Course Content
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Pediatric Heart Failure: “How to approach the management of Pediatric Heart Failure” Understanding heart failure: the basics in pediatric heart failure and congenital heart diseases. Basics of treatment and decision making in clinic cases
- Introduction. Definition of Heart Failure
- Etiology of Heart Failure in pediatric age
- Pathophysiology of Heart Failure
- Heart Failure in Congenital Heart Disease
- Natriuretic peptid system
- Biomarkers in Heart Failure
- Signs and Symptoms in pediatric age
- Classification of severity in pediatric Heart Failure
- Different forms of cardiomyopathies: “Diagnostic techniques and treatments”
- Dilated Cardiomyopathy
- Myocarditis
- Hypertrophic Cardiomyopathy
- Restrictive Cardiomyopathy
- Non-compaction Cardiomyopathy
- Arrhythmogenic Right Ventricular Dysplasia (ARVD)
- Evaluation Cardiomyopathies and Genetics
- Evaluation Quiz
- Arrhythmias in Pediatric Heart Failure: EKG abnormalities
- Indications ICD in adults and pediatric age
- Clinic Cases. Quiz
- Treatment in chronic pediatric Heart Failure
- New treatment: Sacubitril – Valsartan
- New therapies and Experimental
- Summary Pediatric Heart Failure therapies
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Basic and Advanced Echocardiography in Pediatric Heart Failure Description of basic and advanced echocardiography tools for diagnostic and follow-up of children affected by heart failure
- Journal Club: “Basic and advanced echocardiography in advanced heart failure: an overview”
- LV systolic function
- RV systolic function
- Cardiac Diastolic Function and Diastolic Heart Failure
- Tissue Doppler Imaging (DTI) and diastolic dysfunction
- Summary Echo left diastolic dysfunction
- RV diastolic dysfunction
- Management of pediatric diastolic dysfunction
- Clinic Cases
- dP/dt LV function assessment
- Myocardial Performance Index (Tei Index) Doppler Mitral Flow
- Myocardial Performance Index (Tei Index) DTI
- Basics of Strain and Strain-rate
- Global longitudinal Strain (GLS)
- Cardiac output assessment by Echo
- Advanced Imaging in Pediatric Heart Failure
- Echocardiography: Apps and webs
- Clinic Cases
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Pediatric Heart Transplant (I) Basic in inmunology and rejection. Indications of pediatric heart transplant and contraindications. Mechanical support in pediatric age. Surgery and perioperative treatment.
- Basis of transplant immunology
- Human leucocytes antigen (HLA)
- Blood group antigen (ABO)
- Graft Rejection
- Donor selection & evaluation
- Tissue typing and cross matching
- Ischemic time and the TransMedics® Organ Care System (OCS™)
- Indications and Contraindications of Pediatric Heart Transplant
- Indications of pediatric Mechanical cardiac support (MCS)
- Types of Devices for pediatric MCS
- VAD selection for pediatric MCS
- Surgery of Heart Transplant in pediatric age and in Congenital heart disease
- Principle Challenge in immunosuppressive therapies
- Induction therapy during surgery, postoperative period and denervated heart
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Pediatric Heart Transplant (II) Basic of immunosuppression treatment. Management of rejection and infections in pediatric heart transplant. Information for patients and relatives. Outcomes of heart transplant and indications of retransplantation
- Basis of immunosuppression therapy
- Risk of infection after transplantation
- Complication of chronic immunosuppression
- Basis of Rejection and assessment
- Endomyocardial biopsy and rejection
- Treatment of humoral and cellular rejection
- Chronic rejection: Coronary Artery Vasculopathy (CAV)
- Clinic follow-up in patient transplanted
- Cardiac Rehabilitation in pediatric heart transplant
- Survival and Causes of death in pediatric heart transplant
- Indications of retransplantation and survival
- Home Care after Pediatric Heart Transplant
- Palliative care in Pediatric Heart Failure and Heart Transplantation
- Future perspectives. Summary
- Clinic cases
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Final Quizz Congratulations! You finished the course, check your knowledge with this final test
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Fellow Evaluation Course Evaluation of the cardiac fellows who attended the course in May 2020
Risk of infection after transplantation
Temporal relationship between infectious etiology and time after transplantation:
- The risk for bacterial and fungal infection is greatest in the first four weeks related with higher doses of immunosuppressive treatment, and decreases after three months.
- The risk for CMV infection peaks after the discontinuation of antiviral prophylaxis in at-risk patients.
- Viral infections (non CMV) are acquired and develops more than 6 months after surgery.
CMV PROPHYLAXIS AND POST TRANSPLANT MONITORING FOR CMV VIREMIA
- Check recipient CMV IgG pre- transplan; note donor CMV IgG status; note any CMV positive blood products given to donor or recipient; assume donor CMV IgG seropositive if hemodiluted sample; and determine highest risk category. If recipient or donor age <18 months, then serologies likely reflect maternal serologies; 3 months prophylaxis will be considered sufficient with PCR testing post discontinuation.
- CMV prophylaxis is implemented universally for first 3 months post heart transplant due to issues with determining minimal risk, prevalence of disease, and level of immune suppression during that time period.
|
Risk of CMV Disease |
Transplant | Post-transplant
CMV prophylaxis |
Monitoring for CMV |
Rejection CMV prophylaxis |
| High D+/R- | Ganciclovir IV 5mg/kg twice daily through induction
(2 weeks)
|
Valganciclovir Q24h VO
Duration 3months min (max 6). If CMV PCR is positive after discontinuing, then treat followed by continuation of prophylaxis for minimum of 12 months post-transplant |
Check CMV PCR
-on the day of HTx -weekly x 4 weeks -q2 weeks until 3 months’ post Tx -q monthly until 6 months’ post Tx -q3 monthly until one-year post Tx -q6 monthly thereafter -whenever clinically indicated Quantitative PCR for CMV when positive CMV PCR |
CMV prophylaxis x 1 month
Check CMV PCR at time of rejection |
| Intermediate D+/R+
D-/R+ |
Ganciclovir IV 5mg/kg twice daily through induction
(2 weeks) |
Valganciclovir Q24h VO
Duration 1-3 months |
Same as above | CMV prophylaxis x 1 month
Check CMV PCR at time of rejection |
| Minimal* D-/R-
*Risk is only minimal for CMV if D-/R- from a sample that is not hemodiluted and when no CMV positive blood products have been given |
Ganciclovir IV 5mg/kg twice daily through induction
(2 weeks)
|
NO
Monitoring for clinical symptoms
|
Same as above | CMV prophylaxis x 1 month
Check CMV PCR at time of rejection |
CMV: Drugs, doses for prophylaxis and treatment, and renal adjustments:
| Ganciclovir IV | 5 mg/kg – Q 24h for prophylaxis; Q 12h for treatment
For ClCr 50-70 ml/min/1.73m2, give 2.5 mg/kg/dose Q 12h For ClCr 25-50 ml/min/1.73m2, give 2.5 mg/kg/dose Q 24h For ClCr < 25 ml/min/1.73m2, give 1.25 mg/kg/dose Q 24h |
| Valganciclovir
4m – 16 y: 7x BSA x CrCl (max 900mg / dose)
CrCl: creatinine clearance (mL/min/1.732)
Schwartz CrCl: 0,413 x Height (cm) / Serum Creatinine (mg/dL) |
Formulations: 450 mg tablet; 50 mg/mL solution; 900 mg tablet
Dosing: See renal adjustment below for weight-based dosing in renal insufficiency* Weight < 25 kg: 15-18 mg/kg/dose Weight 25-45 kg: 450 mg per dose Weight > 45 kg: 900 mg per dose (once daily for prophylaxis, BID dosing for treatment)]
*For ClCr 40-59 ml/min/1.73m2, administer half of above dose daily For ClCr 25-39 ml/min/1.73m2, administer half of above dose every other day For ClCr 10-24 ml/min/1.73m2, administer half of above dose twice a week For patients on dialysis, use ganciclovir |
| * Foscarnet and cidofovir are alternative antivirals with activity against CMV. If you need to use either, consult with the infectious disease specialist regarding indication and the pharmacist regarding the best dosing regimen as they are both more complicated to administer and both have high prevalence of adverse effects including renal and/or hepatic toxicity. Adapted of Razonable et al. American Journal of Transplantation 2013; 13: 93–106 | |