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Cucchi M, Mariani S, Kawczynski MJ, Shkurka E, Ius F, Comentale G, Hoskote A, Lorusso R. Individual patient data meta-analysis on awake pediatric extracorporeal life support: Feasibility and safety of analgesia, sedation and respiratory support weaning, and physiotherapy. Perfusion 2024:2676591241240377. [PMID: 38652693 DOI: 10.1177/02676591241240377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Awake Extracorporeal Life Support (aECLS) with active mobilization has gained consensus over time, also within the pediatric community. This individual patient data (IPD) meta-analysis summarizes available evidence on pediatric aECLS, its feasibility, and safety regarding sedation weaning, extubation, and physiotherapy. METHODS PubMed/Medline and Cochrane Database were screened until February 2022. Articles reporting on children (≤18 years) undergoing aECLS were selected. IPD were requested, pooled in a single database, and analyzed using descriptive statistics. Primary outcome was survival to hospital discharge. Secondary outcomes included extubation during ECLS, physiotherapy performed, tracheostomy, and complications. RESULTS Nineteen articles and 65 patients (males:n = 30/59,50.8%) were included. Age ranged from 2 days to 17 years. ECLS configurations included veno-venous (n = 42/65, 64.6%), veno-arterial (n = 18/65, 27.7%) and other ECLS settings (n = 5/65, 7.7%). Exclusive neck cannulation was performed in 51/65 (78.5%) patients. Extubation or tracheostomy during ECLS was reported in 66.2% (n = 43/65) and 27.7% (n = 18/65) of patients, respectively. Physiotherapy was reported as unspecified physical activity (n = 34/63, 54%), mobilization in bed (n = 15/63, 23.8%), ambulation (n = 14/63, 22.2%). Complications were reported in 60.3% (n = 35/58) of patients, including hemorrhagic (36.2%), mechanical (17.2%), or pulmonary (17.2%) issues, and need for reintubation (15.5%). Survival at discharge was 81.5% (n = 53/65). CONCLUSION Awake ECLS strategy with active physiotherapy can be applied in children from neonatal age. Ambulation is also possible in selected cases. Complications related to such management were limited. Further studies on aECLS are needed to evaluate safety and efficacy of early physiotherapy and define patient selection.
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Affiliation(s)
- Marta Cucchi
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Pediatric Intensive Care Unit, Queensland Children Hospital, Brisbane, QLD, Australia
| | - Silvia Mariani
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michal J Kawczynski
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Emma Shkurka
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fabio Ius
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Giuseppe Comentale
- IRCCS Policlinico Universitario Sant'Orsola-Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Aparna Hoskote
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Roberto Lorusso
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Scott Eldredge R, Russell KW. Pediatric surgical interventions on ECMO. Semin Pediatr Surg 2023; 32:151330. [PMID: 37931540 DOI: 10.1016/j.sempedsurg.2023.151330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.
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Affiliation(s)
- R Scott Eldredge
- Department of Surgery, Mayo Clinic, Phoenix, AZ, United States; Department of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, United States
| | - Katie W Russell
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, United States.
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Jones A, Olverson G, Hwang J, Bhagat R, McGann K, Bradburn K, Miller M, Louis C. The effect of tracheostomy on extracorporeal membrane oxygenation outcomes. J Card Surg 2022; 37:2543-2551. [PMID: 35662251 DOI: 10.1111/jocs.16666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/23/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The optimal timing for pursuing tracheostomy in patients with prolonged mechanical ventilation with either veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is a discussion of risk versus benefit. Depending on the etiology, cardiothoracic surgical patients carry some of the highest risk for respiratory failure postprocedure. Given that patients with end-stage cardiopulmonary status may be fraught with substantial comorbidities, it is critically important to manage the risk-benefit profile of performing a tracheostomy procedure on a patient requiring ECMO support. These cohorts have risk factors that may depend on each patient's inflammatory state, lung de-recruitment peri-procedure and postprocedure and bleeding requiring transfusions to name a few. We provide a descriptive analysis of ECMO patients on both VA and VV configurations who survived to hospital discharge receiving tracheostomy either during or after their ECMO course. METHODS A retrospective single-institutional study collected all consecutive patients age 18 and above who received any form of ECMO between 2016 and 2020. Five hundred forty-five patients were screened based on having received ECMO. Patients with mixed EMCO modality were excluded due to heterogeneity of disease process. A total of 521 patients received either VV or VA ECMO. A total of 54 patients received tracheostomy and had sufficiently clean data for analysis. Tracheostomy patients were compared based on survival to discharge, tracheostomy surgical complications, ECMO duration, ECMO configuration, inotrope and vasopressor use, transfusion rates, total ventilator days, total days on intravenous sedation, and history of cardiotomy or heart transplant were assessed. Baseline characteristics of race, age, gender, and body mass index (BMI) were also collected. RESULTS A total of 54 patients received tracheostomy. Twenty-nine of those patients received tracheostomy during the course of their ECMO, of whom 13 were on VV ECMO, 16 on VA ECMO. Another 25 patients underwent tracheostomy after successful ECMO explant; 8 of those were VV ECMO with the remaining 17 were on VA ECMO before explantation, with mean delay to tracheostomy, 10 and 19 days after explant between both modalities, respectively. A statistically significantly greater proportion of VV ECMO patients received a tracheostomy at any point versus VA ECMO patients (25.93% vs. 8.35%, p ≤ .0001). No statistically significant difference was noted in timing of tracheostomy when stratified by EMCO modality (VA 51.51% after explant vs. VV 38.10% after explant, p = .33). There was a greater frequency of minor tracheostomy complications in patients who were on ECMO at the time of their tracheostomy (p = .014) than in those who received their tracheostomy after being explanted. However, these minor complications did not contribute to a change in survival to hospital discharge (p = .58). Similarly, the small number of major complications (n = 13) did not impair survival to hospital discharge (p = .84). Finally, mean duration of ECMO was longer in those who received tracheostomy during ECMO versus after ECMO. (488.45 vs. 259.72 h, p < .01). CONCLUSIONS Tracheostomy is known to increase patient mobility, clinical participation, and overall decrease in sedation use. Pursuing tracheostomy during ECMO is feasible, does not result in major bleeding, and is associated with only minor complications that overall do not decrease survival. While there is an increased duration of ECMO support in the tracheostomy cohort, this may be due to existing patient conditions, and may not be causal. Research is needed to further determine the external patient factors and specific timing to optimize both VV and VA ECMO courses. CLINICAL IMPLICATIONS We hope that our analysis will pave the initial pathway for an evidence-based guideline on optimal timing of tracheostomy in ECMO patients, whether initiated during or after ECMO and taking into consideration ECMO configuration, its expected duration, and patient comorbidities.
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Affiliation(s)
- Andrew Jones
- School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, New York, USA
| | - George Olverson
- School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, New York, USA
| | - Jason Hwang
- Division of Pathology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Rohun Bhagat
- School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, New York, USA
| | - Kevin McGann
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn Bradburn
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew Miller
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York, USA
| | - Clauden Louis
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Hong TH, Kim HW, Kim HS, Park S. Assessing Clinical Feasibility and Safety of Percutaneous Dilatational Tracheostomy During Extracorporeal Membrane Oxygenation Support in the Intensive Care Unit. JOURNAL OF ACUTE CARE SURGERY 2022. [DOI: 10.17479/jacs.2022.12.1.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose: A tracheostomy is often used to wean patients off the ventilator, as it helps maintain extracorporeal membrane oxygenation (ECMO) without sedation. A percutaneous dilatational tracheostomy (PDT) performed in critically ill patients is widely accepted, however, its feasibility and safety in ECMO is unclear.Methods: This retrospective observational study included 78 patients who underwent a PDT and ECMO at the surgical intensive care unit (SICU) in a tertiary hospital between January 1, 2016 and December 31, 2019. We analyzed their medical records, including PDT-related complications and clinical variables.Results: The median values of hemoglobin, platelet count, international normalized ratio, partial thromboplastin time, and activated partial thromboplastin time before the tracheostomy were 9.2 (8.5-10.2) g/dL, 81 (56-103) × 103/dL, 1.22 (1.13-1.30), 15.2 (14.3-16.1) seconds, and 55.1 (47.4-61.1) seconds, respectively. No clotting was observed within the extracorporeal circuit, however, minimal bleeding was observed at the tracheostomy site in 10 (12.8%) patients. Of 4 patients with major bleeding, local hemorrhage was controlled in 3 patients, and intratracheal bleeding continued in 1 patient. The mortality rate was 60.9% and 57.1% in the complication and no-complication group, respectively. The durations of SICU stay, hospital stay, and mechanical ventilation were not statistically different between the groups.Conclusion: A PDT performed in critically ill patients was associated with a low rate of bleeding. Complications did not appear to significantly affect the patient outcome. PDT can be performed in patients who usually require a tracheostomy to maintain ECMO.
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Fallon BP, Gadepalli SK, Hirschl RB. Pediatric and neonatal extracorporeal life support: current state and continuing evolution. Pediatr Surg Int 2021; 37:17-35. [PMID: 33386443 PMCID: PMC7775668 DOI: 10.1007/s00383-020-04800-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 12/24/2022]
Abstract
The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, ECLS Laboratory, B560 MSRB II/SPC 5686, Michigan Medicine, University of Michigan, 1150 W. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Samir K Gadepalli
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ronald B Hirschl
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
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Yeo HJ, Yoon SH, Lee SE, Jeon D, Kim YS, Cho WH, Kim D. Safety of Surgical Tracheostomy during Extracorporeal Membrane Oxygenation. Korean J Crit Care Med 2017; 32:197-204. [PMID: 31723634 PMCID: PMC6786719 DOI: 10.4266/kjccm.2017.00059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 12/04/2022] Open
Abstract
Background The risk of bleeding during extracorporeal membrane oxygenation (ECMO) is a potential deterrent in performing tracheostomy at many centers. To evaluate the safety of surgical tracheostomy (ST) in critically ill patients supported by ECMO, we reviewed the clinical correlation between preoperative coagulation status and bleeding complication-related ST during ECMO. Methods From April 1, 2012 to March 31, 2016, ST was performed on 38 patients supported by ECMO. We retrospectively reviewed and analyzed the medical records including complications related to ST. Results Heparin was administered to 23 patients (60.5%) for anticoagulation during ECMO, but 15 patients (39.5%) underwent ECMO without anticoagulation. Of the 23 patients administered anticoagulation therapy, heparin infusion was briefly paused in 13 prior to ST. The median platelet count, international normalized ratio, and activated partial thromboplastin time before ST were 126 × 109/L (range, 46 to 434 × 109/L), 1.2 (range, 1 to 2.3) and 62 seconds (27 to 114.2 seconds), respectively. No peri-procedural clotting complications related to ECMO were observed. Two patients (5.3%) suffering from ST-related major bleeding required surgical hemostasis. Minor bleeding after ST occurred in two cases (5.3%). No significant difference was found according to anticoagulation management (P = 0.723). No fatality was attributable to ST. Conclusions The complication rates of ST in the patients supported by ECMO were low. Therefore, ST performed by an experienced operator, and with careful optimization of coagulation status, is a relatively safe procedure; the use of ST with ECMO should thus not be dismissed on account of the potential for bleeding caused by the administration of anticoagulants.
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Affiliation(s)
- Hye Ju Yeo
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Seong Hoon Yoon
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Seung Eun Lee
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Doosoo Jeon
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Yun Seong Kim
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Woo Hyun Cho
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Dohyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
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Visner GA, Fynn-Thompson F. Paracorporeal lung assist device in infants and toddlers: Coming of age? Pediatr Transplant 2016; 20:191-3. [PMID: 26847863 DOI: 10.1111/petr.12683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Gary A Visner
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.
| | - Francis Fynn-Thompson
- Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.
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Blatter J, Sweet S. Lung Transplantation in Cystic Fibrosis: Trends and Controversies. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2015; 28:237-243. [PMID: 26697265 DOI: 10.1089/ped.2015.0564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article is not an overview of all facets of lung transplantation in cystic fibrosis (CF), but rather it is intended as a review of current allocation controversies, as well as of trends in diagnostics and management in lung transplant recipients and in patients with end-stage lung disease. Despite changes in donor and recipient selection, long-term survival in pediatric lung transplant has continued to be limited by chronic lung allograft dysfunction (CLAD). Due to, in part, this short survival benefit, transplant continues to be an appropriate option for only a subset of pediatric patients with CF. The feasibility of transplant as a therapeutic option is also affected by the limited pediatric organ supply, which has moreover contributed to controversy over lung allocation. Debates over the allocation of this scarce resource, however, may also help to drive innovation in the field of lung transplant. Longer pretransplant survival-as aided by new lung bypass technologies, for example-could help to alleviate organ shortages, as well as facilitate the transport of organs to suitable pediatric recipients. Improved diagnosis and treatment for CLAD and for antibody-mediated rejection have the potential to extend survival in pediatric lung transplant. Regardless, the relative rarity of transplant could pose future challenges for pediatric lung transplant programs, which require adequate numbers of patients to maintain proper expertise.
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Affiliation(s)
- Joshua Blatter
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine , St. Louis, Missouri
| | - Stuart Sweet
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine , St. Louis, Missouri
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Wong JYW, Buchholz H, Ryerson L, Conradi A, Adatia I, Dyck J, Rebeyka I, Lien D, Mullen J. Successful Semi-Ambulatory Veno-Arterial Extracorporeal Membrane Oxygenation Bridge to Heart-Lung Transplantation in a Very Small Child. Am J Transplant 2015; 15:2256-60. [PMID: 25872800 DOI: 10.1111/ajt.13239] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/16/2015] [Accepted: 01/25/2015] [Indexed: 01/25/2023]
Abstract
Lung transplantation (LTx) may be denied for children on extracorporeal membrane oxygenation (ECMO) due to high risk of cerebral hemorrhage. Rarely has successful LTx been reported in children over 10 years of age receiving awake or ambulatory veno-venous ECMO. LTx following support with ambulatory veno-arterial ECMO (VA ECMO) in children has never been reported to our knowledge. We present the case of a 4-year-old, 12-kg child with heritable pulmonary artery hypertension and refractory right ventricular failure. She was successfully bridged to heart-lung transplantation (HLTx) using ambulatory VA ECMO. Initial resuscitation with standard VA ECMO was converted to an ambulatory circuit using Berlin heart cannulae. She was extubated and ambulating around her bed while on VA ECMO for 40 days. She received an HLTx from an oversized marginal lung donor. Despite a cardiac arrest and Grade 3 primary graft dysfunction, she made a full recovery without neurological deficits. She achieved 104% force expiratory volume in 1 s 33 months post-HLTx. Ambulatory VA ECMO may be a useful strategy to bridge very young children to LTx or HLTx. Patient tailored ECMO cannulation, minimization of hemorrhage, and thrombosis risks while on ECMO contributed to a successful HLTx in our patient.
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Affiliation(s)
- J Y W Wong
- Department of Pediatrics, Division of Pediatric Respiratory Medicine, McMaster University, Hamilton, Ontario, Canada
| | - H Buchholz
- Department of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - L Ryerson
- Department of Pediatrics, Pediatric Cardiac Intensive Care Unit, University of Alberta, Edmonton, Alberta, Canada
| | - A Conradi
- Department of Pediatrics, Pediatric Intensive Care Unit, University of Alberta, Edmonton, Alberta, Canada
| | - I Adatia
- Department of Pediatrics, Pediatric Intensive Care Unit, University of Alberta, Edmonton, Alberta, Canada
| | - J Dyck
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - I Rebeyka
- Department of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - D Lien
- Department of Medicine, Division of Respiratory Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - J Mullen
- Department of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
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Sawa Y, Matsuda K, Tatsumi E, Matsumiya G, Abe T, Fukunaga K, Kishida A, Kokubo K, Masuzawa T, Myoui A, Nishimura M, Nishimura T, Nishinaka T, Okamoto E, Tokunaga S, Tomo T, Tsukiya T, Yagi Y, Yamaoka T. Journal of Artificial Organs 2014: the year in review. J Artif Organs 2015; 18:1-7. [PMID: 25701365 DOI: 10.1007/s10047-015-0821-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Indexed: 12/18/2022]
Affiliation(s)
| | - Y Sawa
- Division of Cardiovascular Surgery, Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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