Publications by authors named "Catherine K Allan"

27 Publications

  • Page 1 of 1

Acute coronary artery obstruction following surgical repair of congenital heart disease.

J Thorac Cardiovasc Surg 2020 05 3;159(5):1957-1965.e1. Epub 2019 Oct 3.

Division of Invasive Cardiology, Department of Cardiology, Boston Children's Hospital, Boston, Mass. Electronic address:

Objectives: Acute coronary artery obstruction is a rare complication of congenital heart disease surgery but imposes a high burden of morbidity and mortality. Previous case series have described episodes in specific congenital heart lesions or surgical repairs but have not examined the complication in all-comers to congenital heart surgery. We hypothesize that shorter time from a clinically recognized postoperative sentinel event suggestive of coronary ischemia to diagnosis of coronary obstruction is associated with improved clinical outcomes.

Methods: This was a single-center, retrospective review of patients diagnosed with acute coronary artery obstruction by angiography following surgical repair of congenital heart disease between January 2000 and June 2016.

Results: In total, 34 patients were identified. The most common procedures associated with coronary artery obstruction were the Norwood procedure, arterial switch operation, and aortic valve repair/replacement. In total, 79% required mechanical circulatory support, 41% died, and 27% were listed for heart transplant. Patients who died or were listed for heart transplant had longer median sentinel-event-to-cardiac-catheterization time (28 [6-168] hours vs 10 [3-56] hours, P = .001), and longer median sentinel-event-to-intervention time (32 [11-350] hours vs 13 [5-59] hours, P = .003). Patients with hypoplastic left heart syndrome were at greater risk of death or transplant listing (odds ratio, 9.23, P = .03).

Conclusions: Time from clinically relevant postoperative sentinel event to diagnosis of coronary artery obstruction by angiography was associated with transplant-listing-free survival. Clinicians should maintain a high index of suspicion for coronary obstruction and consider early catheterization and coronary angiography for patients in whom post-operative coronary compromise is suspected.
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http://dx.doi.org/10.1016/j.jtcvs.2019.09.073DOI Listing
May 2020

Applying Educational Theory to Interdisciplinary Education in Pediatric Cardiac Critical Care.

World J Pediatr Congenit Heart Surg 2019 11 30;10(6):742-749. Epub 2019 Oct 30.

Department of Cardiology and Simulator Program, Boston Children's Hospital, Harvard University, Boston, MA, USA.

At the 14th Annual International Meeting for the Pediatric Cardiac Intensive Care Society, the authors presented a simulation workshop for junior multidisciplinary providers focused on cardiopulmonary interactions. We provide an overview of educational theories of particular relevance to curricular design for simulation-based or enhanced activities. We then demonstrate how these theories are applied to curriculum development for individuals to teams and for novice to experts. We review the role of simulation in cardiac intensive care education and the education theories that support its use. Finally, we demonstrate how a conceptual framework, SIMZones, can be applied to design effective simulation-based teaching.
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http://dx.doi.org/10.1177/2150135119881370DOI Listing
November 2019

Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society: Part 2.

Pediatr Crit Care Med 2019 11;20(11):1034-1039

Department of Pediatrics, INOVA Fairfax Hospital, Falls Church, VA.

Objectives: To make recommendations on improving understanding of bleeding and thrombosis with pediatric extracorporeal life support including future research directions.

Data Sources: Evaluation of literature and consensus conferences of pediatric critical care and extracorporeal life support experts.

Study Selection: A team of 10 experts with pediatric cardiac and extracorporeal membrane oxygenation experience and expertise met through the Pediatric Cardiac Intensive Care Society to review current knowledge and make recommendations for future research to establish "best practice" for anticoagulation management related to extracorporeal life support.

Data Extraction/data Synthesis: This white paper focuses on clinical understanding and limitations of current strategies to monitor anticoagulation. For each test of anticoagulation, limitations of current knowledge are addressed and future research directions suggested.

Conclusions: No consensus on best practice for anticoagulation monitoring exists. Structured scientific evaluation to answer questions regarding anticoagulation monitoring and bleeding and thrombotic events should occur in multicenter studies using standardized approaches and well-defined endpoints. Outcomes related to need for component change, blood product administration, healthcare outcome, and economic assessment should be incorporated into studies. All centers should report data on patient receiving extracorporeal life support to a registry.
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http://dx.doi.org/10.1097/PCC.0000000000002104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433702PMC
November 2019

Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society: Part 1.

Pediatr Crit Care Med 2019 11;20(11):1027-1033

Department of Pediatrics, INOVA Fairfax Hospital, Falls Church, VA.

Objectives: To make practical and evidence-based recommendations on improving understanding of bleeding and thrombosis with pediatric extracorporeal life support and to make recommendations for research directions.

Data Sources: Evaluation of literature and consensus conferences of pediatric critical care and extracorporeal life support experts.

Study Selection: A team of 10 experts with pediatric cardiac and extracorporeal membrane oxygenation experience and expertise met through the Pediatric Cardiac Intensive Care Society to review current knowledge and make recommendations for future research to establish "best practice" for anticoagulation management related to extracorporeal life support.

Data Extraction/synthesis: The first of a two-part white article focuses on clinical understanding and limitations of medications in use for anticoagulation, including novel medications. For each medication, limitations of current knowledge are addressed and research recommendations are suggested to allow for more definitive clinical guidelines in the future.

Conclusions: No consensus on best practice for anticoagulation exists. Structured scientific evaluation to answer questions regarding anticoagulant medication and bleeding and thrombotic events should occur in multicenter studies using standardized approaches and well-defined endpoints. Outcomes related to need for component change, blood product administration, healthcare outcome, and economic assessment should be incorporated into studies. All centers should report data on patients receiving extracorporeal life support to a registry. The Extracorporeal Life Support Organization registry, designed primarily for quality improvement purposes, remains the primary and most successful data repository to date.
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http://dx.doi.org/10.1097/PCC.0000000000002054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552911PMC
November 2019

Physiologic effects of delayed sternal closure following stage 1 palliation.

Cardiol Young 2018 Dec 28;28(12):1393-1403. Epub 2018 Aug 28.

1Departments of Cardiology,Boston Children's Hospital,Boston,MA,USA.

Background: Following stage 1 palliation, delayed sternal closure may be used as a technique to enhance thoracic compliance but may also prolong the length of stay and increase the risk of infection.

Methods: We reviewed all neonates undergoing stage 1 palliation at our institution between 2010 and 2017 to describe the effects of delayed sternal closure.

Results: During the study period, 193 patients underwent stage 1 palliation, of whom 12 died before an attempt at sternal closure. Among the 25 patients who underwent primary sternal closure, 4 (16%) had sternal reopening within 24 hours. Among the 156 infants who underwent delayed sternal closure at 4 [3,6] days post-operatively, 11 (7.1%) had one or more failed attempts at sternal closure. Patients undergoing primary sternal closure had a shorter duration of mechanical ventilation and intensive care unit length of stay. Patients who failed delayed sternal closure had a longer aortic cross-clamp time (123±42 versus 99±35 minutes, p=0.029) and circulatory arrest time (39±28 versus 19±17 minutes, p=0.0009) than those who did not fail. Failure of delayed sternal closure was also closely associated with Technical Performance Score: 1.3% of patients with a score of 1 failed sternal closure compared with 18.9% of patients with a score of 3 (p=0.0028). Among the haemodynamic and ventilatory parameters studied, only superior caval vein saturation following sternal closure was different between patients who did and did not fail sternal closure (30±7 versus 42±10%, p=0.002). All patients who failed sternal closure did so within 24 hours owing to hypoxaemia, hypercarbia, or haemodynamic impairment.

Conclusion: When performed according to our current clinical practice, sternal closure causes transient and mild changes in haemodynamic and ventilatory parameters. Monitoring of SvO2 following sternal closure may permit early identification of patients at risk for failure.
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http://dx.doi.org/10.1017/S1047951118001385DOI Listing
December 2018

Accurate Prediction of Congenital Heart Surgical Length of Stay Incorporating a Procedure-Based Categorical Variable.

Pediatr Crit Care Med 2018 10;19(10):949-956

Department of Cardiology, Boston Children's Hospital, Boston MA.

Objectives: There is increasing demand for the limited resource of Cardiac ICU care. In this setting, there is an expectation to optimize hospital resource use without restricting care delivery. We developed methodology to predict extended cardiac ICU length of stay following surgery for congenital heart disease.

Design: Retrospective analysis by multivariable logistic regression of important predictive factors for outcome of postoperative ICU length of stay greater than 7 days.

Setting: Cardiac ICU at Boston Children's Hospital, a large, pediatric cardiac surgical referral center.

Patients: All patients undergoing congenital heart surgery at Boston Children's Hospital from January 1, 2010, to December 31, 2015.

Interventions: No study interventions.

Measurements And Main Results: The patient population was identified. Clinical variables and Congenital Heart Surgical Stay categories were recorded based on surgical intervention performed. A model was built to predict the outcome postoperative ICU length of stay greater than 7 days at the time of surgical intervention. The development cohort included 4,029 cases categorized into five Congenital Heart Surgical Stay categories with a C statistic of 0.78 for the outcome ICU length of stay greater than 7 days. Explanatory value increased with inclusion of patient preoperative status as determined by age, ventilator dependence, and admission status (C statistic = 0.84). A second model was optimized with inclusion of intraoperative factors available at the time of postoperative ICU admission, including cardiopulmonary bypass time and chest left open (C statistic 0.87). Each model was tested in a validation cohort (n = 1,008) with equivalent C statistics.

Conclusions: Using a model comprised of basic patient characteristics, we developed a robust prediction tool for patients who will remain in the ICU longer than 7 days after cardiac surgery, at the time of postoperative ICU admission. This model may assist in patient counseling, case scheduling, and capacity management. Further examination in external settings is needed to establish generalizability.
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http://dx.doi.org/10.1097/PCC.0000000000001668DOI Listing
October 2018

Simulation training improves team dynamics and performance in a low-resource cardiac intensive care unit.

Ann Pediatr Cardiol 2018 May-Aug;11(2):130-136

Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.

Introduction: Although simulation training has been utilized quite extensively in highincome medical environments, its feasibility and effect on team performance in lowresource pediatric Cardiac Intensive Care Unit (CICU) environments has not been demonstrated. We hypothesized that lowfidelity simulationbased crisis resource management training would lead to improvements in team performance in such settings.

Methods: In this prospective observational study, the effect of simulation on team dynamics and performance was assessed in 23 healthcare providers in a pediatric CICU in Southeast Asia. A 5day training program was utilized consisting of various didactic sessions and simulation training exercises. Improvements in team dynamics were assessed using participant questionnaires, expert evaluations, and video analysis of time to intervention and frequency of closedloop communication.

Results: In subjective questionnaires, participants noted significant ( < 0.05) improvement in team dynamics and performance over the training period. Video analysis revealed a decrease in time to intervention and significant ( < 0.05) increase in frequency of closedloop communication because of simulation training.

Conclusions: This study demonstrates the feasibility and effectiveness of simulationbased training in improving team dynamics and performance in lowresource pediatric CICU environments, indicating its potential role in eliminating communication barriers in these settings.
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http://dx.doi.org/10.4103/apc.APC_117_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5963226PMC
June 2018

Education and Training in Pediatric Cardiac Critical Care.

Pediatr Crit Care Med 2018 06;19(6):585-586

Department of Pediatrics, Northwestern University, Chicago, IL Department of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA Department of Cardiology, Harvard Medical School Boston Children's Hospital, Boston, MA.

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http://dx.doi.org/10.1097/PCC.0000000000001561DOI Listing
June 2018

Extracorporeal membrane oxygenation in congenital heart disease.

Semin Perinatol 2018 Mar 2;42(2):104-110. Epub 2018 Jan 2.

Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 21, 225 E Chicago Ave, Chicago, IL 60610.

This review article will discuss the indications for and outcomes of neonates with congenital heart disease who receive extracorporeal membrane oxygenation (ECMO) support. Most commonly, ECMO is used as a perioperative bridge to recovery or temporary support for those after cardiac arrest or near arrest in patients with congenital or acquired heart disease. What had historically been considered a contraindication to ECMO, is evolving and more of the sickest and most complicated babies are cared for on ECMO. Given that, it is imperative for aggressive survellience for long-term morbidity in survivors, particularly neurodevelopmental outcomes.
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http://dx.doi.org/10.1053/j.semperi.2017.12.006DOI Listing
March 2018

A Pediatric Cardiology Fellowship Boot Camp improves trainee confidence.

Cardiol Young 2016 Dec;26(8):1514-1521

1Department of Cardiology,Harvard Medical School,Boston Children's Hospital,Boston,Massachusetts,United States of America.

Introduction New paediatric cardiology trainees are required to rapidly assimilate knowledge and gain clinical skills to which they have limited or no exposure during residency. The Pediatric Cardiology Fellowship Boot Camp (PCBC) at Boston Children's Hospital was designed to provide incoming fellows with an intensive exposure to congenital cardiac pathology and a broad overview of major areas of paediatric cardiology practice.

Methods: The PCBC curriculum was designed by core faculty in cardiac pathology, echocardiography, electrophysiology, interventional cardiology, exercise physiology, and cardiac intensive care. Individual faculty contributed learning objectives, which were refined by fellowship directors and used to build a programme of didactics, hands-on/simulation-based activities, and self-guided learning opportunities.

Results: A total of 16 incoming fellows participated in the 4-week boot camp, with no concurrent clinical responsibilities, over 2 years. On the basis of pre- and post-PCBC surveys, 80% of trainees strongly agreed that they felt more prepared for clinical responsibilities, and a similar percentage felt that PCBC should be offered to future incoming fellows. Fellows showed significant increase in their confidence in all specific knowledge and skills related to the learning objectives. Fellows rated hands-on learning experiences and simulation-based exercises most highly.

Conclusions: We describe a novel 4-week-long boot camp designed to expose incoming paediatric cardiology fellows to the broad spectrum of knowledge and skills required for the practice of paediatric cardiology. The experience increased trainee confidence and sense of preparedness to begin fellowship-related responsibilities. Given that highly interactive activities were rated most highly, boot camps in paediatric cardiology should strongly emphasise these elements.
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http://dx.doi.org/10.1017/S1047951116002614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269113PMC
December 2016

Training fellows in paediatric cardiology: the Harvard experience.

Cardiol Young 2016 Dec;26(8):1499-1506

1Department of Cardiology,Boston Children's Hospital,Boston,Massachusetts,United States of America.

The Fellowship Program of the Department of Cardiology at Boston Children's Hospital seeks to train academically oriented leaders in clinical care and laboratory and clinical investigation of cardiovascular disease in the young. The core clinical fellowship involves 3 years in training, comprising 24 months of clinical rotations and 12 months of elective and research experience. Trainees have access to a vast array of research opportunities - clinical, basic, and translational. Clinical fellows interested in basic science may reverse the usual sequence and start their training in the laboratory, deferring clinical training for 1 or more years. An increasing number of clinical trainees apply to spend a fourth year as a senior fellow in one of the subspecialty areas of paediatric cardiology. From the founding of the Department to the present, we have maintained a fundamental and unwavering commitment to training and education in clinical care and research in basic science and clinical investigation, as well as to the training of outstanding young clinicians and investigators.
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http://dx.doi.org/10.1017/S1047951116001712DOI Listing
December 2016

Enhancing the power of simulation for complex clinical care.

Pediatr Crit Care Med 2014 Nov;15(9):904-6

Division of Cardiac Intensive Care, Department of Cardiology, Boston Children's Hospital, Boston, MA; and Simulator Program, Boston Children's Hospital, Boston, MA Division of Critical Care Medicine, Department of Anesthesiology, Boston Children's Hospital, Boston, MA.

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http://dx.doi.org/10.1097/PCC.0000000000000275DOI Listing
November 2014

Impact of empiric nesiritide or milrinone infusion on early postoperative recovery after Fontan surgery: a randomized, double-blind, placebo-controlled trial.

Circ Heart Fail 2014 Jul 6;7(4):596-604. Epub 2014 Jun 6.

From the Departments of Cardiology (J.M.C., C.D.-M., C.K.A., K.G., J.W.N., R.E.D., P.C.L.), Anesthesia (F.X.M.), and Cardiac Surgery (J.E.M.), Boston Children's Hospital, Harvard Medical School, MA; and Children's National Medical Center, George Washington University, Washington, DC (D.L.W.).

Background: We sought to determine whether empirical nesiritide or milrinone would improve the early postoperative course after Fontan surgery. We hypothesized that compared with milrinone or placebo, patients assigned to receive nesiritide would have improved early postoperative outcomes.

Methods And Results: In a single-center, randomized, double-blinded, placebo-controlled, multi-arm parallel-group clinical trial, patients undergoing primary Fontan surgery were assigned to receive nesiritide, milrinone, or placebo. A loading dose of study drug was administered on cardiopulmonary bypass followed by a continuous infusion for ≥12 hours and ≤5 days after cardiac intensive care unit admission. The primary outcome was days alive and out of the hospital within 30 days of surgery. Secondary outcomes included measures of cardiovascular function, renal function, resource use, and adverse events. Among 106 enrolled subjects, 35, 36, and 35 were randomized to the nesiritide, milrinone, and placebo groups, respectively, and all were analyzed based on intention to treat. Demographics, patient characteristics, and operative factors were similar among treatment groups. No significant treatment group differences were found for median days alive and out of the hospital within 30 days of surgery (nesiritide, 20 [minimum to maximum, 0-24]; milrinone, 18 [0-23]; placebo, 20 [0-23]; P=0.38). Treatment groups did not significantly differ in cardiac index, arrhythmias, peak lactate, inotropic scores, urine output, duration of mechanical ventilation, intensive care or chest tube drainage, or adverse events.

Conclusions: Compared with placebo, empirical perioperative nesiritide or milrinone infusions are not associated with improved early clinical outcomes after Fontan surgery.

Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT00543309.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.113.001312DOI Listing
July 2014

An extracorporeal membrane oxygenation cannulation curriculum featuring a novel integrated skills trainer leads to improved performance among pediatric cardiac surgery trainees.

Simul Healthc 2013 Aug;8(4):221-8

Department of Cardiology, Children's Hospital Boston, Boston, MA, USA.

Introduction: American Heart Association guidelines recommend timely extracorporeal membrane oxygenation (ECMO) cannulation during cardiopulmonary resuscitation for pediatric cardiac arrest refractory to conventional resuscitation. Traditional cannulation training relies on the apprenticeship model. We hypothesized that a simulation-based ECMO cannulation curriculum featuring a novel integrated skills trainer would improve ECMO cannulation during cardiopulmonary resuscitation performance by cardiothoracic surgery trainees.

Methods: An embedded surgical neck cannulation trainer, designed in collaboration with expert surgeons, formed the focus for a simulation-based cannulation curriculum. The course included a didactic presentation and 2 neck cannulations during cardiopulmonary resuscitation with video-assisted expert feedback with a further cannulation at 3 months. Primary outcome was time to cannulation on the trainer. Secondary outcomes were performance on a validated Global Rating Scale (GRS) of surgical technique and a novel Composite ECMO Cannulation Score (CECS).

Results: Ten cardiothoracic surgery trainees participated. The trainer was rated as authentic, and sessions was rated as highly useful. Median time to cannulation decreased between cannulation 1 and 2 (15 minutes 24 seconds vs. 12 minutes 15 seconds, P = 0.002). Improvement was sustained at 3 months (13 minutes 36 seconds, P = 0.157 vs. attempt 2). Likewise, GRS increased significantly at attempt 2 versus 1 (77% vs. 62%, P = 0.003) as did CECS (88% vs. 52%, P = 0.002). No deterioration in GRS or CECS was measured at 3 months.

Conclusions: Cardiothoracic surgery trainees found a contextualized ECMO cannulation during cardiopulmonary resuscitation cannulation curriculum to be highly useful and demonstrated sustained improvement in time to cannulation, CECS, and GRS. Further work will focus on determining the clinical impact of this training and defining the optimal interval and number of training sessions.
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http://dx.doi.org/10.1097/SIH.0b013e31828b4179DOI Listing
August 2013

Risky business: human factors in critical care.

World J Pediatr Congenit Heart Surg 2011 Jul;2(3):468-71

Department of Cardiology, Children's Hospital Boston, Boston, MA, USA.

Remarkable achievements have occurred in pediatric cardiac critical care over the past two decades. The specialty has become well defined and extremely resource intense. A great deal of focus has been centered on optimizing patient outcomes, particularly mortality and early morbidity, and this has been achieved through a focused and multidisciplinary approach to management. Delivering high-quality and safe care is our goal, and during the Risky Business symposium and simulation sessions at the Eighth International Conference of the Pediatric Cardiac Intensive Care Society in Miami, December 2010, human factors, systems analysis, team training, and lessons learned from malpractice claims were presented.
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http://dx.doi.org/10.1177/2150135111406943DOI Listing
July 2011

Outcomes and risk factors for mortality in premature neonates with critical congenital heart disease.

Pediatr Cardiol 2011 Dec 29;32(8):1139-46. Epub 2011 Jun 29.

Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA.

We sought to describe contemporary outcomes and identify risk factors for hospital mortality in premature neonates with critical congenital heart disease who were referred for early intervention. Neonates who were born before 37 weeks' gestation with critical congenital heart disease and admitted to our institution from 2002 to 2008 were included in this retrospective cohort study. Critical congenital heart disease was defined as a defect requiring surgical or transcatheter cardiac intervention or a defect resulting in death within the first 28 days of life. Logistic regression analyses were performed to identify risk factors for mortality before hospital discharge. The study included 180 premature neonates, of whom 37 (21%) died during their initial hospitalization, including 6 (4%) before cardiac intervention and 31 (17%) after cardiac intervention. For the 174 patients undergoing cardiac intervention, independent risk factors for mortality were a 5 min Apgar score ≤ 7, need for preintervention mechanical ventilation, and Risk Adjustment in Congenital Heart Surgery category ≥ 4 or not assignable. Mortality for premature infants with critical congenital heart disease who are referred for early intervention remains high. Patients with lower Apgar scores who receive preintervention mechanical ventilation and undergo more complex procedures are at greatest risk.
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http://dx.doi.org/10.1007/s00246-011-0036-3DOI Listing
December 2011

Intensive care of the adult patient with congenital heart disease.

Prog Cardiovasc Dis 2011 Jan-Feb;53(4):274-80

Children's Hospital Boston, Division of Cardiac Intensive Care, Harvard Medical School, Boston, MA, USA.

Prevalence of congenital heart disease in the adult population has increased out of proportion to that of the pediatric population as survival has improved, and adult congenital heart disease patients make up a growing percentage of pediatric and adult cardiac intensive care unit admissions. These patients often develop complex multiorgan system disease as a result of long-standing altered cardiac physiology, and many require reoperation during adulthood. Practitioners who care for these patients in the cardiac intensive care unit must have a strong working knowledge of the pathophysiology of complex congenital heart disease, and a full team of specialists must be available to assist in the care of these patients. This chapter will review some of the common multiorgan system effects of long-standing congenital heart disease (eg, renal and hepatic dysfunction, coagulation abnormalities, arrhythmias) as well as some of the unique cardiopulmonary physiology of this patient population.
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http://dx.doi.org/10.1016/j.pcad.2010.11.002DOI Listing
March 2011

Management and outcomes in pediatric patients presenting with acute fulminant myocarditis.

J Pediatr 2011 Apr 30;158(4):638-643.e1. Epub 2010 Dec 30.

Department of Cardiology, Children's Hospital Boston, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA.

Objective: To investigate factors associated with mechanical circulatory support and survival in patients with acute fulminant myocarditis (AFM).

Study Design: Retrospective cohort of AFM patients admitted to the cardiac intensive care unit during 1996-2008. AFM was defined as distinct onset of symptoms ≤14 days before admission, rapid-onset cardiogenic shock, and normal left ventricular size. Demographic and physiological variables were compared between patients treated with extracorporeal membrane oxygenation (ECMO) and those who were not and between survivors and nonsurvivors.

Results: Twenty patients (median age 12.7 years) met inclusion criteria. Seventeen patients (85%) survived to hospital discharge. One underwent heart transplantation. Ten (50%) patients required ECMO, and 7 (70%) of these survived. On admission, patients requiring ECMO had elevated lactate (9 vs 1 mmol/L), creatinine (0.8 vs 0.6 mg/dL), and aspartate aminotransferase (256 vs 35 IU/L) (all P < .05) and a trend towards increased incidence of dysrhythmias (80% vs 30%, P = .07). During hospitalization, non-survivors had higher peak lactate (10 vs 3 mmol/L), creatinine (1.5 vs 0.8 mg/dL), and aspartate aminotransferase (3007 vs 156 IU/L) (all P < .05) compared with survivors.

Conclusions: Patients with AFM with end organ dysfunction or arrhythmias on admission may require mechanical circulatory support. The transplant-free survival rate in this critically ill cohort was excellent (80%).
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http://dx.doi.org/10.1016/j.jpeds.2010.10.015DOI Listing
April 2011

The relationship between inflammatory activation and clinical outcome after infant cardiopulmonary bypass.

Anesth Analg 2010 Nov 9;111(5):1244-51. Epub 2010 Sep 9.

Department of Cardiology, Children's Hospital, Boston, MA 02115, USA.

Background: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response. The magnitude and consequences in infants remain unclear. We assessed the relationship between inflammatory state and clinical outcomes in infants undergoing CPB.

Methods: Plasma concentrations of interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor α, IL-1β, and C-reactive protein (CRP) were measured pre-CPB and immediately post-CPB, and at 6, 12, and 24 hours post-CPB in infants ≤9 months old. Perioperative clinical data were collected prospectively.

Results: Diagnoses of 93 patients included transposition of the great arteries (40), tetralogy of Fallot (28), ventricular septal defect (21), truncus arteriosus (2), and complete atrioventricular canal (2). The median age was 37 days (range = 2 to 264). Pre-CPB IL-6 and CRP were higher in younger infants but were not associated with postoperative inflammatory mediator concentrations or measured clinical outcomes. IL-6 increased post-CPB (median 3.2 pg/mL pre-CPB, 24.2 post-CPB, 95.4 at 6 hours, and 90.3 at 24 hours; all P < 0.001). CRP increased post-CPB, peaking at 24 hours (median 27.5 at 24 hours, 0.3 pre-CPB; P < 0.001). IL-10 and IL-8 increased immediately post-CPB. After adjusting for age and diagnosis, postoperative IL-6 and IL-8 correlated with intensive care unit length of stay and postoperative blood product administration and, for IL-8, 24-hour lactate.

Conclusions: Greater preoperative cytokine and CRP production in younger infants did not correlate with postoperative outcomes; correlation between postoperative inflammatory mediator production and clinical course was statistically significant but clinically modest. We conclude that in infants undergoing low-to-moderate-complexity cardiac surgery in a single high-volume center, the contribution of inflammatory mediator production to postoperative morbidity is relatively limited.
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http://dx.doi.org/10.1213/ANE.0b013e3181f333aaDOI Listing
November 2010

Management of suspected myocarditis during critical-care transport.

Pediatr Emerg Care 2010 Jul;26(7):512-7

Division of Critical Care Medicine, Department of Anesthesia, Children's Hospital Boston, MA 02115, USA.

Myocarditis and malignant dysrhythmias are unusual presentations in pediatric patients. We report a series of 4 patients with myocarditis and arrhythmia who presented to community emergency departments and were transported to a pediatric tertiary-care center. Three of the patients required extracorporeal life support. We discuss considerations for stabilization and transport: airway and ventilation, hemodynamic support, induction and sedation medication choices, transport decisions, and the traits of an ideal receiving center.
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http://dx.doi.org/10.1097/PEC.0b013e3181e5bfe1DOI Listing
July 2010

Birth before 39 weeks' gestation is associated with worse outcomes in neonates with heart disease.

Pediatrics 2010 Aug 5;126(2):277-84. Epub 2010 Jul 5.

Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA.

Background: Recent studies have revealed increased morbidity and mortality rates in term neonates without birth defects who were delivered before 39 weeks of completed gestation. We sought to determine if a similar association exists between gestational age at delivery and adverse outcomes in neonates with critical congenital heart disease, with particular interest in those born at 37 to 38 weeks' gestation.

Patients And Methods: We studied 971 consecutive neonates who had critical congenital heart disease and a known gestational age and were admitted to our cardiac ICU from 2002 through 2008. Gestational age was stratified into 5 groups: >41, 39 to 40, 37 to 38, 34 to 36, and <34 completed weeks. Multivariate logistic regression analyses were used to evaluate mortality and a composite morbidity variable. Multivariate Poisson regression was used to evaluate duration of ventilation, intensive care, and hospitalization.

Results: Compared with the referent group of neonates who were delivered at 39 to 40 completed weeks' gestation, neonates born at 37 to 38 weeks had increased mortality (6.9% vs 2.6%; adjusted P = .049) and morbidity (49.7% vs 39.7%; adjusted P = .02) rates and tended to require a longer duration of mechanical ventilation (adjusted P = .05). Patients born after 40 or before 37 weeks also had greater adjusted mortality rates, and those born before 37 weeks had increased morbidity rates and required more days of mechanical ventilation and intensive care.

Conclusions: For neonates with critical congenital heart disease, delivery before 39 weeks' gestation is associated with greater mortality and morbidity rates and more resource use. With respect to neonatal mortality, the ideal gestational age for delivery of these patients may be 39 to 40 completed weeks.
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http://dx.doi.org/10.1542/peds.2009-3640DOI Listing
August 2010

Simulation-based training delivered directly to the pediatric cardiac intensive care unit engenders preparedness, comfort, and decreased anxiety among multidisciplinary resuscitation teams.

J Thorac Cardiovasc Surg 2010 Sep 8;140(3):646-52. Epub 2010 Jun 8.

Department of Cardiology, Children's Hospital Boston, Boston, Mass 02115, USA.

Objectives: Resuscitation of pediatric cardiac patients involves unique and complex physiology, requiring multidisciplinary collaboration and teamwork. To optimize team performance, we created a multidisciplinary Crisis Resource Management training course that addressed both teamwork and technical skill needs for the pediatric cardiac intensive care unit. We sought to determine whether participation improved caregiver comfort and confidence levels regarding future resuscitation events.

Methods: We developed a simulation-based, in situ Crisis Resource Management curriculum using pediatric cardiac intensive care unit scenarios and unit-specific resuscitation equipment, including an extracorporeal membrane oxygenation circuit. Participants replicated the composition of a clinical team. Extensive video-based debriefing followed each scenario, focusing on teamwork principles and technical resuscitation skills. Pre- and postparticipation questionnaires were used to determine the effects on participants' comfort and confidence regarding participation in future resuscitations.

Results: A total of 182 providers (127 nurses, 50 physicians, 2 respiratory therapists, 3 nurse practitioners) participated in the course. All participants scored the usefulness of the program and scenarios as 4 of 5 or higher (5 = most useful). There was significant improvement in participants' perceived ability to function as a code team member and confidence in a code (P < .001). Participants reported they were significantly more likely to raise concerns about inappropriate management to the code leader (P < .001).

Conclusions: We developed a Crisis Resource Management training program in a pediatric cardiac intensive care unit to teach technical resuscitation skills and improve team function. Participants found the experience useful and reported improved ability to function in a code. Further work is needed to determine whether participation in the Crisis Resource Management program objectively improves team function during real resuscitations.
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http://dx.doi.org/10.1016/j.jtcvs.2010.04.027DOI Listing
September 2010

Preoperative extracorporeal membrane oxygenation as a bridge to cardiac surgery in children with congenital heart disease.

Ann Thorac Surg 2009 Oct;88(4):1306-11

Department of Cardiac Surgery, Children's Hospital Boston, Boston, Massachusetts 02115, USA.

Background: The efficacy of extracorporeal membrane oxygenation (ECMO) in bridging children with unrepaired heart defects to a definitive or palliative surgical procedure has been rarely reported. The goal of this study is to report our institutional experience with ECMO used to provide preoperative stabilization after acute cardiac or respiratory failure in patients with congenital heart disease before cardiac surgery.

Methods: A retrospective review of the ECMO database at Children's Hospital Boston was undertaken. Children with unrepaired congenital heart disease supported with ECMO for acute cardiac or respiratory failure as bridge to a definitive or palliative cardiac surgical procedure were identified. Data collection included patient demographics, indication for ECMO, details regarding ECMO course and complications, and survival to hospital discharge.

Results: Twenty-six patients (18 male, 8 female) with congenital heart disease were bridged to surgical palliation or anatomic repair with ECMO. Median age and weight at ECMO cannulation were, respectively, 0.12 months (range, 0 to 193) and 4 kg (range, 1.8 to 67 kg). Sixteen patients (62%) survived to hospital discharge. Variables associated with mortality included inability to decannulate from ECMO after surgery (p = 0.02) and longer total duration of ECMO (p = 0.02). No difference in outcomes was found between patients with single and biventricular anatomy.

Conclusions: Extracorporeal membrane oxygenation, used as a bridge to surgery, represents a useful modality to rescue patients with failing circulation and unrepaired complex heart defects.
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http://dx.doi.org/10.1016/j.athoracsur.2009.06.074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4249921PMC
October 2009

Causes of death after congenital heart surgery.

Ann Thorac Surg 2007 Apr;83(4):1438-45

Tufts University School of Medicine, Boston, Massachusetts, USA.

Background: There has been little research about the causes of death after congenital heart surgery.

Methods: To determine whether mode of death differs after congenital heart surgery, we evaluated the cause of death for 100 consecutive postoperative deaths at our institution. Mode of death was determined based on retrospective chart review including available autopsy reports. Low output states were categorized into ventricular failure; inadequate postoperative physiology (technically adequate surgery and ventricular function, but persistent low cardiac output); pulmonary hypertension; and atrioventricular valve regurgitation.

Results: There was considerable anatomic diversity among patients who died; 46 patients had single-ventricle physiology. The vast majority of patients (n = 79) were in the intensive care unit before surgery. Surgical repairs were revised at initial operation in 22 cases; 7 patients died in the operating room. Seventy-three patients had technically adequate surgical procedures, 23 had residual anatomic defects, and 4 were indeterminate. Thirty patients underwent additional surgical and 9 catheter-based procedures, although some were classified as rescue procedures performed to address minor anatomic or physiologic abnormalities as a last hope to rescue the patient from impending demise. Of 100 deaths, most (n = 52) were due to low cardiac output: 24 inadequate postoperative physiology, 19 ventricular failure, 8 pulmonary hypertension, and 1 valvar regurgitation. Other significant causes of death included sudden cardiac arrest (n = 11), sepsis (n = 11), and procedural complications (n = 8).

Conclusions: More than half of the deaths were due to low cardiac output, but not exclusively ventricular failure.
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http://dx.doi.org/10.1016/j.athoracsur.2006.10.073DOI Listing
April 2007

Indication for initiation of mechanical circulatory support impacts survival of infants with shunted single-ventricle circulation supported with extracorporeal membrane oxygenation.

J Thorac Cardiovasc Surg 2007 Mar;133(3):660-7

Department of Cardiology, Children's Hospital Boston and Harvard Medical School, Boston, Mass 02115, USA.

Objectives: The use of extracorporeal membrane oxygenation to support patients with shunted single-ventricle physiology has been controversial. Variable survivals are reported in a number of small case series. We sought to evaluate outcomes and identify predictors of survival for patients with shunted single-ventricle physiology who require extracorporeal membrane oxygenation support.

Methods: We retrospectively reviewed the medical records of all patients aged less than 1 year with shunted single-ventricle physiology who were supported with extracorporeal membrane oxygenation at Children's Hospital Boston between 1996 and 2005. Survivors and nonsurvivors were compared with respect to demographics, diagnosis, operative variables, indication for extracorporeal membrane oxygenation, and extracorporeal membrane oxygenation variables.

Results: Forty-four infants with shunted single-ventricle physiology were supported with extracorporeal membrane oxygenation. Diagnoses included hypoplastic left heart syndrome (24), other single-ventricle lesions (12), and pulmonary atresia/intact ventricular septum or a variant (8). Overall survival to discharge was 48%. Indication for extracorporeal membrane oxygenation was the strongest predictor of survival to discharge, with 81% of patients cannulated for hypoxemia but only 29% of those cannulated for hypotension surviving to discharge. Specifically, patients cannulated for shunt obstruction had the highest survival (83%).

Conclusions: Overall survival to discharge for patients with shunted single-ventricle physiology is similar to survival reported in the Extracorporeal Life Support Organization registry for all infants supported with cardiac extracorporeal membrane oxygenation. Thus, shunted single-ventricle physiology should not be considered a contraindication to extracorporeal membrane oxygenation. Patients cannulated for hypoxemia, particularly shunt thrombosis, had markedly improved survival compared with those supported primarily for hypotension/cardiovascular collapse. Survival did not differ depending on anatomic diagnosis.
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http://dx.doi.org/10.1016/j.jtcvs.2006.11.013DOI Listing
March 2007

Emergent use of extracorporeal membrane oxygenation during pediatric cardiac catheterization.

Pediatr Crit Care Med 2006 May;7(3):212-9

Department of Cardiology, Children's Hospital, Boston and Harvard Medical School, Boston, MA.

Objectives: The goal of this study was to evaluate the utility of extracorporeal membrane oxygenation (ECMO) to resuscitate patients following critical cardiac events in the catheterization laboratory.

Design: Retrospective review of medical records.

Setting: Cardiac intensive care unit and cardiac catheterization laboratory at a tertiary care children's hospital.

Patients: Pediatric patients cannulated emergently for ECMO in the cardiac catheterization laboratory (n = 22).

Interventions: ECMO was initiated emergently in the cardiac catheterization laboratory for progressive hemodynamic deterioration due to low cardiac output syndrome or catheter-induced complications.

Measurements And Main Results: Twenty-two patients were cannulated for ECMO in the catheterization laboratory between 1996 and 2004. Median age was 33 months (range 0-192), median weight 14.8 kg (2.4-75), and median duration of ECMO 84 hrs (2-343). Indications included catheter-induced complication (n = 14), severe low cardiac output syndrome (n = 7), and hypoxemia (n = 1). Three patients (14%) were cannulated in the catheterization laboratory before catheterization for low cardiac output or hypoxemia. During cannulation, 19 patients (86%) were receiving chest compressions; median duration of cardiopulmonary resuscitation was 29 mins (20-57). Eighteen patients (82%) survived to discharge (five of whom underwent cardiac transplantation) and four (18%) died. Of 19 patients who received cardiopulmonary resuscitation during cannulation, 15 (79%) survived to discharge and nine (47%) sustained neurologic injury. There was no significant difference between survivors and nonsurvivors in age, weight, duration of cardiopulmonary resuscitation or ECMO support, pH, or lactate levels.

Conclusions: ECMO is a technically feasible and highly successful tool in the resuscitation of pediatric patients following critical events in the cardiac catheterization laboratory.
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http://dx.doi.org/10.1097/01.PCC.0000200964.88206.B0DOI Listing
May 2006

Initial experience with fenoldopam after cardiac surgery in neonates with an insufficient response to conventional diuretics.

Pediatr Crit Care Med 2006 Jan;7(1):28-33

Division of Cardiac Intensive Care, Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA.

Objective: Fenoldopam, a selective dopamine-1 receptor agonist, causes systemic vasodilation and increased renal blood flow and tubular sodium excretion. We hypothesized that urine output would improve when fenoldopam was added to conventional diuretic therapy after neonatal cardiopulmonary bypass.

Design: Retrospective cohort study using a time-series design.

Setting: Pediatric cardiac intensive care unit.

Patients: All neonates who received fenoldopam to promote diuresis after cardiac surgery requiring cardiopulmonary bypass from February 2002 through December 2004.

Interventions: Fenoldopam infusion for inadequate urine output despite conventional diuretics.

Measurements: Demographics, diagnostic information, and surgical procedures were recorded. Urine output, fluid balance, inotrope scores, diuretic doses, and other clinical variables that may influence diuresis were recorded for the 24-hr period immediately preceding fenoldopam initiation and during the initial 24 hrs of drug administration.

Main Results: A total of 25 neonates received fenoldopam to promote diuresis after the modified Norwood (n = 14), arterial switch (n = 4), or other operations (n = 7). Heart rate, conventional diuretic dosing, and fluid intake were similar during the 24-hr periods of conventional therapy and fenoldopam use (p = not significant for all), whereas inotrope scores decreased during the study (p = .021). There was a small but statistically significant increase in blood pressure during the 48-hr study period. Median urine output was 3.6 mL x kg(-1) x hr(-1) (range, 0.2-7.2 mL x kg(-1) x hr(-1)) during the 24-hr period of conventional therapy and 5.8 mL x kg(-1) x hr(-1) (range, 1.6-11.7 mL x kg(-1) x hr(-1)) during the initial 24 hrs of fenoldopam administration (Wilcoxon's signed-rank test, p = .001).

Conclusions: Fenoldopam may improve urine output in neonates who are failing to achieve an adequate negative fluid balance despite conventional diuretic therapy after cardiac surgery and cardiopulmonary bypass. This study is limited by its retrospective design and the possibility that urine output improved spontaneously during the treatment period. A randomized, placebo-controlled clinical trial will be required to confirm these findings.
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http://dx.doi.org/10.1097/01.pcc.0000194046.47306.fbDOI Listing
January 2006