Journal of Pediatric Cardiology and Cardiac Surgery 8(2): 65‒69 (2024)

Review[JSPCCS 59th Annual Conference]

Pediatric Cardiac Critical Care in the United States:
Historical Perspectives and the Modern Era
Carolyn Vitale, MD, Ranjit Aiyagari, MD, and John Charpie, MD, PhD
Pediatric Cardiology, University of Michigan, USA

The fields of pediatric cardiology and congenital heart surgery have made significant advancements over the past
70 years, reversing an earlier era of nearly universal mortality for all forms of congenital heart disease. Pediatriccardiac patients, particularly those with congenital heart disease, represent some of the most heterogeneous andcomplex patients to manage with an array of pathophysiologies. A highly functioning and collaborative team isrequired to care for this population effectively. Here we review the history of the field of pediatric cardiac criticalcare, the current system in the United States, and some additional considerations in the modern era.

Keywords: pediatric cardiac intensive care, congenital heart disease

Introduction
The fields of pediatric cardiology and congenital heart
surgery have made significant advancements over the
past 70 years, reversing an earlier era of nearly universal
mortality for all forms of congenital heart disease. Pediatric cardiac patients, particularly those with congenital
heart disease, represent some of the most heterogeneousand complex patients to manage with an array of pathophysiologies. A highly functioning and collaborative
team is required to care for this population effectively.
Here we review the history of the field of pediatric cardiac critical care, the current system in the United States,and some additional considerations in the modern era.

History of Pediatric Cardiac Intensive Care
The development of pediatric cardiac intensive care is
inextricably entwined with the advances in pediatric cardiology and cardiac surgery. Dr. Helen Taussig, lauded
as the “mother of cardiology,” pioneered the field in the1940ʼs using physical examination and fluoroscopy todescribe patterns of congenital heart disease, including

the common cyanotic lesion tetralogy of Fallot (TOF).
With recognition that children with TOF and a patentductus arteriosus (PDA) survived beyond infancy, sheapproached Dr. Robert E. Gross, a surgeon at BostonChildrenʼs Hospital renowned for ligating PDAs, whosummarily dismissed Dr. Taussigʼs suggestion that an
artificial PDA could be surgically created to prolong the
lives of patients with cyanotic congenital heart disease.
Dr. Taussig persisted in her pursuit of treatment of“blue baby syndrome” and partnered with Dr. Alfred
Blalock and his African-American research technician
Vivien Thomas at Johns Hopkins University. Together
they pioneered development of a systemic arterial topulmonary arterial shunt, which originally was named
the Blalock‒Taussig shunt, but today is more appropriately known as the Blalock‒Taussig‒Thomas shuntin recognition of Vivien Thomasʼ instrumental role inits success. The first patient to undergo placement of
a Blalock‒Taussig‒Thomas shunt was 15 month-old
TOF patient Eileen Saxon in 1944, with remarkable
improvement in her cyanosis and reversal of her failure
to thrive.1‒3)

J-STAGE Advance Published Online: July 2, 2024
Corresponding author: Carolyn Vitale, MD, Pediatric Cardiology, University of Michigan, 1540 E Hospital Drive, Office 11‒703, Ann
Arbor, MI 48109, USA
E-mail: vitalec@umich.edu
Carolyn Vitale ( https://orcid.org/0009-0004-2540-3452)
doi: 10.24509/jpccs.24-001© 2024 Japanese Society of Pediatric Cardiology and Cardiac Surgery
This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/)

66

The next great advance in cardiac surgery was development of the cardiopulmonary bypass machine. This
technology was originally intended to be used duringpulmonary embolectomy. The original heart-lungmachine was first successfully used for intracardiac
cardiac repair in 1953 by Dr. John Gibbon to close an
atrial septal defect.4) The successful use of cardiopulmonary bypass during open heart surgery sparked a rapid
expansion of its use for repair and palliation of a varietyof congenital heart lesions, and the concomitant need forspecialized post-surgical intensive care units.
The first pediatric intensive care unit (PICU) wasestablished at the Childrenʼs Hospital in Gotebord,
Sweden in 1955 where they successfully treated a moribund boy after surgery for a ruptured appendicitis withendotracheal intubation, manual ventilation, and bloodtransfusion. In this early model, the lead anesthesiologist, Dr. Goran Haglund, recognized the critical importance of nurses and nurse assistants to this successful
outcome.5) The subsequent decade saw development ofsimilar units throughout Europe, Australia and the first
PICU in the United States at the Childrenʼs Hospitalof Philadelphia in 1967.6) As these PICUs grew andexpanded, specialized training programs evolved andthe American Academy of Pediatrics created a sectionof critical care medicine in 1984, with the American
Board of Pediatrics offering the first certifying exam in
the field in 1987. The expansion PICUs and the technologic advances in monitoring and support devices havepushed the field of pediatric intensive care to its current
state with the ability to rescue and support children,
offering survival to patients who would have perished inprevious eras.

Models of Care for Pediatric Cardiac Patients
Paralleling the expanding fields of pediatric cardiology and pediatric cardiac surgery, the intensive carefield saw further specialization of pediatric cardiac
intensive care. In the current era, the pediatric intensivist is responsible for leading a multi-disciplinary
team to provide cardiorespiratory support throughdisease or intervention, using a complex combinationof medical therapies and technology. As cardiac surgicalvolumes and complexities have grown, there has beena growing need for expertise in the unique anatomic
and physiologic challenges. Institutions have adopted a
few different approaches to caring for pediatric cardiac
J Pediatr Cardiol Card Surg Vol. 8, No. 2 (2024)

patients. The first approach is to care for these patients ina defined pediatric cardiac ICU (CICU) which is designated specifically for the patient with a primary cardiac
condition requiring ICU level care, separate from thecare in the general medical and surgical PICU. The second approach is to provide care in a mixed ICU wherecare of the pediatric cardiac patients occurs in the same
physical location as care of other critically ill children.
In high volume cardiac surgical centers,7), [1] generally
defined as greater than 350 surgical cases per year, mostcenters have designated a dedicated pediatric CICU.
Programs with low cardiac surgical volumes (less than
150 surgical cases per year) represent about 44% of programs in the STS database (CHSD). In these low-volume
programs, the pediatric cardiac intensive care typicallyoccurs within the general PICU. A survey of the caremodels in the United States showed that out of one hundred and twenty ICUs, 59 (49%) were dedicated CICUs.
In the mixed ICU structure, about one third had designated beds for cardiac patients.8) Regardless of the caremodel, all institutions surveyed had advanced support
capabilities with the availability of extracorporeal membrane oxygenation (ECMO). However, dedicated CICUs
had more availability of durable cardiac support devices
and cardiac subspecialists (electrophysiology, heart
failure/transplant and cardiac anesthesia) compared tomixed ICUs.
Given the various models of care, the critical questionis whether one model is superior to another with respect
to outcomes. There has been conflicting data about theassociation of outcomes of patients undergoing pediatricheart surgery across different care models. A study of
neonates with heart disease showed decreased mortality
for those cared for preoperatively in a dedicated CICU.9)
A second neonatal study showed improved resource
utilization, with shorter ICU and hospital lengths ofstay and shorter duration of mechanical ventilation
in a dedicated CICU.10) However, another publicationconsidering all patients undergoing congenital heart
surgery, suggested there was no difference in mortality
for patients cared for in a dedicated CICU, but there
did appear to be a survival benefit for certain high-risk
subgroups including those undergoing atrioventricular[1] The Reference 7) was added by the Editorial office to clarify

the circumstance of the so-called “high volume cardiac surgicalcenters” in the United States.

67

canal repair or arterial switch operation.11) Morbidity
may also be impacted by the ICU care model with one
single-institution study (before and after establishmentof a dedicated CICU) demonstrating lower rates ofsurgical site infection and re-exploration for bleeding inpatients cared for in a dedicated CICU. This study did
however note that following the establishment of a dedicated CICU there was also growth and improved coordination of the healthcare team.12) The consolidation ofexpertise and cohesiveness of the team intuitively leads
to better team performance regardless of the physicalICU space.
In addition to variability in the ICU care model, there
exist many different training pathways for physicians
responsible for the care of pediatric cardiac patient.
Common backgrounds include pediatric intensive
care, pediatric cardiology, pediatric anesthesiology andmore recently, physicians dually-trained in pediatriccardiology and pediatric intensive care. For the general
pediatric patient, studies have shown an improvement inoutcomes, including survival, for patients cared for bya pediatric intensivist, but a study aimed at evaluating
the superiority of a specific training background failed
to find one.13, 14) There has been much controversy withintense opinions about the ideal clinical preparation,and despite this debate, expert consensus training recommendations have been developed by a multi-disciplinary group.15‒19)

Multi-Disciplinary Team Structure
We believe that having a highly skilled and specialized
team contributes significantly to quality care of thiscomplex patient population with the ability to recognize
decompensation sooner and prevent morbidity andmortality. This is a difficult belief to prove in an evidence
based way, but one group studied the period before
and after development of a dedicated cardiac ICU with
reductions in chest re-explorations, wound infections,need for CPR and mortality.12) The authors proposedthat the stable, specialized team was the primary difference with focused education initiatives and dedicatedstaff. It is logical that the pattern recognition that occurs
in high volume centers, consolidated in a dedicated teamwould increase the likelihood of consistency of care aswell as early recognition and rescue of complications.
Engaging a broad group of experts to collaborate inpatient care is one of the hallmarks of care in the pedi-

atric intensive care unit, and this is a model well suitedfor care of the pediatric cardiac intensive care patient.
The team would ideally include a broad range of pediatric intensivists, pediatric cardiologists and cardiac
surgeons, cardiac anesthesiologists, nursing, respiratory
therapists, pharmacists, physical/occupational/speechtherapists, and social workers. It is imperative that teamwork together collaboratively and feel psychologicalsafety to voice expert opinions and raise any concerns.
A highly functioning team may be the most importantfactor in reducing morbidity and mortality, particularly
failure to rescue.

Failure to Rescue
as a Modiﬁable Mortality Risk Factor
Several studies have shown that center volume andmortality are inversely associated in the pediatric cardiac surgery population. This inverse relationship is
most well-studied in the Norwood operation whichshows a modest survival benefit in high volume centers
independent of patient risk factors. However, a closer
examination of this survival benefit after Norwood
operation suggests that it is not entirely explained bycenter volume alone.20, 21) Given that post-operativecomplications across centers is relatively similar andlikely reflective of patient comorbidities and risk factors,
the field has sought to find a better measure of quality ofcare. From this analysis emerged the concept of Failure
to Rescue (FTR) which is defined as mortality following
a post-operative complication.22) A review from theSociety of Thoracic Surgeons Congenital Heart Surgery(STS-CHS) database showed an overall unadjusted mortality rate of 3.7%, a post-operative complication rate of
39%, and a FTR rate of 9%, with a very low rate of mortality in patients without any complication. There was astrong association between a centerʼs mortality rate andFTR rate rather than between overall complication rate
and mortality rate.23) These data suggest that the recognition and management of complications is the potentially modifiable factor impacting mortality rates after
pediatric heart surgery.24) There has been more research
in FTR in the adult populations, for example one study
demonstrated a lower FTR rate in high volume centersin adults undergoing open abdominal aortic aneurysm
repair, perhaps explaining the survival benefit observedin high volume centers.25)
More research is needed in this vein to identify key© 2024 Japanese Society of Pediatric Cardiology and Cardiac Surgery

68factors contributing to FTR and how best to combat it.
One interview-based study identified themes that teammembers identify in successful rescue including teamwork, swift action taking and psychological safety.26)
These themes are intuitive that improved communication of observed and voiced concerns may lead to
improved recognition of complications and the ability
to reverse or support a patient adequately through thatcomplication. It is difficult to measure and study effective teamwork, team and system dynamics and agility ofa team to respond to changes in patient condition, but
this is our belief of the intangible qualities that offer asignificant quality benefit to patients.

Future Directionsin Pediatric Cardiac Critical Care
Artificial intelligence as a supplement to augment
the complex analysis and decision-making capabilitiesof the bedside provider is the next great frontier in ourfield. There is nothing imaginable that can replace ahuman, but artificial intelligence offers a wide array ofpotential for pattern recognition and a deviation fromthe expected clinical course, earlier detection of subtle
signs of deterioration, and automation of some of themore routine aspects of medicine that may be expedited
by machine learning and application of effective artificial intelligence.27‒29) Additionally, off-loading someof the routine cognitive burden from the provider may
allow a shift of attention to more important issues.
Some work already underway has shown that artificial
intelligence can predict cardiac arrests in single ventricle
patients.30‒32)
The field is continuing to advance in novel interventional techniques and application of those techniques
to younger, smaller, and higher risk patient populations.
This has continued the tradition within the field of offering survival to patients who would have otherwise died.
Additionally, as survival of pediatric cardiology patients
has improved, there has been a burgeoning populationof adult congenital heart patients who are pushing the
growth and advancement of that subspeciality, including
their unique critical care needs.
Conﬂicts of Interest
The authors have no conflicts of interest to disclose.

J Pediatr Cardiol Card Surg Vol. 8, No. 2 (2024)

Author Contribution
Dr. Vitale was the primary author and Drs. Aiyagari andCharpie advised and edited the manuscript.
NoteThis is a review article based on the lecture given by Dr.
Charpie (entitled: Pediatric Cardiac Intensive Care: Current
State-of-the-Art and Special Considerations) at the 59th
annual meeting of Japanese Society of Pediatric Cardiology
and Cardiac Surgery on 7 July 2023.

References
1) Engle MA: Dr. Helen Brooke Taussig, living legend in cardiology. Clin Cardiol 1985; 8: 372‒3742) Van Robays J: Helen B. Taussig (1898-1986). Facts Views
Vis ObGyn 2016 Sep 8: 183‒1873) Neubauer K, Murphy AM: Helen Brooke Taussig: Pediatric cardiology leader and innovator. Adv Pediatr 2013; 60:1‒94) Gibbon JH Jr.: Application of a mechanical heart andlung apparatus to cardiac surgery. Minn Med 1954; 37:
171‒185, passim (passim)
5) Donabedian A: Evaluating the quality of medical care.
Milbank Mem Fund Q 1966; 44: 166‒206
6) Levin DL, Todres ID: Chapter 1̶History of Pediatric
Critical Care [Internet]. In: Fuhrman BP, Zimmerman
JJ (eds.), Pediatric Critical Care (Fourth Edition). SaintLouis: Mosby; 2011. pp3‒19.[cited 2023 Oct 26] Available
from: https://www.sciencedirect.com/science/article/pii/
B9780323073073100011
7) Welke KF, OʼBrien SM, Peterson ED, et al: The complex
relationship between pediatric cardiac surgical case volumes and mortality rates in a national clinical database. J
Thorac Cardiovasc Surg 2009; 137: 1133‒1140
8) Horak RV, Alexander PM, Amirnovin R, et al: Pediatriccardiac intensive care distribution, service delivery, andstaffing in the United States in 2018. Pediatr Crit Care Med
2020; 21: 797‒803
9) Gupta P, Beam BW, Noel TR, et al: Impact of preoperative
location on outcomes in congenital heart surgery. Ann
Thorac Surg 2014; 98: 896‒90310) Johnson JT, Tani LY, Puchalski MD, et al: Admission toa dedicated cardiac intensive care unit is associated withdecreased resource use for infants with prenatally diagnosed congenital heart disease. Pediatr Cardiol 2014; 35:1370‒1378
11) Burstein DS, Jacobs JP, Li JS, et al: Care models and associated outcomes in congenital heart surgery. Pediatrics
2011; 127: e1482‒e1489
12) Eldadah M, Leo S, Kovach K, et al: Influence of a dedicatedpaediatric cardiac intensive care unit on patient outcomes.
Nurs Crit Care 2011; 16: 281‒28613) Pollack MM, Cuerdon TT, Patel KM, et al: Impact of
quality-of-care factors on pediatric intensive care unit
mortality. JAMA 1994; 272: 941‒94614) Bhaskar P, Rettiganti M, Gossett JM, et al: Impact of intensive care unit attending physician training background on

69

15)

16)

17)
18)
19)
20)

21)

22)
23)

outcomes in children undergoing heart operations. Ann
Pediatr Cardiol 2018; 11: 48‒55
Graham TP Jr., Beekman RH 3rd, Allen HD, et al:Writing
Committee to Develop Training Recommendations for
Pediatric Cardiology: ACCF/AHA/AAP recommendations for training in pediatric cardiology. A report of theAmerican College of Cardiology Foundation/American
Heart Association/American College of Physicians Task
Force on Clinical Competence (ACC/AHA/AAP Writing
Committee to Develop Training Recommendations for
Pediatric Cardiology). Circulation 2005; 112: 2555‒2580
Baden HP, Zimmerman JJ, Brilli RJ, et al: Intensivist-led
team approach to critical care of children with heartdisease. Pediatrics 2006; 117: 1854‒1856, author reply,
1856‒1857
Baden HP, Berger J, Brilli RI, et al: Pediatric cardiac criticalcare patients should be cared for by intensivists. J Am Coll
Cardiol 2006; 48: 221‒222, author reply, 222‒223
Kulik TJ, Giglia TM, Mahoney LT, et al: Reply. J Am Coll
Cardiol 2006; 48: 222‒223
Tabbutt S, Krawczeski C, McBride M, et al: Standardized
training for physicians practicing pediatric cardiac criticalcare. Pediatr Crit Care Med 2022; 23: 60‒64
Pasquali SK, Jacobs JP, He X, et al: The complex relationship between center volume and outcome in patients
undergoing the Norwood operation. Ann Thorac Surg
2012; 93: 1556‒1562
Welke KF, OʼBrien SM, Peterson ED, et al: The complex
relationship between pediatric cardiac surgical case volumes and mortality rates in a national clinical database. J
Thorac Cardiovasc Surg 2009; 137: 1133‒1140
Pasquali SK, Li JS, Burstein DS, et al: Association of centervolume with mortality and complications in pediatricheart surgery. Pediatrics 2012; 129: e370‒e376
Pasquali SK, He X, Jacobs JP, et al: Evaluation of failure to

24)
25)

26)
27)

28)
29)
30)

31)
32)

rescue as a quality metric in pediatric heart surgery: An
analysis of The STS Congenital Heart Surgery Database.
Ann Thorac Surg 2012; 94: 573‒579, discussion, 579‒580
Verma A, Williamson CG, Bakhtiyar SS, et al: Center-levelvariation in failure to rescue after pediatric cardiac surgery. Ann Thorac Surg 2023; 117: 552‒559.
Scali ST, Giles KA, Kubilis P, et al: Impact of hospital
volume on patient safety indicators and failure to rescue
following open aortic aneurysm repair. J Vasc Surg 2020;
71: 1135‒1146.e4
Smith ME, Wells EE, Friese CR, et al: Interpersonal andorganizational dynamics are key drivers of failure to rescue. Health Aff (Millwood) 2018; 37: 1870‒1876
Saqib M, Iftikhar M, Neha F, et al: Artificial intelligence in
critical illness and its impact on patient care: A comprehensive review. [Internet], Front Med (Lausanne) 2023; 10[cited 2023 Oct 29] Available from: https://www.frontiersin.
org/articles/10.3389/fmed.2023.1176192
Jone P-N, Gearhart A, Lei H, et al: Artificial intelligence incongenital heart disease. JACC Adv 2022; 1: 100153
Sethi Y, Patel N, Kaka N, et al: Artificial intelligence inpediatric cardiology: A scoping review. J Clin Med 2022;
11: 7072
Vu EL, Rusin CG, Penny DJ, et al: A novel electrocardiogram algorithm utilizing ST-segment instability for
detection of cardiopulmonary arrest in single ventricle
physiology: A retrospective study. Pediatr Crit Care Med
2017; 18: 44‒53
Rusin CG, Acosta SI, Vu EL, et al: Automated predictionof cardiorespiratory deterioration in patients with single
ventricle. J Am Coll Cardiol 2021; 77: 3184‒3192
Yu P, Esangbedo I, Li X, et al: Early changes in near-infrared spectroscopy are associated with cardiac arrest inchildren with congenital heart disease. Front Pediatr 2022;
10: 894125© 2024 Japanese Society of Pediatric Cardiology and Cardiac Surgery