RSV infection in children with congenital heart disease

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RSV infection in children with congenital heart
disease

• Ri ???

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Patient data

• 4A2-02 ?X?
• 2 m/o boy
• Down syndrome
• Endocardial cushing defect s/p PA banding for CHF
  and pulmonary hypertension

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Patient data
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Respiratory syncytial virus

• Enveloped RNA paramyxovirus
• Genus Pneumoviurs
• Encodes 10 viral proteins
• Replicate within the hosts cytoplasm
• 3 transmembrane glycoproteins
• Fusion(F), attachment(G), small hydrophobic(SH)

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Respiratory syncytial virus

• F protein
• Penetration of the cell and fusion infected cell
  membranes
• G protein
• Attachment of RSV to cell membranes
• SH protein
• Function is not yet understood
• F and G protein
• Main targets of the host immune response

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RSV infection

• Seasonal patterns
• Northern hemisphere winter months
• Tropics hot, rainy seasons

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RSV infection

• Contagion by large droplets of secretions
• Surface survive for 6 h
• Rubber gloves survive for ½ h
• Cloth gowns survive for 45 min
• Skin survive for 20 min
• Entry to human through mucous membranes of eye,
  nose, and mouth
• 6-feet-rule

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RSV infection

• Leading cause of lower respiratory tract
  infections in infants and young children
• Under 2-year-old
• More severe disease between 13 m/o

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Detection of RSV infection

• Cultures
• Fluorescent antibody techniques
• 85 sensitivity
• 85 specificity
• Enzyme immunoassay (EIA)
• 95 sensitivity
• 97 specificity

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RSV infection

• Risk factors
• Lack of care-giver education
• School-age siblings
• Crowded living situation
• Multiple births
• Birth within 6 months of RSV season
• Discharge from NICU during RSV season
• Passive smoke exposure

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RSV infection

• Risk factor for severs RSV disease
• Prematurity
• Underlying lung disease (cystic fibrosis,
  bronchopulmonary displasia.)
• Congenital heart disease (L-to-R shunt with
  pulmonary hypertension)
• Immunodeficiency (AIDS, chemotherapy, bone marrow
  transplantation)

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Impact of RSV infection in CHD
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RSV infection in CHD

• RSV pneumonitis
• Impair O2 uptake, increase the work of breathing
• At risk of developing respiratory or cardiac
  failure
• Ventilator support

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RSV infection in children with CHD and without CHD
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RSV infection in children with CHD and without CHD
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RSV infection in CHD
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RSV infection in CHD

• Reduced mortality in CHD children with RSV
  infection
• Advances in pediatric intensive care
• Initiation of Ribavirin therapy
• Early correction of CHD
• A long period of ventilator support may be the
  natural course of RSV infection in children with
  significant CHD

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Impact of RSV infection on surgery for CHD
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Cardiac surgery after RSV infection

• Patients
• Children's hospital Los Angeles, Jan. 1990 Apr.
  1995, CHD and RSV infection, cardiac surgery
  within 6 months after RSV infection

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Cardiac surgery after RSV infection
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Cardiac surgery after RSV infection
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Cardiac surgery after RSV infection
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Cardiac surgery after RSV infection
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Cardiac surgery after RSV infection
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Cardiac surgery after RSV infection

• Cardiac surgery performed during RSV infection?
  High risk of post-op complication (pulmonary
  hypertension)
• Earlier surgery? More frequent and severe
  complications
• Elective surgery in pts who recovered from RSV
  infection? fewer and minor complications

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Cardiac surgery complicated by RSV infection

• 8 patients (mean age 67y/o) had RSV infection
  after cardiac surgery
• CABG 4
• CABG valve replacement 3
• Mitral valve replacement 1
• 7 patients required prolonged mechanical
  ventilation
• 4 patients died of respiratory failure

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Treatment and Prevention
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Medical treatment

• There is no valuable curative treatment for RSV
  infection
• Ribavirin therapy is the only agent commercially
  available that may possible reduce the severity
  of pulmonary complications

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Prevention

• Isolation of patients with RSV infection
• Wearing of gown and glove
• Diligent hand washing

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Prevention

• Active immunization
• Formalin inactivated RSV vaccines
• Live virus vaccines
• Purified F protein subunit vaccines

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Prevention with RSV-IVIG

• RSV-IVIG passive immunization
• Human-derived polyclonal product containing
  concentrated neutralizing antibody to RSV
• Dosage 750 mg/kg
• RSV antibody titer gt 100
• Disadvantage
• High viscosity
• Expensive

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Prevention with Palivizumab

• Palivizumab passive immunization
• Humanized monoclonal antibody antibody to F and
  G glycoprotein of RSV
• Potency 50100 times of RSV-IVIG
• Only defined, beneficial, therapeutic
  intervention in the prevention of RSV disease
• Disadvantage expensive

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Thanks for your attention!!