Cardiac Dysfunction Following Brain Death in Children

Abstract

Background Cardiac dysfunction has been reported to occur in as much as 42% of adults with brain death, and may limit cardiac donation after brain death. Knowledge of the prevalence and natural course of cardiac dysfunction after brain death may help to improve screening and transplant practices but adequately sized studies in pediatric brain death are lacking. The aims of our study are to describe the prevalence and course of cardiac dysfunction after pediatric brain death. Methods We conducted a cross-sectional study using an organ procurement organization database (Life Center Northwest) of potential pediatric cardiac donors diagnosed with brain death between January 2011 and November 2013. Transthoracic echocardiograms (TTEs) were reviewed for cardiac dysfunction [defined as ejection fraction (EF) < 50% or the presence of regional wall motion abnormalities (RWMAs)]. Descriptive statistics were used to analyze clinical characteristics and describe longitudinal echocardiogram findings in a subgroup of patients. We examined for heterogeneity between cardiac dysfunction with respect to cause of brain death. Results We identified 60 potential pediatric cardiac donors (age ≤ 18 years) with at least one TTE following brain death. Cardiac dysfunction was present in 23 (38%) patients with brain death. Mean EF (37.6% vs. 62.2%) and proportion of procured hearts (56.5% vs. 83.8%) differed significantly between the groups with and without cardiac dysfunction, respectively. Of the 11 subjects with serial TTE data, the majority (73%) of patients with cardiac dysfunction improved over time, leading to organ procurement. No heterogeneity between cardiac dysfunction and particular causes of brain death was observed. Conclusion The frequency of cardiac dysfunction in children with brain death is high. Serial TTEs in patients with cardiac dysfunction showed improvement of cardiac function in most patients, suggesting that initial decisions to procure should not solely depend on the initial TTE exam results.

Soluble ST2 is a Useful Biomarker for Grading Cerebral–Cardiac Syndrome in Patients after Acute Ischemic Stroke

“…Additionally, there was a strong correlation between increased circulatory inflammatory biomarkers and impaired LVEF (refer to Table 2). Intriguingly, a link between an increase in inflammatory biomarkers and LV dysfunction/heart failure has been clearly elucidated in settings of IS or brain damage with any etiology [28][29][30][31]. Again, our finding was comparable with the findings of previous studies [7,[28][29][30][31] regarding the complex brain-heart interaction.…”

Early Systolic Dysfunction Following Traumatic Brain Injury: A Cohort Study

“…Another prospective study(20) demonstrated troponin elevation in 31% of patients following moderate-severe TBI; while echocardiographic dysfunction was not demonstrated in that study, the majority of echocardiograms were performed several days after injury, a period by which most patients in our study had recovered normal systolic function. Acute systolic dysfunction has also been observed after several severe acute non-TBI neurologic diseases including acute emotional distress(21) (classic Takotsubo’s cardiomyopathy), SAH(22), ischemic stroke(23, 24), epilepsy(25, 26), and brain death(27). …”

Effects of donor cause of death, ischemia time, inotrope exposure, troponin values, cardiopulmonary resuscitation, electrocardiographic and echocardiographic data on recipient outcomes: A review of the literature

“…Numerous studies have demonstrated decreased utilization of potential donor hearts with echocardiographic evidence of ejection fractions <50%, and ISHLT guidelines have similarly recommended refusal of donor hearts with ejection fractions <40% . This practice has been supported by several pediatric and adult studies suggesting higher rates of graft failure following transplant of hearts with ejection fractions <50% and a recent pediatric donor utility survey demonstrating half of all respondents would decline an otherwise acceptable organ with an ejection fraction <50% …”

“…The data in pediatric and young adult populations, where CVA is clearly an uncommon cause of death, are similarly mixed. Some studies suggest that CVA as the donor cause of death is associated with slightly higher 1‐year mortality rates following transplantation, but others have not . While it is plausible that the association between donor CVA and subsequent post‐transplant mortality differs between adults and children, there is insufficient data to support this assertion.…”

“…Conversely, a larger number of pediatric and adult studies have demonstrated comparable recipient outcomes following transplantation of hearts with ejection fractions <50% and/or with evidence of segmental wall motion abnormalities . This difference may be secondary to increased time intervals between initial echocardiograms demonstrating poor function (oftentimes shortly after herniation) and preharvest myocardial function, (whether documented by echocardiogram or not) with the time interval allowing for myocardial recovery from the neurologic death‐induced “catecholamine storm.” Several pediatric and adult studies have documented the phenomenon of significantly improved function between initial and final (preharvest) echocardiogram following a combination of time and medical management using inotropic and/or hormonal therapy.…”