A team of clinician-scientists from the Cardiac Center at Children’s Hospital of Philadelphia (CHOP) recently presented a series of new research findings at the American Heart Association’s 2018 Scientific Sessions in Chicago. The studies covered a wide range of subjects related to cardiovascular disease in children, including proper CPR procedures, exercise capacity for patients who undergo a Fontan procedure, defibrillator use, and other factors that can influence a patient’s survival and success after treatment.
Conventional Bystander CPR Is Associated with Higher Neurologically Favorable Survival in Children Compared to Compression-only CPR Following Pediatric Out of Hospital Cardiac Arrest
Past studies have shown conflicting evidence as to the benefits of performing conventional bystander CPR (BCPR, using both chest compressions and rescue breaths) compared to compression-only BCPR for children who experience cardiac arrest outside of a hospital.
Dr. Maryam Y. Naim, MD, a pediatric cardiac intensive care physician in the Division of Cardiac Critical Care Medicine at CHOP, and her colleagues analyzed the Cardiac Arrest Registry to Enhance Survival (CARES) to study patients 18 years old or younger who experienced an out-of-hospital cardiac arrest (OHCA) between 2013 and 2017. They were primarily looking for neurologically favorable survival. The highest neurologically favorable survival was associated with conventional BCPR. Conventional BCPR was also significantly associated with neurologically favorable survival compared to no BCPR overall and among all age groups. The findings support the current guidelines from the AHA for performing conventional BCPR (as opposed to compression-only BCPR) in response to OHCA.
This presentation was a finalist for Outstanding Research Award in Pediatric Cardiology
Longitudinal Change in Exercise Capacity and Predictors of Performance after Fontan: Results from the Pediatric Heart Network Fontan 3 Study
Undergoing a Fontan procedure — used in patients who only have one working ventricle — often leads to impaired exercise capacity afterward, which can be associated with increased morbidity risk. However, this has never been confirmed in a large cohort study.
Dr. David J. Goldberg, a board-certified attending cardiologist in the Cardiac Center at CHOP, and his colleagues in the NIH/NHLBI’s Pediatric Heart Network studied 336 Fontan patients and compared their ramp cycle ergometry performance over time as they aged. They found that these patients were better able to preserve their submaximal aerobic exercise capacity than their maximal aerobic capacity. However, they did observe an overall decline in exercise performance in the second and third decades of life, with body composition and gender also playing a role in a patient’s exercise capacity, with female patients, left ventricular morphology, and a lack of a pacemaker, all leading to better exercise capacity.
This presentation was a finalist for Outstanding Research Award in Pediatric Cardiology
Failure to Rescue as an Outcome Metric in the Pediatric and Congenital Cardiac Catheterization Laboratory: An Analysis of Data the Improving Adult and Congenital Treatment® (IMPACT®) Registry
When measuring quality of care for pediatric and congenital cardiac catheterization programs, risk-adjusted adverse event (AE) rates have historically been the standard. However, in other settings, failure to rescue (FTR) has been seen as superior to AE rates in terms of measuring quality of care.
Dr. Michael L. O’Byrne, an attending interventional cardiologist in the Cardiac Center at CHOP, and his colleagues performed a multicenter retrospective cohort study of elective and urgent catheterization procedures from the IMPACT Registry between 2010 and 2016. Using a series of analyses, the team compared FTR and major AE. They observed that higher annual pediatric/congenital cardiac catheterization programs (PCCL) volume was associated with a lower FTR risk, while no significant association was seen between catheterization volume and the risk of all AE. This suggests that larger volume programs reduce the risk of an AE progressing to a catastrophic AE.
The researchers concluded that FTR appears to provide additional and complementary information about the quality of PCCL than AE, and should be included in future research and quality improvement projects.
This presentation was a finalist in the CVDY Early Career Young Investigator Competition
The Influence of Age, Race, and Ethnicity on Public Automated External Defibrillator Use and Outcomes of Pediatric Out-of-hospital Cardiac Arrest in the United States: An Analysis of the Cardiac Arrest Registry to Enhance Survival (CARES)
Automated external defibrillators (AEDs) are critical for helping adult patients who undergo out-of-hospital cardiac arrest, but while their benefits for adults are proven and well-known, there is not much known about their use in children.
Dr. Heather Griffis, a research scientist working with the Healthcare Analytics Unit (HAU) at the Center for Pediatric Clinical Effectiveness (CPCE) and PolicyLab at CHOP, collaborated with a clinical team led by Dr. Joseph Rossano, a pediatric cardiologist and Chief of the Division of Cardiology at CHOP, and analyzed the CARES database to study people 18 years old or younger who underwent public, non-traumatic OHCA between 2013 and 2017. They found that among 971 patients who fit the criteria, AEDs were used by bystanders in 117 of those cases, with similar use among white, black, and Hispanic children. They found that neurologically favorable survival was 29.1 percent when someone used an AED compared to 23.7 percent when no bystander AED was used. The results were favorable in children between the ages of 12 and 18, but not for children younger than 12. They also found that neurologically favorable survival was associated with AED use in white children but not with black or Hispanic children.
The authors suggested further investigation is needed to understand these disparities in AED use and outcomes after AED use.
When Laws Save Lives: Impact of Legislation Requiring Cardiopulmonary Resuscitation Education in High Schools on Survival after Sudden Cardiac Arrest
In another study utilizing CARES data, research led by Dr. Victoria L. Vetter, a board-certified cardiologist in the Cardiac Center at CHOP and Medical Director of the Youth Heart Watch program, demonstrated that required CPR education in high school may lead to higher bystander CPR and cardiac arrest survival rates.
Analyzing data from 109,668 out-of-hospital cardiac arrest patients across 42 states, the researchers found that bystander CPR, survival to hospital discharge and neurologically favorable survival were all higher in states that require CPR training in high school.
Fetal Detection of Complex Congenital Heart Disease Does Improve Outcomes
While dozens of papers have supported the use of prenatal ultrasound and echocardiography and have demonstrated improved outcomes, the question may need to be reframed in order to understand exactly what benefits these procedures provide.
Dr. Michael D. Quartermain, an attending cardiologist and Medical Director of the Echocardiography Laboratory in the Cardiac Center at CHOP, and his colleagues wanted to determine if a fetus with a prenatal diagnosis (PND) has less pre-operative instability and improved postnatal status, and whether this leads to improved outcomes after surgery.
When it came to preoperative risk factors, a fetus with PND was less likely to require pre-operative mechanical ventilation or present in shock. In addition, other known pre-operative risk factors, including renal dysfunction, hepatic dysfunction, coagulopathy, and requiring CPR were all less likely to occur in a fetus with PND.
Ultimately, the team concluded that PND almost certainly provides a benefit to children with congenital heart disease, but PND also is more likely to identify a population of neonates with a high level of disease burden, and so these competing risks need to be considered when reviewing published outcomes.
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A team of clinician-scientists from the Cardiac Center at Children’s Hospital of Philadelphia (CHOP) recently presented a series of new research findings at the American Heart Association’s 2018 Scientific Sessions in Chicago. The studies covered a wide range of subjects related to cardiovascular disease in children, including proper CPR procedures, exercise capacity for patients who undergo a Fontan procedure, defibrillator use, and other factors that can influence a patient’s survival and success after treatment.
Conventional Bystander CPR Is Associated with Higher Neurologically Favorable Survival in Children Compared to Compression-only CPR Following Pediatric Out of Hospital Cardiac Arrest
Past studies have shown conflicting evidence as to the benefits of performing conventional bystander CPR (BCPR, using both chest compressions and rescue breaths) compared to compression-only BCPR for children who experience cardiac arrest outside of a hospital.
Dr. Maryam Y. Naim, MD, a pediatric cardiac intensive care physician in the Division of Cardiac Critical Care Medicine at CHOP, and her colleagues analyzed the Cardiac Arrest Registry to Enhance Survival (CARES) to study patients 18 years old or younger who experienced an out-of-hospital cardiac arrest (OHCA) between 2013 and 2017. They were primarily looking for neurologically favorable survival. The highest neurologically favorable survival was associated with conventional BCPR. Conventional BCPR was also significantly associated with neurologically favorable survival compared to no BCPR overall and among all age groups. The findings support the current guidelines from the AHA for performing conventional BCPR (as opposed to compression-only BCPR) in response to OHCA.
This presentation was a finalist for Outstanding Research Award in Pediatric Cardiology
Longitudinal Change in Exercise Capacity and Predictors of Performance after Fontan: Results from the Pediatric Heart Network Fontan 3 Study
Undergoing a Fontan procedure — used in patients who only have one working ventricle — often leads to impaired exercise capacity afterward, which can be associated with increased morbidity risk. However, this has never been confirmed in a large cohort study.
Dr. David J. Goldberg, a board-certified attending cardiologist in the Cardiac Center at CHOP, and his colleagues in the NIH/NHLBI’s Pediatric Heart Network studied 336 Fontan patients and compared their ramp cycle ergometry performance over time as they aged. They found that these patients were better able to preserve their submaximal aerobic exercise capacity than their maximal aerobic capacity. However, they did observe an overall decline in exercise performance in the second and third decades of life, with body composition and gender also playing a role in a patient’s exercise capacity, with female patients, left ventricular morphology, and a lack of a pacemaker, all leading to better exercise capacity.
This presentation was a finalist for Outstanding Research Award in Pediatric Cardiology
Failure to Rescue as an Outcome Metric in the Pediatric and Congenital Cardiac Catheterization Laboratory: An Analysis of Data the Improving Adult and Congenital Treatment® (IMPACT®) Registry
When measuring quality of care for pediatric and congenital cardiac catheterization programs, risk-adjusted adverse event (AE) rates have historically been the standard. However, in other settings, failure to rescue (FTR) has been seen as superior to AE rates in terms of measuring quality of care.
Dr. Michael L. O’Byrne, an attending interventional cardiologist in the Cardiac Center at CHOP, and his colleagues performed a multicenter retrospective cohort study of elective and urgent catheterization procedures from the IMPACT Registry between 2010 and 2016. Using a series of analyses, the team compared FTR and major AE. They observed that higher annual pediatric/congenital cardiac catheterization programs (PCCL) volume was associated with a lower FTR risk, while no significant association was seen between catheterization volume and the risk of all AE. This suggests that larger volume programs reduce the risk of an AE progressing to a catastrophic AE.
The researchers concluded that FTR appears to provide additional and complementary information about the quality of PCCL than AE, and should be included in future research and quality improvement projects.
This presentation was a finalist in the CVDY Early Career Young Investigator Competition
The Influence of Age, Race, and Ethnicity on Public Automated External Defibrillator Use and Outcomes of Pediatric Out-of-hospital Cardiac Arrest in the United States: An Analysis of the Cardiac Arrest Registry to Enhance Survival (CARES)
Automated external defibrillators (AEDs) are critical for helping adult patients who undergo out-of-hospital cardiac arrest, but while their benefits for adults are proven and well-known, there is not much known about their use in children.
Dr. Heather Griffis, a research scientist working with the Healthcare Analytics Unit (HAU) at the Center for Pediatric Clinical Effectiveness (CPCE) and PolicyLab at CHOP, collaborated with a clinical team led by Dr. Joseph Rossano, a pediatric cardiologist and Chief of the Division of Cardiology at CHOP, and analyzed the CARES database to study people 18 years old or younger who underwent public, non-traumatic OHCA between 2013 and 2017. They found that among 971 patients who fit the criteria, AEDs were used by bystanders in 117 of those cases, with similar use among white, black, and Hispanic children. They found that neurologically favorable survival was 29.1 percent when someone used an AED compared to 23.7 percent when no bystander AED was used. The results were favorable in children between the ages of 12 and 18, but not for children younger than 12. They also found that neurologically favorable survival was associated with AED use in white children but not with black or Hispanic children.
The authors suggested further investigation is needed to understand these disparities in AED use and outcomes after AED use.
When Laws Save Lives: Impact of Legislation Requiring Cardiopulmonary Resuscitation Education in High Schools on Survival after Sudden Cardiac Arrest
In another study utilizing CARES data, research led by Dr. Victoria L. Vetter, a board-certified cardiologist in the Cardiac Center at CHOP and Medical Director of the Youth Heart Watch program, demonstrated that required CPR education in high school may lead to higher bystander CPR and cardiac arrest survival rates.
Analyzing data from 109,668 out-of-hospital cardiac arrest patients across 42 states, the researchers found that bystander CPR, survival to hospital discharge and neurologically favorable survival were all higher in states that require CPR training in high school.
Fetal Detection of Complex Congenital Heart Disease Does Improve Outcomes
While dozens of papers have supported the use of prenatal ultrasound and echocardiography and have demonstrated improved outcomes, the question may need to be reframed in order to understand exactly what benefits these procedures provide.
Dr. Michael D. Quartermain, an attending cardiologist and Medical Director of the Echocardiography Laboratory in the Cardiac Center at CHOP, and his colleagues wanted to determine if a fetus with a prenatal diagnosis (PND) has less pre-operative instability and improved postnatal status, and whether this leads to improved outcomes after surgery.
When it came to preoperative risk factors, a fetus with PND was less likely to require pre-operative mechanical ventilation or present in shock. In addition, other known pre-operative risk factors, including renal dysfunction, hepatic dysfunction, coagulopathy, and requiring CPR were all less likely to occur in a fetus with PND.
Ultimately, the team concluded that PND almost certainly provides a benefit to children with congenital heart disease, but PND also is more likely to identify a population of neonates with a high level of disease burden, and so these competing risks need to be considered when reviewing published outcomes.
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