SCCM Resource Library-59-Early Cardiac Complications After Pediatric Hematopoietic Stem Cell Transplant

Video Transcription

Good morning. I'm one of the third-year pediatric residents currently working at Nicholas Children's  Hospital. My name is Diana Belen-Bermudez, and I'm going to be talking about early cardiac  complications after pediatric hematopoietic stem cell transplant. In our pediatric intensive  care unit, we've had patients who had received hematopoietic stem cell transplant, and we wondered what would their cardiac compromise be. Therefore, the importance of this study.  There is no conflict of interest in the following presentation research. It is known that chemotherapy  and radiation regimens used for hematopoietic stem cell transplant are known to have severe  cardiac attack effects. The underlying causes are multifactorial and include drug toxicity,  prior chest irradiation, infection, and pre-existing cardiac disease. While the manifestations  of cardiac damage may be immediate, they are often delayed by months or even years. But when cardiac complications occur early on, it can be more dangerous and life-threatening.  In this study, we focus on detecting early cardiac complications. Research in adults  have demonstrated occurrence of arrhythmias, congestive heart failure, pericarditis, myocarditis,  endocarditis, pericardial infusion, and cardiac tympani. In pediatrics, there are few small  retrospective studies that describe the presence of cardiac complications, but it's merely limited to pericardial infusion and heart failure. The main objective of this study  is to evaluate the presence of cardiac complications and associated mortality in children after  hematopoietic stem cell transplant. We performed a retrospective analysis including more than  2 million known neonatal discharges in a healthcare cause and utilization project, 2016 Kids and  Patient Database. The database was filtered using ICD-10 procedure codes for hematopoietic stem cell transplant for patients between 28 days and 20 years. And we evaluated for  the following cardiac complications including congestive heart failure, pericardial infusion,  cardiac tympani, myocardial infarction, arrhythmias, cardiomyopathy, myocarditis, endocarditis,  and intracardial thrombosis. Comparison of categorical data are percentages, frequencies in percentages. We compared children with hematopoietic stem cell transplant versus  all other discharges. Also, the frequency of cardiac complications among patients with a hematopoietic stem cell transplant having a diagnosis of leukemia versus no leukemia,  acute myeloblastic leukemia versus acute lymphoblastic leukemia, and autologous versus allogenic  transplant. Also, we compared mortality rate between hematopoietic stem cell transplant versus non-hematopoietic stem cell transplant and with or without cardiac complications  among transplant patients. Continuous variables as age are presented as medians with interquantile  range. Categorical variables were compared using CHI-squared tests, and continuous variables  were compared using Mann-Whitney-Q test. FBSS version 25 was used, and FBSS less than 0.05  was considered significant. In this slide, we can see the age group of patients who received hematopoietic stem cell transplant versus overall discharges. The median age of children  of hematopoietic stem cell transplant was 7. Age group distribution among children who received hematopoietic stem cell transplant was significantly different than all of the  hospital discharges. Ages within 2 and 11 were more frequently to be present in the  transplanted group. This slide presents race and ethnic distribution of patients with hematopoietic  stem cell transplant compared to all other discharges. White people are most frequently  present in hematopoietic stem cell transplant, and Black people are less frequently represented.  The median length of the state for those patients who received a transplant with 32 days with interpointing range within 23 and 44 days, the median length of the state for all other  discharges was 2. In this slide, we can see the most common cardiac complications. Out of a total of 2,275 patients, 6.8% corresponding to 155 patients had a cardiac complication.  As you can see, hematopoietic stem cell transplant had a significantly higher prevalence of cardiac  complications compared to other discharges. Some of the common complications include prolongation  of the QT, pericardial effusion, cardiomyopathy, heart failure, and endocarditis. Heart failure  was the fourth most common cause. However, it was not significant. No cases documented for myocarditis nor myocardial infarction were found. In children with hematopoietic  stem cell transplant having leukemia increases the risk of cardiac complications. The prevalence  of cardiac complications was 11.7% in those with leukemia compared to 4.9% in those without the diagnosis of leukemia. Overall, there were more patients who received a hematopoietic  stem cell transplant without having a diagnosis of leukemia. Among patients with leukemia receiving a transplant, children with AML had a higher prevalence of cardiac complications  compared to those with acute lymphoblastic leukemia. As expected, children who received  allogenic hematopoietic stem cell transplant had a higher complication rate compared to those who  received autologous of 9.2% versus 4%. One of the reasons that can explain this finding is  because 98% of children with leukemia received an allogenic transplant, and 2% had an autologous  transplant. Overall mortality in children with hematopoietic stem cell transplant was 4.4% compared to 0.40% of all other discharges. Mortality among children with hematopoietic  stem cell transplant with a cardiac complication was 15.5% compared to 3.5%  in children without a cardiac complication.  This table presents the case fatality rate with specific cardiac complications in children with  hematopoietic stem cell transplant. Although the number of children with cardiac tamponade  and ventricular tachycardia were few, the case fatality rate was very high. Cardiac tamponade,  ventricular tachycardia, heart failure, and pericardial fusion in disorder had a higher percentage of mortality. The strength of this study is that it presents national data and is  the largest reported cohort of pericardial complications after pediatric hematopoietic stem cell transplant. The limitations of the study is that it's a retrospective study.  It's an administrative database study, meaning it's based on physician-coded and eliminated by  diagnostic codes. There is limitation to obtain data on long-term outcomes, and all the variables associated with cardiac complications are not coded in the database. In conclusion,  cardiac complications are not uncommon in children after hematopoietic stem cell transplant in short-term period. Cardiac complications are higher among patients  with leukemia, especially AML, and those who received allogenic transplant.  The three most common cardiac complications included prolongation of the QT, pericardial fusion, cardiomyopathy. Mortality rate was higher in children with hematopoietic stem cell  transplant who developed a cardiac complication. Thereafter, it's important to be aware that cardiac complications can occur in the perihematopoietic stem cell transplant period,  and if they occur, they can be life-threatening. Thank you so much for listening to my presentation. It was a pleasure talking to you. Goodbye.

Video Summary

The speaker, Diana Belen-Bermudez, discusses a study on early cardiac complications after pediatric hematopoietic stem cell transplant. They explain that chemotherapy and radiation used in this procedure can cause severe cardiac effects. The study aims to evaluate the presence of cardiac complications and associated mortality in children after the transplant. They analyze a database of over 2 million discharges and find that cardiac complications are more prevalent in patients who received the transplant compared to others. Leukemia and allogenic transplant increase the risk of complications. The study highlights the importance of early detection and management of cardiac complications in these patients.

Asset Subtitle

Pediatrics, Transplant, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Diana Belen Bermudez

Introduction/Hypothesis: Chemotherapy and radiation regimens used for Hematopoietic stem cell transplant (HSCT) are known to have severe cardiotoxic effects. However, research in pediatrics evaluating the incidence of early cardiac complications after HSCT is lacking. The objective of this study is to assess the incidence of cardiac complications and mortality associated with pediatric HSCT.

Methods: A retrospective analysis of the Healthcare Cost and Utilization Project 2016 Kids Inpatient Database was performed. The database was filtered using ICD-10 procedure codes for HSCT for patients between 28 days and 20 years of age and evaluated the presence of the following cardiac complications including: congestive heart failure, pericardial effusion, cardiac tamponade, myocardial infarction, arrhythmias, cardiomyopathy, myocarditis, endocarditis, intracardiac thrombosis. Basic demographic data was obtained, and statistical analysis using chi-squared was performed on SPSS.

Results: A population of 2,275 patients with HSCT was included. The median age was 7 (IQR 2-13) years. Cardiac complications were found in 6.8% of patients (OR 5.7, CI 4.8 - 6.7), of which prolonged QT interval was the most common diagnosis (2.3%), followed by pericardial effusion (2.2%) and cardiomyopathy (1.2%). Cardiac complications were more common in children with leukemia than in those without leukemia, (11.7% vs 4.9%; OR:2.5, CI 1.8 â€“ 3.6). Acute myeloid leukemia (AML) was more likely to have cardiac complications than patients with acute lymphoblastic leukemia (ALL), (16.6% vs. 10.4%; OR: 3.1 vs OR: 1.6, P < 0.05). Moreover, cardiac complications occurred more frequently after allogenic HSCT than after autologous HSCT, (9.2% vs 4.0%; OR: 2.5, CI: 1.7 â€“ 3.6). The overall mortality in HSCT patients was 4.4%. The mortality in HSCT patients with cardiac complications was 15.5% and without cardiac complications was 3.5% (OR 4.9, CI 3.0 â€“ 8.1).

Conclusions: Our study provides national data on the early cardiac complications and mortality after pediatric HSCT. The incidence of cardiac complications is 6.8%. The overall mortality rate is 4.4% and is higher if a cardiac condition was found. Cardiac complications are more common in children with leukemia, especially with AML, and in children after allogenic compared to autologous HSCT.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Transplant

Knowledge Level Advanced

Membership Level Select

Tag Stem Cells

Tag Transplant

Year 2021

Keywords

Diana Belen-Bermudez

cardiac complications

pediatric hematopoietic stem cell transplant

chemotherapy

radiation

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