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Pediatric
Heart Update
Memphis, Tennessee
Winter 2013
Heart Institute highlights, outcomes: 2012
Ranked in 2012 as a top pediatric cardiology and heart surgery program by U.S. News & World Report, Le Bonheur’s Heart Institute
continues to improve the quality of life for hundreds of children with heart defects.
2012 highlights of the Heart Institute include:
• State-of-the-art heart catheterization labs, including the only hybrid catheterization lab in the region.
• The region’s only pediatric electrophysiologists.
• Three-dimensional reconstruction capabilities and expertise in cardiac MRI.
• Joint research with St. Jude Children’s Research Hospital to improve outcomes for children with cardiomyopathy.
• Expertise in some of the most complex heart defects, including Ebstein’s Anomaly.
• Our pediatric cardiac surgical teams performed more than 350 pediatric heart surgeries in 2012, up 48% from 2008.
Comparative Case Mix Index 2010-2011, Cardiovascular Surgery Patients
Catheterization
APRDRG Peds CMI
7.00
400
6.00
350
5.00
300
250
4.00
LeB survival
3.00
?? ?
2.00
Electrophysiology
200
Interventional Cardiac
150
Diagnostic Cardiac
100
1.00
50
0.00
0
PHIS Hospitals
Data Source: Pediatric Health Information Systems (PHIS), 2012.
2008
2009
2010
2011
2012
(Annualized)
The PHIS hospitals are 43 of the largest and most advanced children’s hospitals in America, and constitute the most demanding standards of pediatric service in America.
Cardiovascular Surgery Volumes
2008-2012
Survival Rate by Procedure, 4 years
250
100
98
200
96
94
al Rate by Complexity, 4 years
150
92
LeB survival
90
STS survival
88
100
86
50
84
82
80
LeB survival
ASD
VSD
CoA
AV Canal
Aortic Valve
Surgery
Norwood
TGA
STS survival
ategory 2
category 3
category 4
A pediatric partner
of The University
of Tennessee Health
Science Center/College
of Medicine and
St. Jude Children’s
Research Hospital
2008
2009
2010
Non-CPB (non-cardiopulmonary bypass)
2011
2012
Annualized
CPB (cardiopulmonary bypass)
Cardiologists re-route hepatic blood flow to left pulmonary artery in special technique
I
www.lebonheur.org/
heart
0
Catheterization lab procedure lowers risk for heart patient
category 5-6
Referrals: 866-870-5570
TOF Repair
nterventional cardiologists in Le Bonheur’s catheterization
lab used a new technique this summer to re-route hepatic
blood flow to the left
pulmonary artery of an
18-year-old girl with a
complex congenital heart
condition – a complex
single ventricle, status post
bilateral cavo-pulmonary
anastamoses with a
Kawashima (because of
interrupted IVC) with
completion Fontan using
an extra-hepatic conduit.
“She had developed extensive micro arterio-venous malformations (AVM) of the left lung. The AVMs formed secondary
due to lack of hepatic blood flow to the
affected lung and would only resolve if
the hepatic blood was re-routed to the
left lung. The blood from the hepatic
conduit streamed preferentially to
the right lung at present,” said Shyam
Sathanandam, MD. “Her oxygen satura-
tions were as low as 54 percent, and surgical conduit revision to
re-route hepatic blood to the left lung carried great risk.”
The girl is a longtime
patient of Le Bonheur
Cardiothoracic Surgeon Chris
Knott-Craig, MD, who conferred
with Sathanandam about
re-routing blood flow in
the catheterization lab.
Sathanandam planned the
procedure for months, meticulously preparing for all scenarios
he might encounter during this
never before done procedure
in the cath lab.
In the cath lab, Sathanandam and Cardiologist Rush
Waller, MD, initially stented the central pulmonary artery and
dilated it to a large diameter.
After the stent was placed, the team pulled a wire through
the struts of the stent from the left superior vena cava and
snared it from a catheter introduced through the left hepatic
vein. A wire rail was created. Incremental balloon sizes were
used to dilate through the struts of the stent. Next, a Viabahn
continued on page 2
Meet the Team
continued from page 1
The Heart Institute at Le Bonheur Children’s Hospital uses
the combined expertise of an advanced pediatric cardiac team to
provide specialized care for children with congenital heart disease. Pediatric cardiologists, pediatric cardiothoracic surgeons, cardiac intensivists, pediatric intensivists and anesthesiologists make up
the Heart Institute. Advanced practice nurses, perfusionists, cardiac
nurses, respiratory therapists and lab and imaging technicians are
specially trained in pediatric cardiology care.
Leaders of the Heart Institute include:
Thomas Chin, co-director of Heart Institute
and chief of Cardiology
Chin attended medical school at the University
of Michigan and completed a fellowship in pediatric cardiology at the University of California,
Los Angeles. He is board certified in pediatrics
with a cardiology subspecialty. Chin is also professor and director of Cardiology for UTHSC. His
patient care emphasis focuses on non-invasive
imaging, fetal and developmental cardiology, cardiomyopathies
and pulmonary hypertension.
Christopher Knott-Craig, co-director of
Heart Institute and chief of Cardiovascular
Surgery
Knott-Craig graduated from the University of
Cape Town in South Africa and completed training in cardiac surgery at the Groote Schuur
Hospital in South Africa. He is board certified
by the South African Medical & Dental Council
in cardiothoracic surgery. Knott-Craig is also
a professor for UTHSC School of Medicine. His areas of special
focus include neonatal/infant cardiac surgery, Ebstein’s anomaly,
Ross Procedure, minimally invasive valve surgery, cardiopulmonary
bypass, ambulatory thoracic surgery, hyperhidrosis and pediatric
congenital heart disease.
Mayte Figueroa, medical director of CVICU
Figueroa is a graduate of Mount Sinai School of
Medicine and completed pediatric cardiology
fellowships at both Mount Sinai Hospital and the
Medical University of South Carolina. Figueroa is
board certified in pediatrics and has a cardiology
subspecialty. She is also an associate professor
at The University of Tennessee Health Science
Center (UTHSC). Her areas of focus include
developmental cardiology, pediatric cardiomyopathy, cardiovascular disease, non-invasive pediatric cardiology and pediatric cardiac
critical care.
Vijay Joshi, medical director of Non-invasive
Cardiology
Joshi attended medical school at the University
of Vermont and completed a fellowship in
pediatric cardiology at Children’s Hospital
of Philadelphia. He is board certified by the
American Board of Pediatrics with a cardiology
subspecialty, and is also an associate professor
at UTHSC. His patient care emphasis is on echocardiography, fetal echocardiography, heart operation planning
and 3-D echocardiography, fetal cardiology, cardiovascular disease,
non-invasive pediatric cardiology, pregnant women for fetal heart
evaluations, exercise- or sports-related cardiology and cardiac MRI.
B. Rush Waller, medical director of
Catheterization Lab
Waller studied at UTHSC and completed fellowships in pediatric cardiology and pediatric interventional cardiology at the Medical University of
South Carolina. Waller is an associate professor
at UTHSC and is board certified by the American
Board of Pediatrics with a cardiology subspecialty. His areas of focus include interventional pediatric cardiology, including therapeutic catheterizations for critically
ill neonates, critically ill preoperative patients and complex cases
of adults with congenital heart disease and transcatheter closure of
intracardiac shunts.
Glenn Wetzel, medical director of Pediatric
Electrophysiology, director of Fellowship
Program
Wetzel completed fellowship training in
pediatric cardiology at University of California
at Los Angeles. He is board certified by the
American Board of Pediatrics and has a cardiology subspecialty. Wetzel is also a professor at
UTHSC. His special interests include pediatric
electrophysiology (arrhythmias), radiofrequency ablation and
cryoablation, cardiomyopathy, pediatric pacemakers and internal
defibrillator devices (ICDs).
Le Bonheur interventions cardiologists planned for months before using the
cath lab to reroute blood flow on an 18-year-old patient
endoprosthesis was placed through the strut of this stent, followed by a
larger diameter endoprosthesis telescoped into the first one proximally
and the extra-hepatic conduit distally. This pinned both the prostheses and
made the assembly stable.
Hepatic venous blood from the liver streamed to the left superior vena
cava through the two telescoped prostheses and then through the first
stent in the central pulmonary artery to both lungs. This ingenious yet simple technique allowed hepatic blood to enter the right and left pulmonary
arteries without needing to perform a complex operation.
One month later, the patient’s oxygen saturation was up to 94 percent,
and Sathanandam expects all the pulmonary AVMs to resolve with time.
T
Studies show benefit of ECMO simulaton
wo studies conducted by researchers at Le Bonheur Children’s aim to
better prepare caregivers for high-risk emergencies in the Cardiovascular
Intensive Care Unit (CVICU). Published in the latest edition of Pediatric
Cardiology, both studies focus on the use of simulation-based training modules.
The first study’s findings suggest that simulation -based training is an
effective method
for improving the
knowledge, ability and
confidence levels of
novice ECMO specialists and physician
trainees. Currently,
training for ECMO— a
form of temporary
cardiopulmonary
support – primarily
uses didactic education and occasionally includes various hands-on training
modules. Simulation courses with mannequins are available at a few centers
as supplemental training, but simulation-based training is not required for
certification. Results from the Le Bonheur study showed the simulationbased training is helpful and improves knowledge, ability and confidence for
ECMO providers.
“ECMO is a complex life-saving medical therapy requiring rapid clinical
decision-making skills in the event of a technical emergency. We have developed a novel ECMO simulation training module and bedside safety checklists
of common ECMO emergencies to train novice learners and to assist expert
caregivers in this intricate management,” said Samir Shah, MD, a Le Bonheur
intensivist and one of the researchers.
A second study proves that simulation-based team training is effective
in increasing teamwork and collaboration among multidisciplinary teams in
the CVICU during an emergency. The study’s training course simulated a
post-pediatric surgery cardiac arrest, a high-risk clinical situation with high
morbidity and mortality. Findings show that participation in the simulationbased training improve teamwork, confidence and communication during
these high-risk events.
“We want to design innovative training for our staff that can, ultimately,
improve patient safety and outcomes in the critical care environment,”
said Mayte Figueroa, medical director of Le Bonheur’s CVICU and a primary
researcher for both studies.
Case Study: Melody valve eliminates need for donor valve
Le Bonheur’s first Melody® valve procedure on May 23, 2012.
I
would be a perfect candidate for the Melody valve — a new device
Shyam Sathanandam, MD, and Rush Waller, MD, implanted
that could help Ashley and eliminate the need for a donor valve.
tion lab in a 32-year-old adult congenital heart patient under
vein and sewn into a large stent. This valved stent is then deliv-
minimal sedation.
ered through a vein in the leg or neck to the heart and then
nterventional cardiologists successfully completed
the transcatheter pulmonary device in Le Bonheur’s catheteriza-
The patient, 32-year-old Ashley Batchelor, was born with
Jones, along with Sathanandam and Waller, thought Ashley
The Melody® valve is a valve harvested from a cow’s jugular
expanded and implanted with a large angioplasty balloon catheter.
Tetralogy of Fallot and had open
It is primarily intended for use in patients
heart surgery soon after birth. She
who have undergone multiple surgeries
underwent another operation at age
that include using donor grafts to con-
5 to receive a donor pulmonary valve
nect the right ventricle to the pulmonary
and then enjoyed a normal child-
arteries. The valve is indicated when these
hood despite having to limit physi-
donor grafts or valves fail.
cal activity, which caused her to feel
“Ashley was an excellent candidate for
light-headed or nauseous. Ashley
the Melody® valve because her donor valve
married, moved to Memphis and
was no longer functioning, her right
delivered a baby, Bailey, in 2007.
ventricle was enlarged, she was symptom-
Ashley continued to see cardiolo-
atic, and she had a good landing zone for
gists annually for her heart defect.
the large stent containing the new valve,”
By the time her child was 3, she grew
Waller said. “This procedure prevented her
tired and lethargic, but dismissed her
from having to have open-heart surgery.”
symptoms as the result of juggling
Sathanandam added that the Melody
work and family. After struggling to conceive a second child and
valve gives patients “trans-catheter replacement of the pulmonary
still not feeling like herself, Ashley’s OB/GYN recommended she
valve that requires no cutting or stitching. The patients are typi-
see experts at Le Bonheur’s Heart Institute.
cally discharged home the next day.”
Pediatric Cardiologist Ryan Jones, MD, found that one part
Since the procedure, Ashley has been doing great. She does
of her heart was enlarged, and an artery was smaller than normal.
not get short of breath and runs regularly on the treadmill for
A large percentage of the blood being pumped to the lung arter-
30-40 minutes. She feels like a new person and is able to bal-
ies was regurgitating back into the right ventricle, the pumping
ance her life as a mom, a wife and as a pharmacist. Since Ashley’s
chamber for the blood going to the lungs.
procedure in May, Sathanandam and Waller have successfully
“It made sense why I was so tired. And why I couldn’t have a
second baby,” said Ashley. “My heart couldn’t handle a pregnancy.”
CVICU earns national honor
L
e Bonheur’s Cardiovascular Intensive Care Unit has
earned a gold-level Beacon Award for Excellence from
the American Association of Critical Care Nurses. Le Bonheur
is just one of a few pediatric CVICUs to receive this award.
The award recognizes unit caregivers who successfully
implanted the Melody valve in several other patients — all of
whom describe complete resolution of symptoms.
Le Bonheur joins multi-center
trial studying pulmonary
hypertension treatment
L
e Bonheur’s Heart Institute has joined a national pharmacokinetics
clinical trial aimed at finding better treatment for children between 6
months and 18 years of age with pulmonary artery hypertension.
The trial, sponsored by Eli Lilly and Co., will enroll patients to study the
improve patient outcomes, provide exceptional patient care
pharmacokinetics of the drug Tadalafil in children with pulmonary hyperten-
and align practices with AACN’s standards for a healthy work
sion. In a subsequent phase of the trial, the safety and effectiveness of the
environment.
drug in treating pulmonary hypertension in children will be determined.
“Our team is dedicated to providing the highest quality
Patients enrolled in this study will be under the close care of physicians and
care and committed to achieving the best outcomes in a
the research staff, and will be monitored with echocardiograms, exercise
family-centered environment. The
tests and blood testing. The principal investigator on this study in Memphis
Beacon Award for Excellence validates
is Thomas Chin, MD, the co-investigator is Alex Arevalo, MD, and the trial
our successful patient outcomes and
coordinator is Neysa Rhoads.
established practices,” said Mayte
Figueroa, MD, FACC, medical director
of Cardiovascular Critical Care Services.
Le Bonheur joins a handful of other select pediatric centers across the
country, including the Children’s Hospital of Philadelphia, the Children’s
Hospital of Denver, Sibley Children’s Hospital in Atlanta and Texas Children’s
Hospital in Houston. Physicians interested in enrolling their patients can
contact Chin at 901-287-5092.
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Pediatric Heart Update is a publication of the Heart Institute at
Le Bonheur Children’s Hospital
Thomas Chin, MD, co-director, Heart Institute
Chris Knott-Craig, MD, co-director, Heart Institute
Bruce Alpert, MD
Mohammed Alsheikh-Ali, MD
Alex Arevalo, MD
Jean Ballweg, MD
Mayte Figueroa, MD
Steven Goldberg, MD
Ryan Jones, MD
Vijay Joshi, MD
Dai Kimura, MD
TK Susheel Kumar, MD
Kelvin Lee, MD
Ronak Naik, MD
Shyam Sathanandam, MD
Andreas Schwingshackl, MD
Samir Shah, MD
B. Rush Waller, MD
Glenn Wetzel, MD, PhD
@LeBonheurChild
Le Bonheur Heart Institute Publications: 2012
Alpert BS. Validation of the Nihon Kohden PVM-2701/Impulse-1 automated device by both AAMI (2002)
and ISO standards testing. Blood Press Monit. 2012;17:207-209.
Chan SY, Figueroa M, Spentzas T, Powell A, Holloway R, Shah S. Prospective assessment of novice learners
in a simulation-based extracorporeal membrane oxygenation (ECMO) education program. Pediatr Cardiol.
2012, August.
Figueroa MI, Sepanski R, Goldberg SP, Shah S. Improving teamwork, confidence, and collaboration among
members of a pediatric cardiovascular intensive care unit multidisciplinary team using simulation-based
team training. Pediatr Cardiol. 2012, September.
Arevalo AR, Boston US, Goldberg SP, Becker JA, KnottCraig CJ. Starnes procedure in a neonate with
pulmonary atresia and intact ventricular septum. Ann Thorac Surg. 2012;93:1703-1704.
Yohannan TM, Goldberg SP, Stamps JK, Mathis CA, Anthony Jr CL, Lasater OE, Knott-Craig CJ. Cardiac
myxolipoma in a child: diagnosis and surgical management. Congenit Heart Dis. 2012, May.
GoldbergSP, Knott-CraigCJ, Joshi VM,Figueroa MI, Ballweg JA, Chin TK. Apical left ventriculotomy is safe
in infants and young children requiring cardiac surgery. World J Pediatric Congenit Heart Surg 2012;3(4),
459-62
Jones RC, Rajasekaran S, Rayburn M, Tobias JD, Kelsey RM, Wetzel GT, Cabrera AG. Initial experience with
conivaptan use in critically ill infants with cardiac disease. J Pediatr Pharmacol Ther. 2012 Jan;17(1):7883. doi: 10.5863/1551-6776-17.1.78.
Knott-CraigCJ, GoldbergSP.Strategies to prevent complications from resternotomy [letter]. Ann Thorac
Surg 2012;94:334-35.
Philip RR, Boston US, BallwegJA, GoldbergSP, Knott-Craig CJ. Iatrogenic pseudoaneurysm of the
innominate artery in a neonate. J Card Surg2012;27(2):242-44
Knott-CraigCJ, GoldbergSP, BallwegJA, Boston US. Surgical decision making in neonatal Ebstein’s
anomaly: an algorithmic approach based on 48 consecutive neonates. World J Pediatric Congenit Heart
Surg2012;3(1)16-20
BallwegJA, GoldbergSP, Boston US, Joshi VM, Knott-Craig CJ. Technical modification to improve valve
stability after aortic root replacement. SA Heart 2012 (submitted)
Kelsey RM, Alpert BS, Dahmer MK, Krushkal J, Quasney MW: Alpha-Adrenergic Receptor Gene
Polymorphisms and Cardiovascular Reactivity to Stress in Black Adolescents and Young Adults
Psychophysiology: 2012;49:401-412.
McCarville MB, Kaste SC, Hoffer FA, Khan RB, Walton RC, Alpert BS, Furman WL, Li C, Xiong X: Contrast
Enhanced Sonography of Malignant Pediatric Abdominal and Pelvic Solid Tumors: Preliminary Safety and
Feasibility Data. Pediatr Radiol: Pediatr Radiol 2012 Jul;42(7):824-33. Epub 2012 Jan 17.
David Gallick, Bruce A. Friedman, Bruce S. Alpert, John D. Seller, David E. Quinn, David Osborn, members
of the AAMI Sphygmomanometer Committee: Response to – Blood Pressure Monitoring: Blood Press
Monit 2012, 17:45.
Alpert BS, Validation of the Nihon Kohden PVM-2701/Impulse-1 automated device by both AAMI (2002)
and ISO Standards testing. Blood Press Monit 2012, 17:207-209.
Alpert BS. Are kiosk blood pressure readings trustworthy? Blood Press Monit 2012, 17:257-258.
Lee KC, Danton GH, Kardon RE. Three-Dimensional Computed Tomographic Analysis of a Rare Left
Coronary to Left Ventricle Fistula. Pediatr Cardiol. 2012.
Gregory T. Armstrong, Vijaya M. Joshi, Liang Zhu, Deokumar Srivastava, Nan Zhang, Kirsten K Ness, Dennis
C. Stokes, Matthew T. Krasin, James A. Fowler, Leslie L. Robison, Melissa M. Hudson, and Daniel M. Green.
Elevated Tricuspid Regurgitant Jet Velocity by Doppler Echocardiography in Adult Survivors of Childhood
Cancer: A Report from the St. Jude Lifetime Cohort Study. Accepted for publication J Clinical Oncology
/2012/430702
Gregory T. Armstrong, Juan Carlos Plana, Nan Zhang, Deokumar Srivastava, Daniel M Green, Kirsten
K Ness, F. Daniel Donovan, Monika L Metzger, Alejandro Arevalo, Jean-Bernard Durand, Vijaya Joshi,
Melissa M Hudson, Leslie L Robison, and Scott Flamm. Screening Adult Survivors of Childhood Cancer
for Cardiomyopathy: Comparison of Echocardiography and Cardiac MRI. J Clin Oncol 8.10.2012 Vol30
No23pp2876-2884
Kevin Krull, Noah D. Sabin, Daniel Green, Alejandro Arevalo, Matthew Krasin, Melissa Hudson.
Neurocognitive Function and CNS Integrity in Adult Survivors of Childhood Hodgkin Lymphoma
J Clin Oncol Sept. 4th, 2012. Volume 42
Stephen Cyran, Ronak Naik, Devyani Chowdhury. Stress echocardiography: a useful tool in children with
aortic stenosis. Journal of the American College of Cardiology, Volume 59, Issue 13, Supplement, 27
March 2012, Page E801
Shyam K Sathanandam, Matthew J. Gillespie, Yoav Dori, Matthew A. Harris, Andrew C. Glatz, and
Jonathan J. Rome: Bilateral Branch Pulmonary Artery Melody Valve Implantation for Treatment of
Complex Right Ventricular Outflow Tract Dysfunction in a High-Risk Patient. Circ Cardiovasc Interv.
2012;4:e21-e23
Book Chapters
Knott-Craig CJ, Goldberg SP. Early presentation of Ebstein’s Anomaly. In: da Cruz E, Hraska V, Ivy DD,
Jaggers J, eds. Pediatric Cardiology, Cardiac Surgery, and Intensive Care. Springer-Verlag, London 2012
(in press…due out 7/31/2013)
Knott-Craig CJ, Goldberg SP. The Ross procedure in children. In: Franco KL, Thourani VH, eds.
Cardiothoracic Surgery Review. Philadelphia, PA: Lippincott, Williams, & Wilkins, 2012
Morgenstein BZ, Gallick D, Alpert BS. Casual Blood Pressure Methodology. In PediatricHypertension,
Flynn JT, Ingelfinger JR, Portman R, editors. Humana Press, 2012, in press.
Sathanandam, Shyam. Evaluation and Therapy: Neonatal Critical Heart Disease. Shaddy R, Rychick J,
Marie Gleason, eds. Pediatric Practice: Cardiology. McGraw-Hill Publishers, NY, NY.
Sathanandam, Shyam. Cardiology. Shah B, Lucchesi M, eds. The Atlas of Pediatric Emergency Medicine,
Second Edition.
/lebonheurchildrens
/lebonheurchildrens
Ebstein’s research helps
establish best practice
A
fter following neonates with
Ebstein’s Anomaly for nearly
20 years, the surgical team at
Le Bonheur’s Heart Institute has published
a review of best treatments for the defect.
The results were published this past
year in the World Journal for Pediatric
and Congenital Heart Surgery in “Surgical
Decision Making in Neonatal Ebstein’s
Anomaly.” The study presented an algorithm for choosing the best management
option for neonates based on analysis of
the Heart Institute’s experience.
“Our extensive work with Ebstein’s
Anomaly helped us establish what we consider best practice in treating neonates,” said Christopher Knott-Craig, MD, chief of Cardiovascular Surgery and
co-director of Le Bonheur’s Heart Institute.
The authors looked at 48 neonates diagnosed with Ebstein’s Anomaly, all
treated between 1994 and 2011. Of these, two died before intervention and 46
were either initially managed medically or underwent surgical intervention
during the neonatal period.
Based on the neonates’ outcomes, researchers found that most symptomatic
neonates with Ebstein’s will require early operation. Those with anatomic pulmonary atresia and mild tricuspid regurgitation may be best served initially with a
modified Blalock-Taussig shunt and reduction atrioplasty.
Those with functional pulmonary atresia and severe tricuspid regurgitation
may be best served with ligaEbstein’s repair survival
tion of the main pulmonary
by age group, 4 years
artery and placement of a
100
Blalock-Taussig shunt to pro95
vide the best initial palliation. 90
85
The review showed others
LeB survival
80
should receive either bivenSTS survival
75
tricular repair or a single70
ventricle palliation.
65
60
neonate
infant
child
adult