Clinical Focus

  • Pediatric Cardiology

Academic Appointments

Professional Education

  • Fellowship:LPCH/Stanford (2015) CA
  • Board Certification: Pediatric Cardiology, American Board of Pediatrics (2014)
  • Fellowship:Cincinnati Children's Hospital Medical Center (2014) OH
  • Board Certification: Pediatrics, American Board of Pediatrics (2011)
  • Residency:Cincinnati Children's Hospital Medical Center (2011) OH
  • Medical Education:Georgetown University (2008) DC

All Publications

  • Acute kidney injury and fluid overload in infants and children after cardiac surgery. Pediatric nephrology Kwiatkowski, D. M., Krawczeski, C. D. 2017


    Acute kidney injury is a common and serious complication after congenital heart surgery, particularly among infants. This comorbidity has been independently associated with adverse outcomes including an increase in mortality. Postoperative acute kidney injury has a complex pathophysiology with many risk factors, and therefore no single medication or therapy has been demonstrated to be effective for treatment or prevention. However, it has been established that the associated fluid overload is one of the major determinants of morbidity, particularly in infants after cardiac surgery. Therefore, in the absence of an intervention to prevent acute kidney injury, much of the effort to improve outcomes has focused on treating and preventing fluid overload. Early renal replacement therapy, often in the form of peritoneal dialysis, has been shown to be safe and beneficial in infants with oliguria after heart surgery. As understanding of the pathophysiology of acute kidney injury and the ability to confidently diagnose it earlier continues to evolve, it is likely that novel preventative and therapeutic interventions will be available in the future.

    View details for DOI 10.1007/s00467-017-3643-2

    View details for PubMedID 28361230

  • Peritoneal Dialysis vs Furosemide for Prevention of Fluid Overload in Infants After Cardiac Surgery: A Randomized Clinical Trial. JAMA pediatrics Kwiatkowski, D. M., Goldstein, S. L., Cooper, D. S., Nelson, D. P., Morales, D. L., Krawczeski, C. D. 2017


    Fluid overload after congenital heart surgery is frequent and a major cause of morbidity and mortality among infants. Many programs have adopted the use of peritoneal dialysis (PD) for fluid management; however, its benefits compared with those of traditional diuretic administration are unknown.To determine whether infants randomized to PD vs furosemide for the treatment of oliguria have a higher incidence of negative fluid balance on postoperative day 1, as well as avoidance of 10% fluid overload; shorter duration of mechanical ventilation, intensive care unit stay, and inotrope use; and fewer electrolyte abnormalities.This single-center, unblinded, randomized clinical trial compared methods of fluid removal after cardiac surgery from October 1, 2011, through March 13, 2015, in a large tertiary pediatric hospital in Ohio. The parents or guardians of all eligible infants (aged <6 months) undergoing cardiac surgery with catheter placement for PD were approached for inclusion. No patients were withdrawn for adverse effects. Recruitment was powered for the primary outcome, and analysis was based on intention to treat. Patients randomized to PD were hypothesized to have superior outcomes.Infants received intravenous furosemide (1 mg/kg every 6 hours) or a standardized PD regimen.The primary end point was incidence of negative fluid balance on postoperative day 1. Secondary end points included incidence of fluid overload, duration of mechanical ventilation and intensive care unit stay, electrolyte abnormalities and repletion doses, duration of inotropic administration, and mortality.Seventy-three patients (47 boys [64%] and 26 girls [35%]; median age, 8 [interquartile range {IQR}, 6-14] days) received treatment and completed the trial. No difference was found between the PD and furosemide groups in the incidence of negative fluid balance on the first postoperative day. The furosemide group was 3 times more likely to have 10% fluid overload (odds ratio [OR], 3.0; 95% CI, 1.3-6.9), was more likely to have prolonged ventilator use (OR, 3.1; 95% CI, 1.2-8.2), and had a longer duration of inotrope use (median, 5.5 [IQR, 4-8] vs 4.0 [IQR, 3-6] days) and higher electrolyte abnormality scores (median, 6 [IQR, 4-7] vs 3 [IQR, 2-5]) compared with the PD group. No statistically significant differences in mortality (3 patients [9.4%] in the furosemide group vs 1 patient [3.1%] in the PD group) or length of cardiac intensive care unit (median, 7 [IQR, 6-12] vs 9 [IQR, 5-15] days) or hospital (15 [IQR, 10-28] vs 14 [IQR, 9-22] days) stay were observed. No serious complications were observed. Dialysis was discontinued early in 9 of 41 patients in the PD group for pleural-peritoneal communication.Use of PD is safe and allows for superior fluid management with improved clinical outcomes compared with diuretic administration. Use of PD should be strongly considered among infants at high risk for postoperative acute kidney injury and fluid Identifer: NCT01709227.

    View details for DOI 10.1001/jamapediatrics.2016.4538

    View details for PubMedID 28241247

  • Incidence, risk factors, and outcomes of acute kidney injury in adults undergoing surgery for congenital heart disease. Cardiology in the young Kwiatkowski, D. M., Price, E., Axelrod, D. M., Romfh, A. W., Han, B. S., Sutherland, S. M., Krawczeski, C. D. 2016: 1-8


    Acute kidney injury after cardiac surgery is a frequent and serious complication among children with congenital heart disease (CHD) and adults with acquired heart disease; however, the significance of kidney injury in adults after congenital heart surgery is unknown. The primary objective of this study was to determine the incidence of acute kidney injury after surgery for adult CHD. Secondary objectives included determination of risk factors and associations with clinical outcomes.This single-centre, retrospective cohort study was performed in a quaternary cardiovascular ICU in a paediatric hospital including all consecutive patients ⩾18 years between 2010 and 2013.Data from 118 patients with a median age of 29 years undergoing cardiac surgery were analysed. Using Kidney Disease: Improving Global Outcome creatinine criteria, 36% of patients developed kidney injury, with 5% being moderate to severe (stage 2/3). Among higher-complexity surgeries, incidence was 59%. Age ⩾35 years, preoperative left ventricular dysfunction, preoperative arrhythmia, longer bypass time, higher Risk Adjustment for Congenital Heart Surgery-1 category, and perioperative vancomycin use were significant risk factors for kidney injury development. In multivariable analysis, age ⩾35 years and vancomycin use were significant predictors. Those with kidney injury were more likely to have prolonged duration of mechanical ventilation and cardiovascular ICU stay in the univariable regression analysis.We demonstrated that acute kidney injury is a frequent complication in adults after surgery for CHD and is associated with poor outcomes. Risk factors for development were identified but largely not modifiable. Further investigation within this cohort is necessary to better understand the problem of kidney injury.

    View details for PubMedID 27869053

  • Right Ventricular Outflow Tract Obstruction: Pulmonary Atresia With Intact Ventricular Septum, Pulmonary Stenosis, and Ebstein's Malformation. Pediatric critical care medicine Kwiatkowski, D. M., Hanley, F. L., Krawczeski, C. D. 2016; 17 (8): S323-9


    The objectives of this review are to discuss the anatomy, pathophysiology, clinical course, and current treatment strategies for pulmonary atresia with intact ventricular septum, pulmonary stenosis, and Ebstein's anomaly.MEDLINE and PubMed.Considerable advances have been made in management strategies for these complex congenital heart lesions, which have led to improved outcomes.

    View details for DOI 10.1097/PCC.0000000000000818

    View details for PubMedID 27490618

  • Acute Kidney Injury and Cardiorenal Syndromes in Pediatric Cardiac Intensive Care. Pediatric critical care medicine Cooper, D. S., Kwiatkowski, D. M., Goldstein, S. L., Krawczeski, C. D. 2016; 17 (8): S250-6


    The objectives of this review are to discuss the definition, diagnosis, and pathophysiology of acute kidney injury and its impact on immediate, short-, and long-term outcomes. In addition, the spectrum of cardiorenal syndromes will be reviewed including the pathophysiology on this interaction and its impact on outcomes.MEDLINE and PubMed.The field of cardiac intensive care continues to advance in tandem with congenital heart surgery. As mortality has become a rare occurrence, the focus of cardiac intensive care has shifted to that of morbidity reduction. Acute kidney injury adversely impact outcomes of patients following surgery for congenital heart disease as well as in those with heart failure (cardiorenal syndrome). Patients who become fluid overloaded and/or require dialysis are at a higher risk of mortality, but even minor degrees of acute kidney injury portend a significant increase in mortality and morbidity. Clinicians continue to seek methods of early diagnosis and risk stratification of acute kidney injury to prevent its adverse sequelae.

    View details for DOI 10.1097/PCC.0000000000000820

    View details for PubMedID 27490607

  • Dexmedetomidine Is Associated With Lower Incidence of Acute Kidney Injury After Congenital Heart Surgery. Pediatric critical care medicine Kwiatkowski, D. M., Axelrod, D. M., Sutherland, S. M., Tesoro, T. M., Krawczeski, C. D. 2016; 17 (2): 128-134


    Recent data have suggested an association between the use of dexmedetomidine and a decreased incidence of acute kidney injury in adult patients after cardiopulmonary bypass. However, no study has focused on this association among pediatric populations where the incidence of acute kidney injury is particularly high and of critical significance. The primary objective of this study was to assess the relationship between the use of postoperative dexmedetomidine and the incidence of acute kidney injury in pediatric patients undergoing cardiopulmonary bypass. The secondary objective was to determine whether there was an association between dexmedetomidine use and duration of mechanical ventilation or cardiovascular ICU stay.Single-center retrospective matched cohort study.A 20-bed quaternary cardiovascular ICU in a university-based pediatric hospital in California.Children less than 18 years old admitted after cardiac surgery with cardiopulmonary bypass between January 1, 2012, and May 31, 2014.None.Data from a cohort of 102 patients receiving dexmedetomidine during the first postoperative day after cardiac surgery were compared to an age- and procedure-matched cohort not receiving dexmedetomidine. Cohorts had similar baseline and demographic characteristics. Patients receiving dexmedetomidine were less likely to develop acute kidney injury (24% vs 36%; odds ratio, 0.54; 95% CI, 0.29-0.99; p = 0.046). After adjusting for age, bypass time, nephrotoxin use, and vasoactive inotropic score, the use of dexmedetomidine was associated with a lower incidence of acute kidney injury with adjusted odds ratio of 0.43 (95% CI, 0.27-0.98; p = 0.048). There was no difference between the cohorts with respect to the duration of mechanical duration (1 d each; p = 0.98) or cardiovascular ICU stays (5 vs 6 d; p = 0.91).The use of a dexmedetomidine infusion in pediatric patients after congenital heart surgery was associated with a decreased incidence of acute kidney injury; however, it was not associated with changes in clinical outcomes. Further prospective study is necessary to validate these findings.

    View details for DOI 10.1097/PCC.0000000000000611

    View details for PubMedID 26673841

  • Training Pathways in Pediatric Cardiac Intensive Care: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society. World journal for pediatric & congenital heart surgery Anand, V., Kwiatkowski, D. M., Ghanayem, N. S., Axelrod, D. M., DiNardo, J., Klugman, D., Krishnamurthy, G., Siehr, S., Stromberg, D., Yates, A. R., Roth, S. J., Cooper, D. S. 2016; 7 (1): 81-88


    The increase in pediatric cardiac surgical procedures and establishment of the practice of pediatric cardiac intensive care has created the need for physicians with advanced and specialized knowledge and training. Current training pathways to become a pediatric cardiac intensivist have a great deal of variability and have unique strengths and weaknesses with influences from critical care, cardiology, neonatology, anesthesiology, and cardiac surgery. Such variability has created much confusion among trainees looking to pursue a career in our specialized field. This is a report with perspectives from the most common advanced fellowship training pathways taken to become a pediatric cardiac intensivist as well as various related topics including scholarship, qualifications, and credentialing.

    View details for DOI 10.1177/2150135115614576

    View details for PubMedID 26714998

  • Short QT Interval Prevalence and Clinical Outcomes in a Pediatric Population CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY Guerrier, K., Kwiatkowski, D., Czosek, R. J., Spar, D. S., Anderson, J. B., Knilans, T. K. 2015; 8 (6): 1460-1464


    Risk associated with short QT interval has recently received recognition. European studies suggest a prevalence of 0.02% to 0.1% in the adult population, but similar studies in pediatric patients are limited. We sought to determine the prevalence of short QT interval in a pediatric population and associated clinical characteristics and outcomes.Retrospective review of an ECG database at a single pediatric institution. The database was queried for ECGs on patients ≤21 years with electronically measured QTc of 140 to 340 ms. Patients with QTc of 140 to 340 ms confirmed by a pediatric electrophysiologist were identified for chart review for associated clinical characteristics, symptoms, and outcome. Patients with and without symptoms were compared in an attempt to identify variables associated with outcome. The query included 272 504 ECGs on 99 380 unique patients. Forty-five patients (35 men, 76%) had QTc ≤340 ms, for a prevalence of 0.05%. Median age was 15 years (interquartile range, 2-17), median QT 330 ms (interquartile range, 280-360), and median QTc 323 ms (IQR, 313-332). Women had significantly shorter QTc compared with men (312 versus 323 ms; P=0.03). Two deaths were noted in chart review--one from respiratory failure and the second of unknown pathogenesis in a patient with dilated cardiomyopathy.Short QT interval was a rare finding in this pediatric population, with a prevalence of 0.05%. Male predominance was identified, although the median QT interval was significantly shorter in women. There seem to be no unifying clinical characteristics for this pediatric patient cohort with short QT interval.

    View details for DOI 10.1161/CIRCEP.115.003256

    View details for Web of Science ID 000366604600022

    View details for PubMedID 26386018

  • Improved outcomes with peritoneal dialysis catheter placement after cardiopulmonary bypass in infants JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Kwiatkowski, D. M., Menon, S., Krawczeski, C. D., Goldstein, S. L., Morales, D. L., Phillips, A., Manning, P. B., Eghtesady, P., Wang, Y., Nelson, D. P., Cooper, D. S. 2015; 149 (1): 230-236


    Acute kidney injury (AKI) is common in infants after cardiopulmonary bypass and is associated with poor outcomes. Peritoneal dialysis improves outcomes in adults with AKI after bypass, but pediatric data are limited. This retrospective case-matched study was conducted to determine if the practice of peritoneal dialysis catheter (PDC) placement during congenital heart surgery is associated with improved clinical outcomes in infants at high risk for AKI.Forty-two infants undergoing congenital heart surgery with planned PDC placement (PDC+) were age-matched to infants undergoing similar surgery without PDC placement (PDC-). Demographic, baseline and outcome data were compared. Our primary outcome was negative fluid balance on postoperative days 1 to 3. Secondary outcomes included time to negative fluid balance, time to extubation, frequency of electrolyte corrective medications, inotrope scores, and other clinical outcomes.Baseline data did not differ between groups. The PDC+ group had a higher percentage of negative fluid balance on postoperative days 1 and 2 (57% vs 33%, P = .04; 85% vs 61%, P = .01). The PDC+ group had shorter time to negative fluid balance (16 vs 32 hours, P < .0001), earlier extubation (80 vs 104 hours, P = .02), improved inotrope scores (P = .04), and fewer electrolyte imbalances requiring correction (P = .03). PDC-related complications were rare.PDC use is safe and associated with earlier negative fluid balance and improved clinical outcomes in infants at high risk for AKI. Routine PDC use should be considered for infants undergoing cardiopulmonary bypass. Further prospective studies are essential to prove causative effects of PDC placement in this population.

    View details for DOI 10.1016/j.jtcvs.2013.11.040

    View details for Web of Science ID 000350550100066

    View details for PubMedID 24503323

  • Acute Kidney Injury After Cardiovascular Surgery in Children Perioperative Kidney Injury Kwiatkowski, D. M., Krawczeski, C. D. Springer New York. 2015; 1: 99–109
  • Diuretics Handbook of Pediatric Cardiovascular Drugs Kwiatkowski, D. M., Donnellan, A., Cooper, D. S. Springer London. 2014; 2: 6
  • Biomarkers of acute kidney injury in pediatric cardiac patients BIOMARKERS IN MEDICINE Kwiatkowski, D. M., Goldstein, S. L., Krawczeski, C. D. 2012; 6 (3): 273-282


    Acute kidney injury is a common and significant complication among pediatric patients with congenital heart disease, occurring most commonly after cardiopulmonary bypass. Current laboratory methods of diagnosis are not timely enough to guide management decisions, thus spurring interest in discovering new biomarkers of acute injury. Several promising candidates, including NGAL, IL-18 and KIM-1, have been the subject of recent investigation and may facilitate earlier and more accurate diagnosis of renal injury within this cohort. There is little evidence demonstrating that it will be possible to rely upon one particular biomarker as a single agent, and evidence supports that the use of biomarker panels will be most effective. Further clinical validation and broader commercial availability of these novel biomarkers will probably revolutionize the care of pediatric cardiac patients with renal injury.

    View details for DOI 10.2217/BMM.12.27

    View details for Web of Science ID 000306455100004

    View details for PubMedID 22731900

  • The Utility of Outpatient Echocardiography for Evaluation of Asymptomatic Murmurs in Children CONGENITAL HEART DISEASE Kwiatkowski, D., Wang, Y., Cnota, J. 2012; 7 (3): 283-288


      The purpose of this study is to review sedated outpatient echocardiograms performed to evaluate asymptomatic murmurs in children between the ages of 1 month and 4 years and describe outcomes of tests done to determine if utility varies among age of study and referral type (primary care physician vs. pediatric cardiologist.) We aim to describe the yield in a contemporary cohort which has increased availability and quality of diagnostic aids such as fetal ultrasound, newborn pulse oximetry, and neonatal echocardiography.  Retrospective cohort study.  Cincinnati Children's Hospital Medical Center: Outpatient Echocardiography Laboratory.  Children between 1 month and 4 years of age with asymptomatic murmurs who are referred for outpatient echocardiogram for evaluation of murmur.  Primary diagnosis of echocardiography studies, classified into severity score. Results.  Four hundred sixty-two sedated echocardiograms were studied. Six (1%) echocardiograms showed severe pathology, and no severe pathology was shown in the echocardiograms ordered at the age of over 6 months old. The yield of studies decreased as age increased. The incidence of abnormal pathology was higher among tests ordered by cardiologists, across all severity levels (P < .0001).  Among echocardiograms ordered for children over 1 year of age with an asymptomatic murmur, there was no severe and little moderate disease. Cardiac disease is significantly less likely when echocardiograms are ordered without referral to a pediatric cardiologist. The workup for asymptomatic murmurs does not require an echocardiogram, and these results may aid clinicians when deciding whether evaluation of a child should include this study.

    View details for DOI 10.1111/j.1747-0803.2012.00637.x

    View details for Web of Science ID 000304437100019

    View details for PubMedID 22348237

  • A Teenager with Marfan Syndrome and Left Ventricular Noncompaction PEDIATRIC CARDIOLOGY Kwiatkowski, D., Hagenbuch, S., Meyer, R. 2010; 31 (1): 132-135


    We report a teenager with Marfan syndrome who presented to Cincinnati Children's Hospital Medical Center as part of a preoperative evaluation for an orthopedic procedure after asymptomatic arrhythmia was recognized. Continuous cardiac monitoring showed frequent premature ventricular contractions and nonsustained runs of ventricular tachycardia. Cardiac magnetic resonance imaging showed left ventricular noncompaction (LVNC), prompting insertion of an implantable cardiac defibrillator. Although Marfan syndrome is associated with cardiac lesions, it has not previously been described with LVNC. Likewise LVNC has been seen in association with other cardiac lesions; however, this report represents the first reference of LVNC in the context of Marfan syndrome.

    View details for DOI 10.1007/s00246-009-9552-9

    View details for Web of Science ID 000273675400027

    View details for PubMedID 19795159

  • Catalytic asymmetric allylation of ketones and a tandem asymmetric allylation/diastereoselective epoxidation of cyclic enones JOURNAL OF THE AMERICAN CHEMICAL SOCIETY Kim, J. G., Waltz, K. M., Garcia, I. F., Kwiatkowski, D., Walsh, P. J. 2004; 126 (39): 12580-12585


    A simple procedure is reported for the catalytic asymmetric allylation of ketones, utilizing titanium tetraisopropoxide, BINOL, 2-propanol additive, and tetraallylstannane as allylating agent. A variety of ketone substrates, including acetophenone derivatives and alpha,beta-unsaturated cyclic enones, reacted to form tertiary homoallylic alcohols in good yields (67-99%) and with high levels of enantioselectivity (generally >80%). A novel one-pot enantioselective allylation/diastereoselective epoxidation has also been introduced. Thus, upon completion of the allyl addition to conjugated cyclic enones, 1 equiv of tert-butyl hydroperoxide is added and the directed epoxidation of the allylic double bond ensues to afford the epoxy alcohol with high diastereoselectivity.

    View details for DOI 10.1021/ja047758t

    View details for Web of Science ID 000224219900077

    View details for PubMedID 15453790

  • Antimitogenic effects of HDL and APOE mediated by cox-2-dependent IP activation JOURNAL OF CLINICAL INVESTIGATION Kothapalli, D., Fuki, I., Ali, K., Stewart, S. A., Zhao, L., Yahil, R., Kwiatkowski, D., Hawthorne, E. A., FitzGerald, G. A., Phillips, M. C., Lund-Katz, S., Pure, E., Rader, D., Assoian, R. K. 2004; 113 (4): 609-618


    HDL and its associated apo, APOE, inhibit S-phase entry of murine aortic smooth muscle cells. We report here that the antimitogenic effect of APOE maps to the N-terminal receptor-binding domain, that APOE and its N-terminal domain inhibit activation of the cyclin A promoter, and that these effects involve both pocket protein-dependent and independent pathways. These antimitogenic effects closely resemble those seen in response to activation of the prostacyclin receptor IP. Indeed, we found that HDL and APOE suppress aortic smooth muscle cell cycle progression by stimulating Cox-2 expression, leading to prostacyclin synthesis and an IP-dependent inhibition of the cyclin A gene. Similar results were detected in human aortic smooth muscle cells and in vivo using mice overexpressing APOE. Our results identify the Cox-2 gene as a target of APOE signaling, link HDL and APOE to IP action, and describe a potential new basis for the cardioprotective effect of HDL and APOE.

    View details for DOI 10.1172/JCI200419097

    View details for Web of Science ID 000189008000016

    View details for PubMedID 14966570