PurposeThe effectiveness of a Healthcare Transition (HCT) toolkit embedded in the Electronic Medical Record (EMR) to improve provider workflow and provide resources and tools to facilitate HCT discussions in adolescents following heart transplant (HT) was assessed. We hypothesized that an EMR-based electronic HCT toolkit would improve Anticipatory Guidance (AG) and transition readiness in HT patients (pts).MethodsA retrospective cohort study was conducted through review of all HT visits in pts > 12 years who received care from 1/1/22-9/1/22. On 5/3/22, a customized electronic HCT toolkit was implemented into the EMR which included: a Best Practice Advisory Alert (BPA) tool reminding providers to address HCT, enabling electronic documentation of AG based on stages in healthcare independence, Transition Assessment Readiness Questionnaire (TRAQ) in the EMR visit navigator, and providing resources for patient portal access and HCT website education by adding two QR codes to the after-visit summary. Data was collected pre- and post- toolkit implementation and included age at visit and frequency of HCT AG and TRAQ administration. The occurrence of documented AG and TRAQ administration pre- and post- toolkit implementation was compared using chi-square analysis.ResultsPre-toolkit, 63 visits were performed: 5% (3/63) had HCT AG documented and 11% (7/63) of patients had a paper TRAQ completed. Post-toolkit, 55 visits were performed: 47% (26/55) had HCT AG documented, and 47% (26/55) of patients had TRAQ documented electronically. TRAQ administration (p<0.01) and AG documentation were significantly higher post-toolkit implementation (p<0.01), Figure 1.ConclusionThis study demonstrates that implementation of an EMR-based electronic HCT toolkit significantly increased assessment of HCT readiness and provision of HCT AG. EMR access to a standardized HCT toolkit has the potential to improve compliance with best practices and facilitate important HCT discussions among providers and patients. The effectiveness of a Healthcare Transition (HCT) toolkit embedded in the Electronic Medical Record (EMR) to improve provider workflow and provide resources and tools to facilitate HCT discussions in adolescents following heart transplant (HT) was assessed. We hypothesized that an EMR-based electronic HCT toolkit would improve Anticipatory Guidance (AG) and transition readiness in HT patients (pts). A retrospective cohort study was conducted through review of all HT visits in pts > 12 years who received care from 1/1/22-9/1/22. On 5/3/22, a customized electronic HCT toolkit was implemented into the EMR which included: a Best Practice Advisory Alert (BPA) tool reminding providers to address HCT, enabling electronic documentation of AG based on stages in healthcare independence, Transition Assessment Readiness Questionnaire (TRAQ) in the EMR visit navigator, and providing resources for patient portal access and HCT website education by adding two QR codes to the after-visit summary. Data was collected pre- and post- toolkit implementation and included age at visit and frequency of HCT AG and TRAQ administration. The occurrence of documented AG and TRAQ administration pre- and post- toolkit implementation was compared using chi-square analysis. Pre-toolkit, 63 visits were performed: 5% (3/63) had HCT AG documented and 11% (7/63) of patients had a paper TRAQ completed. Post-toolkit, 55 visits were performed: 47% (26/55) had HCT AG documented, and 47% (26/55) of patients had TRAQ documented electronically. TRAQ administration (p<0.01) and AG documentation were significantly higher post-toolkit implementation (p<0.01), Figure 1. This study demonstrates that implementation of an EMR-based electronic HCT toolkit significantly increased assessment of HCT readiness and provision of HCT AG. EMR access to a standardized HCT toolkit has the potential to improve compliance with best practices and facilitate important HCT discussions among providers and patients.

PurposeDuring the COVID surge and shutdown (SD) of NYC from 3/20-5/20, we transitioned to telemedicine (TM) to provide routine and urgent care to our pediatric heart transplant (HT) patients (pts). The effectiveness of TM in this population has not been described.MethodsA retrospective cohort study was conducted at the Children's Hospital at Montefiore, Bronx, NY. Electronic health records of all HT pts who received care from 1/3/20-8/31/20 were queried. Data collected included frequency of TM, in person, and emergency room (ER) visits, hospitalizations, immunosuppression (IS) levels requiring adjustment, and out-of-window pt follow-up (f/u). The proportion of IS levels out of range was compared among 4 groups by chi-square analysis.ResultsDuring SD there were 54 TM visits: 61% routine and 39% sick. Five (24%) sick TM visits justified an in person f/u: 3 clinic visits, 2 ER visits, 1 required hospitalization (Figure). During the post-SD period 1 when in person visits resumed, 9 pt visits were out of window for routine f/u, median of 6 weeks delayed. IS levels were not therapeutic in 29% of pts pre-SD compared to 46% during post-SD period 1 (p=0.06). There was a difference between post-SD period 1 and 2 (p=0.04). By SD period 2, IS had returned to pre-SD levels (p=0.6) (Table).ConclusionTM can be utilized to stay connected to pts and reduce the need for in person visits when routine in person care is disrupted. The higher percentage of pts with IS levels out of range seen during the immediate post COVID SD period reinforces the importance of routine IS level surveillance. Home IS level monitoring should be considered as a component of TM in this population. During the COVID surge and shutdown (SD) of NYC from 3/20-5/20, we transitioned to telemedicine (TM) to provide routine and urgent care to our pediatric heart transplant (HT) patients (pts). The effectiveness of TM in this population has not been described. A retrospective cohort study was conducted at the Children's Hospital at Montefiore, Bronx, NY. Electronic health records of all HT pts who received care from 1/3/20-8/31/20 were queried. Data collected included frequency of TM, in person, and emergency room (ER) visits, hospitalizations, immunosuppression (IS) levels requiring adjustment, and out-of-window pt follow-up (f/u). The proportion of IS levels out of range was compared among 4 groups by chi-square analysis. During SD there were 54 TM visits: 61% routine and 39% sick. Five (24%) sick TM visits justified an in person f/u: 3 clinic visits, 2 ER visits, 1 required hospitalization (Figure). During the post-SD period 1 when in person visits resumed, 9 pt visits were out of window for routine f/u, median of 6 weeks delayed. IS levels were not therapeutic in 29% of pts pre-SD compared to 46% during post-SD period 1 (p=0.06). There was a difference between post-SD period 1 and 2 (p=0.04). By SD period 2, IS had returned to pre-SD levels (p=0.6) (Table). TM can be utilized to stay connected to pts and reduce the need for in person visits when routine in person care is disrupted. The higher percentage of pts with IS levels out of range seen during the immediate post COVID SD period reinforces the importance of routine IS level surveillance. Home IS level monitoring should be considered as a component of TM in this population.

Organ transplantation from ABO blood group–incompatible (ABOi) donors requires accurate detection, effective removal and subsequent surveillance of antidonor antibodies. Because ABH antigen subtypes are expressed differently in various cells and organs, measurement of antibodies specific for the antigen subtypes in the graft is essential. Erythrocyte agglutination, the century‐old assay used clinically, does not discriminate subtype‐specific ABO antibodies and provides limited information on antibody isotypes. We designed and created an ABO‐glycan microarray and demonstrated the precise assessment of both the presence and, importantly, the absence of donor‐specific antibodies in an international study of pediatric heart transplant patients. Specific IgM, IgG, and IgA isotype antibodies to nonself ABH subtypes were detected in control participants and recipients of ABO‐compatible transplants. Conversely, in children who received ABOi transplants, antibodies specific for A subtype II and/or B subtype II antigens—the only ABH antigen subtypes expressed in heart tissue—were absent, demonstrating the fine specificity of B cell tolerance to donor/graft blood group antigens. In contrast to the hemagglutination assay, the ABO‐glycan microarray allows detailed characterization of donor‐specific antibodies necessary for effective transplant management, representing a major step forward in precise ABO antibody detection.

Background Previous studies in adults have suggested that donor dopamine treatment may improve recipient outcomes in organ transplantation; in this analysis, we aimed to determine if donor dopamine reduces the incidence of postoperative right heart failure (RHF) in pediatric heart transplant recipients. Methods Data for recipients aged 18 years or younger transplanted at our institution between January 1, 2000, and June 15, 2011, and their respective donors were obtained. The presence of postoperative RHF was assessed for in all subjects. Donor dopamine dose was stratified into 3 groups: none, low-dose (⩽5 &mgr;g/kg per minute), and high-dose (>5 &mgr;g/kg per minute). Logistic regression was used to assess the relationship between donor dopamine dose and recipient RHF. Results Of 192 recipients, 34 (18%) experienced postoperative RHF. There was no difference in baseline demographics between recipients with and without RHF. When controlling for pulmonary vascular resistance index, graft ischemic time, and cardiopulmonary bypass time, donor low-dose dopamine was independently associated with a decreased risk of RHF (odds ratio, 0.16; 95% confidence interval, 0.04-0.70; P = 0.02); however high-dose dopamine was neither associated with, nor protective of, RHF (odds ratio, 0.31; 95% confidence interval, 0.06-1.6; P = 0.16). Conclusions Despite advances in perioperative care of the recipient, RHF persists as a complication of pediatric heart transplantation. In this study, donor pretreatment with low-dose dopamine is associated with a decreased risk of postoperative RHF in pediatric heart recipients. Further studies into this association may be useful in determining the utility of empiric donor pretreatment with low-dose dopamine.

Blood group ABH(O) carbohydrate antigens are carried by precursor structures denoted type I–IV chains, creating unique antigen epitopes that may differ in expression between circulating erythrocytes and vascular endothelial cells. Characterization of such differences is invaluable in many clinical settings including transplantation. Monoclonal antibodies were generated and epitope specificities were characterized against chemically synthesized type I–IV ABH and related glycans. Antigen expression was detected on endomyocardial biopsies (n = 50) and spleen (n = 11) by immunohistochemical staining and on erythrocytes by flow cytometry. On vascular endothelial cells of heart and spleen, only type II–based ABH antigens were expressed; type III/IV structures were not detected. Type II–based ABH were expressed on erythrocytes of all blood groups. Group A1 and A2 erythrocytes additionally expressed type III/IV precursors, whereas group B and O erythrocytes did not. Intensity of A/B antigen expression differed among group A1, A2, A1B, A2B and B erythrocytes. On group A2 erythrocytes, type III H structures were largely un‐glycosylated with the terminal “A” sugar α‐GalNAc. Together, these studies define qualitative and quantitative differences in ABH antigen expression between erythrocytes and vascular tissues. These expression profiles have important implications that must be considered in clinical settings of ABO‐incompatible transplantation when interpreting anti‐ABO antibodies measured by hemagglutination assays with reagent erythrocytes.

The use of ventricular assist devices (VADs) in pediatric heart failure (HF) has increased dramatically in recent years, despite high rates of morbidity and mortality. We reviewed all patients (pts) at our center who were placed on centrifugal continuous flow VADs (CentriMag, PediMag) to assess the relationship of flow rates to complications and outcomes. A retrospective chart review was performed of all pts < 18 years (yrs) who were placed on either a CentriMag or PediMag VAD. Flow rates and RPMs were averaged over the first 48 hours post-implantation, and a cut-off value of 3L/min was used to dichotomize flow rate. Survival and complications were compared between flow rates using logistic regression. A total of 24 pts were implanted. Concomitant use of another LVAD led to exclusion of 4 pts. The median age at support was 8.3 yrs (8 months-17.5 yrs) with a median weight of 25.6 kg (5.8-68 kg). Indication for implantation was worsening chronic HF in 13 (65%), acute HF in 5 (25%), and acute graft rejection in 2 (10%). PediMag was used in 2 pts (10%) and CentriMag in 18 (90%), with LVAD only in 4 (20%), RVAD only in 1 (5%) and BiVAD in 15 (75%). The median duration of support was 13 days (d) (1-53 d). The mean RPM setting was 2863±461 with a median flow rate of 2.35 L/min (IQR: 1.22-4.69), and CI of 2.96±0.53 L/min/m2. Flow rate was <3L/min in 9 (45%) pts. All pts were anticoagulated on heparin, and 8 (40%) pts received antiplatelet therapy. Thrombosis occurred in 6 (30%) at a median of 3.5 d (1-25 d), with an embolic stroke occurring in 3/6 pts at 9-25 d. Hemorrhagic complication occurred in 15 (75%) at a median of 2 d (1-33 d) There were 6 (30%) deaths; 11 (55%) transplanted and 3 (15%) with recovery. Flow rate was not associated with death, hemorrhage or neurologic complications. When flow rates were <3 L/min, 6/9 (67%) had thrombotic complications, as compared to 0 with flow rates ≥3 L/min (p = 0.014). Antiplatelet therapy was not associated with thrombosis or survival independent of flow rate. Pediatric patients on centrifugal VADs with flow rates <3L/min have significantly more thrombotic complications, although with similar survival to those supported on higher flows. Antiplatelet therapy does not appear to ameliorate this risk. Further study into the optimal management of these patients is needed to minimize these morbidities.

BACKGROUND: Traditionally, an elevated pulmonary vascular resistance index (PVRI) has been a relative contraindication to pediatric orthotopic heart transplantation. This study examined the risk of elevated pre-transplant PVRI on early (30-day) and intermediate-term mortality in pediatric heart transplant recipients without congenital heart disease (CHD).METHODS: A review of the prospective multicenter Pediatric Heart Transplant Study registry identified all patients without CHD in whom a pre-transplant PVRI was recorded. Of 35 participating centers, 29 reported heart transplants in children with a markedly elevated PVRI ( > 5 WU x m(2), corresponding to the highest quartile). Multiphase parametric analysis was performed, adjusting for potential risk factors to assess the association of PVRI with early and intermediate-term mortality.RESULTS: Between 1993 and 2011, 1,909 children without CHD underwent heart transplantation at a median age of 9.7 years (range, 1.6 months-18 years). Of those, 795 (42%) had a recorded or calculable pre-transplant PVRI, and PVRI > 5 WU x m(2) was present in 193 patients (24%). For all recipients, median pre-transplant PVRI was 3.15 WU x m(2) (range, 0.4-23 WU x m(2)); 2.8 WU x m(2) in infants < 1 year, 3.5 WU x m(2) in patients aged 1 to 10 years, and 3.0 WU x m(2) in patients aged > 10 years (p = 0.03). Multivariable hazard analysis controlling for graft ischemic time and pre-transplant ventilation showed no association of elevated PVRI with early mortality (relative risk, 1.2; p = 0.66), nor with intermediate mortality when controlled for year of transplant, age, race, and pre-sensitization (relative risk, 0.7; p = 0.27).CONCLUSIONS: Elevation of PVRI did not affect post-transplant survival in this large, multicenter cohort of pediatric heart transplant recipients without CHD, suggesting that the bather of elevated PVRI can be successfully overcome in this population. (C) 2015 International Society for Heart and Lung Transplantation. All rights reserved.

Pediatric donor hearts are regularly refused for donor quality with limited evidence as to which donor parameters are predictive of poor outcomes. We compare outcomes of recipients receiving hearts previously refused by other institutions for quality with the outcomes of recipients of primarily offered hearts. Data for recipients aged ≤18 and their donors were obtained. Specific UNOS refusal codes were used to place recipients into refusal and nonrefusal groups; demographics, morbidity and mortality were compared. Kaplan–Meier analysis with log-rank test was used to determine differences in graft survival. A multivariable Cox proportional hazards model was constructed to determine independent risk factors for postoperative mortality. From July 1, 2000 to April 30, 2011, 182 recipients were transplanted and included for analysis. One hundred thirty received a primarily offered heart; 52 received a refused heart. No difference in postoperative complications or graft survival between the two groups (p = 0.190) was found. Prior refusal was not an independent risk factor for recipient mortality. Analysis of this large pediatric cohort examining outcomes with quality-refused hearts shows that in-hospital morbidity and long-term mortality for recipients of quality-refused hearts are no different than recipients of primarily offered hearts, suggesting that donor hearts previously refused for quality are not necessarily unsuitable for transplant and often show excellent outcomes.