Integrating Pulmonary Hypertension Teams into the Pediatric Cardiac ICU: A Collaborative Approach to Emerging Challenges

Our field demands increasingly collaborative work across specialties in cardiology, critical care, anesthesia, and cardiac surgery. Complementing this comprehensive approach, the integration of pulmonary hypertension (PH) teams into pediatric cardiac ICUs represents an opportunity for enhanced patient care and agile shared decision-making. The harmful effects of pulmonary vascular disease in the perioperative congenital heart disease (CHD) population have long been an area of expertise for both PH and CICU physicians. However, more intimate collaboration between these teams is particularly crucial for complex patients with pulmonary vascular disease, including those with single ventricle physiology and elevated pulmonary vascular resistance (PVR) in left heart disease, especially among those requiring mechanical circulatory support. As our patient cohorts continue to grow in complexity, the need for PH physicians fully conversant with the nuances of the CICU has only increased.

Single ventricle patients with pulmonary vascular disease present a particularly daunting set of challenges. Even modest elevations in PVR are classically considered a contraindication to single ventricle palliation. However, a subpopulation of these patients may respond to targeted PH therapies, allowing for successful progression through staged palliation. This approach requires PH physician integration within both the ICU and single ventricle teams to provide a nuanced understanding of pulmonary vascular pathobiology and advanced diagnostic and therapeutic approaches. By collaborating with intensivists, surgeons, and interventionalists, an ICU-focused PH team member can help provide tailored medical therapies and assist in determining the appropriate timing of further surgical or catheter-based interventions.

Similarly, patients with elevated PVR associated with left heart disease present unique challenges in the CICU. Chronically increased left atrial pressures in these patients often lead to pulmonary hypertension and subsequent right ventricular dysfunction. However, appropriately tailored pulmonary vasodilator therapy perioperatively after left ventricular assist device (LVAD) implantation can obviate the need for biventricular support in such patients. Such high-stakes decision-making defies algorithmic approaches and must rely on highly functioning teams from pre-implantation planning and perioperative decision-making to appropriately nimble postoperative care in the CICU.

The essential components for this integration lie in robust communication, trust, and teamwork. There is no one-size-fits-all model for such partnerships. At our institution, I serve as both the pulmonary hypertension consultant and am among the CVICU faculty—relieving some (but not all!) obstacles to communication. Other successful collaborative models with a PH pulmonologist or cardiologist abound in our field, but the foundations remain the same: flexible mental models to treat underlying causes of pulmonary vascular disease in diverse anatomic and physiologic circumstances and a high-touch, high-trust collaborative decision-making model between the intensivist and PH consultant. Regular interdisciplinary meetings between CICU and PH teams are vital for discussing cases and treatment plans. Such meetings create a platform for sharing insights, updating protocols, and ensuring an aligned team approach.

Ultimately, integrating PH teams within pediatric CICUs can improve outcomes for our patients by ensuring targeted and effective care delivery for patients with pulmonary vascular disease, particularly in those for whom elevated PVR was previously considered a contraindication to either single ventricle palliative procedures or cardiac transplantation. As we continue to navigate the challenges of caring for these vulnerable populations, the emphasis on teamwork and shared decision-making allows for appropriately calibrated risk-taking for novel treatment strategies.