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Perdomo AA, Badawy MK, Mignone C, Forster JC. Exceeding radiation thresholds for cataract induction in diagnostic imaging: a paediatric case report. RADIATION PROTECTION DOSIMETRY 2024; 200:417-422. [PMID: 38195763 DOI: 10.1093/rpd/ncad310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/17/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
This case report investigates the radiation dose received by a paediatric patient with a ventricular assist device who underwent four non-contrast brain computed tomography (CT) scans, two brain perfusion CT scans and two head angiographic CT scans. The total estimated absorbed dose to the lens of the eye is above the 500 mGy radiation-induced cataract threshold. It is recommended that this patient and those with similar imaging histories have routine follow-up with an ophthalmologist. It is also recommended that radiation dose tracking and an electronic medical alert program be implemented to allow the identification of patients who may exceed tissue reaction thresholds.
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Affiliation(s)
- Amanda Alison Perdomo
- Department of Physics, University of Adelaide, Adelaide 5005, South Australia, Australia
- Department of Medical Imaging, The Royal Children's Hospital, 50 Flemington Road, Parkville 3052, Victoria, Australia
| | - Mohamed Khaldoun Badawy
- Monash Health Imaging, Monash Health, 246 Clayton Rd, Clayton 3168, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton 3800, VIC, Australia
| | - Cristina Mignone
- Department of Medical Imaging, The Royal Children's Hospital, 50 Flemington Road, Parkville 3052, Victoria, Australia
| | - Jake Cameron Forster
- Department of Physics, University of Adelaide, Adelaide 5005, South Australia, Australia
- Medical Physics & Radiation Safety, South Australia Medical Imaging, Adelaide 5005, South Australia, Australia
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2
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Barrett LDG, Ryckman KK, Goedken AM, Steinbach EJ, van der Plas E, Beasley G, Khan RS, Exil V, Axelrod DA, Harshman LA. Subsequent kidney transplant after pediatric heart transplant: Prevalence and risk factors. Am J Transplant 2024:S1600-6135(24)00169-2. [PMID: 38431077 DOI: 10.1016/j.ajt.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/22/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
Pediatric heart failure and transplantation carry associated risks for kidney failure and potential need for kidney transplant following pediatric heart transplantation (KT/pHT). This retrospective, United Network of Organ Sharing study of 10,030 pediatric heart transplants (pHTs) from 1987 to 2020 aimed to determine the incidence of waitlisting for and completion of KT/pHT, risk factors for KT/pHT, and risk factors for nonreceipt of a KT/pHT. Among pHT recipients, 3.4% were waitlisted for KT/pHT (median time of 14 years after pHT). Among those waitlisted, 70% received a KT/pHT, and 18% died on the waitlist at a median time of 0.8 years from KT/pHT waitlisting (median age of 20 years). Moderate-high sensitization at KT/pHT waitlisting (calculated panel reactive antibody, ≥ 20%) was associated with a lower likelihood of KT/pHT (adjusted hazard ratio, 0.67; 95% confidence interval, 0.47-0.95). Waitlisting for heart transplantation simultaneously with kidney transplant (adjusted hazard ratio, 3.73; 95% confidence interval, 2.01-6.92) was associated with increased risk of death on the KT/pHT waitlist. While the prevalence of KT/pHT is low, there is substantial mortality among those waitlisted for KT/pHT. These findings suggest a need to consider novel risk factors for nonreceipt of KT/pHT and death on the waitlist in prioritizing criteria/guidelines for simultaneous heart-kidney transplantation.
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Affiliation(s)
- Lucas D G Barrett
- Medical Scientist Training Program, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA; University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Kelli K Ryckman
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA; Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, Bloomington, Indiana, USA
| | - Amber M Goedken
- University of Iowa College of Pharmacy, Iowa City, Iowa, USA
| | - Emily J Steinbach
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Ellen van der Plas
- Psychiatry Department, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA; Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA; Department of Hematology/Oncology, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Gary Beasley
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Rabia S Khan
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of California, Los Angeles Health Sciences, Los Angeles, California, USA
| | - Vernat Exil
- Division of Pediatrics, Cardiology, Saint Louis University, St. Louis, Missouri, USA
| | - David A Axelrod
- Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Lyndsay A Harshman
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA.
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3
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Dipchand AI, Webber SA. Pediatric heart transplantation: Looking forward after five decades of learning. Pediatr Transplant 2024; 28:e14675. [PMID: 38062996 DOI: 10.1111/petr.14675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 02/07/2024]
Abstract
Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease throughout the world. Since the first transplant was performed in 1967, the number of transplants has grown dramatically with 13 449 pediatric heart transplants being reported to The International Society of Heart and Lung Transplant (ISHLT) between January 1992 and June 30, 2018. Outcomes have consistently improved over the last few decades, specifically short-term outcomes. Most recent survival data demonstrate that recipients who survive to 1-year post-transplant have excellent long-term survival with more than 60% of those who were transplanted as infants being alive 25 years later. Nonetheless, the rates of graft loss beyond the first year have remained relatively constant over time; driven primarily by our poor understanding and lack of treatments for chronic allograft vasculopathy (CAV). Acute rejection, CAV, graft failure, and infection continue to be the major causes of death within the first 5 years post-transplant. In addition, renal dysfunction, malignancy, and the need for re-transplantation remain as significant issues that require close follow-up. Looking forward, key challenges include improving donor utilization rates (including donation after cardiac death (DCD) and the use of ex vivo perfusion devices), the development of non-invasive biomarkers for rejection, efforts to mitigate the long-term effects of immunosuppression, and prevention of CAV. It is not possible to cover the entire evolution of pediatric heart transplantation over the last five decades, but in this review, we hope to touch on key observations, lessons learned, and practice changes that have advanced the field, as well as glance ahead to the next decade.
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Affiliation(s)
- Anne I Dipchand
- Department of Paediatrics, Head, Heart Transplant, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Pediatrician-in-Chief, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Deshpande SR, Kennedy KF, Martin GR. Elective and non-elective endomyocardial biopsy in heart transplant patients and procedural outcomes: An IMPACT registry analysis. Pediatr Transplant 2023; 27:e14482. [PMID: 36860141 DOI: 10.1111/petr.14482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/17/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Endomyocardial biopsies are standard of care for transplant surveillance, however the procedural risks are not well established, especially in children. The purpose of the study was therefore to assess procedural risks and outcomes associated with elective (surveillance) biopsies and non-elective (clinically indicated) biopsies. METHODS We used the NCDR IMPACT registry database for this retrospective analysis. Patients undergoing an endomyocardial biopsy were identified using the procedural code, with a diagnosis of heart transplantation required. Data regarding indication, hemodynamics, adverse events and outcomes was gathered and analyzed. RESULTS A total of 32 547 endomyocardial biopsies were performed between 2012-2020; 31 298 (96.5%) elective and 1133 (3.5%) were non-elective biopsies. Non-elective biopsy was more commonly performed in infants and in those above 18 years of age, in female and in Black race patients and in those with non-private insurance (all p < .05) and showed hemodynamic derangements. Overall rate of complications was low. Combined major adverse events were more common in non-elective patients, with sicker patient profile, use of general anesthesia and femoral access with overall decline in these events over time. CONCLUSIONS This large-scale analysis shows safety of surveillance biopsies and that non-elective biopsies carry a small but significant risk of major adverse event. Patient profile impacts the safety of the procedure. These data may serve as important comparison point for newer non-invasive tests and for bench marking, especially in children.
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Affiliation(s)
- Shriprasad R Deshpande
- Pediatric Cardiology Division, Children's National Heart Institute, Children's National Hospital, George Washington University, Washington, District of Columbia, USA
| | - Kevin F Kennedy
- Department of Cardiovascular Research, Saint Luke's Hospital, Kansas City, Missouri, USA
| | - Gerard R Martin
- Pediatric Cardiology Division, Children's National Heart Institute, Children's National Hospital, George Washington University, Washington, District of Columbia, USA
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Nassetta K, Hussain T, Gambetta K, Le K, O’Dwyer LC, Badawy SM. A Systematic Review of Adherence to Immunosuppression among Pediatric Heart Transplant Patients. J Cardiovasc Dev Dis 2022; 9:165. [PMID: 35621876 PMCID: PMC9145350 DOI: 10.3390/jcdd9050165] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/19/2022] [Indexed: 02/04/2023] Open
Abstract
After pediatric heart transplant, commitment to lifelong immunosuppression is crucial to maintaining graft health. However, a review of the current literature surrounding adherence to immunosuppression in pediatric heart transplant patients is lacking. This systematic review aims to summarize the current landscape of adherence to immunosuppression in pediatric heart transplant patients. We conducted searches in PubMed MEDLINE, Embase, CENTRAL register of Controlled Trials (Wiley), and Scopus, from inception to March 2020. Studies were eligible if they outlined an aspect of adherence to immunosuppression and the measurement of adherence was performed with an objective or otherwise validated measure of adherence (e.g., drug levels, adherence questionnaires). The titles/abstracts of 880 articles were reviewed. After initial screening, 106 articles underwent full text review. As such, 14 articles were included in the final review. Baseline adherence estimates varied greatly, with most values between 40% and 70%. Nonadherence to immunosuppression is associated with worse outcomes (rejection, hospitalization, mortality), impaired quality of life, and mental health concerns in pediatric heart transplant patients. As nonadherence to immunosuppression is common and associated with worse outcomes, there is a need for further development and evaluation of interventions in this space.
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Affiliation(s)
- Keira Nassetta
- Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL 60611, USA;
| | - Tasmeen Hussain
- Department of Internal Medicine, Northwestern University McGaw Medical Center, 251 E. Huron St., Ste. 16-738, Chicago, IL 60611, USA;
| | - Katheryn Gambetta
- Division of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL 60611, USA;
| | - Kevin Le
- Department of Pharmacy, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL 60611, USA;
| | - Linda C. O’Dwyer
- Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine, 320 E. Superior Street, Chicago, IL 60611, USA;
| | - Sherif M. Badawy
- Division of Hematology, Oncology, and Stem Cell Transplant, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL 60611, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL 60611, USA
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Laks JA, Dipchand AI. Cardiac allograft vasculopathy: A review. Pediatr Transplant 2022; 26:e14218. [PMID: 34985793 DOI: 10.1111/petr.14218] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/11/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease, and outcomes have consistently improved over the last few decades. CAV, however, remains a leading cause of morbidity and mortality in heart transplantation and is the leading cause of death beyond 3 years post-transplantation. We sought out to provide an in-depth overview of CAV in the pediatric heart transplant population. METHODS Database searches were conducted in both Medline and Embase on the topic of cardiac vasculopathy in pediatric heart transplant recipients. The search used five broad concept terms: heart transplant; pediatric; CAV; diagnosis, prognosis, and risk factors; and guidelines and reviews. References were captured if there was at least one term in each of the concepts. The search was limited to articles in the English language. RESULTS A total of 148 articles were identified via the literature search with further articles identified via review of references. Pediatric data regarding the etiology and development of CAV remain limited although knowledge about the immune and non-immune factors playing a role are increasing. CAV continues to be difficult to detect with many invasive and non-invasive methods available, yet their effectiveness in the detection of CAV remains suboptimal. There remains no proven medical intervention to treat or reverse established CAV disease, and CAV is associated with high rates of graft loss once detected. However, several medications are used in hopes of preventing, slowing progression, or modifying the outcomes. CONCLUSION This review provides a comprehensive overview of CAV, discusses its clinical presentation, risk factors, diagnostic tools used to identify CAV in the pediatric population, and highlights the current therapeutic options and the need for ongoing research.
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Affiliation(s)
- Jessica A Laks
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Anne I Dipchand
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
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Avsar M, Petená E, Ius F, Bobylev D, Cvitkovic T, Tsimashok V, Warnecke G, Böthig D, Beerbaum P, Haverich A, Horke A, Köditz H. Pediatric urgent heart transplantation with age or weight mismatched donors: Reducing waiting time by enlarging donor criteria. J Card Surg 2021; 36:4551-4557. [PMID: 34595768 DOI: 10.1111/jocs.16041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite considerable progress in heart transplantation, pediatric waiting list mortality is still high, and often patients do not have enough time to wait. We hypothesized that extending the donor criteria regarding age and weight mismatch does not significantly affect the early follow-up. METHODS We retrospectively analyzed our pediatric heart transplantation patients operated on from 2014 to 2020 for high (>3.0) or low (<0.6) donor-recipient weight ratio (DRWR) or chronological age mismatches (donor organ >5 years older than recipient age). This patient cohort constituted "mismatched heart transplantations" (mHTX). We compared mHTX preoperative status, postoperative course, 1-year survival, and early clinical follow-up to standard pediatric heart transplantations (sHTX). RESULTS We performed 20 pediatric heart transplantations-10 mHTX and 10 sHTX. The minimum DRWR was 0.44, the maximum was 5.60, and the maximum age mismatch was 42.6 years. Median days in the intensive care unit (p = .436) and time-to-first-rejection episode (p = .925) were comparable. Nine patients in each group were alive after 1 year, two patients were operated within 1 year of follow-up. One mHTX patient developed cardiac allograft vasculopathy after 15 months and died 648 days after transplantation (p = .237). All other patients were alive at the end of follow-up and in good clinical conditions (median follow-up for mHTX was 732.5 days, 1149.5 days for sHTX). CONCLUSION Postoperative course and early follow-up after mHTX were comparable to sHTX. In urgent clinical situations, extended donor criteria may be considered an additional option for pediatric heart transplantation.
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Affiliation(s)
- Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Elena Petená
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tomislav Cvitkovic
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Valery Tsimashok
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Dietmar Böthig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Philipp Beerbaum
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Horke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Harald Köditz
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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Balakrishnan KR, Rao KGS, Subramaniam GK, Tanguturu MK, Arvind A, Ramanan V, Dhushyanthan J, Ramasubramanian K, Kumaran KS, Sellamuthu G, Rajam M, Mettur S, Gnansekharan P, Ratnagiri R. Clinical profiles and risk factors for early and medium-term mortality following heart transplantation in a pediatric population: A single-center experience. Ann Pediatr Cardiol 2021; 14:42-52. [PMID: 33679060 PMCID: PMC7918032 DOI: 10.4103/apc.apc_129_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/30/2020] [Accepted: 11/27/2020] [Indexed: 11/24/2022] Open
Abstract
AIMS AND OBJECTIVES There is a paucity of data regarding the outcomes of Heart transplantation in children from the Indian subcontinent. The data of patients under the age of 18 undergoing an isolated heart transplantation was analyzed for patient clinical profiles and risk factors for early and medium-term mortality. Hospital mortality was defined as death within 90 days of transplantation and medium-term survival as follow up of up to 6 years. MATERIALS AND METHODS A total of 97 patients operated between March 2014 and October 2019 were included in this study. Data was collected about their INTERMACS status, pulmonary vascular resistance, donor heart ischemic times, donor age, donor to recipient weight ratio and creatinine levels. RESULTS The age range was from 1 to 18 with a mean of 10.6 ± 4.6 years. 67 % patients were in INTERMACS category 3 or less.12 children were on mechanical circulatory support at the time of transplant. The 90 day survival was 89 %. The risk factors for hospital mortality was lower INTERMACS category (odd's ratio 0.2143, P = 0.026), elevated creatinine (odd's ratio 5.42, P = 0.076) and elevated right atrial pressure (odd's ratio 1.19, P = 0.015). Ischemic time, pulmonary vascular resistance (PVR) and PVR index (PVRI) had no effect on 90 day survival. Kaplan Meier estimates for 5 year survival was 73 %. The medium term survival was affected by INTERMACS category (Hazard ratio 0.7, P = .078), donor age > 25 (Hazard ratio 1.6, P = 0.26) and raised serum creatinine values.(Hazard ratio 2.7, P = 0.012). All the survivors are in good functional class. CONCLUSIONS Excellent outcomes are possible after heart transplantation in a pediatric population even in a resource constrained environment of a developing economy. More efforts are needed to promote pediatric organ donation and patients need to be referred in better INTERMACS category for optimal outcomes.
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Affiliation(s)
- Komarakshi R. Balakrishnan
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Kemundel Genny Suresh Rao
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Ganapathy Krishnan Subramaniam
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Murali Krishna Tanguturu
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Ajay Arvind
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Veena Ramanan
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Jagdish Dhushyanthan
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - K. Ramasubramanian
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - K. Suresh Kumaran
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Gunalan Sellamuthu
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Mohan Rajam
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Senthil Mettur
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Pradeep Gnansekharan
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Ravikumar Ratnagiri
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
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