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Cleveland V, Contento J, Mass P, Hardikar P, Wu Q, Liu X, Aslan S, Loke YH, Krieger A, Lunos S, Olivieri L, Sinha P. In vitro investigation of axial mechanical support devices implanted in the novel convergent cavopulmonary connection Fontan. Eur J Cardiothorac Surg 2024; 65:ezad413. [PMID: 38180888 DOI: 10.1093/ejcts/ezad413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/08/2023] [Accepted: 01/02/2024] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVES The 2 opposing inflows and 2 outflows in a total cavopulmonary connection make mechanical circulatory support (MCS) extremely challenging. We have previously reported a novel convergent cavopulmonary connection (CCPC) Fontan design that improves baseline characteristics and provides a single inflow and outflow, thus simplifying MCS. This study aims to assess the feasibility of MCS of this novel configuration using axial flow pumps in an in vitro benchtop model. METHODS Three-dimensional segmentations of 12 single-ventricle patients (body surface area 0.5-1.75 m2) were generated from cardiovascular magnetic resonance images. The CCPC models were designed by connecting the inferior vena cava and superior vena cava to a shared conduit ascending to the pulmonary arteries, optimized in silico. The 12 total cavopulmonary connection and their corresponding CCPC models underwent in vitro benchtop characterization. Two MCS devices were used, the Impella RP® and the PediPump. RESULTS MCS successfully and symmetrically reduced the pressure in both vena cavae by >20 mmHg. The devices improved the hepatic flow distribution balance of all CCPC models (Impella RP®P = 0.045, PediPump P = 0.055). CONCLUSIONS The CCPC Fontan design provides a feasible MCS solution for a failing Fontan by balancing hepatic flow distribution and symmetrically decompressing the central venous pressure. Cardiac index may also improve with MCS. Additional studies are needed to evaluate this concept for managing Fontan failure.
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Affiliation(s)
- Vincent Cleveland
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | | | - Paige Mass
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Priyanka Hardikar
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Qiyuan Wu
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Xiaolong Liu
- Department of Mechanical Engineering, Texas Tech University, Lubbock, TX, USA
| | - Seda Aslan
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Yue-Hin Loke
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Axel Krieger
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Scott Lunos
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Laura Olivieri
- Division of Pediatric Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pranava Sinha
- Department of Pediatric Cardiac Surgery, M Health Fairview University of Minnesota, Minneapolis, MN, USA
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Şişli E, Yıldırım C, Aka İB, Tuncer ON, Atay Y, Özbaran M, Pekkan K. Switching the Left and the Right Hearts: A Novel Bi-ventricle Mechanical Support Strategy with Spared Native Single-Ventricle. Ann Biomed Eng 2023; 51:2853-2872. [PMID: 37635154 DOI: 10.1007/s10439-023-03348-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023]
Abstract
End-stage Fontan patients with single-ventricle (SV) circulation are often bridged-to-heart transplantation via mechanical circulatory support (MCS). Donor shortage and complexity of the SV physiology demand innovative MCS. In this paper, an out-of-the-box circulation concept, in which the left and right ventricles are switched with each other is introduced as a novel bi-ventricle MCS configuration for the "failing" Fontan patients. In the proposed configuration, the systemic circulation is maintained through a conventional mechanical ventricle assist device (VAD) while the venous circulation is delegated to the native SV. This approach spares the SV and puts it to a new use at the right-side providing the most-needed venous flow pulsatility to the failed Fontan circulation. To analyze its feasibility and performance, eight SV failure modes have been studied via an established multi-compartmental lumped parameter cardiovascular model (LPM). Here the LPM model is experimentally validated against the corresponding pulsatile mock-up flow loop measurements of a representative 15-year-old Fontan patient employing a clinically-approved VAD (Medtronic-HeartWare). The proposed surgical configuration maintained the healthy cardiac index (3-3.5 l/min/m2) and the normal mean systemic arterial pressure levels. For a failed SV with low ejection fraction (EF = 26%), representing a typical systemic Fontan failure, the proposed configuration enabled a ~ 28 mmHg amplitude in the venous/pulmonary waveforms and a 2 mmHg decrease in the central venous pressure (CVP) together with acceptable mean pulmonary artery pressures (17.5 mmHg). The pulmonary vascular resistance (PVR)-SV failure case provided a ~ 5 mmHg drop in the CVP, with venous/pulmonary pulsatility reaching to ~ 22 mmHg. For the high PVR failure case with a healthy SV (EF = 44%) pulmonary hypertension is likely to occur as expected. While this condition is routinely encountered during the heart transplantation and managed through pulmonary vasodilators a need for precise functional assessment of the spared failed-ventricle is recommended if utilized in the PVR failure mode. Comprehensive in vitro and in silico results encourage this novel concept as a low-cost, more physiological alternative to the conventional bi-ventricle MCS pending animal experiments.
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Affiliation(s)
- Emrah Şişli
- Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Osmangazi University Faculty of Medicine, Büyükdere District, Campus of Meşelik, Tepebaşı, 26480, Eskisehir, Turkey.
| | - Canberk Yıldırım
- Department of Biomedical Sciences and Engineering, Koç University, Istanbul, Turkey
| | - İbrahim Başar Aka
- Department of Mechatronics Engineering, İstanbul Bilgi University, Istanbul, Turkey
| | - Osman Nuri Tuncer
- Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Yüksel Atay
- Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Mustafa Özbaran
- Heart Transplantation, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Kerem Pekkan
- Department of Mechanical Engineering, Koç University, Rumeli Feneri Campus, Sarıyer, Istanbul, Turkey.
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Nissim L, Karnik S, Smith PA, Wang Y, Frazier OH, Fraser KH. Machine learning based on computational fluid dynamics enables geometric design optimisation of the NeoVAD blades. Sci Rep 2023; 13:7183. [PMID: 37137928 PMCID: PMC10156814 DOI: 10.1038/s41598-023-33708-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/18/2023] [Indexed: 05/05/2023] Open
Abstract
The NeoVAD is a proposed paediatric axial-flow Left Ventricular Assist Device (LVAD), small enough to be implanted in infants. The design of the impeller and diffuser blades is important for hydrodynamic performance and haemocompatibility of the pump. This study aimed to optimise the blades for pump efficiency using Computational Fluid Dynamics (CFD), machine learning and global optimisation. Meshing of each design typically included 6 million hexahedral elements and a Shear Stress Transport turbulence model was used to close the Reynolds Averaged Navier-Stokes equations. CFD models of 32 base geometries, operating at 8 flow rates between 0.5 and 4 L/min, were created to match experimental studies. These were validated by comparison of the pressure-flow and efficiency-flow curves with those experimentally measured for all base prototype pumps. A surrogate model was required to allow the optimisation routine to conduct an efficient search; a multi-linear regression, Gaussian Process Regression and a Bayesian Regularised Artificial Neural Network predicted the optimisation objective at design points not explicitly simulated. A Genetic Algorithm was used to search for an optimal design. The optimised design offered a 5.51% increase in efficiency at design point (a 20.9% performance increase) as compared to the best performing pump from the 32 base designs. An optimisation method for the blade design of LVADs has been shown to work for a single objective function and future work will consider multi-objective optimisation.
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Affiliation(s)
- Lee Nissim
- Department of Mechanical Engineering, University of Bath, Bath, BA2 7AY, UK
| | - Shweta Karnik
- Innovative Device and Engineering Applications (IDEA) Lab, Texas Heart Institute, Houston, Texas, 77030, USA
| | - P Alex Smith
- Innovative Device and Engineering Applications (IDEA) Lab, Texas Heart Institute, Houston, Texas, 77030, USA
| | - Yaxin Wang
- Innovative Device and Engineering Applications (IDEA) Lab, Texas Heart Institute, Houston, Texas, 77030, USA
| | - O Howard Frazier
- Innovative Device and Engineering Applications (IDEA) Lab, Texas Heart Institute, Houston, Texas, 77030, USA
| | - Katharine H Fraser
- Department of Mechanical Engineering, University of Bath, Bath, BA2 7AY, UK.
- Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK.
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An Up-to-Date Literature Review on Ventricular Assist Devices Experience in Pediatric Hearts. LIFE (BASEL, SWITZERLAND) 2022; 12:life12122001. [PMID: 36556366 PMCID: PMC9788166 DOI: 10.3390/life12122001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022]
Abstract
Ventricular assist devices (VAD) have gained popularity in the pediatric population during recent years, as more and more children require a heart transplant due to improved palliation methods, allowing congenital heart defect patients and children with cardiomyopathies to live longer. Eventually, these children may require heart transplantation, and ventricular assist devices provide a bridge to transplantation in these cases. The FDA has so far approved two types of device: pulsatile and continuous flow (non-pulsatile), which can be axial and centrifugal. Potential eligible studies were searched in three databases: Medline, Embase, and ScienceDirect. Our endeavor retrieved 16 eligible studies focusing on five ventricular assist devices in children. We critically reviewed ventricular assist devices approved for pediatric use in terms of implant indication, main adverse effects, and outcomes. The main adverse effects associated with these devices have been noted to be thromboembolism, infection, bleeding, and hemolysis. However, utilizing left VAD early on, before end-organ dysfunction and deterioration of heart function, may give the patient enough time to recuperate before considering a more long-term solution for ventricular support.
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Wald R, Mertens L. Hypoplastic Left Heart Syndrome Across the Lifespan: Clinical Considerations for Care of the Fetus, Child, and Adult. Can J Cardiol 2022; 38:930-945. [PMID: 35568266 DOI: 10.1016/j.cjca.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 12/14/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is the most common anatomic lesion in children born with single ventricle physiology and is characterized by the presence of a dominant right ventricle and a hypoplastic left ventricle along with small left-sided heart structures. Diagnostic subgroups of HLHS reflect the extent of inflow and outflow obstruction at the aortic and mitral valves, specifically stenosis or atresia. If left unpalliated, HLHS is a uniformly fatal lesion in infancy. Following introduction of the Norwood operation, early survival has steadily improved over the past four decades, mirroring advances in operative and peri-operative management as well as reflecting refinements in patient surveillance and interstage clinical care. Notably, survival following staged palliation has increased from 0% to a 5-year survival of 60-65% for children in some centres. Despite the prevalence of HLHS in childhood with relatively favourable surgical outcomes in contemporary series, this cohort is only now reaching early adult life and longer-term outcomes have yet to be elucidated. In this article we focus on contemporary clinical management strategies for patients with HLHS across the lifespan, from fetal to adult life. Nomenclature and diagnostic considerations are discussed and current literature pertaining to putative genetic etiologies is reviewed. The spectrum of fetal and pediatric interventional strategies, both percutaneous and surgical, are described. Clinical, patient-reported and neurodevelopmental outcomes of HLHS are delineated. Finally, note is made of current areas of clinical uncertainty and suggested directions for future research are highlighted.
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Affiliation(s)
- Rachel Wald
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
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In-Vitro Validation of Self-Powered Fontan Circulation for Treatment of Single Ventricle Anomaly. FLUIDS 2021. [DOI: 10.3390/fluids6110401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Around 8% of all newborns with a Congenital Heart Defect (CHD) have only a single functioning ventricle. The Fontan operation has served as palliation for this anomaly for decades, but the surgery entails multiple complications, and the survival rate is less than 50% by adulthood. A rapidly testable novel alternative is proposed by creating a bifurcating graft, or Injection Jet Shunt (IJS), used to “entrain” the pulmonary flow and thus provide assistance while reducing the caval pressure. A dynamically scaled Mock Flow Loop (MFL) has been configured to validate this hypothesis. Three IJS nozzles of varying diameters 2, 3, and 4 mm with three aortic anastomosis angles and pulmonary vascular resistance (PVR) reduction have been tested to validate the hypothesis and optimize the caval pressure reduction. The MFL is based on a Lumped-Parameter Model (LPM) of a non-fenestrated Fontan circulation. The best outcome was achieved with the experimental testing of a 3 mm IJS by producing an average caval pressure reduction of more than 5 mmHg while maintaining the clinically acceptable pulmonary flow rate (Qp) to systemic flow rate (Qs) ratio of ~1.5. Furthermore, alteration of the PVR helped in achieving higher caval pressure reduction with the 3 mm IJS at the expense of an increase in Qp/Qs ratio.
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A Tribute to Ajit Yoganathan's Cardiovascular Fluid Mechanics Lab: A Survey of Its Contributions to Our Understanding of the Physiology and Management of Single-Ventricle Patients. Cardiovasc Eng Technol 2021; 12:631-639. [PMID: 34018153 DOI: 10.1007/s13239-021-00540-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 04/30/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Among patients with congenital heart disease, those born with only a single working ventricle represent a particularly complex sub-population, typically requiring multiple surgeries and suffering from high levels of mortality and morbidity. Their cardiac care is complex and has evolved considerably since surgical palliation was first introduced more than 50 years ago. Improvements in treatment have been driven both by growing clinical experience and by knowledge gained through experimental and computational studies of blood flow in these patients. The Cardiovascular Fluid Mechanics Lab at the Georgia Institute of Technology, founded 30 years ago by Dr. Ajit Yoganathan, has pioneered work in this field. METHODS In this review, key contributions of Dr. Yoganathan's Cardiovascular Fluid Dynamics Lab are surveyed, including experimental flow loop studies as well as computational fluid dynamics analyses that address many of the critical challenges that cardiologists and surgeons face in treating these patients, including how to reconstruct cardiovascular anatomy to minimize power loss, balance blood flow distribution at key bifurcation points, and avoid other unfavorable hemodynamic conditions. CONCLUSIONS Among many contributions in this field, work from the Cardiovascular Fluid Mechanics Lab has led to novel medical devices and patient-specific computational modeling workflows and software tools. These key contributions from this group have enhanced our understanding of the physiology and management of single-ventricle patients.
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Farahmand M, Kavarana MN, Trusty PM, Kung EO. Target Flow-Pressure Operating Range for Designing a Failing Fontan Cavopulmonary Support Device. IEEE Trans Biomed Eng 2020; 67:2925-2933. [PMID: 32078526 DOI: 10.1109/tbme.2020.2974098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fontan operation as the current standard of care for the palliation of single ventricle defects results in significant late complications. Using a mechanical circulatory device for the right circulation to serve the function of the missing subpulmonary ventricle could potentially stabilize the failing Fontan circulation. This study aims to elucidate the hydraulic operating regions that should be targeted for designing cavopulmonary blood pumps. By integrating numerical analysis and available clinical information, the interaction of the cavopulmonary support via the IVC and full assist configurations with a wide range of simulated adult failing scenarios was investigated; with IVC and full assist corresponding to the inferior venous return or the entire venous return, respectively, being routed through the device. We identified the desired hydraulic operating regions for a cavopulmonary assist device by clustering all head pressures and corresponding pump flows that result in hemodynamic improvement for each simulated failing Fontan physiology. Results show that IVC support can produce beneficial hemodynamics in only a small fraction of failing Fontan scenarios. Cavopulmonary assist device could increase cardiac index by 35% and decrease the inferior vena cava pressure by 45% depending on the patient's pre-support hemodynamic state and surgical configuration of the cavopulmonary assist device (IVC or full support). The desired flow-pressure operating regions we identified can serve as the performance criteria for designing cavopulmonary assist devices as well as evaluating off-label use of commercially available left-side blood pumps for failing Fontan cavopulmonary support.
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Trusty PM, Alan Wei Z, Fogel MA, Maher K, Deshpande SR, Yoganathan AP. Computational modeling of a right-sided Fontan assist device: Effectiveness across patient anatomies and cannulations. J Biomech 2020; 109:109917. [PMID: 32807331 DOI: 10.1016/j.jbiomech.2020.109917] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 10/23/2022]
Abstract
The use of mechanical circulatory support for failing Fontan patients is an area of growing interest, as the increased life expectancy of these patients continues to be accompanied by numerous end-organ complications. In vitro work has shown positive results using the CentriMag device for right-sided Fontan support, however the generalizability across various patient anatomies and cannulations is unknown. Computational simulations are first validated against in vitro modeling, then used to assess generalizability and further explore hemodynamic metrics including relative pressure changes, hepatic flow distribution, wall shear stress and power added. Computational modeling matched previous in vitro work very well, with vessel flow rates and relative average pressure change each within 1%. Positive results were seen across all patient anatomies and cannulations. On average, pressure from the vena cava to pulmonary arteries increased by 5.4 mmHg corresponding to 32 mW of power added. Hepatic flow distribution and wall shear stress were within acceptable ranges, with an average hepatic flow distribution of 47% and all patients showing ≤ 1% of the total Fontan connection surface area at a wall shear stress above 150 Pa. The positive results previously seen using CentriMag as a right-sided Fontan support device were found to be repeatable across multiple patient anatomies and cannulations. While animal models and eventual patient studies will provide further insight into the efficacy of this support strategy, our findings here suggest this method may reproduce right heart function.
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Affiliation(s)
- Phillip M Trusty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Kevin Maher
- Pediatric Cardiology Division, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Shriprasad R Deshpande
- Pediatric Cardiology Division, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States.
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Broda CR, Downing TE, John AS. Diagnosis and management of the adult patient with a failing Fontan circulation. Heart Fail Rev 2020; 25:633-646. [DOI: 10.1007/s10741-020-09932-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Honjo O, Doyle MG, Amon CH. Commentary: Engineering an optimal mechanical circulatory support system for the cavopulmonary connection. J Thorac Cardiovasc Surg 2019; 159:e143-e144. [PMID: 31540736 DOI: 10.1016/j.jtcvs.2019.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/05/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Osami Honjo
- Division of Cardiovascular Surgery, Department of Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Matthew G Doyle
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Cristina H Amon
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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Broda CR, Adachi I. Commentary: Fontan assist device support: Road map to "stage 4" palliation. J Thorac Cardiovasc Surg 2019; 158:1422-1423. [PMID: 31493880 DOI: 10.1016/j.jtcvs.2019.06.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Christopher R Broda
- Department of Pediatrics, Pediatric and Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex
| | - Iki Adachi
- Department of Surgery, Congenital Heart Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex.
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