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Zheng JY, Chen BH, Wu R, An DA, Shi RY, Wu CW, Tang LL, Zhao L, Wu LM. Prognostic value of right atrial strains in arrhythmogenic right ventricular cardiomyopathy. Insights Imaging 2024; 15:58. [PMID: 38411736 PMCID: PMC10899550 DOI: 10.1186/s13244-024-01630-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/18/2024] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVES Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy characterized by progressive fibrofatty infiltration of atrial and ventricular myocardium resulting in adverse cardiac events. Atrial function has been increasingly recognized as prognostically important for cardiovascular disease. As the right atrial (RA) strain is a sensitive parameter to describe RA function, we aimed to analyze the prognostic value of the RA strain in ARVC. METHODS RA strain parameters were derived from cardiac magnetic resonance (CMR) images of 105 participants with definite ARVC. The endpoint was defined as a combination of sudden cardiac death, survival cardiac arrest, and appropriate implantable cardioverter-defibrillator intervention. Cox regression and Kaplan-Meier survival analyses were performed to evaluate the association between RA strain parameters and endpoint. Concordance index (C index), net reclassification index (NRI), and integrated discrimination improvement (IDI) were calculated to assess the incremental value of RA strain in predicting the endpoint. RESULTS After a median follow-up of 5 years, 36 (34.3%) reaching the endpoint displayed significantly reduced RA strain parameters. At Kaplan-Meier analysis, impaired RA reservoir (RARS) and booster strains (RABS) were associated with an increased risk of the endpoint. After adjusting for conventional risk factors, RARS (hazard ratio [HR], 0.956; p = 0.005) and RABS (HR, 0.906; p = 0.002) resulted as independent predictors for endpoint at Cox regression analyses. In addition, RARS and RABS improved prognostic value to clinical risk factors and CMR morphological and functional predictors (all p < 0.05). CONCLUSION RARS and RABS were independent predictors for adverse cardiac events, which could provide incremental prognostic value for conventional predictors in ARVC. CRITICAL RELEVANCE STATEMENT We evaluated the prognostic value of right atrial strain in ARVC patients and suggested cardiologists consider RA strain as a predictive parameter when evaluating the long-term outcome of ARVC patients in order to formulate better clinical therapy. KEY POINTS • Patients with ARVC had significantly reduced RA strain and strain rates compared with healthy participants. • Participants with lower RA reservoir and booster stains were associated with a significantly higher risk of adverse cardiac events. • RA booster and reservoir strain provide incremental value to conventional parameters.
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Affiliation(s)
- Jin-Yu Zheng
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
| | - Bing-Hua Chen
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
| | - Rui Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
| | - Dong-Aolei An
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
| | - Ruo-Yang Shi
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
| | - Chong-Wen Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
| | - Lang-Lang Tang
- Department of Radiology, Longyan First Hospital, Affiliated to Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Lei Zhao
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People's Republic of China.
| | - Lian-Ming Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China.
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Meier C, Eisenblätter M, Gielen S. Myocardial Late Gadolinium Enhancement (LGE) in Cardiac Magnetic Resonance Imaging (CMR)-An Important Risk Marker for Cardiac Disease. J Cardiovasc Dev Dis 2024; 11:40. [PMID: 38392254 PMCID: PMC10888577 DOI: 10.3390/jcdd11020040] [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: 12/12/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Cardiovascular magnetic resonance (CMR) has significantly revolutionized the comprehension and diagnosis of cardiac diseases, particularly through the utilization of late gadolinium enhancement (LGE) imaging for tissue characterization. LGE enables the visualization of expanded extracellular spaces in conditions such as fibrosis, fibrofatty tissue, or edema. The growing recognition of LGE's prognostic capacity underscores its importance, evident in the increasing explicit recommendations within guidelines. Notably, the contemporary characterization of cardiomyopathies relies on LGE-based scar assessment by CMR to a large extent. This review describes the pattern and prognostic value of LGE in detail for various cardiac diseases. Despite its merits, establishing LGE as a reliable risk marker encounters challenges. Limitations arise from the fact that not all diseases show LGE, and it should always be analyzed in the context of all CMR sequences and the patient's medical history. In summary, LGE stands as a robust indicator of adverse outcomes in diverse cardiovascular diseases. Its further integration into routine practice is desirable, necessitating widespread availability and application to accumulate both individual and scientific experience.
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Affiliation(s)
- Claudia Meier
- Universitätsklinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Ostwestfalen-Lippe, Campus Klinikum Lippe, D-32756 Detmold, Germany
- Medizinische Fakultät, Universität Bielefeld, D-33615 Bielefeld, Germany
| | - Michel Eisenblätter
- Medizinische Fakultät, Universität Bielefeld, D-33615 Bielefeld, Germany
- Universitätsinstitut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Ostwestfalen-Lippe, Campus Klinikum Lippe, D-32756 Detmold, Germany
| | - Stephan Gielen
- Universitätsklinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Ostwestfalen-Lippe, Campus Klinikum Lippe, D-32756 Detmold, Germany
- Medizinische Fakultät, Universität Bielefeld, D-33615 Bielefeld, Germany
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3
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Zheng JY, Chen BH, Wu R, An DA, Shi RY, Wu CW, Xie JY, Jiang SS, Jia V, Zhao L, Wu LM. 3D Fractal Dimension Analysis: Prognostic Value of Right Ventricular Trabecular Complexity in Participants with Arrhythmogenic Cardiomyopathy. J Magn Reson Imaging 2024. [PMID: 38258534 DOI: 10.1002/jmri.29237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Arrhythmogenic cardiomyopathy (ACM) is characterized by progressive myocardial fibro-fatty infiltration accompanied by trabecular disarray. Traditionally, two-dimensional (2D) instead of 3D fractal dimension (FD) analysis has been used to evaluate trabecular disarray. However, the prognostic value of trabecular disorder assessed by 3D FD measurement remains unclear. PURPOSE To investigate the prognostic value of right ventricular trabecular complexity in ACM patients using 3D FD analysis based on cardiac MR cine images. STUDY TYPE Retrospective. POPULATION 85 ACM patients (mean age: 45 ± 17 years, 52 male). FIELD STRENGTH/SEQUENCE 3.0T/cine imaging, T2-short tau inversion recovery (T2-STIR), and late gadolinium enhancement (LGE). ASSESSMENT Using cine images, RV (right ventricular) volumetric and functional parameters were obtained. RV trabecular complexity was measured with 3D fractal analysis by box-counting method to calculate 3D-FD. Cox and logistic regression models were established to evaluate the prognostic value of 3D-FD for major adverse cardiac events (MACE). STATISTICAL TESTS Cox regression and logistic regression to explore the prognostic value of 3D-FD. C-index, time-dependent receiver operating characteristic (ROC) curves and area under the ROC curve (AUC) to evaluate the incremental value of 3D-FD. Intraclass correlation coefficient for interobserver variability. P < 0.05 indicated statistical significance. RESULTS 26 MACE were recorded during the 60 month follow-up (interquartile range: 48-67 months). RV 3D-FD significantly differed between ACM patients with MACE (2.67, interquartile range: 2.51 ~ 2.81) and without (2.52, interquartile range: 2.40 ~ 2.67) and was a significant independent risk factor for MACE (hazard ratio, 1.02; 95% confidence interval: 1.01, 1.04). In addition, prognostic model fitness was significantly improved after adding 3D-FD to RV global longitudinal strain, LV involvement, and 5-year risk score separately. DATA CONCLUSION The myocardial trabecular complexity assessed through 3D FD analysis was found associated with MACE and provided incremental prognostic value beyond conventional ACM risk factors. EVIDENCE LEVEL 4 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Jin-Yu Zheng
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bing-Hua Chen
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Rui Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dong-Aolei An
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ruo-Yang Shi
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chong-Wen Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | | | | | - Victor Jia
- University of Michigan, Ann Arbor, Michigan, USA
| | - Lei Zhao
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lian-Ming Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Trancuccio A, Kukavica D, Sugamiele A, Mazzanti A, Priori SG. Prevention of Sudden Death and Management of Ventricular Arrhythmias in Arrhythmogenic Cardiomyopathy. Card Electrophysiol Clin 2023; 15:349-365. [PMID: 37558305 DOI: 10.1016/j.ccep.2023.04.004] [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: 08/11/2023]
Abstract
Arrhythmogenic cardiomyopathy is an umbrella term for a group of inherited diseases of the cardiac muscle characterized by progressive fibro-fatty replacement of the myocardium. As suggested by the name, the disease confers electrical instability to the heart and increases the risk of the development of life-threatening arrhythmias, representing one of the leading causes of sudden cardiac death (SCD), especially in young athletes. In this review, the authors review the current knowledge of the disease, highlighting the state-of-the-art approaches to the prevention of the occurrence of SCD.
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Affiliation(s)
- Alessandro Trancuccio
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Deni Kukavica
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Andrea Sugamiele
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Andrea Mazzanti
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Silvia G Priori
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.
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Aljehani A, Kew T, Baig S, Cox H, Sommerfeld LC, Ensam B, Kalla M, Steeds RP, Fabritz L. Characterisation of patients referred to a tertiary-level inherited cardiac condition clinic with suspected arrhythmogenic right ventricular cardiomyopathy (ARVC). BMC Cardiovasc Disord 2023; 23:14. [PMID: 36635648 PMCID: PMC9837886 DOI: 10.1186/s12872-022-03021-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC) or arrhythmogenic cardiomyopathy is a rare inherited disease with incomplete penetrance and an environmental component. Although a rare disease, ARVC is a common cause of sudden cardiac death in young adults. Data on the different stages of ARVC remains scarce. The purpose of this study is to describe the initial presentation and cardiac phenotype of definite and non-definite ARVC for patients seen at a tertiary service. METHODS This is a single centre, observational cohort study of patients with definite and non-definite ARVC seen at the Inherited Cardiac Conditions services at University Hospital Birmingham (UHB) in the period 2010-2021. Patients were identified by interrogation of digital health records, medical history, imaging and by examining 12-lead electrocardiograms (ECG). RESULT The records of 1451 patients were reviewed; of those, 165 patients were at risk of ARVC (mean age 41 ± 17 years, 56% male). 60 patients fulfilled task force criteria for definite ARVC diagnosis (n = 40, 67% males), and 38 (72%) of them carried a known pathogenic variant. The remaining 105 patients (50% males) were non-definite, and of these 45 (62%) carried a known pathogenic variant. Patients in the definite group were more symptomatic, with palpitations (57% vs. 17%), syncope (35% vs. 6%) and shortness of breath (28% vs. 5%, p < 0.001). T-wave inversion in V1-V3 and epsilon waves were observed only in the definite group. Both PR interval and QRS duration were longer in the definite (170 ± 34 ms and 100 ± 19 ms, p < 0.001) compared to (149 ± 25 and 91 ± 14 ms, p = 0.005). Patients with definite ARVC had significantly larger RV end diastolic areas and significantly reduced biventricular function (RVEDA = 27 ± 10 cm2, RVFAC = 37 ± 11% and EF = 56 ± 12%) compared to the non-definite group (RVEDA = 18 ± 4 cm2, RVFAC 49 ± 6% and LVEF 64 ± 7%, p < 0.001). Sustained ventricular tachycardia (VT) occurred more frequently in the definite group compared to the non-definite group (27% vs. 2%, p < 0.001). Ventricular fibrillation was observed in the definite group only (8 of 60 patients, 13%). CONCLUSION Our study showed differences between definite and non-definite ARVC patients in terms of clinical, electrophysiological and imaging features. Major adverse cardiac events occurred more commonly in the definite group, but also were observed in non-definite ARVC. This single centre observational cohort study forms a basis for further prospective multicentre interventional studies.
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Affiliation(s)
- A. Aljehani
- grid.6572.60000 0004 1936 7486Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK ,grid.412563.70000 0004 0376 6589Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK ,grid.412149.b0000 0004 0608 0662King Saud Bin Abdulaziz University For Health Sciences, Echocardiography Cardiovascular Technology (ECVT) Program, Riyadh, Saudi Arabia
| | - T. Kew
- grid.6572.60000 0004 1936 7486Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK ,grid.412563.70000 0004 0376 6589Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S. Baig
- grid.6572.60000 0004 1936 7486Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK ,grid.412563.70000 0004 0376 6589Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - H. Cox
- grid.498025.20000 0004 0376 6175West Midlands Regional Genetics Unit, Clinical Genetics, Birmingham Women’s and Children’s NHS Foundation Trust (BWC) Birmingham, Birmingham, UK
| | - L. C. Sommerfeld
- grid.6572.60000 0004 1936 7486Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK ,grid.13648.380000 0001 2180 3484University Centre of Cardiovascular Science, UKE Hamburg, Hamburg, Germany
| | - B. Ensam
- grid.412563.70000 0004 0376 6589Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M. Kalla
- grid.6572.60000 0004 1936 7486Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK ,grid.412563.70000 0004 0376 6589Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R. P. Steeds
- grid.6572.60000 0004 1936 7486Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK ,grid.412563.70000 0004 0376 6589Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - L. Fabritz
- grid.6572.60000 0004 1936 7486Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK ,grid.412563.70000 0004 0376 6589Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK ,Department of Cardiology, University Heart and Vascular Centre Hamburg, UKE Hamburg and DZHK, Hamburg/Kiel/Luebeck, Germany ,grid.13648.380000 0001 2180 3484University Centre of Cardiovascular Science, UKE Hamburg, Hamburg, Germany
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6
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Corianò M, Tona F. Strategies for Sudden Cardiac Death Prevention. Biomedicines 2022; 10:639. [PMID: 35327441 PMCID: PMC8944952 DOI: 10.3390/biomedicines10030639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/06/2022] [Accepted: 03/06/2022] [Indexed: 12/12/2022] Open
Abstract
Sudden cardiac death (SCD) represents a major challenge in modern medicine. The prevention of SCD orbits on two levels, the general population level and individual level. Much research has been done with the aim to improve risk stratification of SCD, although no radical changes in evidence and in therapeutic strategy have been achieved. Artificial intelligence (AI), and in particular machine learning (ML) models, represent novel technologic tools that promise to improve predictive ability of fatal arrhythmic events. In this review, firstly, we analyzed the electrophysiological basis and the major clues of SCD prevention at population and individual level; secondly, we reviewed the main research where ML models were used for risk stratification in other field of cardiology, suggesting its potentiality in the field of SCD prevention.
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Affiliation(s)
| | - Francesco Tona
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy;
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Malik N, Mukherjee M, Wu KC, Zimmerman SL, Zhan J, Calkins H, James CA, Gilotra NA, Sheikh FH, Tandri H, Kutty S, Hays AG. Multimodality Imaging in Arrhythmogenic Right Ventricular Cardiomyopathy. Circ Cardiovasc Imaging 2022; 15:e013725. [PMID: 35147040 DOI: 10.1161/circimaging.121.013725] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare, heritable myocardial disease associated with the development of ventricular arrhythmias, heart failure, and sudden cardiac death in early adulthood. Multimodality imaging is a central component in the diagnosis and evaluation of ARVC. Diagnostic criteria established by an international task force in 2010 include noninvasive parameters from echocardiography and cardiac magnetic resonance imaging. These criteria identify right ventricular structural abnormalities, chamber and outflow tract dilation, and reduced right ventricular function as features of ARVC. Echocardiography is a widely available and cost-effective technique, and it is often selected for initial evaluation. Beyond fulfillment of diagnostic criteria, features such as abnormal tricuspid annular plane excursion, increased right ventricular basal diameter, and abnormal strain patterns have been described. 3-dimensional echocardiography may also expand opportunities for structural and functional assessment of ARVC. Cardiac magnetic resonance has the ability to assess morphological and functional cardiac features of ARVC and is also a core modality in evaluation, however, tissue characterization of the right ventricle is limited by spatial resolution and low specificity for detection of pathological changes. Nonetheless, the ability of cardiac magnetic resonance to identify left ventricular involvement, offer high negative predictive value, and provide a reproducible structural evaluation of the right ventricle enhance the ability and scope of the modality. In this review, the prognostic significance of multimodality imaging is outlined, including the supplemental value of multidetector computed tomography and nuclear imaging. Strengths and weaknesses of imaging techniques, as well as future direction of multimodality assessment, are also described.
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Affiliation(s)
- Nitin Malik
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC (N.M., F.H.S.).,Georgetown University, Washington, DC (N.M., F.H.S.)
| | - Monica Mukherjee
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Katherine C Wu
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Stefan L Zimmerman
- Johns Hopkins University Department of Radiology, Baltimore, MD (S.L.Z.)
| | - Junzhen Zhan
- Johns Hopkins University Department of Pediatrics, Division of Pediatric Cardiology, Baltimore, MD (J.Z., S.K.)
| | - Hugh Calkins
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Cynthia A James
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Nisha A Gilotra
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Farooq H Sheikh
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC (N.M., F.H.S.).,Georgetown University, Washington, DC (N.M., F.H.S.)
| | - Harikrishna Tandri
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
| | - Shelby Kutty
- Johns Hopkins University Department of Pediatrics, Division of Pediatric Cardiology, Baltimore, MD (J.Z., S.K.)
| | - Allison G Hays
- Johns Hopkins University Department of Medicine, Division of Cardiology, Baltimore, MD (M.M., K.C.W., H.C., C.A.J., N.A.G., H.T., A.G.H.)
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