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Introduction
I am interest in research of short and long term health outcomes for critically ill children with heart disease and those supported with extracorporeal life support
Current institution
Publications
Publications (425)
In neonates with pulmonary hypertension (PH) supported on veno-venous extracorporeal membrane oxygenation (VV-ECMO), keeping the ductus arteriosus (DA) open ensures a high cardiac output of well-oxygenated blood through the right to left (R-L) ductal shunt. After PH resolution, timely closure of the patent DA (PDA) prevents pulmonary overcirculatio...
Neurological morbidity and mortality remain high in children requiring extracorporeal membrane oxygenation (ECMO). Although the severity of illness at the time of ECMO initiation and the nature of the underlying disease are strongly linked to the development of acute brain injury, several important factors are associated with neurological complicat...
Objectives
In children reported to the Extracorporeal Life Support Organization (ELSO) registry, to compare mortality, the need for additional cannulas, and complications associated with dual-lumen (DL) or multisite cannulation for venovenous extracorporeal membrane oxygenation (ECMO).
Design
Multicenter retrospective study using the ELSO registry...
Introduction
In children with myocarditis or dilated cardiomyopathy (DCM) on extracorporeal membrane oxygenation (ECMO) for cardiogenic shock, it is often necessary to decompress the left heart to minimize distension and promote myocardial recovery. We compare outcomes in those who underwent balloon atrial septostomy (BAS) versus direct left atrial...
Patients with restrictive cardiomyopathy (RCM) and hypertrophic cardiomyopathy (HCM) were previously considered poor candidates for mechanical circulatory support due to technical limitations related to restrictive ventricular physiology and small ventricular size, limiting the ability to provide adequate flows and decompress the heart. Literature...
Data describing the use of extracorporeal membrane oxygenation (ECMO) in pediatric acute liver failure (PALF) are scarce. Thus, we aimed to describe the use of ECMO in patients with PALF using the data from the Extracorporeal Life Support Organization (ELSO) Registry between January 1, 2010, to December 31, 2022. We described patients’ characterist...
Nutrition provision for children with heart disease supported with extracorporeal membrane oxygenation (ECMO) involves nuanced decision making. We examined nutrition provision while on ECMO in the CICU and the relationship between energy and protein adequacy and end organ function as assessed by pediatric sequential organ failure assessment (pSOFA)...
Objective:
Epidemiologic data on extracorporeal cardiopulmonary resuscitation (ECPR) use in children with cardiac disease after in-hospital cardiac arrest (IHCA) are lacking. We aimed to investigate trends in ECPR use over time in critically ill children with cardiac disease.
Data sources:
We performed a secondary analysis of a recent systematic...
OBJECTIVES
To present recommendations and consensus statements with supporting literature for the clinical management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus conference.
DATA SOURCES
Systematic review was performed using PubMed, Embas...
OBJECTIVES
To identify and prioritize research questions for anticoagulation and hemostasis management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus.
DATA SOURCES
Systematic review was performed using PubMed, EMBASE, and Cochrane Library (C...
OBJECTIVES
To derive systematic-review informed, modified Delphi consensus regarding anticoagulation monitoring assays and target levels in pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE.
DATA SOURCES
A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (...
Objectives
To study the impact of social determinants of health (SDoH) on pediatric extracorporeal membrane oxygenation (ECMO) outcomes.
Design, Setting, and Patients
Retrospective study of children (< 18 yr) supported on ECMO (October 1, 2015 to March 1, 2021) using Pediatric Health Information System (44 U.S. children’s hospitals). Patients were...
Race-conscious research identifies health disparities with 1) rigorous and responsible data collection, 2) intentionality and considered analyses, and 3) interpretation of results that advance health equity. Individual registries must overcome specific challenges to promote race-conscious research, and this paper describes ways to achieve this with...
There are minimal data describing use of extracorporeal membrane oxygenation (ECMO) in pediatric patient after a liver transplantation (LT). This study aimed at describing ECMO run in this specific situation using the data from Extracorporeal Life Support Organization (ELSO) Registry between January 1, 2010, to December 31, 2022. We described patie...
This study presents Neuro-SPARK, the first scoring system developed to assess the risk of neurologic injury in pediatric and neonatal patients on extracorporeal membrane oxygenation (ECMO). Using the extracorporeal life support organization (ELSO) registry, we applied robust machine learning methodologies and clinical expertise to a 10 years datase...
Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) typically presents in infancy; however, there are cases of patients who survive the infant period and present later in life. We aimed to characterize patients with late ALCAPA diagnoses and to assess perioperative and functional outcomes. A retrospective chart review of patients who...
Objectives
To determine factors associated with brain death in children treated with extracorporeal cardiopulmonary resuscitation (E-cardiopulmonary resuscitation).
Design
Retrospective database study.
Settings
Data reported to the Extracorporeal Life Support Organization (ELSO), 2017–2021.
Patients
Children supported with venoarterial extracorp...
The Extracorporeal Life Support Organization (ELSO) registry which collects data from hundreds of participating centers supports research in ECMO to help improve patient outcomes. The ELSO Scientific Oversight Committee, an international and diverse group of ECMOlogists (https://www.elso.org/registry/socmembers.aspx), selected the most impactful an...
Objectives
Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation (CPR) is increasingly used in children suffering cardiac arrest after cardiac surgery. However, its efficacy in promoting survival has not been evaluated. We compared survival of pediatric cardiac surgery patients suffering in-hospital cardiac arrest who were re...
BACKGROUND
Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we e...
OBJECTIVES
A recent study from Germany found that survival after respiratory extracorporeal life support (ECLS) was lower among patients 10–20 years old than 20–30 years old. The objective of this study was to compare survival between teenage and young adult patients who receive respiratory ECLS.
DESIGN
Retrospective cohort study.
SETTING
Extraco...
Background
Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) typically presents in infancy; however, there are cases of patients who survive the infant period and present later in life. We aimed to characterize patients with late ALCAPA diagnoses and to assess perioperative and functional outcomes.
Methods
A retrospective chart revi...
Importance:
Enrolling racially and ethnically diverse pediatric research participants is critical to ensuring equitable access to health advances and generalizability of research findings.
Objectives:
To examine the reporting of race and ethnicity for National Institutes of Health (NIH)-funded pediatric clinical trials and to assess the represen...
Objectives
Existing literature provides limited data about ICU characteristics and pediatric extracorporeal cardiopulmonary resuscitation (E-CPR) outcomes. We aimed to evaluate the associations between patient and ICU characteristics, and outcomes after E-CPR in the pediatric cardiac population.
Design
Retrospective analysis of the Virtual Pediatr...
Children with cardiac disease are at a higher risk of cardiac arrest as compared to healthy children. Delivering adequate cardiopulmonary resuscitation (CPR) can be challenging due to anatomic characteristics, risk profiles, and physiologies. We aimed to review the physiological aspects of resuscitation in different cardiac physiologies, summarize...
Aim:
To analyze the association between hypothermia and neurologic complications among children who were treated with extracorporeal cardiopulmonary resuscitation (ECPR) using the Extracorporeal Life Support Organization (ELSO) international registry METHODS: We conducted a retrospective, multicenter, database study utilizing ELSO data for ECPR en...
Objectives:
Extracorporeal membrane oxygenation (ECMO) has been used successfully to support adults with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related cardiac or respiratory failure refractory to conventional therapies. Comprehensive reports of children and adolescents with SARS-CoV-2-related ECMO support for conditions, inc...
Objectives:
To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes.
Data sources:
PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 t...
Objective:
Neurologic complications in pediatric patients supported by extracorporeal membrane oxygenation (ECMO) are common and lead to morbidity and mortality; however, few modifiable factors are known.
Design:
Retrospective study of the Extracorporeal Life Support Organization registry (2010-2019).
Setting:
Multicenter international databas...
To provide optimal, equitable care to patients, hospital systems must have intentional efforts to advance health equity. We present both intentional and actionable steps that our senior executive leadership prioritized to improve the health equity of the children and families we serve and to create a more inclusive working and learning environment...
Importance:
Data on trends in incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease in the intensive care unit (ICU) are lacking. Additionally, there is limited information on factors associated with IHCA and mortality in this population.
Objective:
To investigate incidence, trends, and factors associated...
Unlabelled:
Children presenting with acute myocarditis may experience rapid clinical deterioration requiring extracorporeal membrane oxygenation (ECMO); however, our understanding of best practices and timing of ECMO initiation are lacking. We explored the relationships between pre-cannulation factors and survival in this high-acuity patient popul...
Introduction: Social determinants of health (SDoH) impact general pediatric readmissions and pediatric cardiac surgical mortality. Yet, little is known of their influence on readmissions in pediatric cardiac disease.
Hypothesis: Children with cardiac disease from underrepresented populations, under-resourced neighborhoods or on public insurance are...
Introduction: Clinical data within the electronic health record (EHR) combined with artificial intelligence (AI) and machine learning (ML) offer the promise of rapid advancement of knowledge at the point of care.
Hypothesis: We hypothesized that aggregating clinical data with preservation of relational elements will yield a more precise and less bi...
Introduction: Studies evaluating trends in the incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease admitted to the intensive care unit (ICU) are rare. Additionally, there is limited information on factors associated with IHCA and mortality.
Hypothesis: We hypothesized that the incidence of IHCA and the mor...
Background
Data regarding the impact of intraoperative residual lesions on extracorporeal membrane oxygenation (ECMO) following the Norwood procedure are limited. Moreover, the significance of postoperative ECMO timing on in-hospital outcomes remains incompletely characterized.
Methods
This was a single-center, retrospective review of consecutive...
Objectives:
IV calcium administration during cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) is associated with worse survival. We evaluated survival to hospital discharge in children with heart disease (HD), where calcium is more frequently administered during CPR.
Design:
Retrospective study of a multicenter...
IMPORTANCE:. It is not know if hospital-level extracorporeal cardiopulmonary resuscitation (ECPR) case volume, or postcannulation clinical management associate with survival outcomes.
OBJECTIVES:. To describe variation in postresuscitation management practices, and annual hospital-level case volume, for patients who receive ECPR and to determine as...
Objectives:
Morbidity and mortality related to modified Blalock-Taussig shunt (mBTTS) thrombosis remain a significant risk. Platelet inhibition following mBTTS may reduce this risk. However, oral antiplatelet agents have variable absorption following surgery. We determine risk factors for mBTTS thrombosis and hypothesize that IV glycoprotein IIb/I...
Objective
To examine the resilience of parents of children with congenital heart disease and to investigate socio-demographic factors that may influence parents’ resilience.
Methods
This is a web-based survey study using a cross-sectional design. A purposive sampling method was utilized to recruit 515 parents who care for children with CHD. Resili...
Background
The association of near-infrared spectroscopy (NIRS) with various outcomes after pediatric cardiac surgery has been studied extensively. However, the role of NIRS in the prediction of cardiac arrest (CA) in children with heart disease has yet to be evaluated. We sought to determine if a model utilizing regional cerebral oximetry (rSO2c)...
Purpose
Despite extracorporeal membrane oxygenation (ECMO) utilization in up to 20% of cases, there are limited outcome data in pediatric patients with acute fulminant myocarditis (AFM) requiring mechanical circulatory support.
Methods
Retrospective cohort of patients <18 years with AFM admitted to a single center cardiac ICU and supported with EC...
Research Question
Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival?
Methods
Observational cohort study of 7,488 adult patients with ECPR from the Extracor...
Pediatric cardiac extracorporeal membrane oxygenation (ECMO) patients have high mortality rates. The purpose of our study was to develop and validate the Pediatric Survival After Veno-arterial ECMO (Pedi-SAVE) score for predicting survival at hospital discharge after pediatric cardiac veno-arterial (VA) ECMO. We used data for pediatric cardiac VA-E...
Importance
Elective surgeries are primarily scheduled according to surgeon availability with less consideration of patients' postoperative cardiac intensive care unit (CICU) length of stay. Furthermore, the CICU census can exhibit a high rate of variation in which the CICU is operating at over-capacity, resulting in admission delays and cancellatio...
Objective
When patients deteriorate after decannulation from extracorporeal membrane oxygenation (ECMO), a second run of extracorporeal support may be considered. However, repeat cannulation can be difficult and poor outcomes associated with multiple ECMO runs are a concern. The aim of this study was to evaluate outcomes and identify factors associ...
Objectives
The aim of this study was to develop and validate a score to accurately predict the probability of death for adult extracorporeal cardiopulmonary resuscitation (ECPR).
Background
ECPR is being increasingly used to treat refractory in-hospital cardiac arrest (IHCA), but survival varies from 20% to 40%.
Methods
Adult patients with extrac...
CONTEXT
Cardiovascular dysfunction is associated with poor outcomes in critically ill children.
OBJECTIVE
We aim to derive an evidence-informed, consensus-based definition of cardiovascular dysfunction in critically ill children.
DATA SOURCES
Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 using medical s...
Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was co...
Introduction: Gas exchange during ECMO can occur independent of the lungs through ECMO, enabling a wider range of ventilator settings and blood gas values. Yet it is not known if potentially modifiable mechanical ventilation parameters or blood gas values are associated with survival for patients who receive ECPR.
Hypothesis: To determine associati...
Introduction: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been increasingly utilized during in-hospital arrest in postoperative pediatric cardiac surgical patients. Despite this and the significant associated mortality, few pediatric multicenter analyses have evaluated if E-CPR increases survival for in-hospital cardiac arrest compared...
Background
Research evaluating hemostatic agents for the treatment of clinically significant bleeding has been hampered by inconsistency and lack of standardized primary clinical trial outcomes. Clinical trials of hemostatic agents in both cardiac surgery and mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) a...
Rationale:
Extracorporeal membrane oxygenation (ECMO) is increasingly used to bridge waitlisted children failing conventional respiratory support to lung transplantation.
Objectives:
To compare in-hospital mortality and a composite outcome of 1-year mortality or re-transplantation in children bridged with ECMO with those on mechanical ventilatio...
Objectives:
In the vast majority of Children's Hospitals, the critically ill patient can be found in one of three locations: the PICU, the neonatal ICU, and the cardiac ICU. Training, certification, and maintenance of certification for neonatology and critical care medicine are over seen by the Accreditation Council for Graduate Medical Education...
Severe forms of pulmonary embolism (PE) in children are rare but cause significant morbidity and mortality. In this article, we review the pathophysiology of severe (high- and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision making.
We define pediatric hig...
Background
Left atrial (LA) decompression on extracorporeal membrane oxygenation (ECMO) can reduce left ventricular distension, allowing myocardial rest and recovery, and protect from lung injury secondary to cardiogenic pulmonary edema. However, clinical benefits remain unknown. We sought to evaluate the association between LA decompression and in...
Aim
We aimed to characterize extracorporeal CPR (ECPR) outcomes in our center and to model prediction of severe functional impairment or death at discharge.
Methods
All ECPR events between 2011-2019 were reviewed. The primary outcome measure was severe functional impairment or death at discharge (Functional Status Score [FSS] ≥16). Organ dysfuncti...
The history of cardiopulmonary resuscitation and the Society of Critical Care Medicine have much in common, as many of the founders of the Society of Critical Care Medicine focused on understanding and improving outcomes from cardiac arrest. We review the history, the current, and future state of cardiopulmonary resuscitation.
Objectives:
To describe the use and outcomes of extracorporeal membrane oxygenation support among children with immune-mediated conditions.
Design:
Retrospective cohort study.
Setting:
The Extracorporeal Life Support Organization registry.
Patients:
Patients 1 month to 18 years old with International Classification of Diseases, 9th Edition a...
Background
Previous studies suggest that infant heart transplant (HT) recipients are at higher risk of developing severe primary graft dysfunction (PGD) than older children. We sought to identify risk factors for developing severe PGD in infant HT recipients.
Methods and Results
We identified all HT recipients aged <1 year in the United States dur...
Although extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly utilized in the pediatric critical care environment, our understanding regarding pediatric candidacy for ECPR remains unknown. Our objective is to explore current practice and indications for pediatric ECPR. Scenario-based, self-administered, online survey, evaluating clin...
The AngioVac System (AVS) extracts venous and pulmonary artery (PA) thrombi. We report modified use of the second-generation AVS with concurrent venoarterial extracorporeal membrane oxygenation (VA-ECMO) in a 10-year-old, 23 kg patient with failing Fontan circulation due to acute-on-chronic Fontan and PA thrombosis. Emergent femoral VA-ECMO was ini...
In children with severe advanced heart failure where medical management has failed, mechanical circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) or ventricular assist device represents life-sustaining therapy. This review provides an overview of VA ECMO used for cardiovascular support including medical a...
These guidelines are applicable to neonates and children with cardiac failure as indication for extracorporeal life support. These guidelines address patient selection, management during extracorporeal membrane oxygenation, and pathways for weaning support or bridging to other therapies. Equally important issues, such as personnel, training, creden...
Objectives:
Fluid boluses are commonly administered to improve the cardiac output and tissue oxygen delivery in pediatric septic shock. The objective of this study is to evaluate the effect of an early fluid bolus administered to children with septic shock on the cardiac index and mean arterial pressure, as well as on the hemodynamic response and...
Objectives:
Anticoagulation plays a key role in the management of children supported with extracorporeal membrane oxygenation. However, the ideal strategy for monitoring anticoagulation remains unclear. Our objective was to evaluate the utility of laboratory measures of anticoagulation in pediatric extracorporeal membrane oxygenation.
Design:
Re...
Once a mainstay in the treatment of neonates with d-transposition of the great arteries (d-TGA), the application of balloon atrial septostomy (BAS) in the d-TGA population has become more selective. Currently, there is no clear evidence for or against a selective BAS strategy. The aims of this single-center retrospective study were to determine the...
Ventricular assist devices (VAD) are used more in children. Safe and effective anticoagulation is required for successful management of children supported with ventricular assist devices. Developmental hemostasis, device hemocompatibility, plastic to body ratio, surgical variable techniques, lack of knowledge on pharmacokinetics of anticoagulants,...
Objective: The goal of this work is to provide insight into survival and neurologic outcomes of pediatric patients supported with extracorporeal cardiopulmonary resuscitation.
Data sources: A systematic search of Embase, PubMed, Cochrane, Scopus, Google Scholar, and Web of Science was performed from January 1990 to May 2020.
Study selection: A co...
Objectives:
Patients undergoing extracorporeal membrane oxygenation are at high risk for bleeding and thrombotic complications. Current laboratory methods for assessing the coagulation system may be imprecise and complicate clinical decision-making. We hypothesize that thromboelastography may be more strongly associated with bleeding events than t...
Objectives:
Hemoptysis is uncommon in children, even among the critically ill, with a paucity of epidemiological data to inform clinical decision-making. We describe hemoptysis-associated ICU admissions, including those who were critically ill at hemoptysis onset or who became critically ill as a result of hemoptysis, and identify predictors of mo...
