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Prospective Evaluation of Ventricular Loading Trend in Pediatric Patients with Pulsatile Flow LVAD
Abstracts S277 Methods: Medical records of CF lung transplant recipients (LTR) from January 2011 to June 2016 were reviewed. Microbiology results in the first 7 days were obtained. Sepsis was defined using the 2005 International Pediatric Consensus Conference. Modifiable risk factors collected included duration of central venous access (CVA), history of multi-drug resistant (MDR) infection, surgical times, nutritional status and donor infection. Outcomes included hospital length of stay (LOS). Results: There were 26 patients with a mean age of 13.4 years (range 8-18), 57.7% (15/26) female. All infections were bloodstream infections (BSI) and occurred in 30.7% (8/26) of all LTR, with 34.6% (9/26) septic. The most common isolate was Methicillin-resistant Staphylococcus aureus (4/8), and 75% (6/8) of infected LTR were previously colonized with the same organism. LTR with infection had a significantly higher donor ischemic time > 7hrs (63% vs. 0 %, p= 0 .0009) and a trend with higher cardiopulmonary bypass time > 450min (50% vs 11 %, p = 0.05). LTR with infection did not have a higher incidence of MDR isolate (63% vs 39%, p= 0.27), donor infection (38% vs 39%, p= 0.95) or weight for age z score < = -2 (50% vs 44%, p= 0.99). All 8 BSI occurred in patients with CVA. Median duration of CVA was longer for infected (13.5 d, range 4-48) vs. non-infected recipients (6.89 d, range 3-17) but not significantly different (p= 0.93). Hospital LOS was longer for LTR with sepsis (41.33 d, range 11-226) than without (12.76 d, range 8-23) (p= 0.02). Conclusion: In pediatric CF LTR, sepsis and BSI remain important in the early postoperative period. Of the modifiable risk factors identified, only donor ischemic time was significantly associated with infection in this small study. Further studies are needed to fully identify modifiable risk factors and determine the optimal strategy to reduce post-transplant infections. 7( 30) Reduced Use of Intensive Care After Pediatric Lung Transplantation: Influence of Early Extubation C. Brooks ,1 S. Labarinas,2 J. Bujan,1 C. Pymento,3 J.M. Pena,4 E. Melicoff-Portillo,1 M.C. Gazzaneo.5 1Lung Transplant, Texas Children's Hospital, Houston, TX; 2Critical Care, Baylor College of Medicine/ Texas Children's Hospital, Houston, TX; 3Critical Care, Texas Children's Hospital, Houston, TX; 4Critical Care, University Hospital of Maracaibo/ University of Zulia, Maracaibo, Venezuela, Bolivarian Republic of; 5Critical Care/Lung Transplant, Texas Children's Hospital, Houston, TX. Purpose: Lung transplantation is a viable therapeutic option for children with end-stage lung disease. Mechanical ventilation and admission to the pediatric intensive care unit (PICU) is the standard of care immediately post-transplant and comprises a high proportion of the transplantation costs. Therefore, finding the earliest and safest time to extubate after the procedure can lead to decreased length of stay in the PICU. The majority of literature has looked at adult airway management after lung transplant. We sought to determine the proportion of early extubation in the pediatric population and its influence on length of stay in the pediatric intensive care unit. Methods: Single center retrospective chart review of pediatric patients after lung transplantation in a tertiary intensive care unit between 2013 and 2015. The primary outcome was early extubation, defined as removal of endotracheal tube within 24 hours (h) after lung transplantation and subsequent length of stay in the pediatric intensive care unit. Secondary outcomes included hospital length of stay, early rehabilitation time after transplant, median time of intubation, rates of failed extubation (reintubation within 24h), and causes of reintubation. Results: 42 patients were transplanted in this period, 9 of which were excluded due to tracheostomy prior to transplantation. Median age was 10.3 years and cystic fibrosis was the most common diagnosis (52%). Of the 33 patients, 17 were extubated within 24h (52%), 16 after 24h (48%). Median PICU and hospital length of stay for the 33 patients was 4 and 14 days (d) respectively. Patients that were extubated within 24h had shorter ICU (3d) and hospital length of stay (13d) as compared to patients extubated after 24h at 5d and 19d respectively. Conclusion: After pediatric lung transplantation, early extubation seems to be a safe intervention and is associated with a decreased pediatric intensive care unit stay. In addition, it may lead to decreased use of hospital resources and complications associated with mechanical ventilation such as ventilator associated pneumonia, atelectasis, risks of barotrauma and hemodynamic instability.
7( 31) Prospective Evaluation of Ventricular Loading Trend in Pediatric Patients with Pulsatile Flow LVAD A. Di Molfetta , R. Iacobelli, G. Grutter, S. Filippelli, G. Perri, F. Iodice, L. Pasquini, P. Guccione, A. Amodeo. Pediatric Hospital Bambino Gesù, Rome, Italy. Purpose: Left ventricular (LV) reverse remodeling and heart recovery in LVAD have been extensively studied in adults, while there is a paucity of data in pediatrics. In theory, heart remodeling and recovery are more promising in children than in adults because of the abundance of cardiac progenitor cells and the shorter duration of heart failure. The aim of this study was to describe the echocardiographic trend of LV and right ventricular (RV) function after pulsatile flow LVAD in pediatrics. Methods: From December 2013 to September 2016, we prospectively enrolled 13 consecutive pediatric LVAD pts. Clinical and echocardiographic data were collected at the baseline, within 24 hours after implantation and monthly until LVAD explant. Results: Thirteen pts were enrolled with an average age and weight at the implant of 12.4±11.0 months and 7.0±3.6kg, respectively. Twelve (93%) were affected by dilative cardiomyopathy and 1 by restrictive cardiomyopathy. The average LVAD staying was 226.2±121.2 days. Nine (70%) were successfully transplanted, 4 (30%) died (3 for major neurological complication and 1 after LVAD explant for heart recovery). After an average LVAD staying of 120 days, 4 pts required prolonged inotropes administration for RV failure. LV reverse remodeling decreased over time and was significant only until two months follow up. LV end-systolic and end-diastolic volumes were reduced in the acute phase (p= 0.034 and p= 0.004), at one month (p= 0.0075 and p= 0.0005) and two months (p= 0.019 and p= 0.001). RV function improved in the acute phase, but then it started to decrease over time with a progressive increase in RV dimensions. After 4 months follow up, RV fractional area change (RVFAC) worsening was related with the deterioration of LV unloading (p= 0.0036) with need of prolonged inotropes support dependent by RVFAC worsening (p= 0.032). Conclusion: Pulsatile LVAD in pediatrics is followed by an early and midterm LV reverse remodeling due to loading condition change, but doesn't remain stable at long term follow up. RV function improved in the acute phase, but a progressive dilatation of RV was noted over time. In some pts, RV failure might lead to the need of inotropic support at long term follow up. The potential of heart recovery seems to be more promising during the early phase post LVAD. Further studies are necessary to understand how to prolong the benefits provided by the LVAD. 7( 32) Outcomes After First Infection in Adolescents and Young Adults with Ventricular Assist Devices: An Analysis of the PEDIMACS/INTERMACS Database S. Chen ,1 D.N. Rosenthal,1 R.C. Cantor,2 B. Hong,3 R.D. Jaquiss,4 S.R. Auerbach,5 K.R. Schumacher,6 J.C. Alejos,7 B. Das,8 C.S. Almond,1 P. Egtesady,9 J.K. Kirklin,10 A. Jeewa.11 1Stanford University, Palo Alto, CA; 2Kirklin Institute for Research and Surgical Outcomes, The University of Alabama at Birmingham,, Birmingham, AL; 3Seattle Children's Hospital, Seattle, WA; 4Duke University School of Medicine, Durham, NC; 5Children's Hospital Colorado Heart Institute, Aurora, CO; 6C.S. Mott Children's Hospital, Ann Arbor, MI; 7UCLA Mattel Children's Hospital, Los Angeles, CA; 8UT South Western Medical Center, Dallas, TX; 9Washington University School of Medicine, St. Louis, MO; 10Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL; 11The Hospital for Sick Children, Toronto, ON, Canada. Purpose: To examine outcomes after infections in adolescents and young adults with continuous flow left ventricular assist devices (CF-LVAD) bridged to transplant (BTT). Our hypothesis was that patients with an infection have lower survival on VAD compared to those who remain without infection. Methods: From PEDIMACS/INTERMACS registries, we identified patients with a CF-LVAD implanted from 9/2012 to 3/2016 as BTT. RVADs and biventricular VADs were excluded. An infection was defined as the 1st episode of any reported infection after VAD implantation; serious infection was defined as a positive blood culture, pump-related infection, or central line infection.
7( 31) Prospective Evaluation of Ventricular Loading Trend in Pediatric Patients with Pulsatile Flow LVAD A. Di Molfetta , R. Iacobelli, G. Grutter, S. Filippelli, G. Perri, F. Iodice, L. Pasquini, P. Guccione, A. Amodeo. Pediatric Hospital Bambino Gesù, Rome, Italy. Purpose: Left ventricular (LV) reverse remodeling and heart recovery in LVAD have been extensively studied in adults, while there is a paucity of data in pediatrics. In theory, heart remodeling and recovery are more promising in children than in adults because of the abundance of cardiac progenitor cells and the shorter duration of heart failure. The aim of this study was to describe the echocardiographic trend of LV and right ventricular (RV) function after pulsatile flow LVAD in pediatrics. Methods: From December 2013 to September 2016, we prospectively enrolled 13 consecutive pediatric LVAD pts. Clinical and echocardiographic data were collected at the baseline, within 24 hours after implantation and monthly until LVAD explant. Results: Thirteen pts were enrolled with an average age and weight at the implant of 12.4±11.0 months and 7.0±3.6kg, respectively. Twelve (93%) were affected by dilative cardiomyopathy and 1 by restrictive cardiomyopathy. The average LVAD staying was 226.2±121.2 days. Nine (70%) were successfully transplanted, 4 (30%) died (3 for major neurological complication and 1 after LVAD explant for heart recovery). After an average LVAD staying of 120 days, 4 pts required prolonged inotropes administration for RV failure. LV reverse remodeling decreased over time and was significant only until two months follow up. LV end-systolic and end-diastolic volumes were reduced in the acute phase (p= 0.034 and p= 0.004), at one month (p= 0.0075 and p= 0.0005) and two months (p= 0.019 and p= 0.001). RV function improved in the acute phase, but then it started to decrease over time with a progressive increase in RV dimensions. After 4 months follow up, RV fractional area change (RVFAC) worsening was related with the deterioration of LV unloading (p= 0.0036) with need of prolonged inotropes support dependent by RVFAC worsening (p= 0.032). Conclusion: Pulsatile LVAD in pediatrics is followed by an early and midterm LV reverse remodeling due to loading condition change, but doesn't remain stable at long term follow up. RV function improved in the acute phase, but a progressive dilatation of RV was noted over time. In some pts, RV failure might lead to the need of inotropic support at long term follow up. The potential of heart recovery seems to be more promising during the early phase post LVAD. Further studies are necessary to understand how to prolong the benefits provided by the LVAD. 7( 32) Outcomes After First Infection in Adolescents and Young Adults with Ventricular Assist Devices: An Analysis of the PEDIMACS/INTERMACS Database S. Chen ,1 D.N. Rosenthal,1 R.C. Cantor,2 B. Hong,3 R.D. Jaquiss,4 S.R. Auerbach,5 K.R. Schumacher,6 J.C. Alejos,7 B. Das,8 C.S. Almond,1 P. Egtesady,9 J.K. Kirklin,10 A. Jeewa.11 1Stanford University, Palo Alto, CA; 2Kirklin Institute for Research and Surgical Outcomes, The University of Alabama at Birmingham,, Birmingham, AL; 3Seattle Children's Hospital, Seattle, WA; 4Duke University School of Medicine, Durham, NC; 5Children's Hospital Colorado Heart Institute, Aurora, CO; 6C.S. Mott Children's Hospital, Ann Arbor, MI; 7UCLA Mattel Children's Hospital, Los Angeles, CA; 8UT South Western Medical Center, Dallas, TX; 9Washington University School of Medicine, St. Louis, MO; 10Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL; 11The Hospital for Sick Children, Toronto, ON, Canada. Purpose: To examine outcomes after infections in adolescents and young adults with continuous flow left ventricular assist devices (CF-LVAD) bridged to transplant (BTT). Our hypothesis was that patients with an infection have lower survival on VAD compared to those who remain without infection. Methods: From PEDIMACS/INTERMACS registries, we identified patients with a CF-LVAD implanted from 9/2012 to 3/2016 as BTT. RVADs and biventricular VADs were excluded. An infection was defined as the 1st episode of any reported infection after VAD implantation; serious infection was defined as a positive blood culture, pump-related infection, or central line infection.