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Cardiology, Inside Pediatrics

Children’s of Alabama Receives Prestigious Accreditation from Children’s Cardiomyopathy Foundation

Cardiomyopathy_WEB

Livie Wheeler of Pell City, Alabama was diagnosed with dilated cardiomyopathy and underwent a successful heart transplant at Children’s of Alabama. Livie was discharged home just in time for her second birthday.

Children’s of Alabama was recently named an accredited center of care by the Children’s Cardiomyopathy Foundation (CCF), a national nonprofit committed to improving the health outcomes and quality of life for children with cardiomyopathy.

“We’re glad to be able to participate,” said F. Bennett Pearce, M.D., outgoing medical director of the Pediatric Advanced Heart Failure and Transplant Program at Children’s of Alabama. “CCF promotes education and helps families connect and choose centers with experience in these kinds of patients.”

The Pediatric and Congenital Heart Center of Alabama at Children’s of Alabama is one of the largest pediatric cardiovascular programs in the Southeast. In 2018, its team of 250 dedicated professionals treated more than 230 patients with pediatric cardiomyopathy. The team includes surgeons, intensivists, cardiologists and many others, including nurses, social workers, child life specialists, genetic counselors, nutritionists, occupational and physical therapists, and chaplains.

“We have traditionally had very strong clinical abilities and success with treating a variety of these conditions,” Pearce said. “Over the 25 years that I’ve worked in the program, I feel we have been among the finest centers, but we have not been quite so active in getting the word out. That needs to change because we want to make families aware that there’s a good resource for them here.”

The CCF offers a plethora of educational and supportive programs for families, as well as a research grant program for basic, clinical, population/epidemiologic, or translational studies focused on primary pediatric cardiomyopathy.

Its accreditation program was established in 2017 to recognize excellence in diagnosing and treating pediatric cardiomyopathy and provide families with standardized center information to help them find an expert treatment center in their area. To date, 39 centers in the U.S. and Canada, including Children’s of Alabama, have been accredited.

The CCF has very strict criteria for accreditation. Centers must:

  • Manage 30 or more cardiomyopathy patients up to age 18 annually or 60 pediatric cardiomyopathy patient visits a year.
  • Have at least one pediatric cardiologist who treats patients with dilated, hypertrophic, restrictive arrhythmogenic and right ventricular or left ventricular non-compaction cardiomyopathy.
  • Be part of a teaching hospital affiliated with a medical school.
  • Offer the following:
    • Prenatal or fetal echocardiography
    • High quality imaging (echocardiogram, cardiac magnetic resonance imaging)
    • Interventional cardiology (catheterization, endomyocardial biopsy)
    • Pediatric cardiac electrophysiology
    • Cardiac surgical services (septal myectomy, cardiac device implantation)
    • Genetic testing and counseling
    • Pediatric neurology
    • Social work
    • Child life services
  • Centers must also have at least one of the following (Children’s of Alabama meets all four):
    • A specialized clinic or program focused on pediatric cardiomyopathy or familial hypertrophic cardiomyopathy with a dedicated team of professionals.
    • Involvement with the North American Pediatric Cardiomyopathy Registry, Pediatric Cardiomyopathy Repository or Pediatric Heart Transplant Study Group.
    • Engagement in pediatric cardiomyopathy research.
    • Advanced heart failure management and transplantation.

“We have everything needed to offer to this group of patients,” Pearce said. “And we want to make sure that when a family confronts this difficult diagnosis, they can easily find our program and be assured that it is a good resource.”

 

Cardiology, Inside Pediatrics

Discharged with an iPad: Children’s of Alabama Uses Telehealth to Monitor Complex Heart Patients at Home

Telehealth_WEB

Children’s of Alabama has partnered with Locus Health to provide a special iPad app that connects parents with nurse practitioners who treat infants who have undergone complex surgery.

Babies born with a single ventricle must undergo three major open-heart surgeries by the time they are toddlers. The first and most complex surgery occurs at 1 to 2 weeks; the second between 4 and 12 months. The months spent at home between the two can be overwhelming for parents.

Now families served at Children’s of Alabama have a new tool to help them cope – an iPad containing a special app from Locus Health, a Charlottesville, Virginia-based company that develops software to ease the discharge process and transition from hospital to home. The app forms the core of a remote monitoring system that connects parents with the nurse practitioners at Children’s of Alabama who care for their infants.

“These parents have been through a tremendous amount of stress,” said Katelyn Staley, discharge coordinator for Cardiovascular Services at Children’s of Alabama. “Not only do they have a newborn, but the baby requires major open-heart surgery in that first week or two of life. Then they are discharged home; it’s an overwhelming process,” she said.

“The Locus platform was designed specifically for the pediatric patient population with congenital heart disease,” said Sarah Blair, RN, MSN, CRNP, of Children’s of Alabama’s Hearts at Home Program. More than a dozen of the country’s leading children’s hospitals now use the system, which studies find can reduce post-discharge emergency room visits as much as 40 percent and the total hospital days by up to two weeks.

Children’s of Alabama had been using another electronic program, but it was cumbersome, not user-friendly and difficult to extract data from. Before that, all data was collected the old-fashioned way – with paper and pencil.

With the Locus app, parents enter their child’s daily weight, oxygen saturation, heart rate, number of diapers, Synagis dosing and nutritional intake, noting if there is any vomiting or diarrhea. They can also upload photos and videos.

Timely information is critical. For instance, weight gain is vitally important because if the baby stops gaining or loses weight the team needs to intervene quickly before complications occur. In addition, values can be individualized for each infant depending on their medical status. “If a parent enters an out-of-range value it creates a red flag and prompts the caregiver to call the hospital immediately,” Staley said.

The data automatically populates the congenital heart clinical dashboard, which nurse practitioners and clinical nutritionists monitor. Parents can also see current and past data and even track trends across time, Blair said. Data can also be downloaded into a PDF and emailed to physicians.

The remote monitoring is also beneficial since many patients live hours from the hospital and may be followed by a local cardiologist. “Now we can share the information with the cardiologist where they live,” she said.

“It definitely keeps us in constant communication with the families,” Blair said. “We still call and talk to them, but it relieves some of that pressure.”

“Sending families home with the reassurance that nurse practitioners are logging into the system on a daily basis and that they have 24/7 access to a provider is very reassuring,” Staley said.

Cardiology

Thanks to Team-Oriented Approach, Heart Transplant Program Leads Country in Outcomes

transplant_team

The Pediatric Advanced Heart Failure and Transplant Team at Children’s Alabama, seated, left to right: Sally Smith, DNP, CRNP, CCTC; Meloneysa Hubbard, MSN, CRNP, CCTC; and Kimberly Sullivan, MSN, CCTC, CRNP. Standing, left to right: Mariah Strickland, MSN, CRNP; Waldemar F. Carlo, M.D.; David C. Mauchley, M.D.; F. Bennett Pearce, M.D; and Robert J. Dabal, M.D.

The numbers tell the story of the heart transplant program at Children’s of Alabama.

• 176 pediatric heart transplants since 1981
• 59 transplants since 2012
• Zero deaths since 2014
• A 97 percent one-year survival rate over the last decade — considerably higher than the national rate of 90.2 percent

One major reason? “We have a very cohesive, experienced, stable team,” said Medical Director F. Bennett Pearce, M.D. That team includes surgical director Robert J. Dabal, M.D., pediatric cardiologist Waldemar F. Carlo, M.D., and pediatric surgeon David C. Mauchley, M.D., as well as four cardiac nurse practitioners, three of whom are certified clinical transplant coordinators.

Until 2012, the pediatric transplant program was housed at the University of Alabama at Birmingham (UAB). But with the opening of the new children’s hospital that year, the transplant team was able to create a separate entity and move into a state-of-the-art cardiac care facility at Children’s. Today, it serves as a regional referral center and is the only pediatric heart transplant program in the state. The program also provides comprehensive care for patients with advanced heart failure using evidence-based medical management and mechanical circulatory support. Its surgeons also perform heart transplants, including ABO incompatible transplants, in infants.

Although the United Network of Organ Sharing (UNOS) considers the Children’s program to be a relatively young program, Pearce said, “the reality is far different” given the team’s depth and length of experience. The team is also diverse, he said, bringing different viewpoints and interests, which expands the program’s potential.

Moving to Children’s brought several advantages, he said, particularly access to pediatric specialists. “We can provide better multidisciplinary care for patients,” he said. The program also now has its own administrative structure and identity, providing families with a central place to call with questions or concerns.

The center also features dedicated social workers, child life therapists, physical/occupational therapists, dietary counselors, psychosocial counselors, specialty pharmacists and pastoral care. “We realize that when a patient is listed for transplant that you’re entering into a relationship the family as well as the patient,” Pearce said, “and we do all we can to optimize that relationship.”

Research is a major part of the program, he said, with ongoing studies on cardiomyopathy, pulmonary hypertension and heart transplantation. For instance, one major study is evaluating alternative immune suppression techniques for post-transplant children. The center also participates in numerous quality initiatives with other transplant programs around the country in order to identify best practices.

Largest Pediatric Heart Transplant Registry in the World

UAB houses the international Pediatric Heart Transplant Society, which maintains the largest registry in the world on heart transplantation. Data from the registry is used to encourage and stimulate basic and clinical research in the field of pediatric heart transplantation and to promote new therapeutic strategies. Since its founding in 1993, data from the registry has been used to produce more than 100 abstracts and presentations, and 87 publications. Today, 56 centers participate in the registry, which contains information on more than 6,542 transplants. James Kirklin, M.D., who was surgical director of Adult and Pediatric Heart Transplant program at UAB and Children’s until his retirement from clinical work in 2017, initiated the registry.

Cardiology Heart Transplant Chart

The Heart of It All
Visit www.childrensal.org/advanced-heart-failure-and-transplant to learn more about the Pediatric Advanced Heart Failure and Transplant team at Children’s of Alabama.

Cardiology

‘Not-So-Stressful’ Stress Testing Evaluates Pediatric Congenital Heart Disease and Exercise-related Complaints

exercise_labPut a seemingly timid child with congenital heart disease (CHD) on a treadmill, attach electrodes to their chest and place a mask over their mouth and nose to measure gas exchange, and it’s amazing what you can learn about their cardiovascular and pulmonary health.  That’s the premise behind Children’s of Alabama’s new Cardiometabolic Exercise Testing Lab, which opened this summer. The lab was made possible through the generosity of Gene and Leslie Cash in loving memory of their daughter Kelly Cash.

“Exercise capacity can be highly predictive of the risk of complications related to CHD, including developing heart failure,” said pediatric cardiologist Camden Hebson, M.D., who runs the lab. “Given that the heart and lungs are usually the limiting factors on the extent of exercise capacity, stress testing is a wonderful way to evaluate how well patients are supported.”

In contrast, evaluating a child at rest, as with an EKG and echocardiogram, “is like evaluating the quality of a car when it’s in the shop versus taking it out on the road and seeing how well it drives,” he said.

While the test mimics the traditional stress test, the use of the mask to measure oxygen consumption (VO2) and CO2 elimination is particularly important, Hebson said.

“These become the key variables to say from a quantitative standpoint how well the heart and lungs support you as you exercise,” he said.

Children who have been living with a heart condition for years may underappreciate the severity of their symptoms, he said. The exercise test, however, provides objective data that can demonstrate problems and allow intervention.

“Many patients become accustomed to how they feel with exercise, yet with stress testing we can identify limitations early on and thus intervene in a timelier manner,” he said.

The test also enables serial assessments to assess function over time.

In some instances, he said, a patient’s symptoms are attributed to cardiovascular function, but the stress test can show it was related to pulmonary function instead.

“Sometimes that’s hard to tease out because we’re always focused on the heart,” he said. “Exercise testing offers a way to make that connection.”

Children as young as 7 years old can complete the test, he said, and those that can’t walk or run on the treadmill can use a bike. The key point is that “they need to be comfortable enough to come in and wear a mask, EKG leads, etc., while exercising,” he said.

To take some of the fear and anxiety out of the experience, the team has decorated the room to look more inviting with posters of sports figures and decals. They even added a scoreboard where kids can write their “code name” and see how they compare to others taking the test. The goal,  Hebson said, is to make the lab look less like a clinic or hospital setting and more like a place to have fun.

The test itself takes about 15 minutes, with another 30 minutes for the setup and explanations. It is typically covered by insurance.

Hebson, nursing staff, and parents are always in the room. As he noted, “We try to make it the least stressful as possible, even though it’s a stress test.”

Interested in a Pediatric Cardiology Fellowship at Children’s of Alabama?
Learn more at childrensal.org/pediatric-cardiology-fellowship.

Cardiology

Kylin’s Brave Heart

kylin_heart

Hearts are full at Children’s of Alabama because Kylin Harris’ heart is well. Inside a hospital conference room in June 2018, the banner was hung, the tablecloth was draped and the cake was cut in celebration of Kylin, the first-ever patient at Children’s to be successfully weaned from a pediatric ventricular assist device without the need for a heart transplant. The 1-year-old guest of honor arrived in what is by far Children’s most popular mode of transportation – a red Radio Flyer wagon – a stark contrast from her arrival just four months prior.

Kylin was flown by helicopter to Children’s after her mother, Keianna Harris, came home to find her daughter uncharacteristically lethargic. Kylin hadn’t slept well the past two nights and a startled Harris, a nurse by trade, took Kylin to their local emergency room. While en route to the hospital, Kylin had a seizure and fell limp.  Doctors at Children’s intubated Kylin and later diagnosed her with advanced heart failure due to myocarditis. Kylin experienced cardiac arrest while being transferred to the Cardiovascular Intensive Care Unit. Doctors performed chest compressions and CPR, and placed her on extracorporeal membrane oxygenation therapy (ECMO), which pumps and oxygenates a patient’s blood outside the body allowing the heart and lungs to rest for a limited time.

The Pediatric Advanced Heart Failure and Transplant Team at Children’s discussed every detail of Kylin’s care with Harris. It was apparent ECMO would not provide long enough support for Kylin’s heart. First, doctors would convert Kylin from ECMO to the Berlin Heart® EXCOR, a long-term cardiac assist device that functions as a heart outside of the body. The Berlin Heart acts as a bridge to transplantation for children in heart failure, allowing the patient mobility and freedom to rehabilitate in preparation for transplant surgery. Available in several sizes, the Berlin Heart is not totally implanted inside the body. Doctors insert cannulas, or flexible tubes, in the heart and they extend through the skin and connect to a small pump located outside the body. That pump, along with its computerized drive unit, maintains blood flow.

“It was a lot to take in … It all happened so fast,” Harris said. “My biggest fear was losing her. It was scary not knowing whether she was going to make it through.”

The Pediatric Advanced Heart Failure and Transplant Team, a partnership between Children’s and the University of Alabama at Birmingham (UAB),  is among the first in the U.S. to use the Berlin Heart in children and reported the first successful Berlin Heart bridge to transplantation for a child with a single ventricle. Children’s and UAB first used the device in 2005, when UAB was home to the pediatric cardiac unit. The following year, the team weaned its first patient, now an adult, from the Berlin Heart without the need for transplant at UAB. In 2012, with the opening of the Benjamin Russell Hospital for Children and Bruno Pediatric Cardiac Unit, all pediatric cardiac care to relocated to Children’s.

The team’s success with the Berlin Heart led to a landmark study published in the New England Journal of Medicine in 2012 featuring two team members as co-authors – pediatric cardiologist F. Bennett Pearce, M.D., and David Naftel, Ph.D, professor in the UAB Division of Cardiothoracic Surgery. The research team, known as the Berlin Heart Study Investigators, evaluated ECMO and the Berlin Heart to see which offered children the best chance of survival until they could receive a new heart or recover enough heart function not to need a support device or transplant.

Pearce says 46 percent of children diagnosed with heart failure die or receive a heart transplant within the first five years after diagnosis. A heart transplant is a child’s best hope of survival, with the survival rate after a transplant estimated at 83 percent at three years. However, with limited donor hearts available, the wait is often long.

“Children on waiting lists for heart transplants experience the highest waiting-list mortality for any age or organ,” Pearce says. “This research demonstrates that the Berlin Heart, available in variety of appropriate sizes for children, has the potential to effectively and safely bridge children from diagnosis to transplantation or in some cases recovery, for long periods of time.”

Before the study and subsequent approval of the Berlin Heart by the U.S. Food and Drug Administration, ECMO was the mainstay for mechanical circulatory support as a bridge to transplantation. The effective period of support with ECMO is typically limited to 10 to 20 days before serious complications such as bleeding and major organ system failure, often prohibiting transplantation. The short duration of support afforded by ECMO is often inadequate, the study reads, citing only 40 to 60 percent of children requiring support with ECMO survive long enough to undergo heart transplantation. Researchers found that the longest duration of support for the younger, smaller children was 174 days for the Berlin Heart and 21 days for ECMO therapy. The longest duration of support for the larger, older children was 192 days for the Berlin Heart and 28 days for ECMO.

“The Berlin Heart provided better survival over longer support periods than ECMO therapy,” Pearce says. “These longer support periods on the Berlin Heart allow for patient rehabilitation, improved nutrition and weaning from ventilator support to use of the patient’s own respiratory system so that the children may be better candidates for successful transplantation or so that long-term cardiac recovery can occur.”

Kylin lived with the Berlin Heart for 83 days. In that time span, doctors noted signs of cardiac recovery and further testing gave doctors the green light to again operate on Kylin to remove the device. Pearce credits fellow pediatric cardiologist Waldemar F. Carlo, M.D., who was the first to see hints of Kylin’s recovery.

“He was the strongest advocate for us to explore whether her degree of recovery was enough for her to be off the device,” said Pearce, adding Kylin’s echocardiogram and catheterization data yielded positive results. “We followed the protocol of the Berlin Heart Clinical Support Team. We were in daily communication with the team from the moment we considered weaning her off.

“She has continued to show us normal cardiac function. We removed her from the transplant list because she had improved so much. We’re following her closely, but our hope is she won’t require a heart transplant,” Pearce said.

And much to Harris’ delight and relief, her baby girl did make it through. Kylin is her old self again, she says, smiling from ear to ear.

“When Kylin was in the hospital, she wouldn’t smile. She felt miserable,” Harris said. “But now her personality is back. She’s been grinning ever since we left.”

Joseph S. Bruno Pediatric Heart Center
Learn more about the services provided by the Bruno Pediatric Heart Center at Children’s of Alabama at https://www.childrensal.org/heart-inpatient-services.