IU Indianapolis ScholarWorks :: Browsing by Author "Mastropietro, Christopher W."

Browsing by Author "Mastropietro, Christopher W."

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Characteristics and Operative Outcomes for Children Undergoing Repair of Truncus Arteriosus: A Contemporary Multicenter Analysis
(Elsevier, 2019) Mastropietro, Christopher W.; Amula, Venu; Sassalos, Peter; Buckley, Jason R.; Smerling, Arthur J.; Iliopoulos, Illias; Riley, Christine M.; Jennings, Aimee; Cashen, Katherine; Narasimhulu, Sukumar Suguna; Gowda, Keshava Murty Narayana; Bakar, Adnan M.; Wilhelm, Michael; Badheka, Aditya; Moser, Elizabeth A. S.; Costello, John M.; Pediatrics, School of Medicine
Objective We sought to describe characteristics and operative outcomes of children who underwent repair of truncus arteriosus and identify risk factors for the occurrence of major adverse cardiac events (MACE) in the immediate postoperative period in a contemporary multicenter cohort. Methods We conducted a retrospective review of children who underwent repair of truncus arteriosus between 2009 and 2016 at 15 centers within the United States. Patients with associated interrupted or obstructed aortic arch were excluded. MACE was defined as the need for postoperative extracorporeal membrane oxygenation (ECMO), cardiopulmonary resuscitation (CPR), or operative mortality. Risk factors for MACE were identified using multivariable logistic regression analysis and reported as odds ratios (OR) with 95% confidence intervals (CI). Results We reviewed 216 patients. MACE occurred in 44 patients (20%) and did not vary significantly over time. Twenty-two patients (10%) received postoperative ECMO, 26 (12%) received CPR, and 15 (7%) suffered operative mortality. With multivariable logistic regression analysis (which included adjustment for center effect), factors independently associated with MACE were failure to diagnose truncus arteriosus prior to discharge from the nursery (OR:3.1; 95%CI:1.3,7.4), cardiopulmonary bypass duration greater than 150 minutes (OR:3.5; 95%CI:1.5,8.5), and right ventricle-to-pulmonary artery conduit diameter greater than 50mm/m2 (OR:4.7; 95%CI:2.0,11.1). Conclusions In a contemporary multicenter analysis, 20% of children undergoing repair of truncus arteriosus experienced MACE. Early diagnosis, shorter duration of cardiopulmonary bypass, and use of smaller diameter right ventricle-to-pulmonary artery conduits represent potentially modifiable factors that could decrease morbidity and mortality in this fragile patient population.
Development and Validation of a Seizure Prediction Model in Neonates Following Cardiac Surgery
(Elsevier, 2020) Naim, Maryam Y.; Putt, Mary; Abend, Nicholas S.; Mastropietro, Christopher W.; Frank, Deborah U.; Chen, Jonathan M.; Fuller, Stephanie; Gangemi, James J.; Gaynor, J. William; Heinan, Kristin; Licht, Daniel J.; Mascio, Christopher E.; Massey, Shavonne; Roeser, Mark E.; Smith, Clyde J.; Kimmel, Stephen E.; Pediatrics, School of Medicine
BACKGROUND Electroencephalographic seizures (ES) following neonatal cardiac surgery are often subclinical and have been associated with poor outcomes. An accurate ES prediction model could allow targeted continuous electroencephalographic monitoring (CEEG) for high-risk neonates. METHODS Development and validation of ES prediction models in a multi-center prospective cohort where all postoperative neonates with cardiopulmonary bypass (CPB) underwent CEEG. RESULTS ES occurred in 7.4% of neonates (78 of 1053). Model predictors included gestational age, head circumference, single ventricle defect, DHCA duration, cardiac arrest, nitric oxide, ECMO, and delayed sternal closure. The model performed well in the derivation cohort (c-statistic 0.77, Hosmer-Lemeshow p=0.56), with a net benefit (NB) over monitoring all and none over a threshold probability of 2% in decision curve analysis (DCA). The model had good calibration in the validation cohort (Hosmer-Lemeshow, p=0.60); however, discrimination was poor (c-statistic 0.61) and in DCA there was no NB of the prediction model between the threshold probabilities of 8% and 18%. Using a cut-point that emphasized negative predictive value (NPV) in the derivation cohort, 32% (236 of 737) of neonates would not undergo CEEG, including 3.5% (2 of 58) with ES (NPV 99%, sensitivity 97%). CONCLUSIONS In this large prospective cohort, a prediction model of ES in neonates following CPB had good performance in the derivation cohort with a NB in DCA. However, performance in the validation cohort was weak with poor discrimination, calibration, and no NB in DCA. These findings support CEEG monitoring of all neonates following CPB.
Establishment of prophylactic enoxaparin dosing recommendations to achieve targeted anti-factor Xa concentrations in children with CHD
(Cambridge, 2018-05) Israel, Emily N.; Thomas, Christopher A.; Mastropietro, Christopher W.; Pediatrics, School of Medicine
Background Enoxaparin may be used to prevent central venous catheter-related thrombosis in patients with CHD. We aimed to determine whether current enoxaparin dosing regimens effectively achieve anti-factor Xa concentrations within prophylactic goal ranges in this patient population. Methods We implemented a formal protocol aimed at reducing central venous catheter-related thrombosis in children with CHD in January, 2016. Standard empiric prophylactic enoxaparin dosing regimens were used – for example, 0.75 mg/kg/dose every 12 hours for patients <2 months of age and 0.5 mg/kg/dose every 12 hours for patients ⩾2 months of age – with anti-factor Xa goal range of 0.25–0.49 IU/ml. Patients <2 years of age who received enoxaparin and had at least one valid steady-state anti-factor Xa measurement between 25 January, 2016 and 31 August, 2016 were retrospectively reviewed. Results During the study period, 47 patients had 186 anti-factor Xa concentrations measured, of which 20 (11%) were above and 112 (60%) were below the prophylactic goal range. Anti-factor Xa concentrations within the goal range were ultimately achieved in 31 patients. Median dose required to achieve anti-factor Xa concentrations within the prophylactic range was 0.89 mg/kg/dose (25, 75%: 0.75, 1.11) for patients <2 months (n=23 patients) and 0.79 mg/kg/dose (25, 75%: 0.62, 1.11) for patients ⩾2 months (n=8 patients). Conclusions Enoxaparin doses required to achieve prophylactic anti-factor Xa concentrations in young children with CHD were consistently higher than the currently recommended prophylactic dosing regimens. Further study is needed to determine whether dose titration to achieve prophylactic anti-factor Xa concentrations is effective in preventing central venous catheter-related thrombosis.
Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document
(American Thoracic Society, 2023) Abu-Sultaneh, Samer; Iyer, Narayan Prabhu; Fernández, Analía; Gaies, Michael; González-Dambrauskas, Sebastián; Hotz, Justin Christian; Kneyber, Martin C. J.; López-Fernández, Yolanda M.; Rotta, Alexandre T.; Werho, David K.; Baranwal, Arun Kumar; Blackwood, Bronagh; Craven, Hannah J.; Curley, Martha A. Q.; Essouri, Sandrine; Fioretto, Jose Roberto; Hartmann, Silvia M. M.; Jouvet, Philippe; Korang, Steven Kwasi; Rafferty, Gerrard F.; Ramnarayan, Padmanabhan; Rose, Louise; Tume, Lyvonne N.; Whipple, Elizabeth C.; Wong, Judith J. M.; Emeriaud, Guillaume; Mastropietro, Christopher W.; Napolitano, Natalie; Newth, Christopher J. L.; Khemani, Robinder G.; Pediatrics, School of Medicine
Rationale: Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients’ readiness for extubation. Methods: Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of ⩾80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ⩾80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. Conclusions: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.
Extubation Failure after Neonatal Cardiac Surgery: A Multicenter Analysis
(Elsevier, 2017-03) Mastropietro, Christopher W.; Cashen, Katherine; Grimaldi, Lisa M.; Narayana Gowda, Keshava Murty; Piggott, Kurt D.; Wilhelm, Michael; Gradidge, Eleanor; Moser, Elizabeth A. S.; Benneyworth, Brian D.; Costello, John M.; Department of Medicine, School of Medicine
Objectives To describe the epidemiology of extubation failure and identify risk factors for its occurrence in a multicenter population of neonates undergoing surgery for congenital heart disease. Study design We conducted a prospective observational study of neonates ≤30 days of age who underwent cardiac surgery at 7 centers within the US in 2015. Extubation failure was defined as reintubation within 72 hours of the first planned extubation. Risk factors were identified with the use of multivariable logistic regression analysis and reported as OR with 95% CIs. Multivariable logistic regression analysis was conducted to examine the relationship between extubation failure and worse clinical outcome, defined as hospital length of stay in the upper 25% or operative mortality. Results We enrolled 283 neonates, of whom 35 (12%) failed their first extubation at a median time of 7.5 hours (range 1-70 hours). In a multivariable model, use of uncuffed endotracheal tubes (OR 4.6; 95% CI 1.8-11.6) and open sternotomy of 4 days or more (OR 4.8; 95% CI 1.3-17.1) were associated independently with extubation failure. Accordingly, extubation failure was determined to be an independent risk factor for worse clinical outcome (OR 5.1; 95% CI 2-13). Conclusions In this multicenter cohort of neonates who underwent surgery for congenital heart disease, extubation failure occurred in 12% of cases and was associated independently with worse clinical outcome. Use of uncuffed endotracheal tubes and prolonged open sternotomy were identified as independent and potentially modifiable risk factors for the occurrence of this precarious complication.
High variability in cardiac education and experiences during United States paediatric critical care fellowships
(Cambridge University Press, 2023) Hanson, Amy E.; Mastropietro, Christopher W.; Murphy, Lee D.; Rowan, Courtney M.; Pediatrics, School of Medicine
Background: Paediatric cardiac critical care continues to become more sub-specialised, and many institutions have transitioned to dedicated cardiac ICUs. Literature regarding the effects of these changes on paediatric critical care medicine fellowship training is limited. Objective: To describe the current landscape of cardiac critical care education during paediatric critical care medicine fellowship in the United States and demonstrate its variability. Methods: A review of publicly available information in 2021 was completed. A supplemental REDCap survey focusing on cardiac ICU experiences during paediatric critical care medicine fellowships was e-mailed to all United States Accreditation Council of Graduate Medical Education-accredited paediatric critical care medicine fellowship programme coordinators/directors. Results are reported using inferential statistics. Results: Data from 71 paediatric critical care medicine fellowship programme websites and 41 leadership responses were included. Median fellow complement was 8 (interquartile range: 6, 12). The majority (76%, 31/41) of programmes had a designated cardiac ICU. Median percentage of paediatric critical care medicine attending physicians with cardiac training was 25% (interquartile range: 0%, 69%). Mandatory cardiac ICU time was 16 weeks (interquartile range: 13, 20) with variability in night coverage and number of other learners present. A minority of programmes (29%, 12/41) mandated other cardiac experiences. Median CHD surgical cases per year were 215 (interquartile range: 132, 338). When considering the number of annual cases per fellow, programmes with higher case volume were not always associated with the highest case number per fellow. Conclusions: There is a continued trend toward dedicated cardiac ICUs in the United States, with significant variability in cardiac training during paediatric critical care medicine fellowship. As the trend toward dedicated cardiac ICUs continues and practices become more standardised, so should the education.
An Interprofessional Quality Improvement Initiative to Standardize Pediatric Extubation Readiness Assessment
(Wolters Kluwer, 2017-10) Abu-Sultaneh, Samer; Hole, Acrista J.; Tori, Alvaro J.; Benneyworth, Brian D.; Lutfi, Riad; Mastropietro, Christopher W.; Pediatrics, School of Medicine
Objectives: Establishing protocols to wean mechanical ventilation and assess readiness for extubation, with the goal of minimizing morbidity associated with extubation failure and prolonged mechanical ventilation, have become increasingly important in contemporary PICUs. The aim of this quality improvement initiative is to establish a respiratory therapist–led daily spontaneous breathing trial protocol to standardize extubation readiness assessment and documentation in our PICU. Design: A quality improvement project. Setting: Single center, tertiary care Children’s Hospital PICU. Patients: All intubated patients admitted to PICU requiring conventional mechanical ventilation between February 2013 and January 2016. Interventions: A working group of pediatric intensivists, respiratory therapists, nurses, and information technology specialists established the protocol, standardized documentation via the electronic medical record, and planned education. Daily spontaneous breathing trial protocol implementation began in February 2015. All patients on mechanical ventilation were screened daily at approximately 4 AM by a respiratory therapist to determine daily spontaneous breathing trial eligibility. If all screening criteria were met, patients were placed on continuous positive airway pressure of 5 cm H2O with pressure support of 8 cm H2O for up to 2 hours. If tolerated, patients would be extubated to supplemental oxygen delivered via nasal cannula in the morning, after intensivist approval. Daily audits were done to assess screening compliance and accuracy of documentation. Measurements and Main Results: We analyzed data from 398 mechanically ventilated patients during daily spontaneous breathing trial period (February 2015–January 2016), compared with 833 patients from the pre–daily spontaneous breathing trial period (February 2013–January 2015). During the daily spontaneous breathing trial period, daily screening occurred in 92% of patients. Extubation failure decreased from 7.8% in the pre–daily spontaneous breathing trial period to 4.5% in daily spontaneous breathing trial period. The use of high-flow nasal cannula slightly increased during the project, while there was no change in duration of mechanical ventilation or the use of noninvasive ventilation. Conclusions: An interprofessionally developed respiratory therapist–led extubation readiness protocol can be successfully implemented in a busy tertiary care PICU without adverse events.
Management of Complications Caused By a Massive Left Ventricle Tumor in a Neonate
(Elsevier, 2018) Yabrodi, Mouhammad; Mastropietro, Christopher W.; Darragh, Robert K.; Parent, John J.; Ayres, Mark D.; Kean, Adam C.; Turrentine, Mark; Pediatrics, School of Medicine
We report a case of a neonate born with a giant fibroma occupying the entirety of her left ventricle. Due to the extensive resection, her postoperative course was complicated by severely diminished left ventricular function and complete heart block necessitating extracorporeal support. Ultimately, cardiac resynchronization therapy was employed, after which the infant’s ventricular function gradually improved and she was successfully discharged to home.
Multi-Lobar Atelectasis in Children Receiving Venoarterial Extracorporeal Membrane Oxygenation for Cardiac Indications
(Daedalus, 2022-11-15) Nader, Maria Abou; Friedman, Matthew L.; Mastropietro, Christopher W.; Pediatrics, School of Medicine
Background: Respiratory complications are common in patients who require venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for cardiac indications. We aimed to examine the frequency and characteristics of patients who develop multi-lobar atelectasis early in the course of VA ECMO and to identify factors associated with its occurrence. Methods: We performed a single-center retrospective review of consecutive pediatric subjects on VA ECMO in the cardiovascular ICU from 2014 to 2019. Chest radiographs before VA ECMO initiation and daily for up to 5 d of VA ECMO support were reviewed. Multi-lobar atelectasis was defined as the collapse of ≥2 lobes of the same lung. Patients with multi-lobar atelectasis before or immediately after VA ECMO cannulation were excluded. Bivariate comparisons and multivariable logistic regression analyses were performed to identify factors independently associated with lung collapse. Results of the multivariable analysis are provided as odds ratio (OR) with 95% CI. Results: We reviewed 119 VA ECMO runs in 101 unique subjects. Multi-lobar atelectasis occurred in 36 runs (30%), with an isolated collapse of the left lung occurring most frequently (no. runs = 20). VA ECMO runs complicated by multi-lobar atelectasis were significantly longer and associated with lower hospital survival (51% vs 77%, survival in subjects without multi-lobar atelectasis; P = .01). Multivariable logistic regression analysis identified a subsequent ECMO run during the same admission to be independently associated with multi-lobar atelectasis (OR 5.4, 95% CI 1.2-21.5). Subanalysis of the subjects with isolated left lung collapse revealed male sex (OR 8.9, 95% CI 1.6-48.2) and subsequent ECMO run during the same admission (OR 4.0, 95% CI 1.2-13.6) to be independently associated with this complication, and mechanical ventilation at least 12 h before ECMO may be protective (OR 0.22, 95% CI 0.07-0.76). Conclusions: Multi-lobar atelectasis commonly occurred in children who were receiving VA ECMO for cardiac failure and was associated with worse outcomes. Male patients, a subsequent VA ECMO run during the same hospitalization, and patients in whom mechanical ventilation was initiated shortly before ECMO cannulation may be at increased risk for this complication.
Multicenter Analysis of Early Childhood Outcomes Following Repair of Truncus Arteriosus
(Elsevier, 2018) Buckley, Jason R.; Amula, Venu; Sassalos, Peter; Costello, John M.; Smerling, Arthur J.; Iliopoulos, lias; Jennings, Aimee; Riley, Christine M.; Cashen, Katherine; Narasimhulu, Sukumar Suguna; Gowda, Keshava Murthy Narayana; Bakar, Adnan M.; Wilhelm, Michael; Badheka, Aditya; Moser, Elizabeth A. S.; Mastropietro, Christopher W.; Biostatistics, School of Public Health
Background Literature describing morbidity and mortality following truncus arteriosus repair is predominated by single-center reports. We created and analyzed a multicenter dataset to identify risk factors for late mortality and right ventricle-to-pulmonary artery (RV-PA) conduit reintervention for this patient population. Methods We retrospectively collected data on children who underwent repair of truncus arteriosus without concomitant arch obstruction at 15 centers between 2009 and 2016. Cox regression survival analysis was conducted to determine risk factors for late mortality, defined as death occurring after hospital discharge and greater than 30 days after surgery. Probability of any RV-PA conduit reintervention was analyzed over time using Fine-Gray modelling. Results We reviewed 216 patients, with median follow-up of 2.9 years (range:0.1-8.8). Operative mortaility occurred in 15 patients (7%). Of the 201 survivors, there were 14 (7%) late deaths. DiGeorge syndrome (HR:5.4; 95%CI:1.6-17.8) and need for postoperative tracheostomy (HR:5.9; 95%CI:1.8-19.4) were identified as independent risk factors for late mortality. At least one RV-PA conduit catheterization or surgical reintervention was performed in 109 patients (median time to reintervention:23 months, range:0.3-93). Risk factors for reintervention included use of pulmonary or aortic homografts versus Contegra® bovine jugular vein conduits (HR:1.9; 95%CI:1.2,3.1) and smaller conduit size (HR per mm/m2:1.05; 95%CI:1.03,1.08). Conclusions In a multicenter dataset, DiGeorge syndrome and need for tracheostomy postoperatively were found to be independent risk factors for late mortality after repair of truncus arteriosus, while risk of conduit reintervention was independently influenced by both initial conduit type and size.

Browsing by Author "Mastropietro, Christopher W."

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