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Heart failure metrics specific to the pediatric population are required to successfully implement quality improvement initiatives in children with heart failure. Medication use at the time of discharge following admission for decompensated heart failure has been identified as a potential quality metric in this population. This study aimed to report medication use at discharge in the current era for children admitted with acute decompensated heart failure. All patients

Purpose The significance of atypical infiltrates, defined as eosinophils or plasma cells on endomyocardial biopsy (EMB) after pediatric heart transplant (HTx) is not known. We hypothesize that atypical infiltrates are associated with worse post-HTx outcomes. Methods We performed a retrospective cohort study of 96 consecutive patients status-post primary HTx (age Results Atypical infiltrates were seen in 24/96 (25%) patients. Of these patients, 14/24 (58%) had 1 EMB and 10/24 (42%) had >2 EMB with atypical infiltrates. Atypical cells were abundant in 6/24 (25%), while they were a rare cell type in 18/24 (75%). The presence of atypical infiltrates on EMB was associated with higher likelihood of reaching the composite outcome compared to no atypical infiltrates (HR 6.9 [2.9-16.3], Fig 1A). Two or more EMBs with atypical infiltrates were associated with greater risk of composite outcome compared to no atypical infiltrates (HR 11.1 [4.2-29.1], Fig 1B). All patients with abundant atypical infiltrates met the composite outcome within the study period (HR 21.6 [7.7-60.2], Fig 1C, compared to no atypical infiltrates). Conclusion Atypical infiltrates on EMB are associated with increased risk of CAV, graft failure, or death after HTx. The risk is higher with increasing frequency and greater extent of atypical infiltrates on EMB. Patients with atypical infiltrates are an at-risk population that require close follow up.

Purpose The number of patients with failing single ventricle physiology is increasing, and ventricular assist device (VAD) support in this population is challenging. The purpose of this study was to describe our clinical experience with VAD for failing Glenn physiology. Methods A retrospective review of clinical outcomes was conducted in patients that underwent durable VAD placement for failing Glenn circulation between 2010 and 2020 at Texas Children's Hospital. Results Ten patients met inclusion criteria; all had a morphologic right ventricle (RV): 6 hypoplastic left heart syndrome/variant and 4 with isomerism with RV dominant atrioventricular septal defect. INTERMACS profiles were 1 in 3 patients (1 with ECMO) and 2 in 7 patients. Four patients were intubated. Age, weight, and body surface area at VAD implantation were 3.2 (0.9-10.1) years, 13.0 (7.7-22.8) kg, and 0.50 (0.36-0.90) m2, respectively. The device-strategy included HVAD in 6, Jarvik 2015 in 1, and Berlin cannula (with Berlin and/or Rotaflow pumps) in 3. Concomitant Fontan completion was performed in 5 patients (1 with fenestration), while the other 5 remained with Glenn circulation. PaO2/FiO2 ratio (median, range) on postoperative day 1 was significantly higher with Fontan completion [192 (53-336)] than without [76 (59-78), p=0.05] except a patient with Glenn circulation on ECMO. The median duration of mechanical ventilation after VAD was 2 days (range, 1 - 14). There was 1 early mortality 8 days after HVAD placement with Fontan completion due to neurologic insult intraoperatively. The remaining 9 patients (90%) were bridged to transplant at a median support duration of 3.8 (0.1-16.6) months. Five of the 6 HVAD patients were able to be discharged home prior to transplant. One patient encountered a pump thrombus requiring pump exchange and 1 patient suffered a thromboembolic stroke due to a mobile intraventricular thrombus. One patient had a subdural and subarachnoid hemorrhage 27 days after VAD implantation, with complete neurologic recovery without deficits. Conclusion This single-institutional experience suggests long term VAD support is sustainable for failing Glenn physiology with accompanying Fontan completion in selected patients. Further studies are warranted to optimize long term VAD support in this challenging population.

Purpose Therapeutic ranges of Mycophenolic Acid (MPA) concentrations have not been established in pediatric heart transplant recipients. There are limited data supporting are under the concentration-time curve (AUC) in adult heart transplant on outcomes such as rejection, but AUC monitoring may be not be feasible in clinical practice. The purpose of our study is to evaluate the relationship between mycophenolic acid (MPA) trough levels and incidence of biopsy proven rejection and adverse effects in pediatric heart transplant patients. Methods A single-center retrospective chart review was performed on patients receiving heart transplant between Jan 2011 and Dec 2015. Patients included for analysis were ≤18 years at transplant and received maintenance immunosuppression with tacrolimus, mycophenolate, and a corticosteroid. Endomyocardial biopsy grades up to one-year post transplant and simultaneous MPA levels were recorded. Patients with acute cellular rejection scores of 2R or 3R or immunopathologic evidence of antibody mediated rejection were considered as biopsy proven acute rejection (BPAR). Leukopenia, gastrointestinal side effects, and mycophenolate dose decreases were also recorded. Results A total of 47 patients were included in the final analysis. There were no significant differences in baseline demographics between patients who had BPAR and those who did not. Overall 24% of patients had at least 1 incidence of BPAR after heart transplant. The mean MPA trough levels between the group of patients with rejection (2.4 ug/mL +/- 1.62) and those without rejection (2.46 ug/mL +/- 1.74) was not significantly different (p=0.38). Mean MPA trough levels also were also not consistent when examining rejection by time from transplant. Only examining by individual MPA trough levels on biopsy days did we observe a significantly lower MPA trough 1.6 ug/mL +/- 1.05 in those with rejection versus those without 2.5 ug/mL +/- 1.69 (p=0.02). The mean MPA level associated with a dose decrease due to an adverse effect between these two groups was not significant. Conclusion MPA trough levels may have a relationship with incidence of biopsy proven rejection or with incidence of adverse events within one-year post transplant in this population. Controlled prospective studies with are warranted to further evaluate this potential relationship.