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Loomba RS, Dyamenahalli U, Savorgnan F, Acosta S, Villarreal E, Farias JS, Wong J, Flores S. Association of Immediate Postoperative Hemodynamic and Laboratory Values in Predicting Norwood Admission Outcomes. Pediatr Cardiol 2024; 45:1232-1241. [PMID: 36350339 DOI: 10.1007/s00246-022-03044-2] [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: 04/27/2022] [Accepted: 11/01/2022] [Indexed: 11/10/2022]
Abstract
The primary objective of this study was to determine whether or not hemodynamic parameters and laboratory values at the time of admission to the pediatric cardiac intensive care unit after the Norwood operation were associated with a composite outcome of either need for extracorporeal membrane oxygenation or inpatient mortality. This was a single-center retrospective study of infants with functionally univentricular hearts admitted to intensive care after the Norwood procedure from January 2011 to January 2020. Data were obtained at a single point (after a Norwood procedure) and then compared between two subsets of patients based on the presence or not of the composite outcome of interest. In univariate and multiple regression analyses, a series of receiver operator curves were generated to assess the relationship between the variables of interest and the composite outcome. Eight (7.6%) experienced the composite outcome out of a total of 104 patients. Those who experienced the composite endpoint had significantly higher oxygen extraction ratio (0.43 vs. 0.31, p = 0.01), lower systemic blood flow (2.5 L/min versus 3.1 L/min, p = 0.01), and higher systemic vascular resistance (20.2 indexed woods units versus 14.8 indexed woods units, p = 0.01). Those with systemic blood flow of less than 2.5 L/min/m2 had a 17% risk of experiencing the composite endpoint AUC = 0.79. Those with systemic vascular resistance of greater than 19 indexed woods units had a 22% risk of experiencing the composite endpoint AUC 0.80. Systemic blood flow and systemic vascular resistance are independently associated with this composite outcome.
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Affiliation(s)
- Rohit S Loomba
- Department of Pediatrics, Advocate Children's Hospital, The Heart Institute, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Oak Lawn, Illinois, USA
| | - Umesh Dyamenahalli
- Department of Pediatrics, Advocate Children's Hospital, The Heart Institute, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Oak Lawn, Illinois, USA
| | - Fabio Savorgnan
- Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Sebastian Acosta
- Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Enrique Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de La Salud, Monterrey, Nuevo Leon, Mexico
| | - Juan S Farias
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de La Salud, Monterrey, Nuevo Leon, Mexico
| | - Joshua Wong
- Department of Pediatrics, Advocate Children's Hospital, The Heart Institute, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Oak Lawn, Illinois, USA
| | - Saul Flores
- Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Iskander C, Nwankwo U, Kumanan KK, Chiwane S, Exil V, Lowrie L, Tan C, Huddleston C, Agarwal HS. Comparison of Morbidity and Mortality Outcomes between Hybrid Palliation and Norwood Palliation Procedures for Hypoplastic Left Heart Syndrome: Meta-Analysis and Systematic Review. J Clin Med 2024; 13:4244. [PMID: 39064284 PMCID: PMC11277754 DOI: 10.3390/jcm13144244] [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: 04/30/2024] [Revised: 06/20/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Hybrid palliation (HP) procedures for hypoplastic left heart syndrome (HLHS) are increasing. Our objective was to compare mortality and morbidity following HP and NP (Norwood palliation) procedures. Methods: Systematic review and meta-analysis of HLHS patients of peer-reviewed literature between 2000 and 2023. Mortality and/or heart transplantation in HP versus NP in the neonatal period, interstage period, and at 1, 3 and 5 years of age, and morbidity including completion of Stage II and Stage III palliation, unexpected interventions, pulmonary artery pressures, right ventricle function, neurodevelopmental outcomes and length of hospital stay were evaluated. Results: Twenty-one (meta-analysis: 16; qualitative synthesis: 5) studies evaluating 1182 HLHS patients included. HP patients had higher interstage mortality (RR = 1.61; 95% CI: 1.10-2.33; p = 0.01) and 1-year mortality (RR = 1.22; 95% CI: 1.03-1.43; p = 0.02) compared to NP patients without differences in 3- and 5-years mortality. HP procedure in high-risk HLHS patients had lower mortality (RR = 0.48; 95% CI: 0.27-0.87; p = 0.01) only in the neonatal period. HP patients underwent fewer Stage II (RR = 0.90; 95% CI: 0.81-1.00; p = 0.05) and Stage III palliation (RR = 0.78; 95% CI: 0.69-0.90; p < 0.01), had more unplanned interventions (RR = 3.38; 95% CI: 2.04-5.59; p < 0.01), and longer hospital stay after Stage I palliation (weighted mean difference = 12.88; 95% CI: 1.15-24.62; p = 0.03) compared to NP patients. Conclusions: Our study reveals that HP, compared to NP for HLHS, is associated with increased morbidity risk without an improved survival rate.
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Affiliation(s)
- Christopher Iskander
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Ugonna Nwankwo
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Krithika K. Kumanan
- Advanced Data Health Institution, Saint Louis University, Saint Louis, MO 63104, USA;
| | - Saurabh Chiwane
- Division of Pediatric Critical Care Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
| | - Vernat Exil
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Lia Lowrie
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
| | - Corinne Tan
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Charles Huddleston
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Hemant S. Agarwal
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
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Soynov IA, Arkhipov AN, Manukian SN, Kulyabin YY, Kobelev E, Malakhova OY, Voitov AV, Suzdalova OA. Biventricular repair in low-weight patient with interrupted aortic arch and aortic atresia. Egypt Heart J 2024; 76:84. [PMID: 38965125 PMCID: PMC11224169 DOI: 10.1186/s43044-024-00516-z] [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: 03/29/2024] [Accepted: 06/29/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Aortic atresia with ventricular septal defect is a very rare congenital cardiac anomaly, especially in combination with aortic arch interruption. It is always challenging to choose the optimal treatment tactics for such patients. One of the possible types of intervention is the Yasui procedure. There are only 19 reported cases in the literature of aortic atresia with interruption of the aortic arch type B or C, and not a single clinical case of type A. CASE PRESENTATION The proband was a 2-day-old boy with diagnosis: aortic atresia with a ventricular septal defect and interruption of the aortic arch type B. The child underwent a Yasui procedure without serious postoperative complications and with good long-term result. CONCLUSIONS The Yasui procedure in patients with aortic atresia and interrupted aortic arch can be performed with minimal complications, even in low-weight patients.
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Affiliation(s)
- Ilya A Soynov
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Rechkunovskaya Str. 15, Novosibirsk, Russia, 630055.
| | - Alexey N Arkhipov
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Rechkunovskaya Str. 15, Novosibirsk, Russia, 630055
| | - Serezha N Manukian
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Rechkunovskaya Str. 15, Novosibirsk, Russia, 630055
| | - Yuriy Y Kulyabin
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Rechkunovskaya Str. 15, Novosibirsk, Russia, 630055
| | - Evgeniy Kobelev
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Rechkunovskaya Str. 15, Novosibirsk, Russia, 630055
| | - Oksana Y Malakhova
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Rechkunovskaya Str. 15, Novosibirsk, Russia, 630055
| | - Alexey V Voitov
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Rechkunovskaya Str. 15, Novosibirsk, Russia, 630055
| | - Olga A Suzdalova
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Rechkunovskaya Str. 15, Novosibirsk, Russia, 630055
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Yilmaz Furtun B, Morris SA. Catheter-Based Fetal Cardiac Interventions. J Cardiovasc Dev Dis 2024; 11:167. [PMID: 38921667 PMCID: PMC11204342 DOI: 10.3390/jcdd11060167] [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: 04/16/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/27/2024] Open
Abstract
Fetal cardiac intervention (FCI) is an emerging and rapidly advancing group of interventions designed to improve outcomes for fetuses with cardiovascular disease. Currently, FCI is comprised of pharmacologic therapies (e.g., trans-placental antiarrhythmics for fetal arrhythmia), open surgical procedures (e.g., surgical resection of pericardial teratoma), and catheter-based procedures (e.g., fetal aortic valvuloplasty for aortic stenosis). This review focuses on the rationale, criteria for inclusion, technical details, and current outcomes of the three most frequently performed catheter-based FCI procedures: (1) aortic valvuloplasty for critical aortic stenosis (AS) associated with evolving hypoplastic left heart syndrome (HLHS), (2) atrial septal intervention for HLHS with severely restrictive or intact atrial septum (R/IAS), and (3) pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum (PA/IVS).
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Affiliation(s)
| | - Shaine Alaine Morris
- Texas Children’s Hospital, Baylor College of Medicine, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
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Jacquemyn X, Singh TP, Gossett JG, Averin K, Kutty S, Zühlke LJ, Abdullahi LH, Kulkarni A. Mortality and Heart Transplantation After Hybrid Palliation of Hypoplastic Left Heart Syndrome: A Systematic Review and Meta-Analysis. World J Pediatr Congenit Heart Surg 2024; 15:215-223. [PMID: 38404131 DOI: 10.1177/21501351231224323] [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: 02/27/2024]
Abstract
BACKGROUND Newborns with hypoplastic left heart syndrome (HLHS) who are considered at increased risk for death following Norwood/Sano surgery often undergo hybrid palliation (HP) as initial surgery. We aimed to compile the HP experience in HLHS and its variants and assess the rates of, and risk factors for, death and heart transplantation. METHODS CINAHL, CINAHL PLUS, PubMed/MEDLINE, and SCOPUS were systematically searched for HP outcome studies of death or heart transplantation in HLHS between 1998 and 2022. Pooled incidence was estimated, and potential risk factors were identified using random-effects meta-analysis and reconstructed time-to-event data from Kaplan-Meier curves. RESULTS Thirty-three publications were included in our review. Overall, of 1,162 patients 417 died and 57 underwent heart transplantation, resulting in a combined outcome of 40.7%, (474/1,162). There was a trend toward decreasing mortality risk across the stages of palliation. Pooled mortality between HP and comprehensive stage 2 palliation was 25%, after stage 2 up to Fontan palliation was 16%, and 6% post-Fontan. The incidence of death or heart transplantation was higher in high-risk patients-43% died and 10% received heart transplantation. CONCLUSION Our systematic review and meta-analysis found high rates of death or heart transplantation in HP of HLHS patients between HP and Fontan surgeries. All patients should be closely followed during the initial interstage period, which is associated with the highest hazard. Prospective studies on appropriate patient selection, indications, and / or alternatives, as well as refining HP strategies for managing newborns with HLHS are needed to improve outcomes.
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Affiliation(s)
- Xander Jacquemyn
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Tajinder P Singh
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jeffrey G Gossett
- Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, New Hyde Park, NY, USA
| | - Konstantin Averin
- Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, New Hyde Park, NY, USA
| | - Shelby Kutty
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Liesl J Zühlke
- President's Office, South African Medical Research Council, Cape Town, South Africa
- Division of Paediatric Cardiology, Department of Paediatrics, Institute of Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Leila H Abdullahi
- Save the Children International (SCI), Somalia/Somaliland Country Office. Nairobi, Kenya
| | - Aparna Kulkarni
- Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, New Hyde Park, NY, USA
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Ruiz-Avila DR, Lahiri S, Zaidi SJ, Turbendian HK. Deferred Norwood in the setting of airway compression in double-inlet left ventricle with dextro-transposition of the great arteries. Ann Pediatr Cardiol 2024; 17:149-151. [PMID: 39184115 PMCID: PMC11343387 DOI: 10.4103/apc.apc_30_24] [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: 02/22/2024] [Revised: 03/18/2024] [Accepted: 04/04/2024] [Indexed: 08/27/2024] Open
Abstract
A 4.1 kg male neonate with a diagnosis of double-inlet left ventricle with dextro-transposition of the great arteries was intubated shortly after birth due to respiratory insufficiency. The initial management consisted of a successful Stage I hybrid procedure. Persistent respiratory insufficiency led to cross-sectional imaging and bronchoscopy that demonstrated severe airway compression from a dilated main pulmonary artery. A Norwood procedure with Blalock-Thomas-Taussig shunt was performed at 1 month of age to relieve the airway obstruction. The patient was discharged home on room air at 2 months of age. This case highlights a unique single-ventricle anatomic variant with airway compression, which was successfully managed with deferred Norwood palliation.
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Affiliation(s)
| | - Subhrajit Lahiri
- Department of Pediatrics, Division of Pediatric Cardiology, University of Illinois College of Medicine, Peoria, IL, USA
| | | | - Harma Khachig Turbendian
- Pediatric and Congenital Heart Surgery, OSF Children’s Hospital of Illinois, Peoria, IL, USA
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA
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7
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Burkhart HM, Nakamura Y, Salkini A, Schwartz RM, Ranallo CD, Makil ES, Campbell M, Daves SM, Henry ED, Mir A. Bilateral pulmonary artery banding in higher risk neonates with hypoplastic left heart syndrome. JTCVS OPEN 2023; 16:689-697. [PMID: 38204678 PMCID: PMC10774943 DOI: 10.1016/j.xjon.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/07/2023] [Accepted: 08/02/2023] [Indexed: 01/12/2024]
Abstract
Objectives Limited data on performing bilateral pulmonary artery banding (BPAB) before stage 1 Norwood procedure suggest that some patients may benefit through the postponement of the major cardiopulmonary bypass procedure. The objective of this study was to evaluate the effectiveness of BPAB in the surgical management of high-risk patients with hypoplastic left heart syndrome (HLHS). Methods A retrospective review of all high-risk neonates with HLHS who underwent BPAB at our institution was performed. No patients, including those with intact or highly restrictive atrial septum (IAS), were excluded. Results Between October 2015 and April 2021, 49 neonates with HLHS (including 6 with IAS) underwent BPAB, 40 of whom progressed to the Norwood procedure. Risk factors for not progressing to the Norwood procedure after BPAP include low birth weight (P = .043), the presence of multiple extracardiac anomalies (P = .005), and the presence of genetic disorders (P = .028). Operative mortality was 7.5% (3/40). IAS was associated with operative mortality (P = .022). Conclusions The strategy of BPAB prestage 1 Norwood procedure was successful in identifying at-risk patients and improving Norwood survival. Although not all patients will need this hybrid approach, a significant number can be expected to benefit from this tactic. These results support the need for a substantial hybrid strategy, in addition to a primary stage 1 Norwood surgical strategy, in the management of HLHS.
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Affiliation(s)
- Harold M. Burkhart
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Yuki Nakamura
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Anas Salkini
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Randall M. Schwartz
- Department of Anesthesia, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Courtney D. Ranallo
- Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Elizabeth S. Makil
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Matthew Campbell
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Suanne M. Daves
- Department of Anesthesia, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Emilie D. Henry
- Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Arshid Mir
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
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8
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Carvajal HG, Canter MW, Wan F, Eghtesady P. Hypoplastic Left Heart Syndrome With Low Birth Weight or Prematurity: What Is the Optimal Approach? Ann Thorac Surg 2023; 116:988-995. [PMID: 37429513 DOI: 10.1016/j.athoracsur.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/08/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Hypoplastic left heart syndrome with low birth weight or prematurity comprises a high-risk population with no optimal treatment pathway. Using the Pediatric Health Information System, we compared management approaches across the United States. METHODS We analyzed neonates (≤30 days) with birth weight <2500 grams or gestational age <36 weeks between 2012 and 2021. Four strategies were identified: Norwood procedure, ductus arteriosus stent + pulmonary artery banding, pulmonary artery banding + prostaglandin infusion, or comfort care. Outcomes included hospital survival, discharge disposition, staged palliation completion, and 1-year transplant-free survival. RESULTS Of 383 infants identified, 36.4% (n = 134) received comfort care, 43.9% (n = 165) Norwood, 12.4% (n = 49) ductal stent + pulmonary artery bands, and 8.8% (n = 34) pulmonary artery bands + prostaglandins. Neonates receiving comfort care had the lowest gestational age (35 weeks; interquartile range [IQR], 31.5-37 weeks) and birth weight (2.0 kg; IQR, 1.5-2.3 kg); 24.6% (33 of 134) had chromosomal anomalies. Infants undergoing primary Norwood had the highest birth weight (2.4 kg; IQR, 2.2-2.5 kg) and gestational age (37 weeks; IQR, 35-38 weeks). Glenn palliation was performed in 66.1% (109 of 165) compared with ductal stent + pulmonary artery band in 18.4% (9 of 49) and pulmonary artery band + prostaglandins in 35.3% (12 of 34). Only 11.3% (6 of 53) born <2 kg survived to 1 year, all after Norwood. Primary Norwood yielded higher hospital and 1-year transplant-free survival than hybrid strategies. CONCLUSIONS Comfort care is routinely provided, particularly for infants with low birth weight, gestational age, or chromosomal anomalies. Primary Norwood offered the lowest hospital and 1-year mortality and highest palliation completion rates; birth weight was the most important factor determining 1-year survival.
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Affiliation(s)
- Horacio G Carvajal
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Matthew W Canter
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Fei Wan
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri.
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9
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Bigelow AM, Karamlou T. Shades of Uncertainty: Perspectives on Hypoplastic Left Heart Syndrome in Premature and Low-Birth-Weight Infants. Ann Thorac Surg 2023; 116:995-996. [PMID: 37536487 DOI: 10.1016/j.athoracsur.2023.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 07/22/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Amee M Bigelow
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Tara Karamlou
- Division of Congenital Cardiac Surgery, Cleveland Clinic Children's and Heart, Vascular and Thoracic Institute, 9500 Euclid, M41-022A, Cleveland, OH 44195.
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10
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Kizilski SB, Recco DP, Sperotto F, Lang N, Hammer PE, Baird CW, Maschietto N, Hoganson DM. Transcatheter Pulmonary Artery Banding in High-Risk Neonates: In-Vitro Study Provoked by Initial Clinical Experience. Cardiovasc Eng Technol 2023; 14:640-654. [PMID: 37580629 DOI: 10.1007/s13239-023-00674-2] [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: 04/25/2023] [Accepted: 07/17/2023] [Indexed: 08/16/2023]
Abstract
PURPOSE Very high-risk, ductal-dependent or complex two-ventricle patients with associated comorbidities often require pulmonary blood flow restriction as bridge to a more definitive procedure, but current surgical options may not be well-tolerated. An evolving alternative utilizes a fenestrated Micro Vascular Plug (MVP) as a transcatheter, internal pulmonary artery band. In this study, we report a case series and an in-vitro evaluation of the MVP to elicit understanding of the challenges faced with device implantation. METHODS Following single-center, retrospective review of eight patients who underwent device placement, an in-vitro flow study was conducted on MVP devices to assess impact of device and fenestration sizing on pulmonary blood flow. A mathematical model was developed to relate migration risk to vessel size. Results of the engineering analysis were compared to the clinical series for validation. RESULTS At median follow-up of 8 months (range 1-15), survival was 63% (5/8), and 6 (75%) patients underwent subsequent target surgical intervention with relatively low mortality (1/6). Occluder-related challenges included migration (63%) and peri-device flow, which were evaluated in-vitro. The device demonstrated durability over normal and supraphysiologic conditions with minimal change in fenestration size. Smaller vessel size significantly increased pressure gradient due to reduced peri-device flow and smaller effective fenestration size. CONCLUSION Device oversizing, with appropriate adjustment to fenestration size, may reduce migration risk and provide a clinically appropriate balance between resulting pressure gradient and Qp:Qs. Our results can guide the interventionalist in appropriately selecting the device and fenestrations based on patient-specific anatomy and desired post-implantation flow characteristics.
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Affiliation(s)
- Shannen B Kizilski
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA
| | - Dominic P Recco
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA
| | - Francesca Sperotto
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Nora Lang
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatric Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter E Hammer
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA
| | - Christopher W Baird
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA
| | - Nicola Maschietto
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - David M Hoganson
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Bader, 2nd Floor, Boston, MA, 02215, USA.
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11
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Handler SS, Chan T, Ghanayem NS, Rudd N, Wright G, Visotcky A, Sparapani R, Mitchell ME, Hoffman GM, Frommelt MA. Impact of Reintervention During Stage 1 Palliation Hospitalization: A National, Multicenter Study. Ann Thorac Surg 2023; 115:975-981. [PMID: 36306859 DOI: 10.1016/j.athoracsur.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/28/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Stage 1 palliation (S1P) for hypoplastic left heart syndrome remains associated with high morbidity and mortality. Previous studies on burden of reinterventions did not include patients who remain hospitalized before stage 2 palliation (S2P). This study described the rate of reintervention during S1P hospitalization and sought to determine the impact of reintervention on outcomes. METHODS All participants enrolled in phase II of the National Pediatric Cardiology Quality Improvement Collaborative after S1P were included in this study. The primary outcome was the rate of reintervention during hospitalization after S1P and before hospital discharge or S2P. Reintervention was defined as 1 or more unplanned interventional cardiac catheterizations or surgical reoperations. RESULTS Between March 1, 2016 and October 1, 2019, 1367 participants underwent S1P and 339 (24.8%) had a reintervention; most commonly to address the source of pulmonary blood flow. Gestational age, weight at S1P, atrioventricular septal defect, heterotaxy, preoperative pulmonary artery bands, hybrid S1P, and an additional bypass run or early extracorporeal membrane oxygenation were significantly associated with reintervention. Participants in the reintervention group experienced higher rates of nearly all postoperative complications, were less likely to be discharged before S2P (57.1% vs 86%; P < .001), and more likely to experience in-hospital mortality (17% vs 5%; P < .001). CONCLUSIONS Unplanned reintervention during hospitalization after S1P palliation occurred in 25% of participants in a large, registry-based national cohort. Participants who underwent reintervention were more likely to remain as inpatient and were less likely to survive to S2P. Reintervention was associated with a multitude of postoperative complications that affect survival and long-term outcome.
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Affiliation(s)
- Stephanie S Handler
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Titus Chan
- Division of Critical Care Medicine and Cardiology, Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, University of Chicago and Advocate Children's Hospital, Chicago, Illinois
| | - Nancy Rudd
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gail Wright
- Department of Pediatrics, Santa Clara Valley Health and Hospital System, San Jose, California
| | - Alexis Visotcky
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rodney Sparapani
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - George M Hoffman
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michele A Frommelt
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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12
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Backes ER, Afonso NS, Guffey D, Tweddell JS, Tabbutt S, Rudd NA, O'Harrow G, Molossi S, Hoffman GM, Hill G, Heinle JS, Bhat P, Anderson JB, Ghanayem NS. Cumulative comorbid conditions influence mortality risk after staged palliation for hypoplastic left heart syndrome and variants. J Thorac Cardiovasc Surg 2023; 165:287-298.e4. [PMID: 35599210 DOI: 10.1016/j.jtcvs.2022.01.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/29/2021] [Accepted: 01/27/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Prematurity, low birth weight, genetic syndromes, extracardiac conditions, and secondary cardiac lesions are considered high-risk conditions associated with mortality after stage 1 palliation. We report the impact of these conditions on outcomes from a prospective multicenter improvement collaborative. METHODS The National Pediatric Cardiology Quality Improvement Collaborative Phase II registry was queried. Comorbid conditions were categorized and quantified to determine the cumulative burden of high-risk diagnoses on survival to the first birthday. Logistic regression was applied to evaluate factors associated with mortality. RESULTS Of the 1421 participants, 40% (575) had at least 1 high-risk condition. The aggregate high-risk group had lower survival to the first birthday compared with standard risk (76.2% vs 88.1%, P < .001). Presence of a single high-risk diagnosis was not associated with reduced survival to the first birthday (odds ratio, 0.71; confidence interval, 0.49-1.02, P = .066). Incremental increases in high-risk diagnoses were associated with reduced survival to first birthday (odds ratio, 0.23; confidence interval, 0.15-0.36, P < .001) for 2 and 0.17 (confidence interval, 0.10-0.30, P < .001) for 3 to 5 high-risk diagnoses. Additional analysis that included prestage 1 palliation characteristics and stage 1 palliation perioperative variables identified multiple high-risk diagnoses, poststage 1 palliation extracorporeal membrane oxygenation support (odds ratio, 0.14; confidence interval, 0.10-0.22, P < .001), and cardiac reoperation (odds ratio, 0.66; confidence interval, 0.45-0.98, P = .037) to be associated with reduced survival odds to the first birthday. CONCLUSIONS The presence of 1 high-risk diagnostic category was not associated with decreased survival at 1 year. Cumulative diagnoses across multiple high-risk diagnostic categories were associated with decreased odds of survival. Further patient accrual is needed to evaluate the impact of specific comorbid conditions within the broader high-risk categories.
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Affiliation(s)
- Emily R Backes
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex.
| | - Natasha S Afonso
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Danielle Guffey
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - James S Tweddell
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sarah Tabbutt
- Divisions of Critical Care and Cardiology, Department of Pediatrics, University of California San Francisco and Benioff Children's Hospital, San Francisco, Calif
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Ginny O'Harrow
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill
| | - Silvana Molossi
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - George M Hoffman
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Garick Hill
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey S Heinle
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Priya Bhat
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Jeffrey B Anderson
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill; Advocate Children's Hospital, Oak Lawn, Ill
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Emani SM. Management of the Borderline Left Heart and Alternatives to Fontan. World J Pediatr Congenit Heart Surg 2022; 13:645-649. [PMID: 36053112 DOI: 10.1177/21501351221116278] [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: 11/15/2022]
Abstract
Management of borderline left heart can be divided into single ventricle and biventricular repair strategies. Recently, the strategy of left heart recruitment has been applied to select patients. Left heart recruitment strategies and alternatives to Fontan circulation are reviewed. The criteria utilized for decision-making include size and function of left heart structures as well as hemodynamics measured by cardiac catheterization.
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Affiliation(s)
- Sitaram M Emani
- Department of Cardiac Surgery, 1862Children's Hospital Boston, Boston, MA, USA
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D'Angelo J, Suguna Narasimhulu S, Pourmoghadam K, Hsia TY, Fleishman C, Kube A, Lucchesi N, DeCampli W. Outcomes Following Norwood Procedures: Analysis of a "Small Volume" Program. World J Pediatr Congenit Heart Surg 2022; 13:655-663. [PMID: 35593094 DOI: 10.1177/21501351221098599] [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: 11/15/2022]
Abstract
BACKGROUND Institutional survival following Norwood procedures is traditionally correlated with a center's surgical volume. Multiple single and multi-institutional studies conducted at large-volume centers have recently demonstrated improved survival following Norwood procedures. We report both short- and long-term outcomes at a single, small-volume institution and comment on factors potentially influencing outcomes at this institution. METHODS All patients undergoing Norwood procedures from January 1, 2005, to January 1, 2020, at our institution were included in this study. Kaplan-Meier survival and Cox regression risk factor analyses were performed in addition to first interstage risk factor scoring to compare observed versus expected survival. RESULTS The cohort included 113 patients. Kaplan-Meier freedom from death or transplant was 88%, 80%, and 76% at 1, 5, and 10 years, respectively. Freedom from death following hospital discharge after Norwood procedures was 94%, 87%, and 83% at 1, 5, and 10 years, respectively. The presence of genetic syndromes was a significant risk factor for mortality. First interstage observed-to-expected mortality following discharge was 0.57 (P = .04). Postoperative length of stay was comparable to that reported for the period 2015 to 2018 in the Society of Thoracic Surgeons Database. CONCLUSIONS Survival outcomes at this single, small-volume institution were similar to those reported by large-volume centers and multi-institutional collaborative studies. These results may be related to structural and functional features that have been demonstrated to influence outcomes in other studies. These factors are achievable by small-volume programs with sufficient resource allocation.
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Affiliation(s)
- John D'Angelo
- 124506University of Central Florida College of Medicine, Orlando, FL, USA
| | - Sukumar Suguna Narasimhulu
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Kamal Pourmoghadam
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Tain-Yen Hsia
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Craig Fleishman
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Alicia Kube
- 25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Nicole Lucchesi
- 25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - William DeCampli
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
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15
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Winlaw DS, Hill GD, Heydarian HC, Shahanavaz S. Invited Commentary: What Do We Achieve With Expedited Left Atrial Decompression? World J Pediatr Congenit Heart Surg 2022; 13:321-323. [PMID: 35446212 DOI: 10.1177/21501351221089924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David S Winlaw
- Cardiothoracic Surgery, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Garick D Hill
- Cardiology, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Haleh C Heydarian
- Cardiology, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shabana Shahanavaz
- Cardiology, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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16
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Accuracy of Fetal Echocardiography in Defining Anatomical Details: A Single Institutional Experience Over a 12-year Period. J Am Soc Echocardiogr 2022; 35:762-772. [DOI: 10.1016/j.echo.2022.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 02/28/2022] [Indexed: 11/18/2022]
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17
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Ceneri NM, Desai MH, Tongut A, Ozturk M, Ramakrishnan K, Staffa SJ, Zurakowski D, Donofrio MT, Downing T, d’Udekem Y, Jonas RA, Yerebakan C, Clauss S, Kalinger K, Kanter J, Munoz R, Peer SM, Sinha P, Wernovsky G. Hybrid Strategy in Neonates with Ductal-Dependent Systemic Circulation and Multiple Risk Factors. J Thorac Cardiovasc Surg 2022; 164:1291-1303.e6. [DOI: 10.1016/j.jtcvs.2021.11.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/07/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022]
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18
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Modified Microvascular Plug as a Flow Restrictor in Hypoplastic Left Heart Syndrome with Dysplastic Tricuspid and Pulmonary Valves. Pediatr Cardiol 2021; 42:1653-1657. [PMID: 34363497 DOI: 10.1007/s00246-021-02701-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
While the Norwood operation is the most common palliative surgery for neonates with hypoplastic left heart syndrome (HLHS), initial hybrid strategy aiming to restrict pulmonary blood flow and maintain systemic output is necessary when Norwood is contraindicated or at high risk. The traditional mainstay of initial hybrid palliation is surgical pulmonary artery branch banding (PABB) plus interventional ductal stenting. We present a case of a transcatheter approach for pulmonary flow restriction (PFR) that was accomplished by modifying a Medtronic microvascular plug (MVP)™. The patient is a 2.4 kg neonate diagnosed with HLHS, dysplastic tricuspid and pulmonary valves with pulmonary stenosis, tricuspid stenosis, and regurgitation. He was not considered a candidate for surgical intervention. He started developing sequelae of unbalanced pulmonary and systemic blood flow; therefore, he underwent placement of transcatheter PFR as alternative to PABB. He underwent successful orthotopic heart transplant 104 days after index procedure. This case demonstrates the significant complexity that can occur in patients with HLHS and abnormal right sided valves. Additionally, it is another example that transcatheter branch pulmonary artery flow restriction can be a safe and feasible alternative to PABB as initial palliation strategy. It may benefit patients in whom primary Norwood procedure would have increased risks or who will undergo primary transplant.
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19
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High Risk Status for Stage I Palliation Increases Mortality Following Stage II But Not Stage III. Ann Thorac Surg 2021; 114:1427-1433. [PMID: 34363794 DOI: 10.1016/j.athoracsur.2021.06.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/15/2021] [Accepted: 06/28/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND High risk (HR) factors have been shown to have increased rates of mortality following Stage 1 palliation (S1P) for single ventricle physiology. It remains unclear how initial HR status affects longitudinal outcomes following subsequent Stage 2 (S2P) and Stage 3 (S3P) palliation. METHODS Single ventricle patients undergoing S1P between July of 2004 and October of 2018 at a single institution were included. Patients having ≥ 1 HR factor were considered HR status, with all others classified as low risk (LR). Longitudinal survival stratified by risk status was compared following each palliative stage, in addition to re-admission and length of stay (LOS). Proportional hazard modeling was used to determine risk factors for longitudinal mortality. RESULTS Of 132 patients presenting during the study for S1P, 57 (43.2%) were classified as HR. Overall 10-year survival was decreased in the HR cohort (p=0.001). HR patients were at significantly increased risk of death during Interstage I (p=0.01) and Interstage II (p=0.01), but survival was similar to LR patients following S3P (p=0.31). Re-admission rates following S2P were higher among HR patients (41.9% vs 22.5%, p=0.029), but were similar following S3P. LOS was increased in the HR cohort following S2P (median 11 vs 9 days, p=0.024) but similar to the LR group following S3P. Prematurity was the risk factor most consistently associated with increased mortality following all stages. CONCLUSIONS HR status for patients undergoing S1P portends a higher risk of mortality, LOS, and re-admission following S2P. HR patients enjoy similar survival to low-risk patients following S3P.
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21
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Overbey DM, Lodge AJ. Commentary: Neonatal heart transplant: A good option in a bad situation. J Thorac Cardiovasc Surg 2021; 162:1371-1372. [PMID: 33712240 DOI: 10.1016/j.jtcvs.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Douglas M Overbey
- Cardiothoracic Surgery Residency Program, Durham, NC; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Andrew J Lodge
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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22
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Bichell DP. Commentary: The importance and treachery of patient selection for neonatal heart transplant. J Thorac Cardiovasc Surg 2021; 162:1370-1371. [PMID: 33726902 DOI: 10.1016/j.jtcvs.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Affiliation(s)
- David P Bichell
- Department of Cardiac Surgery, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn.
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23
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Lin Y, Davis TJ, Zorrilla-Vaca A, Wojcik BM, Miyamoto SD, Everitt MD, Campbell DN, Jaggers JJ, Rajab TK. Neonatal heart transplant outcomes: A single institutional experience. J Thorac Cardiovasc Surg 2021; 162:1361-1368. [PMID: 34099271 DOI: 10.1016/j.jtcvs.2021.01.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Neonatal orthotopic heart transplantation was introduced in the 1980s as a treatment for complex congenital heart disease. Progress in single-ventricle palliation and biventricular correction has resulted in a decline in neonatal heart transplant volume. However, limited reports on neonatal heart transplants have demonstrated favorable outcomes. We report the long-term outcomes of patients with neonatal heart transplants at our institution spanning nearly 30 years. METHODS A retrospective analysis of neonatal heart transplants and neonates listed for transplant was performed at Children's Hospital Colorado. Primary outcomes were early and late survival. Secondary outcomes were rejection episodes, retransplantation, and development of cardiac allograft vasculopathy or post-transplant lymphoproliferative disease. RESULTS A total of 21 neonates underwent orthotopic heart transplantation at our institution. Among these, 10 neonates were transplanted from 1991 to 2000, 8 neonates were transplanted from 2001 to 2010, and 3 neonates were transplanted from 2011 to 2020. The average age of these patients was 17 days, and the average weight was 3.43 kg. Early survival was 95.2%. Survival at 1 and 5 years was 85.7% (confidence interval [CI], 61.9%-95.2%) and 75% (CI, 45.6%-85.5%), respectively. Of eligible patients, the 10-year and 20-year survival was 72.2% (CI, 45.1%-85.3%) and 50% (CI, 25.9%-70.1%), respectively. CONCLUSIONS Our institution reports favorable outcomes of neonatal heart transplantation. These results should be considered within the context of outcomes for patients awaiting transplant and the limited donor availability. However, the successful nature of these procedures suggest it may be necessary to reevaluate the indications for neonatal heart transplantation, particularly where risk of mortality and morbidity with palliative or corrective surgery is high.
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Affiliation(s)
- Yihan Lin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | | | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Brandon M Wojcik
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Shelley D Miyamoto
- University of Colorado School of Medicine, Aurora, Colo; Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Melanie D Everitt
- University of Colorado School of Medicine, Aurora, Colo; Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - David N Campbell
- Division of Congenital Cardiac Surgery, Children's Hospital Colorado, University of Colorado, Aurora, Colo
| | - James J Jaggers
- Division of Congenital Cardiac Surgery, Children's Hospital Colorado, University of Colorado, Aurora, Colo
| | - T Konrad Rajab
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC.
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Bichell DP. Commentary: Unwanted baggage tossed or carried on the single ventricle journey? JTCVS OPEN 2020; 4:56-57. [PMID: 36004292 PMCID: PMC9390739 DOI: 10.1016/j.xjon.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 11/26/2022]
Affiliation(s)
- David P. Bichell
- Department of Cardiac Surgery, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn
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25
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Lawrence KM, Ittenbach RF, Hunt ML, Kaplinski M, Ravishankar C, Rychik J, Steven JM, Fuller SM, Nicolson SC, Gaynor JW, Spray TL, Mascio CE. Attrition between the superior cavopulmonary connection and the Fontan procedure in hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2020; 162:385-393. [PMID: 33581902 DOI: 10.1016/j.jtcvs.2020.10.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/11/2020] [Accepted: 10/16/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We investigated the incidence and predictors of failure to undergo the Fontan in children with hypoplastic left heart syndrome who survived superior cavopulmonary connection. METHODS The cohort consists of all patients with hypoplastic left heart syndrome who survived to hospital discharge after superior cavopulmonary connection between 1988 and 2017. The primary outcome was attrition, which was defined as death, nonsuitability for the Fontan, or cardiac transplantation before the Fontan. Subjects were excluded if they were awaiting the Fontan, were lost to follow-up, or underwent biventricular repair. The study period was divided into 4 eras based on changes in operative or medical management. Attrition was estimated with 95% confidence intervals, and predictors were identified using adjusted, logistic regression models. RESULTS Of the 856 hospital survivors after superior cavopulmonary connection, 52 died, 7 were deemed unsuitable for Fontan, and 12 underwent or were awaiting heart transplant. Overall attrition was 8.3% (71/856). Attrition rate did not change significantly across eras. A best-fitting multiple logistic regression model was used, adjusting for superior cavopulmonary connection year and other influential covariates: right ventricle to pulmonary artery shunt at Norwood (P < .01), total support time at superior cavopulmonary connection (P < .01), atrioventricular valve reconstruction at superior cavopulmonary connection (P = .02), performance of other procedures at superior cavopulmonary connection (P = .01), and length of stay after superior cavopulmonary connection (P < .01). CONCLUSIONS In this study spanning more than 3 decades, 8.3% of children with hypoplastic left heart syndrome failed to undergo the Fontan after superior cavopulmonary connection. This attrition rate has not decreased over 30 years. Use of a right ventricle to pulmonary artery shunt at the Norwood procedure was associated with increased attrition.
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Affiliation(s)
- Kendall M Lawrence
- Department of Surgery, Weill Cornell New York Presbyterian, New York, NY
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mallory L Hunt
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Michelle Kaplinski
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, Calif
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - James M Steven
- Division of Cardiac Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiac Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa.
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Michalowski AK, Gauvreau K, Kaza A, Quinonez L, Hoganson D, Del Nido P, Nathan M. Technical Performance Score: A Predictor of Outcomes After the Norwood Procedure. Ann Thorac Surg 2020; 112:1290-1297. [PMID: 32987019 DOI: 10.1016/j.athoracsur.2020.07.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/12/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Technical Performance Score (TPS) can predict outcomes after congenital cardiac surgery. We sought to validate TPS as a predictor of both short- and long-term outcomes of the Norwood procedure. METHODS We conducted a retrospective review of patients who underwent the Norwood procedure from 1997 to 2017. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention for major residua before discharge) based on subcomponent scores from discharge echocardiograms or unplanned reinterventions, or both. Multivariable Cox or competing risk analysis, adjusted for preoperative patient- and procedure-related covariates, examined the association of TPS with postoperative hospital length of stay, transplant-free survival, and postdischarge reinterventions. RESULTS Among 500 patients, 319 (64%) were male, 54 (11%) were premature, 56 (11%) had noncardiac anomalies/syndromes, 146 (29%) had preoperative risk factors, and 480 (96%) were assigned TPS. On multivariable analysis, class 3 had greater hazard for reinterventions in transplant-free survivors (class 3: subdistribution hazard ratio [HR], 2.06; 95% confidence interval [CI] 1.34-3.16; P = .001) and was associated with increased hospital length of stay vs class 1 (HR, 0.25; 95% CI, 0.18-0.34; P < .001). Transplant-free survival after Norwood surgery was shorter for both class 2 (HR, 2.48; 95% CI, 1.68-3.66; P < .001) and class 3 (HR, 3.29; 95% CI, 2.18-4.95; P < .001). CONCLUSIONS TPS predicts early and late outcomes after Norwood. Absence of residual lesions results in improved long-term prognosis for single-ventricle patients. TPS may improve outcomes after Norwood by identifying patients warranting closer follow-up and potentially earlier reintervention.
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Affiliation(s)
- Anna K Michalowski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Aditya Kaza
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Luis Quinonez
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - David Hoganson
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Pedro Del Nido
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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d'Udekem Y, Caldaroni F. Commentary: Just Open the Restrictive Atrial Septum of Single Ventricles … Surgically Please! Semin Thorac Cardiovasc Surg 2020; 32:529-530. [PMID: 32376466 DOI: 10.1053/j.semtcvs.2020.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/27/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Yves d'Udekem
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Heart Research, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia.
| | - Federica Caldaroni
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
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Schneider K, Hahn E, Statile C, Hirsch R, Khoury PR, Cnota J, Divanovic A. Pulmonary venous Doppler patterns and midterm outcomes in fetuses with left-sided obstructive lesions and restrictive atrial septum. Prenat Diagn 2020; 40:776-784. [PMID: 32176365 DOI: 10.1002/pd.5682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/29/2020] [Accepted: 03/04/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare length of stay of the initial neonatal hospitalization and mortality across multiple stages of surgical palliation for infants with left-sided obstructive lesions and severely restrictive or intact atrial septum (I/RAS). METHODS Retrospective cohort study of patients prenatally diagnosed with left-sided obstructive lesions and I/RAS, defined by fetal pulmonary venous Dopplers. RESULTS We identified 76 fetal patients with 59 live born intending to pursue intervention. Those with I/RAS had longer durations of mechanical ventilation (P = .031) but no difference in intensive care unit or total length of stay. Survival to discharge from neonatal hospitalization was 41.7% in the I/RAS group and 80.7% in the unrestrictive group (P = .001). There was a higher proportion of deaths between stage 1 and stage 2 in the I/RAS group - 5/9 (55.6%) vs 9/50 (18%) in the unrestrictive group (P = .027). Beyond stage 2 palliation there was trend toward a difference in overall mortality (66.7% in I/RAS vs 35.7% in unrestrictive, P = .05) but no statistically significant difference in transplant-free survival (33.3% in I/RAS vs 53.5% in unrestrictive, P = .11). CONCLUSION The survival disadvantage conferred by prenatally diagnosed severe atrial septal restriction is most pronounced in the neonatal and early infancy period, with no detectable difference in late midterm transplant-free survival in our cohort.
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Affiliation(s)
- Kristin Schneider
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eunice Hahn
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher Statile
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Russel Hirsch
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Philip R Khoury
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James Cnota
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Allison Divanovic
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Burkhart HM, Mir A, Schwartz RM. Commentary: Hypoplastic left heart syndrome with intact atrial septum: Planning for success. JTCVS OPEN 2020; 1:59-60. [PMID: 36003192 PMCID: PMC9390662 DOI: 10.1016/j.xjon.2020.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/13/2020] [Accepted: 03/20/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Harold M. Burkhart
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Arshid Mir
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Randall M. Schwartz
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
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Affiliation(s)
- David Bichell
- Monroe Carell, Jr., Children's Hospital, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232-9292.
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