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Read J, Ridout D, Johnson S, Hoskote A, Sheehan K, Wellman P, Jones A, Wray J, Brown K. Postoperative morbidities with infant cardiac surgery and toddlers' neurodevelopment. Arch Dis Child 2022; 107:922-928. [PMID: 35793944 DOI: 10.1136/archdischild-2021-322756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 05/04/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the relationship between morbidities after infant cardiac surgery and neurodevelopment and behaviour at age 2-3 years. DESIGN/SETTING A prospective cohort follow-up study, in four paediatric cardiac centres. We excluded children with known syndromes. Home-based neurodevelopmental assessments using the Bayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III) were undertaken in 81 children and secondary outcome measures of development and behaviour were completed by parents. A further 41 families completed the secondary outcome measures remotely. RESULTS Children were grouped as multiple morbidities/extracorporeal life support (ECLS) (n=19), single morbidities (n=36) and no morbidities (n=59). Group comparisons found that children with multiple morbidities/ECLS, compared with no morbidities, had: (a) lower adjusted mean scores for core Bayley-III composites (none reached the level of statistical significance), with mean differences of cognitive -6.1 (95% CI -12.4 to 0.1) p=0.06, language -9.1 (95% CI -18.6 to 0.3) p=0.06 and motor -4.4 (95% CI -12.0 to 3.1) p=25; (b) greater adjusted odds of at least one low or borderline Bayley-III composite result 4.0 (95% CI 1.0 to 16.0) (p=0.05); (c) greater adjusted risk of an abnormal Ages and Stages Questionnaire (ASQ) result 5.3 (95% CI 1.3 to 21.1) (p=0.03) and a borderline ASQ result 4.9 (95% CI 1.0 to 25.0) (p=0.05); and no difference in the risk of an abnormal Strengths and Difficulties Questionnaire result 1.7 (95% CI 0.3 to 10.4) p=0.58. These outcomes were not statistically different between the single morbidity and no morbidity groups. CONCLUSIONS Children who experience multiple morbidities/ECLS after infant heart surgery are at a greater risk of neurodevelopmental difficulties than their peers who had no complications and should be prioritised for neurodevelopmental follow-up.
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Affiliation(s)
- Julie Read
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Deborah Ridout
- Paediatric Epidemiology Biostatistics, University College London Institute of Child Health, London, UK
| | - Samantha Johnson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital National Institute Health Research Biomedical Research Centre, London, UK
| | - Karen Sheehan
- Department of Paediatric Cardiology, Bristol Royal Children's Hospital, Bristol, UK
| | - Paul Wellman
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, UK
| | - Alison Jones
- Department of Paediatric Intensive Care, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Jo Wray
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Katherine Brown
- Heart and Lung Division, Great Ormond Street Hospital National Institute Health Research Biomedical Research Centre, London, UK
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Tjoeng YL, Jenkins K, Deen JF, Chan T. Association between race/ethnicity, illness severity, and mortality in children undergoing cardiac surgery. J Thorac Cardiovasc Surg 2020; 160:1570-1579.e1. [PMID: 32739167 DOI: 10.1016/j.jtcvs.2020.06.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 06/07/2020] [Accepted: 06/12/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Prior studies demonstrate an association between nonwhite race/ethnicity, insurance status, and mortality after pediatric congenital heart surgery. The influence of severity of illness on that association is unknown. We examined the relationship between race/ethnicity, severity of illness, and mortality in congenital cardiac surgery, and whether severity of illness is a mechanism by which nonwhite patients experience increased surgical mortality. METHODS We performed a retrospective cohort study of children younger than age 18 years old undergoing cardiac surgery admitted to the intensive care unit (n = 40,545) between 2009 and 2016 from the Virtual Pediatric Systems (VPS, LLC, Los Angeles, Calif) database. Multivariate regression models were constructed to examine the role of severity of illness as a mediator between race/ethnicity and mortality in children undergoing cardiac surgery. RESULTS In multivariate models examining severity of illness scores, African-American patients had statistically significant higher severity of illness scores when compared with their white counterparts. In multivariate models of intensive care unit mortality after adjustment for covariates, African-American patients had a higher odds of postoperative mortality (odds ratio, 1.40, 95% confidence interval, 1.04-1.89) when compared with white children. This increased odds of mortality was mediated through higher severity of illness, because adjustment for severity of illness removed this survival disadvantage for black patients. CONCLUSIONS Although African-American children undergoing cardiac surgery had higher postoperative mortality, this survival difference appears to be mediated via severity of illness. Preoperative and intraoperative factors may be drivers for this survival disparity.
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Affiliation(s)
- Yuen Lie Tjoeng
- Division of Critical Care Medicine, Seattle Children's Hospital, University of Washington, Seattle, Wash; Division of Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Wash.
| | - Kathy Jenkins
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Jason F Deen
- Division of Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Wash; Center of Health Equity, Diversity and Inclusion, School of Medicine, University of Washington, Seattle, Wash
| | - Titus Chan
- Division of Critical Care Medicine, Seattle Children's Hospital, University of Washington, Seattle, Wash; Division of Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Wash
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Karamichalis JM. Commentary: Performance, safety monitoring, and needle counts in the operating room. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)30198-7. [PMID: 32067789 DOI: 10.1016/j.jtcvs.2020.01.008] [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: 01/01/2020] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 11/25/2022]
Affiliation(s)
- John M Karamichalis
- Cardiac Surgery, LeBonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn.
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Kothari LG, Shah K, Barach P. Simulation based medical education in graduate medical education training and assessment programs. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Cunningham MEA, Donofrio MT, Peer SM, Zurakowski D, Jonas R, Sinha P. Influence of Age and Weight on Technical Repair of Tetralogy of Fallot. Ann Thorac Surg 2016; 102:864-869. [PMID: 27154147 DOI: 10.1016/j.athoracsur.2016.02.087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/21/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND We have previously shown that early primary repair of tetralogy of Fallot can be performed without increased morbidity or resource utilization. The technical performance score (TPS) is a self-assessment tool used to identify patients at risk of poor postoperative outcomes. We hypothesized that adequate technical repair can be obtained regardless of the patient's preoperative age or size. METHODS A retrospective review of all tetralogy of Fallot patients repaired between September 2004 and December 2013 was performed. The postoperative predischarge echocardiogram was reviewed to assign a TPS rating of optimal, adequate, or inadequate. The TPS groups were compared by univariate analysis using the Kruskal-Wallis test for continuous variables and χ(2) analysis for categoric variables. Multivariable logistic regression analysis was performed to identify independent predictors of inadequate TPS. RESULTS Among 167 patients (1 operative mortality), TPS was optimal in 88, adequate in 62, and inadequate in 17. Patients with worse TPS had longer ventilation time (p = 0.031), hospital length of stay (p = 0.036), and higher hospital charges (p = 0.005). Multivariable regression analysis revealed discontinuous branch pulmonary arteries (odds ratio 18.24, 95% confidence interval: 1.42 to 234, p = 0.015) as the only independent predictor of inadequate TPS. Younger age at repair (p = 0.245) and smaller weight (p = 0.260) were not associated with inadequate TPS. CONCLUSIONS Technical adequacy of tetralogy of Fallot repair is affected by anatomic subsets (discontinuous branch pulmonary arteries) and not by the patient's age or size. Worse TPS is associated with higher postoperative morbidity and hospital charges. Younger age and size should not be a deterrent for early primary repair.
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Affiliation(s)
| | - Mary T Donofrio
- Department of Cardiology, Children's National Health System, Washington, DC
| | - Syed Murfad Peer
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC.
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Szasz P, Louridas M, Harris KA, Aggarwal R, Grantcharov TP. Assessing Technical Competence in Surgical Trainees. Ann Surg 2015; 261:1046-55. [DOI: 10.1097/sla.0000000000000866] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Nathan M, Gauvreau K, Liu H, Pigula FA, Mayer JE, Colan SD, Del Nido PJ. Outcomes differ in patients who undergo immediate intraoperative revision versus patients with delayed postoperative revision of residual lesions in congenital heart operations. J Thorac Cardiovasc Surg 2014; 148:2540-6.e1-5. [PMID: 25173124 DOI: 10.1016/j.jtcvs.2014.07.073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/07/2014] [Accepted: 07/20/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES In a previous study of infants less than 6 month old, we found that delayed revision of residual lesions resulted in worse patient outcomes compared with intraoperative revision. We explored a larger cohort to determine if this finding persisted. METHODS A prospective cohort followed from index surgery to discharge from January 2011 to September 2013 were divided into 4 groups: (1) intraoperative revisions (IO) of residual lesions, (2) delayed postoperative revision (PO) of residual lesions during the same hospital stay, (3) both intraoperative and delayed (BOTH) revision of residual lesions, (4) no intraoperative or postoperative revision (NO). Linear and logistic regression analyses were used to compare outcomes of postoperative hospital length of stay, postoperative adverse events (AE), hospital costs, and mortality, after adjusting for age, prematurity, presence of extracardiac anomalies, and RACHS-1 (Risk Adjustment for Congenital Heart Surgery-1) risk category known to affect outcomes. RESULTS Of the 2427 patients discharged after a congenital cardiac operation, 1886 were eligible for this study after exclusion of adults, procedures performed off cardiopulmonary bypass, and transplants and assist devices. On multivariable modeling adjusting for other significant patient factors, the NO group fared better than the other 3 groups. The IO group had significantly lower postoperative length of stay, AE rate, and hospital costs compared with the PO and BOTH groups, but showed no significant differences in mortality. CONCLUSIONS Intraoperative correction of residual lesions results in shorter length of stay, and lower postoperative AE and costs compared with delayed postoperative revision of residual lesions.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Hua Liu
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Frank A Pigula
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
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Nathan M, Karamichalis J, Liu H, Gauvreau K, Colan S, Saia M, Pigula F, Fynn-Thompson F, Emani S, Baird C, Mayer JE, del Nido PJ. Technical Performance Scores are strongly associated with early mortality, postoperative adverse events, and intensive care unit length of stay-analysis of consecutive discharges for 2 years. J Thorac Cardiovasc Surg 2013; 147:389-94, 396.e1-396.e3. [PMID: 24035318 DOI: 10.1016/j.jtcvs.2013.07.044] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 06/20/2013] [Accepted: 07/16/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Previous work in our institution has indicated that the Technical Performance Score (TPS) is highly associated with early outcomes in select subsets of procedures and age groups. We hypothesized that the TPS could predict early outcomes in a wide range of diagnoses and age groups. METHODS Consecutive patients discharged from January 2011 to March 2013 were prospectively evaluated. The TPS was assigned according to the discharge echocardiographic findings and the need for reinterventions in the anatomic area of interest. Case complexity was determined using Risk Adjustment for Congenital Heart Surgery (RACHS-1) categories. Early mortality and postoperative adverse events were recorded. Relationships between the TPS and outcomes were assessed after adjusting for the baseline patient characteristics. RESULTS The median age of the 1926 patients was 1.8 years (range, 0 days to 68 years). Bypass was used in 1740 (90%); 322 (17%) were neonates, 520 (27%) infants, 873 (45%) children, 211 (11%) adults. TPS was class 1 (optimal) in 956 (50%), class 2 (adequate) in 584 (30%), and class 3 (inadequate) in 226 (12%); 160 patients (8%) could not be scored. A total of 51 early deaths (2.6%) and 111 adverse events (5.7%) occurred. On univariate analysis, age, RACHS-1 category, and TPS were significantly associated with mortality and the occurrence of adverse events. On multivariate modeling, class 3 (inadequate) TPS was strongly associated with mortality (odds ratio, 16.9; 95% confidence interval, 6.7-42.9; P < .001), adverse events (odds ratio, 6.9; 95% confidence interval, 4.1-11.6; P < .001), and postoperative intensive care unit length of stay (coefficient, 2.3; 95% confidence interval, 2.0-2.6; P < .001) after adjusting for other covariates. CONCLUSIONS The TPS is strongly associated with early outcomes across a wide range of ages and disease complexity and can serve as important tool for self-assessment and quality improvement.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
| | - John Karamichalis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Hua Liu
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Kimberley Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Steven Colan
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Matthew Saia
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Frank Pigula
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Pedro J del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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Nathan M, Pigula FA, Liu H, Gauvreau K, Colan SD, Fynn-Thompson F, Emani S, Baird CA, Mayer JE, Del Nido PJ. Inadequate technical performance scores are associated with late mortality and late reintervention. Ann Thorac Surg 2013; 96:664-9. [PMID: 23782646 DOI: 10.1016/j.athoracsur.2013.04.043] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/10/2013] [Accepted: 04/15/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND We have shown previously that technical performance score (TPS) is strongly associated with early mortality and major postoperative adverse events in a diverse group of patients. We now report evaluation of the validity of TPS in predicting late outcomes in the same group of patients. METHODS Patients who underwent surgery between June 1, 2005 and June 30, 2006 were included. The TPS were assigned based on discharge echocardiograms and certain clinical criteria as previously described. Follow-up data for up to 4 years were retrospectively collected. Cox proportional hazards models were used for analysis. RESULTS A total of 679 patients were included in the analysis. One hundred twenty-three (18%) were neonates, 213 (31%) infants, 291 (435) children, and 52 (8%) adults. Four hundred ninety-one (72%) were in low-risk adjustment in congenital heart surgery (RACHS; 1 to 3), 109 (16%) in high risk (4 to 6), and 27 (4%) were less than 18 years and could not be assigned a RACHS score. Three hundred thirty-one (48%) had an optimal TPS, 283 (42%) adequate, 61 (9%) inadequate, and 4 (1%) could not be scored. There were 34 (5%) late deaths and 149 (22%) late unplanned reinterventions. By univariate analysis, age, RACHS-1 categories, and TPS were all significantly associated with late reintervention (p < 0.001 for all), while TPS and RACHS-1 were significant factors for mortality (p < 0.001). On multivariable modeling, inadequate TPS was strongly associated with both late mortality (p = 0.001; HR [hazard ratio] 3.8, CI [confidence interval] 1.7 to 8.4) and late reintervention (p = 0.002, HR 2.1, CI 1.3 to 3.3) after controlling for RACHS-1 and age. CONCLUSIONS The TPS has a strong association with late outcomes across a wide range of age and disease complexity and may serve as a tool to identify patients who are at a higher risk for late reintervention or mortality.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Karamichalis JM, Colan SD, Nathan M, Pigula FA, Baird C, Marx G, Emani SM, Geva T, Fynn-Thompson FE, Liu H, Mayer JE, del Nido PJ. Technical performance scores in congenital cardiac operations: a quality assessment initiative. Ann Thorac Surg 2012; 94:1317-23; discussion 1323. [PMID: 22795058 DOI: 10.1016/j.athoracsur.2012.05.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 04/27/2012] [Accepted: 05/02/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Technical performance in congenital cardiac operations and its association with clinical outcomes was previously examined in infants and neonates. The purpose of this study was the development and implementation of a system for measuring technical performance in the majority of congenital cardiac operations to be used as a surgeon's self-assessment tool. METHODS Using the methodologic framework piloted at our institution, measures of technical performance were created for more than 90% of all congenital cardiac operations. Each operation was divided into multiple subprocedures to be assessed separately. Criteria for technical scores were created using a consensus panel of senior clinicians and were based primarily on the predischarge echocardiographic findings and need for early postoperative reinterventions. This system of procedure modules was then piloted by prospectively assigning technical scores to all patients undergoing operations. RESULTS Thirty modules were created covering more than 90% of the cardiac operations performed. One hundred eighty-five patients were enlisted. One hundred one (54.6%) cases were scored as class 1 (highest), 46 (24.9%) cases as class 2, 22 (11.9%) cases as class 3 (lowest); 16 cases (8.6%) could not be scored. The results were further analyzed by RACHS (Risk Adjustment for Congenital Heart Surgery) categories and outcomes. Valve-procedure-specific criteria were calibrated to reflect specific echocardiographic measurements. CONCLUSIONS The development and implementation of a broad technical performance self-assessment system for congenital cardiac operations is possible. Based on this scoring system, the impact of a less than optimal (2 or 3) technical score depends on case risk category, with higher mortality in the higher risk group, and increased resource use for lower risk procedures.
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Affiliation(s)
- John M Karamichalis
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts, USA.
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