Reappraisal of the Subtropical Guidelines on Palivizumab Prophylaxis in Congenital Heart Disease

Abstract

Objective: To define the impact of associated abnormalities on the efficacy of the novel subtropical guidelines for palivizumab prophylaxis on respiratory syncytial virus (RSV)-related hospitalizations in patients with hemodynamically significant congenital heart disease (hsCHD).Method: This prospective study enrolled every patient seen at a tertiary care center for hsCHD, who was born between 2014 and 2018 and received at least 1 dose of palivizumab, according to the subtropical guidelines. The patients were followed until the age of 2 years.Results: A total of 772 patients (49% male) were enrolled. Cyanotic CHD was seen in 46% of patients, of whom 23% had associated abnormalities. Lung/airway abnormalities (14%) were the most common followed by the genetic syndromes associated with CHD (7.3%). Among the 772 patients, RSV-related hospitalizations occurred in 3.2 and 2.2% children aged ≤ 12 and 13–24 months, respectively. Most of the RSV infections occurred in patients no longer satisfying the criteria for palivizumab prophylaxis. The patients with associated abnormalities but not the type of CHD, patient age, and patient sex were risk factors for RSV-related hospitalizations. The rates of RSV-related hospitalizations, admission to the intensive care unit, and endotracheal intubation were higher for patients with associated anomalies than for other patients before 24 months of age (10.2 vs. 4.0%, 67 vs. 33%, and 39 vs. 4.2%, p = 0.004, 0.06, 0.013, respectively).Conclusion: Children with abnormalities, especially genetic syndromes and lung/airway problems associated with CHD, are at high risk for RSV-related hospitalization. Our current subtropical guidelines for palivizumab prophylaxis in patients with hsCHD, should be revised to include the results of this study.

The implications of airway anomalies on children with congenital heart disease and bronchiolitis

“…The length of hospital stay in children who did not meet the hemodynamically significant CHD criteria but had lower airway anomalies was relatively high. 13,17 Hospital stay was significantly longer in hemodynamically significant CHD patients with airway anomalies than in those without anomalies. To achieve successful and sustainable outcomes in children with CHD, early identification of concomitant airway anomalies is crucial for the prevention and treatment of viral infection in the care of children with CHD and airway anomalies.…”

“…Airway anomalies are common in children with CHD, but their severity varies. The length of hospital stay in children who did not meet the hemodynamically significant CHD criteria but had lower airway anomalies was relatively high 13,17 . Hospital stay was significantly longer in hemodynamically significant CHD patients with airway anomalies than in those without anomalies.…”

“…The CHD diagnosis was confirmed using echocardiography or computed tomography. Hemodynamically significant CHD included all cases of cyanotic and acyanotic heart diseases with signs of heart failure or at least two medications required 13 . Airway anomalies were identified using computed tomography with three‐dimensional reconstruction (Figure 1) or flexible bronchoscopy, and included: laryngomalacia, tracheomalacia, bronchomalacia, structural stenosis, or external compression of the airway (including compression by blood vessels, heart, or mass).…”

“…However, the possible overestimation would not interfere with the data analysis in the study, and a future nationwide survey based on the results of this pilot study is needed to clarify the causes and benefits of passive vaccination strategies. Second, the definition of hemodynamically significant CHD is not universal; in our study, we used the common criteria in Taiwan, and previous reports also adopted the same criteria 13,18 . The diagnosis of bronchiolitis was clinical, and no written criteria was established.…”

“…Hemodynamically significant CHD included all cases of cyanotic and acyanotic heart diseases with signs of heart failure or at least two medications required. 13 Airway anomalies were identified using computed tomography with three-dimensional reconstruction (Figure 1 used for post hoc analysis. We used linear regression to identify risk factor for longer hospital stay.…”