease (25%) and myocarditis (9%). Regarding device type, implantable continuous (IC) VADs were most common at 40%, followed by paracorporeal pulsatile (PP; 28%) and paracorporeal continuous (PC; 26%). Baseline demographics differed, with the PC cohort being younger, smaller, more complex (ie, congenital heart disease), and sicker at implantation (P < .0001). At 6 months after VAD implantation, a favorable outcome (transplantation, recovery, or alive on device) was achieved in 84% of patients, which was greatest among those on IC VADs (92%) and least for PC VADs (69%). Adverse events were not uncommon, with nongastrointestinal bleeding (incidence of 14%) and neurologic dysfunction (11% [stroke, 4%]), within 2 weeks after implantation being the most prevalent. Stroke and bleeding had negative impacts on overall survival (P = .002 and P < .001, respectively). CONCLUSIONS This Sixth Pedimacs Report demonstrates the continued evolution of the pediatric field. The complexity of cardiac physiologies and anatomic constraint mandates the need for multiple types of devices used (PC, PP, IC). Detailed analyses of each device type in this report provide valuable information to further advance the care of this challenging and vulnerable population.
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20
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Hollander SA, Barkoff L, Giacone H, Adamson GT, Kaufman BD, Motonaga KS, Dubin AM, Chubb H. Risk factors and outcomes of sudden cardiac arrest in pediatric heart transplant recipients. Am Heart J 2022; 252:31-38. [PMID: 35705134 DOI: 10.1016/j.ahj.2022.06.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/16/2022] [Accepted: 06/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Sudden cardiac arrest (SCA) is a prevailing cause of mortality after pediatric heart transplant (HT) but remains understudied. We analyzed the incidence, outcomes, and risk factors for SCA at our center. METHODS Retrospective review of all pediatric HT patients at our center from January 1, 2009 to January 1, 2021. SCA was defined as an abrupt loss of cardiac function requiring cardiopulmonary resuscitation and/or mechanical circulatory support (MCS). Events that occurred in the setting of limited resuscitative wishes, or while on MCS were excluded. Patient characteristics and risk factors were analyzed. RESULTS Fourteen of 254 (6%) experienced SCA at a median of 3 (1, 4) years post-HT. Seven (50%) events occurred out-of-hospital. Eleven (79%) died from their initial event, 2 (18%) after failure to separate from extracorporeal membrane (ECMO). In univariate analysis, black race, younger donor age, prior acute cellular rejection (ACR) episode, pacemaker and/or ICD in place, and pre-mortem diagnosis of allograft vasculopathy were associated with SCA (P = .003-0.02). In multivariable analysis, history of ACR, younger donor age, and black race retained significance. [OR = 6.3, 95% CI: 1.6-25.4, P = .01], [OR = 0.9, 95% CI: 0.8-1, P = .04], and [OR = 7.3, 95% CI: 1.1-49.9, P = .04], respectively. SCA occurred in 3 patients with a functioning ICD or pacemaker, which failed to restore a perfusing rhythm. CONCLUSIONS SCA occurs relatively early after pediatric HT and is usually fatal. Half of events happen at home. Those who received younger donors, have a history of ACR, or are of black race are at increased risk. ICDs/pacemakers may offer limited protection.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA.
| | - Lynsey Barkoff
- Solid Organ Transplant Services, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Heather Giacone
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Greg T Adamson
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Kara S Motonaga
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Anne M Dubin
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Henry Chubb
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
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21
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Sullivan RT, Handler SS, Feinstein JA, Ogawa M, Liu E, Ma M, Hopper RK, Norris J, Hollander SA, Chen S. Subcutaneous Treprostinil Improves Surgical Candidacy for Next Stage Palliation in Single Ventricle Patients With High-Risk Hemodynamics. Semin Thorac Cardiovasc Surg 2022; 35:733-743. [PMID: 35931345 DOI: 10.1053/j.semtcvs.2022.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/11/2022]
Abstract
Single ventricle (SV) patients with pulmonary vascular disease (SV-PVD) are considered poor surgical candidates for Glenn or Fontan palliation. Given limited options for Stage 1 (S1) and Stage 2 (S2) SV patients with SV-PVD, we report on the use of subcutaneous treprostinil (TRE) to treat SV-PVD in this population. This single-center, retrospective cohort study examined SV patients who were not candidates for subsequent surgical palliation due to SV-PVD and were treated with TRE. The primary outcome was ability to progress to the next surgical stage; secondary outcomes included changes in hemodynamics after TRE initiation. Between 3/2014 and 8/2021, 17 SV patients received TRE for SV-PVD: 11 after S1 and 6 after S2 (median PVR 4.1 [IQR 3.2-4.8] WU*m2 and 5.0 [IQR 1.5-6.1] WU*m2, respectively). Nine of 11 (82%) S1 progressed to S2, and 2 (18%) underwent heart transplant (HTx). Three of 6 (50%) S2 progressed to Fontan, 1 underwent HTx and 2 are awaiting Fontan on TRE. TRE significantly decreased PVR in S1 patients with median post-treatment PVR of 2.0 (IQR 1.5-2.6) WU*m2. TRE can allow for further surgical palliation in select pre-Fontan patients with SV-PVD, obviating the need for HTx. Improvement in PVR was significant in S1 patients and persisted beyond discontinuation of therapy for most patients.
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Affiliation(s)
- Rachel T Sullivan
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Stephanie S Handler
- Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jeffrey A Feinstein
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Michelle Ogawa
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Esther Liu
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Michael Ma
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Rachel K Hopper
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Jana Norris
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Seth A Hollander
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Sharon Chen
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California..
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22
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Nasirov T, Dykes JC, Hollander SA, Almond CS, Reinhartz O, Maeda K, Martin E, Murray J, Chen S, Chen CY, Kaufman BD, Bernstein D, Profita EL, Rosenthal DN, Ma M. PEDS3: Twenty Years of Pediatric Ventricular Assist Device Support at a Single Institution. ASAIO J 2022. [DOI: 10.1097/01.mat.0000841104.02767.6a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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23
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Godown J, Fountain D, Bansal N, Ameduri R, Anderson S, Beasley G, Burstein D, Knecht K, Molina K, Pye S, Richmond M, Spinner JA, Watanabe K, West S, Reinhardt Z, Scheel J, Urschel S, Villa C, Hollander SA. Heart Transplantation in Children With Down Syndrome. J Am Heart Assoc 2022; 11:e024883. [PMID: 35574952 PMCID: PMC9238550 DOI: 10.1161/jaha.121.024883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Children with Down syndrome (DS) have a high risk of cardiac disease that may prompt consideration for heart transplantation (HTx). However, transplantation in patients with DS is rarely reported. This project aimed to collect and describe waitlist and post– HTx outcomes in children with DS. Methods and Results This is a retrospective case series of children with DS listed for HTx. Pediatric HTx centers were identified by their participation in 2 international registries with centers reporting HTx in a patient with DS providing detailed demographic, medical, surgical, and posttransplant outcome data for analysis. A total of 26 patients with DS were listed for HTx from 1992 to 2020 (median age, 8.5 years; 46% male). High‐risk or failed repair of congenital heart disease was the most common indication for transplant (N=18, 69%). A total of 23 (88%) patients survived to transplant. All transplanted patients survived to hospital discharge with a median posttransplant length of stay of 22 days. At a median posttransplant follow‐up of 2.8 years, 20 (87%) patients were alive, 2 (9%) developed posttransplant lymphoproliferative disorder, and 8 (35%) were hospitalized for infection within the first year. Waitlist and posttransplant outcomes were similar in patients with and without DS (P=non‐significant for all). Conclusions Waitlist and post‐HTx outcomes in children with DS selected for transplant listing are comparable to pediatric HTx recipients overall. Given acceptable outcomes, the presence of DS alone should not be considered an absolute contraindication to HTx.
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Affiliation(s)
- Justin Godown
- Division of Pediatric Cardiology Monroe Carell Jr. Children’s Hospital at VanderbiltNashville TN
| | - Darlene Fountain
- Division of Pediatric Cardiology Monroe Carell Jr. Children’s Hospital at VanderbiltNashville TN
| | - Neha Bansal
- Division of Pediatric Cardiology Children’s Hospital at MontefioreBronx NY
| | - Rebecca Ameduri
- Division of Pediatric Cardiology University of Minnesota Minneapolis MN
| | - Susan Anderson
- Division of Pediatric Cardiology University of Minnesota Minneapolis MN
| | - Gary Beasley
- Division of Pediatric Cardiology LeBonheur Children's HospitalMemphis TN
| | - Danielle Burstein
- Division of Pediatric Cardiology Children's Hospital of PhiladelphiaPhiladelphia PA
| | - Kenneth Knecht
- Division of Pediatric Cardiology Arkansas Children's HospitalLittle Rock AR
| | - Kimberly Molina
- Division of Pediatric Cardiology Primary Children's HospitalSalt Lake City UT
| | - Sherry Pye
- Division of Pediatric Cardiology Arkansas Children's HospitalLittle Rock AR
| | - Marc Richmond
- Division of Pediatric Cardiology Columbia University Medical Center New York NY
| | - Joseph A. Spinner
- Division of Pediatric Cardiology Texas Children's HospitalHouston TX
| | - Kae Watanabe
- Division of Pediatric Cardiology Lurie Children's HospitalChicago IL
| | - Shawn West
- Division of Pediatric Cardiology Children's Hospital of PittsburghPittsburgh PA
| | - Zdenka Reinhardt
- Division of Pediatric Cardiology Freeman Hospital The Newcastle upon TyneUnited Kingdom
| | - Janet Scheel
- Division of Pediatric Cardiology Washington University St. Louis MO
| | - Simon Urschel
- Division of Pediatric Cardiology University of Alberta Edmonton AB Canada
| | - Chet Villa
- Division of Pediatric Cardiology Cincinnati Children's Hospital Medical Center Cincinnati OH
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24
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Gorzynski JE, Goenka SD, Shafin K, Jensen TD, Fisk DG, Grove ME, Spiteri E, Pesout T, Monlong J, Bernstein JA, Ceresnak S, Chang PC, Christle JW, Chubb H, Dunn K, Garalde DR, Guillory J, Ruzhnikov MR, Wright C, Wusthoff CJ, Xiong K, Hollander SA, Berry GJ, Jain M, Sedlazeck FJ, Carroll A, Paten B, Ashley EA. Ultra-Rapid Nanopore Whole Genome Genetic Diagnosis of Dilated Cardiomyopathy in an Adolescent With Cardiogenic Shock. Circ Genom Precis Med 2022; 15:e003591. [DOI: 10.1161/circgen.121.003591] [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] [Indexed: 11/16/2022]
Affiliation(s)
- John E. Gorzynski
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Sneha D. Goenka
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Kishwar Shafin
- University of California at Santa Cruz Genomics Institute, Santa Cruz, CA (K.S., T.P., J.M., M.J., B.P.)
| | - Tanner D. Jensen
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | | | | | - Elizabeth Spiteri
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Trevor Pesout
- University of California at Santa Cruz Genomics Institute, Santa Cruz, CA (K.S., T.P., J.M., M.J., B.P.)
| | - Jean Monlong
- University of California at Santa Cruz Genomics Institute, Santa Cruz, CA (K.S., T.P., J.M., M.J., B.P.)
| | - Jonathan A. Bernstein
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Scott Ceresnak
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | | | - Jeffrey W. Christle
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Henry Chubb
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Kyla Dunn
- Stanford Children’s Health, Palo Alto, CA (K.D.)
| | | | - Joseph Guillory
- Oxford Nanopore Technologies, United Kingdom (D.R.G., J.G., C.W.)
| | - Maura R.Z. Ruzhnikov
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Chris Wright
- Oxford Nanopore Technologies, United Kingdom (D.R.G., J.G., C.W.)
| | - Courtney J. Wusthoff
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Katherine Xiong
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Seth A. Hollander
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Gerald J. Berry
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
| | - Miten Jain
- University of California at Santa Cruz Genomics Institute, Santa Cruz, CA (K.S., T.P., J.M., M.J., B.P.)
| | | | | | - Benedict Paten
- University of California at Santa Cruz Genomics Institute, Santa Cruz, CA (K.S., T.P., J.M., M.J., B.P.)
| | - Euan A. Ashley
- Stanford University, CA (J.E.G., S.D.G., T.D.J., E.S., J.A.B., S.C., J.W.C., H.C., M.R.Z.R., C.J.W., K.X., S.A.H., G.J.B., E.A.A.)
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25
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Cousino MK, Yu S, Blume ED, Henderson H, Hollander SA, Khan S, Parent J, Schumacher KR. Circumstances surrounding end-of-life in pediatric patients pre- and post-heart transplant: a report from the Pediatric Heart Transplant Society. Pediatr Transplant 2022; 26:e14196. [PMID: 34820983 PMCID: PMC10466174 DOI: 10.1111/petr.14196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although mortality has decreased considerably in pediatric heart transplantation, waitlist and post-transplant death rates remain notable. End-of-life focused research in this population, however, is very limited. This Pediatric Heart Transplant Society study aimed to describe the circumstances surrounding death of pediatric heart transplant patients. METHODS A retrospective analysis of the multi-institutional, international, Pediatric Heart Transplant Society registry was conducted. Descriptive statistics and univariate analyses were performed to 1) describe end-of-life in pediatric pre- and post-heart transplant patients and 2) examine associations between location of death and technological interventions at end-of-life with demographic and disease factors. RESULTS Of 9217 patients (0-18 years) enrolled in the registry between 1993 and 2018, 2804 (30%) deaths occurred; 1310 while awaiting heart transplant and 1494 post-heart transplant. The majority of waitlist deaths (89%) occurred in the hospital, primarily in ICU (74%) with most receiving mechanical ventilation (77%). Fewer post-transplant deaths occurred in the hospital (22%). Out-of-hospital death was associated with older patient age (p < .01). CONCLUSIONS ICU deaths with high use of technological interventions at end-of-life were common, particularly in patients awaiting heart transplant. In this high mortality population, findings raise challenging considerations for clinicians, families, and policy makers on how to balance quality of life amidst high risk for hospital-based death.
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Affiliation(s)
- Melissa K. Cousino
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI
- University of Michigan Congenital Heart Center, Ann Arbor, MI
- University of Michigan Transplant Center, Ann Arbor, MI
| | - Sunkyung Yu
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI
- University of Michigan Congenital Heart Center, Ann Arbor, MI
| | | | - Heather Henderson
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Seth A. Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA
| | - Sairah Khan
- Division of Cardiology, Children’s National Hospital, Washington, DC
| | - John Parent
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Kurt R. Schumacher
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI
- University of Michigan Congenital Heart Center, Ann Arbor, MI
- University of Michigan Transplant Center, Ann Arbor, MI
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Algaze CA, Margetson TD, Sutherland SM, Kwiatkowski DM, Maeda K, Navaratnam M, Samreth SP, Price EP, Zook NB, Yang JK, Hollander SA. Impact of a clinical pathway on acute kidney injury in patients undergoing heart transplant. Pediatr Transplant 2022; 26:e14166. [PMID: 34727417 DOI: 10.1111/petr.14166] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND To evaluate the impact of a clinical pathway on the incidence and severity of acute kidney injury in patients undergoing heart transplant. METHODS This was a 2.5-year retrospective evaluation using 3 years of historical controls within a cardiac intensive care unit in an academic children's hospital. Patients undergoing heart transplant between May 27, 2014, and April 5, 2017 (pre-pathway) and May 1, 2017, and November 30, 2019 (pathway) were included. The clinical pathway focused on supporting renal perfusion through hemodynamic management, avoiding or delaying nephrotoxic medications, and providing pharmacoprophylaxis against AKI. RESULTS There were 57 consecutive patients included. There was an unadjusted 20% reduction in incidence of any acute kidney injury (p = .05) and a 17% reduction in Stage 2/3 acute kidney injury (p = .09). In multivariable adjusted analysis, avoidance of Stage 2/3 acute kidney injury was independently associated with the clinical pathway era (AOR -1.3 [95% CI -2.5 to -0.2]; p = .03), achieving a central venous pressure of or less than 12 mmHg (AOR -1.3 [95% CI -2.4 to -0.2]; p = .03) and mean arterial pressure above 60 mmHg (AOR -1.6 [95% CI -3.1 to -0.01]; p = .05) in the first 48 h post-transplant, and older age at transplant (AOR - 0.2 [95% CI -0.2 to -0.06]; p = .002). CONCLUSIONS This report describes a renal protection clinical pathway associated with a reduction in perioperative acute kidney injury in patients undergoing heart transplant and highlights the importance of normalizing perioperative central venous pressure and mean arterial blood pressure to support optimal renal perfusion.
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Affiliation(s)
- Claudia A Algaze
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA.,Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tristan D Margetson
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Scott M Sutherland
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - David M Kwiatkowski
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Katsuhide Maeda
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Manchula Navaratnam
- Department of Anesthesia, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sarah P Samreth
- Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth P Price
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nina B Zook
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeffrey K Yang
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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Chen CY, Montez-Rath ME, May LJ, Maeda K, Hollander SA, Rosenthal DN, Krawczeski CD, Sutherland SM. Hemodynamic Predictors of Renal Function After Pediatric Left Ventricular Assist Device Implantation. ASAIO J 2021; 67:1335-1341. [PMID: 34860188 PMCID: PMC8647769 DOI: 10.1097/mat.0000000000001460] [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] [Indexed: 11/26/2022] Open
Abstract
Although renal function often improves after pediatric left ventricular assist device (LVAD) implantation, recovery is inconsistent. We aimed to identify hemodynamic parameters associated with improved renal function after pediatric LVAD placement. A single-center retrospective cohort study was conducted in patients less than 21 years who underwent LVAD placement between June 2004 and December 2015. The relationship between hemodynamic parameters and estimated glomerular filtration rate (eGFR) was assessed using univariate and multivariate modeling. Among 54 patients, higher preoperative central venous pressure (CVP) was associated with eGFR improvement after implantation (p = 0.012). However, 48 hours postimplantation, an increase in CVP from baseline was associated with eGFR decline over time (p = 0.01). In subgroup analysis, these associations were significant only for those with normal pre-ventricular assist device renal function (p = 0.026). In patients with preexisting renal dysfunction, higher absolute CVP values 48 and 72 hours after implantation predicted better renal outcome (p = 0.005). Our results illustrate a complex relationship between ventricular function, volume status, and renal function. Additionally, they highlight the challenge of using CVP to guide management of renal dysfunction in pediatric heart failure. Better methods for evaluating right heart function and volume status are needed to improve our understanding of how hemodynamics impact renal function in this population.
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Affiliation(s)
- Chiu-Yu Chen
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Lindsay J May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Seth A Hollander
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- From the Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Catherine D Krawczeski
- Division of Pediatric Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Scott M Sutherland
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Affiliation(s)
- Danton S Char
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology, Center for Biomedical Ethics, Stanford University School of Medicine
| | - Seth A Hollander
- Pediatric Heart Failure & Transplantation Section, Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine
| | - Chris Feudtner
- The Department of Medical Ethics, The Children's Hospital of Philadelphia
- Departments of Pediatrics, Medical Ethics and Healthcare Policy, The Perelman School of Medicine, The University of Pennsylvania
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29
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Duong SQ, Zhang Y, Hall M, Hollander SA, Thurm CW, Bernstein D, Feingold B, Godown J, Almond C. Impact of institutional routine surveillance endomyocardial biopsy frequency in the first year on rejection and graft survival in pediatric heart transplantation. Pediatr Transplant 2021; 25:e14035. [PMID: 34003559 DOI: 10.1111/petr.14035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/11/2021] [Accepted: 04/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Routine surveillance biopsy (RSB) is performed to detect asymptomatic acute rejection (AR) after heart transplantation (HT). Variation in pediatric RSB across institutions is high. We examined center-based variation in RSB and its relationship to graft loss, AR, coronary artery vasculopathy (CAV), and cost of care during the first year post-HT. METHODS We linked the Pediatric Health Information System (PHIS) and Scientific Registry of Transplant Recipients (SRTR, 2002-2016), including all primary-HT aged 0-21 years. We characterized centers by RSB frequency (defined as median biopsies performed among recipients aged ≥12 months without rejection in the first year). We adjusted for potential confounders and center effects with mixed-effects regression analysis. RESULTS We analyzed 2867 patients at 29 centers. After adjusting for patient and center differences, increasing RSB frequency was associated with diagnosed AR (OR 1.15 p = 0.004), a trend toward treated AR (OR 1.09 p = 0.083), and higher hospital-based cost (US$390 315 vs. $313 248, p < 0.001) but no difference in graft survival (HR 1.00, p = 0.970) or CAV (SHR 1.04, p = 0.757) over median follow-up 3.9 years. Center RSB-frequency threshold of ≥2/year was associated with increased unadjusted rates of treated AR, but no association was found at thresholds greater than this. CONCLUSION Center RSB frequency is positively associated with increased diagnosis of AR at 1 year post-HT. Graft survival and CAV appear similar at medium-term follow-up. We speculate that higher frequency RSB centers may have increased detection of clinically less important AR, though further study of the relationship between center RSB frequency and differences in treated AR is necessary.
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Affiliation(s)
- Son Q Duong
- Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Yulin Zhang
- Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Seth A Hollander
- Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Cary W Thurm
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Daniel Bernstein
- Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Brian Feingold
- Pediatrics (Cardiology) and Clinical Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Justin Godown
- Pediatrics (Cardiology), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Christopher Almond
- Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
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Hollander SA, Kaufman BD, Bui C, Gregori B, Murray JM, Sacks L, Ryan KR, Ma M, Rosenthal DN, Char D. Compassionate Deactivation of Pediatric Ventricular Assist Devices: A Review of 14 Cases. J Pain Symptom Manage 2021; 62:523-528. [PMID: 33910026 DOI: 10.1016/j.jpainsymman.2021.01.125] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/21/2021] [Accepted: 01/27/2021] [Indexed: 11/16/2022]
Abstract
CONTEXT Compassionate deactivation (CD) of ventricular assist device (VAD) support is a recognized option for children when the burden of therapy outweighs the benefits. OBJECTIVES To describe the prevalence, indications, and outcomes of CD of children supported by VADs at the end of life. METHODS Review of cases of CD at our institution between 2011 and 2020. To distinguish CD from other situations where VAD support is discontinued, patients were excluded from the study if they died during resuscitation (including extracorporeal membrane oxygenation), experienced brain or circulatory death prior to deactivation, or experienced a non-survivable brain injury likely to result in imminent death regardless of VAD status. RESULTS Of 24 deaths on VAD, 14 (58%) were CD. Median age was 5.7 (interquartile range (IQR) 0.6, 11.6) years; 6 (43%) had congenital heart disease; 4 (29%) were on a device that can be used outside of the hospital. CD occurred after 40 (IQR: 26, 75) days of support; none while active transplant candidates. CD discussions were initiated by the caregiver in 6 (43%) cases, with the remainder initiated by a medical provider. Reasons for CD were multifactorial, including end-organ injury, infection, and stroke. CD occurred with endotracheal extubation and/or discontinuation of inotropes in 12 (86%) cases, and death occurred within 10 (IQR: 4, 23) minutes of CD. CONCLUSION CD is the mode of death in more than half of our VAD non-survivors and is pursued for reasons primarily related to noncardiac events. Caregivers and providers both initiate CD discussions. Ventilatory and inotropic support is often withdrawn at time of CD with ensuing death.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA.
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Christine Bui
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Bianca Gregori
- Department of Social Work, Lucile Packard Children's Hospital Stanford (B.G.), Palo Alto, California, USA
| | - Jenna M Murray
- Solid Organ Transplant Services, Lucile Packard Children's Hospital Stanford (J.M.M), Palo Alto, California, USA
| | - Loren Sacks
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Kathleen R Ryan
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine (M.M.), Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Danton Char
- Department of Anesthesia, Stanford University School of Medicine (D.C.), Palo Alto, California, USA
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31
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Dasgupta MN, Montez-Rath ME, Hollander SA, Sutherland SM. Using kinetic eGFR to identify acute kidney injury risk in children undergoing cardiac transplantation. Pediatr Res 2021; 90:632-636. [PMID: 33446916 DOI: 10.1038/s41390-020-01307-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/12/2020] [Accepted: 11/18/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common following pediatric cardiac transplantation. Since no treatments exist, strategies focus on early identification and prevention. Kinetic glomerular filtration rate (kGFR) was developed to assess renal function in the non-steady state. Although used to predict AKI in adults, kGFR has not been explored in children. Our study examines AKI and the ability of kGFR to identify AKI risk in pediatric heart transplant recipients. METHODS One hundred and seventy-five patients under 21 years who underwent cardiac transplantation at Lucile Packard Children's Hospital between September 2007-December 2017 were included. kGFR1 was calculated using pre-operative and immediate post-operative creatinines; kGFR2 was calculated with the first two post-operative creatinines. The primary outcome was AKI as defined by the Kidney Disease: Improving Global Outcomes criteria. RESULTS One hundred and thirty-one (75%) and 78 (45%) patients developed AKI and severe AKI, respectively; 5 (2.9%) required dialysis. kGFR was moderately associated with post-operative AKI risk. The adjusted area under the curve (AUC) for kGFR1 was 0.72 (discovery) and 0.65 (validation). The AUC for kGFR2 was 0.72 (discovery) and 0.68 (validation). CONCLUSIONS AKI is pervasive in children undergoing cardiac transplant, particularly in the 24 h after surgery. kGFR moderately identifies AKI risk and may represent a novel risk stratification technique. IMPACT Our research suggests that kGFR, a dynamic assessment of renal function that uses readily available laboratory values, can moderately identify AKI risk in children undergoing cardiac transplantation. Current published studies on kGFR are in adult populations; this study represents the first formal study of kGFR in a pediatric population. kGFR may serve as an early AKI indicator, allowing providers to implement preventative strategies sooner in a patient's clinical course.
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Affiliation(s)
| | | | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Scott M Sutherland
- Department of Pediatrics (Nephrology), Stanford University, Palo Alto, CA, USA
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32
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Sganga D, Hollander SA, Vaikunth S, Haeffele C, Bensen R, Navaratnam M, McDonald N, Profita E, Maeda K, Concepcion W, Bernstein D, Chen S. Comparison of combined heart‒liver vs heart-only transplantation in pediatric and young adult Fontan recipients. J Heart Lung Transplant 2021; 40:298-306. [PMID: 33485775 PMCID: PMC8026537 DOI: 10.1016/j.healun.2020.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 07/11/2020] [Revised: 11/23/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Indications for a heart‒liver transplantation (HLT) for Fontan recipients are not well defined. We compared listing characteristics, post-operative complications, and post-transplant outcomes of Fontan recipients who underwent HLT with those of patients who underwent heart-only transplantation (HT). We hypothesized that patients who underwent HLT have increased post-operative complications but superior survival outcomes compared with patients who underwent HT. METHODS We performed a retrospective review of Fontan recipients who underwent HLT or HT at a single institution. Characteristics at the time of listing, including the extent of liver disease determined by laboratory, imaging, and biopsy data, were compared. Post-operative complications were assessed, and the Kaplan‒Meier survival method was used to compare post-transplant survival. Univariate regression analyses were performed to identify the risk factors for increased mortality and morbidity among patients who underwent HT. RESULTS A total of 47 patients (9 for HLT, 38 for HT) were included. Patients who underwent HLT were older, were more likely to be on dual inotrope therapy, and had evidence of worse liver disease. Whereas ischemic time was longer for the group who underwent HLT, post-operative complications were similar. Over a median post-transplant follow-up of 17 (interquartile range: 5-52) months, overall mortality for the cohort was 17%; only 1 patient who underwent HLT died (11%) vs 7 patients who underwent HT (18%) (p = 0.64). Among patients who underwent HT, cirrhosis on pre-transplant imaging was associated with worse outcomes. CONCLUSIONS Despite greater inotrope need and more severe liver disease at the time of listing, Fontan recipients undergoing HLT have post-transplant outcomes comparable with those of patients undergoing HT. HLT may offer a survival benefit for Fontan recipients with liver disease.
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Affiliation(s)
| | | | | | | | | | | | - Nancy McDonald
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvannia
| | - Waldo Concepcion
- Department of Transplantation Services, Mohammed Bin Rashid University School of Medicine, Dubai, UAE
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33
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Almond CS, Chen S, Dykes JC, Kwong J, Burstein DS, Rosenthal DN, Kipps AK, Teuteberg J, Murray JM, Kaufman BD, Hollander SA, Profita E, Yarlagadda VY, Sacks LD, Chen CY. The Stanford acute heart failure symptom score for patients hospitalized with heart failure. J Heart Lung Transplant 2020; 39:1250-1259. [DOI: 10.1016/j.healun.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/24/2020] [Accepted: 08/02/2020] [Indexed: 11/17/2022] Open
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Lee A, Concepcion W, Gonzales S, Sutherland SM, Hollander SA. Acute kidney injury and chronic kidney disease after combined heart-liver transplant in patients with congenital heart disease: A retrospective case series. Pediatr Transplant 2020; 24:e13833. [PMID: 32985770 DOI: 10.1111/petr.13833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022]
Abstract
Although it is known that children undergoing heart transplantation are at increased risk for both AKI and CKD, renal function following CHLT remains understudied. All pediatric CHLT patients from 2006 to 2019 were included. The prevalence of AKI in the first 7 post-operative days, renal recovery at 30 post-operative days, and CKD were ascertained. AKI was defined as an increase in creatinine greater than 1.5 times baseline, and CKD, as an eCrCl less than 90 mL/min/1.73 m2 . The need for RRT was also analyzed. 10 patients were included, with an average age of 20 years and an average listing time of 130 days. Preoperatively, the median eCrCl was 91.12 mL/min/m2 (IQR 70.51, 127.75 min/mL/m2 ). 5 (50%) patients had CKD, with 4 at stage 2 and 1 at stage 3. AKI occurred post-operatively in 3 of 9 (33%) patients: 2 at stage 1 and 1 at stage 2. 2 (67%) resolved by 7 days. Of the 5 patients who reached their 1-year follow-up, 1 (20%) had stage 3 CKD. Among 2 patients, neither had CKD at 5 years. One patient required RRT 2 weeks after CHLT. Despite an increased prevalence of preoperative CKD, patients undergoing CHLT have a lower AKI prevalence than those receiving an isolated heart or liver transplant. Of those with AKI, early renal recovery is common, although at 1 year CKD remains present in 20%. Among long-term survivors, normal renal function is achievable.
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Affiliation(s)
- Angela Lee
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Waldo Concepcion
- Division of Abdominal Transplantation, Department of General Surgery, Stanford University, Stanford, California, USA
| | - Selena Gonzales
- Division of Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Scott M Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Seth A Hollander
- Division of Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
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Hollander SA, Nandi D, Bansal N, Godown J, Zafar F, Rosenthal DN, Lorts A, Jeewa A. A coordinated approach to improving pediatric heart transplant waitlist outcomes: A summary of the ACTION November 2019 waitlist outcomes committee meeting. Pediatr Transplant 2020; 24:e13862. [PMID: 32985785 DOI: 10.1111/petr.13862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
The number of children needing heart transplantation continues to rise. Although improvements in heart failure therapy, particularly durable mechanical support, have reduced waitlist mortality, the number of children who die while waiting for a suitable donor organ remains unacceptably high. Roughly, 13% of children and 25% of infants on the heart transplant waitlist will not survive to transplantation. With this in mind, the Advanced Cardiac Therapies Improving Outcomes Collaborative Learning Network (ACTION), through its Waitlist Outcomes Committee, convened a 2-day symposium in Ann Arbor, Michigan, from 2-3 November 2019, to better understand the factors that contribute to pediatric heart transplant waitlist mortality and to focus future efforts on improving the organ allocation rates for children needing heart transplantation. Using improvement science methodology, the heart failure-transplant trajectory was broken down into six key steps, after which modes of failure and opportunities for improvement at each step were discussed. As a result, several projects aimed at reducing waitlist mortality were initiated.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Deipanjan Nandi
- Division of Pediatrics (Cardiology), Nationwide Children's Hospital, Columbus, OH, USA
| | - Neha Bansal
- Division of Pediatrics Cardiology, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Justin Godown
- Department of Pediatrics (Cardiology), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Aamir Jeewa
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, USA
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Knoll C, Kaufman B, Chen S, Murray J, Cohen H, Sourkes BM, Rosenthal DN, Hollander SA. Palliative Care Engagement for Pediatric Ventricular Assist Device Patients: A Single-Center Experience. ASAIO J 2020; 66:929-932. [PMID: 32740354 DOI: 10.1097/mat.0000000000001092] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Outcomes in pediatric patients with ventricular assist devices (VADs) for advanced heart failure (HF) are improving, but the risk of associated morbidity and mortality remains substantial. Few data exist on the involvement of pediatric palliative care (PPC) in this high-risk patient population. We aimed to characterize the extent of palliative care involvement in the care of patients requiring VAD placement at our institution. Single-center retrospective chart review analyzing all VAD patients at a large pediatric center over a 4 year period. Timing and extent of palliative care subspecialty involvement were analyzed. Between January 2014 and December 2017, 55 HF patients underwent VAD implantation at our institution. Pediatric palliative care utilization steadily increased over consecutive years (2014: <10% of patients, 2015: 20% of patients, 2016: 50% of patients, and 2017: 65% of patients) and occurred in 42% (n = 23) of all patients. Of these, 57% (n = 13) occurred before VAD placement while 43% (n = 10) occurred after implantation. Patients who died during their VAD implant hospitalization (24%, n = 13) were nearly twice as likely to have PPC involvement (62%) as those who reached transplant (38%). Of those who died, patients who had PPC involved in their care were more likely to limit resuscitation efforts before their death. Four patients had advanced directives in place before VAD implant, of which three had PPC consultation before device placement. Three families (5%) refused PPC involvement when offered. Pediatric palliative care utilization is increasing in VAD patients at our institution. Early PPC involvement occurred in the majority of patients and appears to lead to more frequent discussion of goals-of-care and advanced directives.
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Affiliation(s)
- Christopher Knoll
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Beth Kaufman
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Sharon Chen
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Jenna Murray
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Harvey Cohen
- Division of Hematology/Oncology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Barbara M Sourkes
- Division of Pediatric Critical Care, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - David N Rosenthal
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Seth A Hollander
- From the Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
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Hollander SA, Ogawa MT, Hopper RK, Liu E, Chen S, Rosenthal DN, Feinstein JA. Treprostinil improves hemodynamics and symptoms in children with mild pulmonary hypertension awaiting heart transplantation. Pediatr Transplant 2020; 24:e13742. [PMID: 32428328 DOI: 10.1111/petr.13742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/05/2020] [Accepted: 04/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Treprostinil, a prostacyclin analog, is a safe and effective therapy for children with PAH; however, the use of this agent in children with mild PVR elevations related to HF, including those with SV congenital heart disease awaiting HT, is understudied. We describe the hemodynamic and symptomatic changes in pediatric patients awaiting HT treated with treprostinil. METHODS Single-center retrospective review of all patients was listed for HT who received treprostinil during the listing period. Changes in hemodynamic and functional indices between the baseline catheterization (prior to drug initiation), and prior to HT, and patient outcomes were analyzed. RESULTS Among 16/17 (94%) who survived to HT, 8 (50%) were female, and 10 (63%) had SV physiology. The median age at drug initiation was 9 (IQR: 1, 14) years. The median duration of therapy prior to HT was 253 (IQR: 148, 504) days. Treprostinil significantly decreased PVR (3.8 vs 3.1 WU, P = .03), while mLA or mPCW pressure did not change (11 vs 13 mm Hg, P = .9). HF symptoms improved in 9/15 (60%) patients without VAD support prior to drug initiation, including 4/10 (40%) who did not receive a VAD any point while awaiting HT. CONCLUSIONS Treprostinil may be used safely in patients with mild PAH awaiting HT, including those with SV disease. PVR falls without substantial increases in mLA/mPCW pressure. HF symptoms improve in some patients.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Michelle T Ogawa
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Rachel K Hopper
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Esther Liu
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Sharon Chen
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, California, USA
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Chen CY, Chen SF, Hollander SA, Rosenthal D, Maeda K, Burgart A, Almond CS, Chen S. Donor heart selection during the COVID-19 pandemic: A case study. J Heart Lung Transplant 2020; 39:497-498. [PMID: 32362395 PMCID: PMC7193142 DOI: 10.1016/j.healun.2020.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/21/2020] [Accepted: 03/21/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Chiu-Yu Chen
- Department of Pediatrics, Divisions of Pediatric Cardiology
| | | | | | | | | | - Alyssa Burgart
- Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California
| | | | - Sharon Chen
- Department of Pediatrics, Divisions of Pediatric Cardiology
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Power A, Schultz L, Dennis K, Rizzuto S, Hollander AM, Rosenthal DN, Almond CS, Hollander SA. Growth stunting in single ventricle patients after heart transplantation. Pediatr Transplant 2020; 24:e13634. [PMID: 31845499 DOI: 10.1111/petr.13634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/09/2019] [Accepted: 11/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Malnutrition is common among children with single ventricle (SV) congenital heart disease (CHD). The impact of heart transplantation (HT) on nutritional status in SV patients is understudied. Our aim was to evaluate anthropometric changes in SV patients after HT, compared with those transplanted for cardiomyopathy (CM). METHODS We performed a single-center retrospective chart review of SV and CM patients < 18 years who underwent HT from January 01, 2010 to December 05, 2017. Wasting and stunting were defined as z-scores for weight-for-age or height-for-age ≤-2, respectively. Changes in these indices between HT and 3 years post-HT were analyzed. RESULTS Of 86 eligible patients, 28 (33%) had SV CHD and 58 (67%) had CM. Data were available at 3 years post-HT for 57 patients. At transplant, wasting was equally present in SV versus CM patients (7/28, 25% vs. 9/58, 16%, P = .22), which remained true at 3 years post-HT (2/16, 13% vs. 3/41, 7%, P = .61). At transplant, stunting was more common in SV than CM patients (17/28, 61% vs. 8/58, 14%, P < .001). At 3 years post-HT, 6 of 16 (38%) SV patients and 3 of 41 (7%) CM patients remained stunted (P = .01). Among all patients, wasting decreased from transplant to end-point (19% vs. 9%, P = .05), but stunting did not (29% vs. 16%, P = .2), such that wasting and stunting were associated at transplant (P < .001) but not at end-point (P = .17). CONCLUSIONS Longitudinal growth remains impaired for several years after HT in SV patients, even when weight gain is achieved, suggesting that some factors contributing to growth impairment persist despite resolution of SV physiology.
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Affiliation(s)
- Alyssa Power
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Lisa Schultz
- Nutrition Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Katelin Dennis
- Nutrition Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Sandra Rizzuto
- Rehabilitation Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Amanda M Hollander
- Rehabilitation Services, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | | | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
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Wilkens SJ, Priest J, Kaufman BD, Barkoff L, Rosenthal DN, Hollander SA. Pediatric waitlist and heart transplant outcomes in patients with syndromic anomalies. Pediatr Transplant 2020; 24:e13643. [PMID: 31891211 DOI: 10.1111/petr.13643] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/11/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE We sought to determine whether the presence of a systemic SA with potential complicating factors affects waitlist and post-HT outcomes in pediatric patients. METHODS This is a single-center retrospective review of pediatric patients listed for HT between January 1, 2009, and July 1, 2018. Patients were selected based on the presence of any underlying syndromes, which included chromosomal anomalies, skeletal myopathies, connective tissue disorders, mitochondrial disease,and other systemic disorders. Waitlist and post-HT outcomes were compared to those without SA. RESULTS A total of 243 patients were listed for HT, of which 21 (9%) patients had associated SA. Of those, 16 (76%) survived to transplant, 3 (14%) died while on the waitlist, 1 (5%) improved and was removed from the waitlist, and 1 (5%) patient is currently listed. Waitlist survival was not different between those with/without an associated syndrome (P = 1.0). Among those who survived to HT, there was no difference in listing days (70 vs 90, P = .8), survival to hospital discharge [14 (93%) vs 150 (95%), P = .6], post-HT intubation days (2 vs 2 days, P = .6), or post-HT hospital length of stay (18 vs 18 days, P = .8). Overall survival during the study period post-HT was not different between groups (P = .8). CONCLUSION A SA was present in 9% of pediatric patients wait-listed for HT, but was not associated with an increased waitlist mortality or post-HT hospital morbidity or long-term survival. For several anomalies, HT is safe and feasible.
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Affiliation(s)
- Sarah J Wilkens
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - James Priest
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Beth D Kaufman
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Lynsey Barkoff
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - David N Rosenthal
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Seth A Hollander
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
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Hollander SA, Cantor RS, Sutherland SM, Koehl DA, Pruitt E, McDonald N, Kirklin JK, Ravekes WJ, Ameduri R, Chrisant M, Hoffman TM, Lytrivi ID, Conway J. Renal injury and recovery in pediatric patients after ventricular assist device implantation and cardiac transplant. Pediatr Transplant 2019; 23:e13477. [PMID: 31124590 DOI: 10.1111/petr.13477] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/05/2019] [Accepted: 04/18/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The use of ventricular assist devices (VADs) in children with heart failure may be of particular benefit to those with accompanying renal failure, as improved renal function is seen in some, but not all recipients. We hypothesized that persistent renal dysfunction at 7 days and/or 1 month after VAD implantation would predict chronic kidney disease (CKD) 1 year after heart transplantation (HT). METHODS Linkage analysis of all VAD patients enrolled in both the PEDIMACS and PHTS registries between 2012 and 2016. Persistent acute kidney injury (P-AKI), defined as a serum creatinine ≥1.5× baseline, was assessed at post-implant day 7. Estimated glomerular filtration rate (eGFR) was determined at implant, 30 days thereafter, and 12 months post-HT. Pre-implant eGFR, eGFR normalization (to ≥90 mL/min/1.73 m2 ), and P-AKI were used to predict post-HT CKD (eGFR <90 mL/min/1.73 m2 ). RESULTS The mean implant eGFR was 85.4 ± 46.5 mL/min/1.73 m2 . P-AKI was present in 19/188 (10%). Mean eGFR at 1 month post-VAD implant was 131.1 ± 62.1 mL/min/1.73 m2 , significantly increased above baseline (P < 0.001). At 1 year post-HT (n = 133), 60 (45%) had CKD. Lower pre-implant eGFR was associated with post-HT CKD (OR 0.99, CI: 0.97-0.99, P = 0.005); P-AKI was not (OR 0.96, CI: 0.3-3.0, P = 0.9). Failure to normalize renal function 30 days after implant was highly associated with CKD at 1 year post-transplant (OR 12.5, CI 2.8-55, P = 0.003). CONCLUSIONS Renal function improves after VAD implantation. Lower pre-implant eGFR and failure to normalize renal function during the support period are risk factors for CKD development after HT.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Scott M Sutherland
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Palo Alto, California
| | - Devin A Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth Pruitt
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nancy McDonald
- Solid Organ Transplant Services, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Rebecca Ameduri
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
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Machado DS, Hollander SA, Murray J, Philip J, Bleiweis M, Kittelson S. Ventricular assist device deactivation in children: Preparedness planning and procedural checklist. J Heart Lung Transplant 2019; 38:1116-1118. [PMID: 31301967 DOI: 10.1016/j.healun.2019.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 06/07/2019] [Accepted: 06/16/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Desiree S Machado
- Department of Pediatric Cardiac Critical Care, Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Stanford, California
| | - Jenna Murray
- Department of Pediatrics (Cardiology), Stanford University, Stanford, California
| | - Joseph Philip
- Department of Pediatric Cardiac Critical Care, Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Mark Bleiweis
- Departments of Surgery, Division of Thoracic and Cardiovascular Surgery, Congenital Heart Center
| | - Sheri Kittelson
- Palliative Care, University of Florida, Gainesville, Florida
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Navaratnam M, Maeda K, Hollander SA. Pediatric ventricular assist devices: Bridge to a new era of perioperative care. Paediatr Anaesth 2019; 29:506-518. [PMID: 30758099 DOI: 10.1111/pan.13609] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 01/17/2023]
Abstract
Pediatric ventricular assist devices (VADs) are evolving as a standard therapy for end stage heart failure in children. Major recent developments include the increased use of continuous flow (CF) devices in children and increased experience with congenital heart disease (CHD) and outpatient management. In the current and future era anesthesiologists will encounter more children presenting for VAD implantation, subsequent procedures and heart transplantation. Successful perioperative management requires an understanding of the interaction between the patient's physiology and the device and a framework to troubleshoot problems. This review focuses on CF devices, VAD support for CHD and perioperative management of pulsatile and CF devices in the pediatric population.
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Affiliation(s)
- Manchula Navaratnam
- Pediatric Anesthesia, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California
| | - Katsuhide Maeda
- Pediatric Cardiac Surgery, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California
| | - Seth A Hollander
- Pediatric Cardiology, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California
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Kaufman BD, Hollander SA, Zhang Y, Chen S, Bernstein D, Rosenthal DN, Almond CS, Murray JM, Burgart AM, Cohen HJ, Kirkpatrick JN, Blume ED. Compassionate deactivation of ventricular assist devices in children: A survey of pediatric ventricular assist device clinicians' perspectives and practices. Pediatr Transplant 2019; 23:e13359. [PMID: 30734422 DOI: 10.1111/petr.13359] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/29/2018] [Accepted: 01/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study's objective was to investigate compassionate ventricular assist device deactivation (VADdeact) in children from the perspective of the pediatric heart failure provider. BACKGROUND Pediatric VAD use is a standard therapy for advanced heart failure. Serious adverse events may affect relative benefit of continued support, leading to consideration of VADdeact. Perspectives and practices regarding VADdeact have been studied in adults but not in children. METHODS A web-based anonymous survey of clinicians for pediatric VAD patients (<18 years) was sent to list-serves for the ISHLT Pediatric Council, the International Consortium of Circulatory Assist Clinicians Pediatric Taskforce, and the Pediatric Cardiac Intensivist Society. RESULTS A total of 106 respondents met inclusion criteria of caring for pediatric VAD patients. Annual VAD volume per clinician ranged from <4 (33%) to >9 (20%). Seventy percent of respondents had performed VADdeact of a child. Response varied to VADdeact requests by parent or patient and was influenced by professional degree and region of practice. Except for the scenario of intractable suffering, no consensus on VADdeact appropriateness was reported. Age of child thought capable of making informed requests for VADdeact varied by subspecialty. The majority of respondents (62%) do not feel fully informed of relevant legal issues; 84% reported that professional society supported guidelines for VADdeact in children had utility. CONCLUSION There is limited consensus regarding indications for VADdeact in children reported by pediatric VAD provider survey respondents. Knowledge gaps related to legal issues are evident; therefore, professional guidelines and educational resources related to pediatric VADdeact are needed.
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Affiliation(s)
- Beth D Kaufman
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Yulin Zhang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sharon Chen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Daniel Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Christopher S Almond
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jenna M Murray
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Alyssa M Burgart
- Anesthesiology, Perioperative and Pain Medicine, Stanford Center for Biomedical Ethics, Stanford University, Palo Alto, California
| | - Harvey J Cohen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - James N Kirkpatrick
- Division of Cardiology, Department of Bioethics and Humanities, University of Washington Medical Center, Seattle, Washington
| | - Elizabeth D Blume
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
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Hollander SA, Schultz LM, Dennis K, Hollander AM, Rizzuto S, Murray JM, Rosenthal DN, Almond CS. Impact of ventricular assist device implantation on the nutritional status of children awaiting heart transplantation. Pediatr Transplant 2019; 23:e13351. [PMID: 30628144 DOI: 10.1111/petr.13351] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Malnutrition is common in pediatric heart failure and is associated with mortality. The effect of VAD support on malnutrition in children is unknown. We sought to compare the prevalence and severity of malnutrition at HT in children on VAD support vs OMT to inform decisions regarding support strategies. METHODS Retrospective chart review involving all patients <18 years who underwent HT at Stanford between 1/1/2011 and 3/1/2018. Malnutrition diagnosis and severity were defined by ASPEN guidelines using the lowest age-adjusted z-score for weight (WAZ), height (HAZ), and BMI (BMIZ) when the patient was euvolemic. Changes in z-scores from baseline to HT and across groups were analyzed. RESULTS A total of 104 patients (52 in each group) were included. Among all patients, WAZ (-0.9 vs 0.3, P < 0.001) and BMIZ (0 vs 0.6, P < 0.001) improved while HAZ (-0.9 vs -0.9, P = 0.4) did not. Compared to children on OMT, children on VAD experienced greater increases in WAZ (0.8 vs 0.3, P < 0.001) and BMIZ (0.7 vs 0.2, P < 0.003) at HT. The prevalence of moderate-to-severe malnutrition decreased in VAD patients (40% to 19%, P < 0.001) and increased in OMT patients (37% to 46%, P < 0.001), leading to a lower prevalence of moderate-to-severe malnutrition at HT (19% vs 46%, P = 0.003). CONCLUSIONS Malnutrition is common in pediatric HT candidates. Compared to children on OMT, children on VAD support had greater improvement in nutritional status while awaiting HT, and a lower prevalence of malnutrition at HT.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Lisa M Schultz
- Nutrition Services, Lucile Packard Children's Hospital, Stanford, California
| | - Katelin Dennis
- Nutrition Services, Lucile Packard Children's Hospital, Stanford, California
| | - Amanda M Hollander
- Rehabilitation Services, Lucile Packard Children's Hospital, Stanford, California
| | - Sandra Rizzuto
- Rehabilitation Services, Lucile Packard Children's Hospital, Stanford, California
| | - Jenna M Murray
- Solid Organ Transplant Services, Lucile Packard Children's Hospital, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Christopher S Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
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Oren D, Chau P, Manning M, Kwong J, Kaufman BD, Maeda K, Rosenthal DN, Hollander SA. Heart transplantation in two adolescents with Danon disease. Pediatr Transplant 2019; 23:e13335. [PMID: 30536852 DOI: 10.1111/petr.13335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/24/2018] [Accepted: 11/08/2018] [Indexed: 12/01/2022]
Abstract
Danon disease (DD) is an X-linked dominant disorder caused by a mutation in the lysosomal-associated membrane protein-2 (LAMP-2) gene coding for the LAMP-2 protein. We report two cases of successful heart transplantation (HT) in adolescent brothers with DD, including one who was bridged to HT for 34 days with a HeartWare left ventricular assist device. In both patients, the post-transplant course was complicated by profound skeletal muscle weakness that resolved with corticosteroid withdrawal. These cases highlight that both HT and ventricular assist device support are feasible in patients with DD. Corticosteroid use may exacerbate skeletal myopathy, and therefore, steroid minimization may be warranted whenever possible.
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Affiliation(s)
- Daniel Oren
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Peter Chau
- Department of Pediatrics (Cardiology), Loma Linda Medical Center, Loma Linda, California
| | - Melanie Manning
- Department of Pediatrics (Medical Genetics) and Pathology, Stanford University Medical Center, Stanford University, Stanford, California
| | - Joann Kwong
- Rehabilitation Services, Lucile Packard Children's Hospital, Stanford, California
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Stanford University, Stanford, California
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Stanford University, Stanford, California
| | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Stanford University, Stanford, California
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Peng DM, Ding VY, Hollander SA, Khalapyan T, Dykes JC, Rosenthal DN, Almond CS, Sakarovitch C, Desai M, McElhinney DB. Long-term surveillance biopsy: Is it necessary after pediatric heart transplant? Pediatr Transplant 2019; 23:e13330. [PMID: 30506612 PMCID: PMC8063536 DOI: 10.1111/petr.13330] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/15/2018] [Accepted: 11/02/2018] [Indexed: 12/16/2022]
Abstract
Due to limited and conflicting data in pediatric patients, long-term routine surveillance endomyocardial biopsy (RSB) in pediatric heart transplant (HT) remains controversial. We sought to characterize the rate of positive RSB and determine factors associated with RSB-detected rejection. Records of patients transplanted at a single institution from 1995 to 2015 with >2 year of post-HT biopsy data were reviewed for RSB-detected rejections occurring >2 year post-HT. We illustrated the trajectory of significant rejections (ISHLT Grade ≥3A/2R) among total RSB performed over time and used multivariable logistic regression to model the association between time and risk of rejection. We estimated Kaplan-Meier freedom from rejection rates by patient characteristics and used the log-rank test to assess differences in rejection probabilities. We identified the best-fitting Cox proportional hazards regression model. In 140 patients, 86% did not have any episodes of significant RSB-detected rejection >2 year post-HT. The overall empirical rate of RSB-detected rejection >2 year post-HT was 2.9/100 patient-years. The percentage of rejection among 815 RSB was 2.6% and remained stable over time. Years since transplant remained unassociated with rejection risk after adjusting for patient characteristics (OR = 0.98; 95% CI 0.78-1.23; P = 0.86). Older age at HT was the only factor that remained significantly associated with risk of RSB-detected rejection under multivariable Cox analysis (P = 0.008). Most pediatric patients did not have RSB-detected rejection beyond 2 years post-HT, and the majority of those who did were older at time of HT. Indiscriminate long-term RSB in pediatric heart transplant should be reconsidered given the low rate of detected rejection.
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Affiliation(s)
- David M. Peng
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - Victoria Y. Ding
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Seth A. Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - Tigran Khalapyan
- Clinical and Translational Research Program, Palo Alto, California
| | - John C. Dykes
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - David N. Rosenthal
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California
| | - Christopher S. Almond
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California,Clinical and Translational Research Program, Palo Alto, California
| | - Charlotte Sakarovitch
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Manisha Desai
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Doff B. McElhinney
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Betty Irene Moore Children’s Heart Center, Palo Alto, California,Clinical and Translational Research Program, Palo Alto, California,Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
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Peng DM, Kipps AK, Palmon M, Tacy TA, Peng LF, Hollander SA, McElhinney DB. Utility of screening echocardiogram after endomyocardial biopsy for identification of cardiac perforation or tricuspid valve injury. Pediatr Transplant 2018; 22:e13275. [PMID: 30076684 DOI: 10.1111/petr.13275] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 07/03/2018] [Accepted: 07/12/2018] [Indexed: 11/27/2022]
Abstract
Per protocol, our institution obtains echocardiograms immediately after each EMB to rule out procedural complication. We sought to determine the incidence of echocardiogram-detected cardiac perforation and TV injury and to evaluate the utility of routine screening echocardiogram after each EMB in the current era. At a single center, 99% (1917/1942) EMB performed in 162 patients were immediately followed by an echocardiogram per protocol. There were five newly diagnosed pericardial effusions, and only one required pericardiocentesis. In the three echocardiograms demonstrating new flail TV, only one patient underwent surgical repair 2 months later. This study demonstrates the very low incidence of significant hemopericardium and TV injury after EMB in pediatric heart transplant recipients and argues against the utility of post-EMB echocardiograms to screen solely for procedural complications.
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Affiliation(s)
- David M Peng
- The Heart Center Clinical and Translational Research Program, Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, California.,Department of Pediatrics, Stanford University, Palo Alto, California
| | - Alaina K Kipps
- The Heart Center Clinical and Translational Research Program, Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, California.,Department of Pediatrics, Stanford University, Palo Alto, California
| | - Michal Palmon
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - Theresa A Tacy
- The Heart Center Clinical and Translational Research Program, Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, California.,Department of Pediatrics, Stanford University, Palo Alto, California
| | - Lynn F Peng
- The Heart Center Clinical and Translational Research Program, Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, California.,Department of Pediatrics, Stanford University, Palo Alto, California
| | - Seth A Hollander
- The Heart Center Clinical and Translational Research Program, Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, California.,Department of Pediatrics, Stanford University, Palo Alto, California
| | - Doff B McElhinney
- The Heart Center Clinical and Translational Research Program, Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, California.,Department of Pediatrics, Stanford University, Palo Alto, California.,Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
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Hollander SA, Peng DM, Mills M, Berry GJ, Fedrigo M, McElhinney DB, Almond CS, Rosenthal DN. Pathological antibody-mediated rejection in pediatric heart transplant recipients: Immunologic risk factors, hemodynamic significance, and outcomes. Pediatr Transplant 2018; 22:e13197. [PMID: 29729067 DOI: 10.1111/petr.13197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 12/31/2022]
Abstract
Biopsy-diagnosed pAMR has been observed in over half of pediatric HT recipients within 6 years of transplantation. We report the incidence and outcomes of pAMR at our center. All endomyocardial biopsies for all HT recipients transplanted between 2010 and 2015 were reviewed and classified using contemporary ISHLT guidelines. Graft dysfunction was defined as a qualitative decrement in systolic function by echocardiogram or an increase of ≥3 mm Hg in atrial filling pressure by direct measurement. Among 96 patients, pAMR2 occurred in 7 (7%) over a median follow-up period of 3.1 years, while no cases of pAMR3 occurred. A history of CHD, DSA at transplant, and elevated filling pressures were associated with pAMR2. Five-sixths (83%) of patients developed new C1q+ DSA at the time of pAMR diagnosis. There was a trend toward reduced survival, with 43% of patients dying within 2.3 years of pAMR diagnosis.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - David M Peng
- Department of Pediatrics (Cardiology), University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Marcos Mills
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Gerald J Berry
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Marny Fedrigo
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, LPCH Heart Center Clinical and Translational Research Program, Stanford University, Stanford, CA, USA
| | - Christopher S Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
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