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Pediatric Outpatient VAD Experience at Stanford
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The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
suppression which in some patients was accompanied by abnormal echocardiogram or biopsy. GEP of 84 genes in the inflammatory cascade (chemokines, cytokines and their receptors) was performed on peripheral mononuclear lymphocytes by commercially available PCR (Illumina Biosciences) array. Expression profiles were analyzed with the commonly used Significant Analysis of Microarray (SAM). Comparison was within individual at time of AR and quiescence. The genes that differentially expressed with and without AR were identified by controlling the false discovery rates at 5%. Results: Gene expression profiling was conducted on 17 blood samples (AR and quiescent) from five subjects. A total of 47331 transcripts from the 84 genes were analyzed. Expression levels of defensin family of genes were significantly higher at the time of at AR than at the time of quiescence. This pattern was consistent in 3 of 5 subjects. Conclusions: Gene expression profiling holds promise in identifying specific regulatory pathways or gene families with differential activity at times of AR in pediatric HTx recipients. The gene family identified in this study is different from those identified in adult HTx recipients. Further study could lead to improved ability to modulate immunosuppression and/or predict impending AR. 802 Is Ventricular Assist Device an Effective Tool To Support Children with a Failing Cardiac Graft? I. Adachi,1 M.S. Khan,1 E.D. McKenzie,1 J.S. Heinle,1 C.M. Mery,1 A.G. Cabrera,2 A. Jeewa,2 S.W. Denfield,2 W.J. Dreyer,2 J.F. Price,2 C.D. Fraser Jr.1 1Congenital Heart Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX; 2Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX. Purpose: Ventricular assist device (VAD) support in heart transplant recipients is challenging especially because these patients are immunocompromised. Total artificial heart (TAH) is an attractive alternative to VAD for adult patients since it alleviates the need for immunosuppression. Unlike for adults, TAH is not currently available for children due to size limitations. The aim of this study is to determine if VAD support, currently the only realistic option, plays a role in the treatment of cardiac graft failure in the pediatric population. Methods and Materials: A retrospective analysis was performed of all pediatric heart transplant (Tx) recipients who required VAD support at Texas Children’s Hospital for cardiac graft dysfunction. We identified 16 VAD runs in 15 patients; 9 with short-term extracorporeal VAD and 7 with long-term VAD. The type of device was chosen based on the etiology of heart failure; short-term VAD for acute process (e.g. acute rejection) and long-term VAD for chronic process (e.g. transplant coronary artery disease). Median age and weight at VAD placement were 11y (1–18y) and 43kg (9–94kg). Median time from Tx to VAD support was 1.1y (0d–2.7y) for short-term VADs and 3.6y (10m–11y) for long-term VADs. Results: Short-term VAD support was successfully weaned off following cardiac recovery in 8 (89%), with support duration of 5d (2-7d). One patient was bridged to long-term VAD. In contrast, successful outcome was achieved only in 2 (29%) patients with longterm VAD support, both of whom were bridged to re-transplant with support duration of 28 and 83 days. The remaining 5 (71%) died on long-term VAD. None of the 2 patients who required resuscitation with ECMO prior to long-term VAD survived. Of note, 3 of the 5 mortalities were related to fungus infection. Conclusions: Short-term VAD support is an effective therapy for acute graft failure. Long-term VAD support, however, has a limited role for chronic graft failure. The search for alternative treatment strategies for children with chronically failing grafts is warranted. 803 Psychiatric Diagnoses and the Use of Psychiatric Medication in Pediatric Ventricular Assist Device Recipients D.S. Lefkowitz,1 R.S. Novosel,1 Z. Mohamad,1 A. Scharko,1 K.Y. Lin,1,2 R.E. Shaddy,1,2 S.M. Paridon,1,2 K. Miller,1 B.D. Kaufman,1,2 J.W. Gaynor,1,2 J.W. Rossano.1,2 1Children’s Hospital
of Philadelphia, Philadelphia, PA; 2University of Pennsylvania School of Medicine, Philadelphia, PA. Purpose: Mental health issues in the pediatric VAD population are poorly understood. Data from the adult VAD population suggests a high prevalence of psychiatric distress, often resulting in prophylactic or adjunctive treatment with psychiatric medications. We investigated the prevalence of psychiatric diagnosis and psychiatric medication usage in pediatric VAD recipients. Methods and Materials: A retrospective study of the Pediatric Health Information System, a large administrative database of 43 US children’s hospitals, was performed for patients 6-20 years of age undergoing VAD placement from 2000-2010. Results: 70 of 238 patients (29.4%) with VADs had documented psychiatric diagnoses, most commonly adjustment disorders (n¼24). 59 of 238 (24.8%) patients with VADs received psychiatric medication (excluding benzodiazepines) during hospitalization, most commonly antidepressants (n¼41). Of the patients who received psychiatric medication, 34 of them (56%) had documented psychiatric diagnoses. Of the 70 patients with documented psychiatric diagnoses, 33 of them (47%) received psychiatric medication. None of the patients who received antidepressant medication had documented diagnoses of depression. Patients who had a stroke were more likely to have been treated with psychiatric medications (p¼0.04). Hospital length of stay (LOS) and total charges were greater among patients treated with psychiatric medications (po0.0001) and among patients with psychiatric diagnoses (po0.0001). Conclusions: One quarter of pediatric VAD patients received psychiatric diagnoses and one quarter were treated with psychiatric medications. Nearly half of patients receiving psychiatric medication did not have documented psychiatric diagnoses. Psychiatric diagnoses and medications were associated with longer hospital LOS and greater hospital charges. Further research is needed to understand patterns of and indications for psychiatric medication usage, as well as the burden and treatment of psychiatric disorders in this population. 804 Pediatric Outpatient VAD Experience at Stanford A. Lin, E. Liu, M. Keating, K. Maeda, S. Hollander, D. Rosenthal. Pediatric Cardiology, Lucile Packard Children’s Hospital, Palo Alto, CA. Purpose: With recent advances in pediatric ventricular assist devices (VADs), patients are able to be discharged from the hospital. However, the course of outpatient care following outpatient VAD placement is not well described. Methods and Materials: We retrospectively reviewed all patients with the Thoratec Heartmate II LVAS (HMII) at our institution between June 2010 and November 2012. Results: Seven patients received HMII; patient age ranged from 10 to 18 (mean, 15). All patients had dilated cardiomyopathy; three had an underlying diagnosis of Becker’s muscular dystrophy and one with congenital heart disease. Two patients were transplanted prior to discharge and one patient is currently still hospitalized. Four patients were successfully discharged to the outpatient transition home 1.3 miles away. Average length of stay was 38 days with clinic visits every five days. Once discharged home, patients were seen every one to three months depending on clinical stability. The distance from the implanting center to each patient’s home ranges from 14 to 231 miles away. These four patients have been supported for 87, 583, 169, and 75 outpatient days respectively. There were a total of six rehospitalizations for rule out infection, rule out hemolysis, post cardiac catherization recovery, knee effusion and rule out hemearthrosis, bilateral pleural effusions, and decompensated cardiogenic shock and multi-system organ failure. Thus far, three patients continue to be supported on outpatient VADs and one is deceased. Conclusions: Pediatric VADs can be successfully transitioned to outpatient care even despite distance from implanting center, however, close follow-up and a multidisciplanry highly coordinated approach are absolute requirements.
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
suppression which in some patients was accompanied by abnormal echocardiogram or biopsy. GEP of 84 genes in the inflammatory cascade (chemokines, cytokines and their receptors) was performed on peripheral mononuclear lymphocytes by commercially available PCR (Illumina Biosciences) array. Expression profiles were analyzed with the commonly used Significant Analysis of Microarray (SAM). Comparison was within individual at time of AR and quiescence. The genes that differentially expressed with and without AR were identified by controlling the false discovery rates at 5%. Results: Gene expression profiling was conducted on 17 blood samples (AR and quiescent) from five subjects. A total of 47331 transcripts from the 84 genes were analyzed. Expression levels of defensin family of genes were significantly higher at the time of at AR than at the time of quiescence. This pattern was consistent in 3 of 5 subjects. Conclusions: Gene expression profiling holds promise in identifying specific regulatory pathways or gene families with differential activity at times of AR in pediatric HTx recipients. The gene family identified in this study is different from those identified in adult HTx recipients. Further study could lead to improved ability to modulate immunosuppression and/or predict impending AR. 802 Is Ventricular Assist Device an Effective Tool To Support Children with a Failing Cardiac Graft? I. Adachi,1 M.S. Khan,1 E.D. McKenzie,1 J.S. Heinle,1 C.M. Mery,1 A.G. Cabrera,2 A. Jeewa,2 S.W. Denfield,2 W.J. Dreyer,2 J.F. Price,2 C.D. Fraser Jr.1 1Congenital Heart Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX; 2Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX. Purpose: Ventricular assist device (VAD) support in heart transplant recipients is challenging especially because these patients are immunocompromised. Total artificial heart (TAH) is an attractive alternative to VAD for adult patients since it alleviates the need for immunosuppression. Unlike for adults, TAH is not currently available for children due to size limitations. The aim of this study is to determine if VAD support, currently the only realistic option, plays a role in the treatment of cardiac graft failure in the pediatric population. Methods and Materials: A retrospective analysis was performed of all pediatric heart transplant (Tx) recipients who required VAD support at Texas Children’s Hospital for cardiac graft dysfunction. We identified 16 VAD runs in 15 patients; 9 with short-term extracorporeal VAD and 7 with long-term VAD. The type of device was chosen based on the etiology of heart failure; short-term VAD for acute process (e.g. acute rejection) and long-term VAD for chronic process (e.g. transplant coronary artery disease). Median age and weight at VAD placement were 11y (1–18y) and 43kg (9–94kg). Median time from Tx to VAD support was 1.1y (0d–2.7y) for short-term VADs and 3.6y (10m–11y) for long-term VADs. Results: Short-term VAD support was successfully weaned off following cardiac recovery in 8 (89%), with support duration of 5d (2-7d). One patient was bridged to long-term VAD. In contrast, successful outcome was achieved only in 2 (29%) patients with longterm VAD support, both of whom were bridged to re-transplant with support duration of 28 and 83 days. The remaining 5 (71%) died on long-term VAD. None of the 2 patients who required resuscitation with ECMO prior to long-term VAD survived. Of note, 3 of the 5 mortalities were related to fungus infection. Conclusions: Short-term VAD support is an effective therapy for acute graft failure. Long-term VAD support, however, has a limited role for chronic graft failure. The search for alternative treatment strategies for children with chronically failing grafts is warranted. 803 Psychiatric Diagnoses and the Use of Psychiatric Medication in Pediatric Ventricular Assist Device Recipients D.S. Lefkowitz,1 R.S. Novosel,1 Z. Mohamad,1 A. Scharko,1 K.Y. Lin,1,2 R.E. Shaddy,1,2 S.M. Paridon,1,2 K. Miller,1 B.D. Kaufman,1,2 J.W. Gaynor,1,2 J.W. Rossano.1,2 1Children’s Hospital
of Philadelphia, Philadelphia, PA; 2University of Pennsylvania School of Medicine, Philadelphia, PA. Purpose: Mental health issues in the pediatric VAD population are poorly understood. Data from the adult VAD population suggests a high prevalence of psychiatric distress, often resulting in prophylactic or adjunctive treatment with psychiatric medications. We investigated the prevalence of psychiatric diagnosis and psychiatric medication usage in pediatric VAD recipients. Methods and Materials: A retrospective study of the Pediatric Health Information System, a large administrative database of 43 US children’s hospitals, was performed for patients 6-20 years of age undergoing VAD placement from 2000-2010. Results: 70 of 238 patients (29.4%) with VADs had documented psychiatric diagnoses, most commonly adjustment disorders (n¼24). 59 of 238 (24.8%) patients with VADs received psychiatric medication (excluding benzodiazepines) during hospitalization, most commonly antidepressants (n¼41). Of the patients who received psychiatric medication, 34 of them (56%) had documented psychiatric diagnoses. Of the 70 patients with documented psychiatric diagnoses, 33 of them (47%) received psychiatric medication. None of the patients who received antidepressant medication had documented diagnoses of depression. Patients who had a stroke were more likely to have been treated with psychiatric medications (p¼0.04). Hospital length of stay (LOS) and total charges were greater among patients treated with psychiatric medications (po0.0001) and among patients with psychiatric diagnoses (po0.0001). Conclusions: One quarter of pediatric VAD patients received psychiatric diagnoses and one quarter were treated with psychiatric medications. Nearly half of patients receiving psychiatric medication did not have documented psychiatric diagnoses. Psychiatric diagnoses and medications were associated with longer hospital LOS and greater hospital charges. Further research is needed to understand patterns of and indications for psychiatric medication usage, as well as the burden and treatment of psychiatric disorders in this population. 804 Pediatric Outpatient VAD Experience at Stanford A. Lin, E. Liu, M. Keating, K. Maeda, S. Hollander, D. Rosenthal. Pediatric Cardiology, Lucile Packard Children’s Hospital, Palo Alto, CA. Purpose: With recent advances in pediatric ventricular assist devices (VADs), patients are able to be discharged from the hospital. However, the course of outpatient care following outpatient VAD placement is not well described. Methods and Materials: We retrospectively reviewed all patients with the Thoratec Heartmate II LVAS (HMII) at our institution between June 2010 and November 2012. Results: Seven patients received HMII; patient age ranged from 10 to 18 (mean, 15). All patients had dilated cardiomyopathy; three had an underlying diagnosis of Becker’s muscular dystrophy and one with congenital heart disease. Two patients were transplanted prior to discharge and one patient is currently still hospitalized. Four patients were successfully discharged to the outpatient transition home 1.3 miles away. Average length of stay was 38 days with clinic visits every five days. Once discharged home, patients were seen every one to three months depending on clinical stability. The distance from the implanting center to each patient’s home ranges from 14 to 231 miles away. These four patients have been supported for 87, 583, 169, and 75 outpatient days respectively. There were a total of six rehospitalizations for rule out infection, rule out hemolysis, post cardiac catherization recovery, knee effusion and rule out hemearthrosis, bilateral pleural effusions, and decompensated cardiogenic shock and multi-system organ failure. Thus far, three patients continue to be supported on outpatient VADs and one is deceased. Conclusions: Pediatric VADs can be successfully transitioned to outpatient care even despite distance from implanting center, however, close follow-up and a multidisciplanry highly coordinated approach are absolute requirements.