1
|
Sur LM, Armat I, Sur G, Tisa IB, Bordea MA, Lupan I, Samasca G, Lazar C. Practical Aspects of Upper Gastrointestinal Bleeding in Children. J Clin Med 2023; 12:jcm12082921. [PMID: 37109257 PMCID: PMC10145382 DOI: 10.3390/jcm12082921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/01/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
Upper gastrointestinal bleeding (UGB) in children is a potentially life-threatening condition that represents a challenge for pediatricians and pediatric surgeons. It is defined as bleeding from any location within the upper esophagus to the ligament of Treitz. UGB can have many causes that vary with age. The impact on the child is often proportional to the amount of blood lost. This can range from mild bleeding that is unlikely to cause hemodynamic instability, to massive bleeding that requires admission to the intensive care unit. Proper and prompt management are very important factors in reducing morbidity and mortality. This article aims to summarize current research regarding the diagnosis and treatment of UGB. Most of the data used in the literature published on this subject is extrapolated from adulthood.
Collapse
Affiliation(s)
- Lucia Maria Sur
- Department of Pediatrics I, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Ionel Armat
- Department of Pediatrics II, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Genel Sur
- Department of Pediatrics II, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Ioana Badiu Tisa
- Department of Pediatrics III, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Madalina Adriana Bordea
- Department of Microbiology, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Iulia Lupan
- Department of Molecular Biology, Babes Bolyai University, 400084 Cluj-Napoca, Romania
| | - Gabriel Samasca
- Department of Immunology, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Calin Lazar
- Department of Pediatrics I, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| |
Collapse
|
2
|
Esmaeili A, Schrewe R, Wong F, Schranz D. Axillary artery access for stenting of aortic coarctation in a 1.2 kg premature newborn with malignant systemic hypertension: a case report. Eur Heart J Case Rep 2021; 5:ytaa554. [PMID: 33598622 PMCID: PMC7873809 DOI: 10.1093/ehjcr/ytaa554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/07/2020] [Accepted: 12/10/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Axillary artery access is rarely used for demanding percutaneous transcatheter interventions. However, there are many clear advantages. CASE SUMMARY We describe this attractive approach in a 3-week-old premature neonate (bodyweight of 1.2 kg) with severe aortic coarctation. Percutaneous transcatheter intervention was performed with analgo-sedation and local anaesthesia; and a coronary stent was placed with a low fluoroscopy time of 2 min. Malignant systemic hypertension (160/54 mmHg) was effectively treated without any residual blood pressure gradient, with the aim for definitive surgery with stent resection and end-to-end anastomosis at the age of 6-12 months. DISCUSSION Axillary artery access is an attractive, alternative approach to treat newborns and premature infants with low body weight with complex heart diseases.
Collapse
Affiliation(s)
- Anoosh Esmaeili
- Department of Children and Adolescent Medicine, Pediatric cardiology, Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Roland Schrewe
- Department of Children and Adolescent Medicine, Pediatric cardiology, Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Flora Wong
- Monash Newborn, Children’s Hospital, Melbourne, Australia
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Paediatrics, Monash University Clinic, Melbourne, Australia
| | - Dietmar Schranz
- Department of Children and Adolescent Medicine, Pediatric cardiology, Frankfurt University Hospital, Frankfurt am Main, Germany
| |
Collapse
|
3
|
Abstract
The hypoplasia of left-sided heart structures shows great variability and complexity. What the many variants have in common is that their heart structures are neither fully developed before nor after birth. Fetuses and newborns require an individual therapy depending on anatomy and function of the heart. Fetal interventions focus on improving left heart structures by catheter-based interventions and maternal hyperoxygenation which promotes growth as the left ventricular preload and blood flow within the cavity increase. Stage-I management of newborns with single ventricle physiology is usually based on the Norwood/Sano surgery or the Hybrid approach. Two more steps are required to ultimately achieve a Fontan circulation. Some centers also use the Hybrid approach for subsequent Norwood operation beyond the neonatal period. After the Hybrid approach, a comprehensive stage-II or corrective surgery is performed, the latter if a bi-ventricular circulation is possible. With progressively improved catheter-based interventions, particularly ductal stenting and manipulations of the atrial septum, the next advance is to develop a bespoke flow restrictor that can be easily inserted into the branches of the pulmonary artery. The main goal is to avoid complex heart operations under general anesthesia, followed by substantial intensive care in the neonatal period, especially for patients with complex heart defects. Based on the current state of the art of surgical treatment of hypoplastic left heart syndrome and variants with the Norwood surgery or the Hybrid approach, our main focus is on an alternative percutaneous transcatheter technique in the sense of a completely non-surgical stage-I approach.
Collapse
|
4
|
Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | |
Collapse
|
5
|
Lv Y, Liu Z, Huang J, Yu J, Dong Y, Wang J. LncRNA nuclear-enriched abundant transcript 1 regulates hypoxia-evoked apoptosis and autophagy via mediation of microRNA-181b. Mol Cell Biochem 2019; 464:193-203. [PMID: 31853799 DOI: 10.1007/s11010-019-03660-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/16/2019] [Indexed: 12/22/2022]
Abstract
Nuclear-enriched abundant transcript 1 (NEAT1), a vital long noncoding RNA (lncRNA), exhibits the functions in disparate cancers. Nevertheless, the influences of NEAT1 in congenital heart disease (CHD) remain unreported. The research delves into whether NEAT1 affects H9c2 cells apoptosis and autophagy under the hypoxia condition. Overexpressed NEAT1 vector was transfected into H9c2 cells; then, functions of NEAT1 in cell viability, apoptosis, autophagy, PI3K/AKT/mTOR and JAK1/STAT3 pathways were detected in H9c2 cells under hypoxia condition. Expression of NEAT1 and miR-181b in hypoxia and blood samples from CHD was evaluated. After miR-181b inhibitor transfection, functions of miR-181b repression in the above-mentioned cell behavior and PI3K/AKT/mTOR and JAK1/STAT3 pathways were reassessed. Overexpressed NEAT1 clearly allayed hypoxia-triggered H9c2 cells apoptosis and autophagy. The decreased NEAT1 and miR-181b were showcased in hypoxia and blood samples from CHD; meanwhile, elevated miR-181b evoked by overexpressed NEAT1 was observed in hypoxia-managed H9c2 cells. More importantly, miR-181b inhibition obviously overturned the influences of NEAT1 in hypoxia-affected H9c2 cells apoptosis and autophagy. Besides, overexpressed NEAT1 facilitated PI3K/AKT/mTOR and JAK1/STAT3 activations via enhancing miR-181b. The research exposed that NEAT1 eased hypoxia-triggered H9c2 cells apoptosis and autophagy by expediting PI3K/AKT/mTOR and JAK1/STAT3 pathways via elevating miR-181b.
Collapse
Affiliation(s)
- Ying Lv
- Department of Cardiovascular Surgery, The First Hospital of Hebei Medical University, No. 89 Donggang Road, Shijiazhuang, 050031, Hebei, China
| | - Zhaoming Liu
- Department of Pediatric Surgery, Shijiazhuang Maternity & Child Healthcare Hospital, No. 9 Jianguo Road, Shijiazhuang, 050051, Hebei, China
| | - Jiancheng Huang
- Department of Cardiovascular Surgery, The First Hospital of Hebei Medical University, No. 89 Donggang Road, Shijiazhuang, 050031, Hebei, China
| | - Jie Yu
- Department of Cardiovascular Surgery, The First Hospital of Hebei Medical University, No. 89 Donggang Road, Shijiazhuang, 050031, Hebei, China
| | - Yanbo Dong
- Department of Cardiovascular Surgery, The First Hospital of Hebei Medical University, No. 89 Donggang Road, Shijiazhuang, 050031, Hebei, China
| | - Jun Wang
- Department of Cardiovascular Surgery, The First Hospital of Hebei Medical University, No. 89 Donggang Road, Shijiazhuang, 050031, Hebei, China.
| |
Collapse
|
6
|
Khalil M, Jux C, Rueblinger L, Behrje J, Esmaeili A, Schranz D. Acute therapy of newborns with critical congenital heart disease. Transl Pediatr 2019; 8:114-126. [PMID: 31161078 PMCID: PMC6514285 DOI: 10.21037/tp.2019.04.06] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Critical congenital heart disease (cCHD) is the most common reason for acute cardiac failure in the neonatal period. cCHD, defined by systemic low cardiac output (LCO) and requiring surgery or catheter-based intervention in the first year of life, has an incidence of approximately 15% of CHD and is responsible for up to 25% fatalities of newborn infants. Clinical deterioration develops in most cases due to rapid closure of the ductus arteriosus (DA). Early diagnosis and immediate treatment determinate beneficial outcome. Critical CHD can be classified in duct-dependent systemic flow, duct-dependent pulmonary flow and transposition of the great arteries. The latter two manifest themselves in oxygen resistant cyanosis, whereas CHD with duct-dependent systemic flow may present itself with cardiogenic shock, which can be difficult to differentiate from other causes of shock such as sepsis. Besides prostaglandin therapy for reopening the arterial duct, a balanced parallel pulmonary and systemic circulation should be a therapeutic goal. In CHD with duct-dependent systemic flow a decrease of pulmonary resistance should be avoided; therefore inadequate oxygen therapy, hyperventilation and alkalosis due to excessive treatment of acidosis, should be averted. Volume therapy should be performed carefully. In CHD with duct-dependent pulmonary flow, pulmonary resistance can be decreased, in case of poor pulmonary flow systemic resistance should be increased, mild alkalosis is recommended. Intense volume therapy is in most cases necessary, except if a restrictive atrial communication is present. In addition to intensive care measures, an arsenal of catheter- and surgery-based procedures need to be hold available as back-up for emergency procedures. Transcatheter interventions are nowadays decisive. Atrial-septostomy was the first and still the most utilized high-urgency procedure; DA-stenting is used in prostaglandin-refractory duct stenosis. In the presence of critical aortic valve stenosis, palliation consists of balloon valvuloplasty. In critical aortic coarctation with myocardial failure and no response to prostaglandin, palliative balloon angioplasty may be the method of choice as bridging for corrective surgery.
Collapse
Affiliation(s)
- Markus Khalil
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany
| | - Christian Jux
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany
| | - Lucie Rueblinger
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany
| | - Johanna Behrje
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany
| | - Anoosh Esmaeili
- Pediatric Heart Center of Hessen, Goethe University, Frankfurt am Main, Germany
| | - Dietmar Schranz
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany.,Pediatric Heart Center of Hessen, Goethe University, Frankfurt am Main, Germany
| |
Collapse
|
7
|
Steinbrenner B, Recla S, Thul J, Akintuerk H, Schranz D. Ideal intensive care unit course following comprehensive stage II in hypoplastic left heart syndrome. Transl Pediatr 2019; 8:161-166. [PMID: 31161083 PMCID: PMC6514283 DOI: 10.21037/tp.2019.04.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/28/2019] [Indexed: 11/06/2022] Open
Abstract
Comprehensive stage II is the advanced surgical part of the staged treatment of a newborn with hypoplastic left heart syndrome (HLHS) palliated initially by a Giessen-Hybrid approach. We report an almost ideal course following comprehensive stage II operation with focus on postoperative intensive care strategy. Following a short introduction of the postnatally performed Giessen-Hybrid approach, in which the surgical part is focused on bilateral pulmonary banding and duct stenting as well as manipulation of the atrial septum is postponed to transcatheter approach, it should be emphasized, that the quality of inter-stage I is eminently important for the success of the following comprehensive stage II. Furthermore, the interplay of the responsible surgeon, anesthesiologist, cardiologist and intensivist is mandatory for working as a team with a similar pathophysiological background. Presupposed a sophisticated surgical and anesthesiologic management, the immediate post-operative intensive care is crucial for the patient's final outcome, not only in terms of mortality but even morbidity (long-term neurological condition). Detailed treatment strategies are presented by pathophysiological reasonable hypotheses and the current pharmacological knowledge. Aiming to improve systemic and regional oxygen delivery and lowering oxygen consumption, as a sine qua none for a favorable patient's outcome.
Collapse
Affiliation(s)
| | - Sabine Recla
- Pediatric Heart Center, Justus-Liebig University-Giessen, Giessen, Germany
| | - Josef Thul
- Pediatric Heart Center, Justus-Liebig University-Giessen, Giessen, Germany
| | - Hakan Akintuerk
- Pediatric Heart Center, Justus-Liebig University-Giessen, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University-Giessen, Giessen, Germany
| |
Collapse
|
8
|
The Creation of an Interatrial Right-To-Left Shunt in Patients with Severe, Irreversible Pulmonary Hypertension: Rationale, Devices, Outcomes. Curr Cardiol Rep 2019; 21:31. [DOI: 10.1007/s11886-019-1118-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
9
|
Melekoglu AN, Baspinar O. Transcatheter cardiac interventions in neonates with congenital heart disease: A single centre experience. J Int Med Res 2018; 47:615-625. [PMID: 30373426 PMCID: PMC6381459 DOI: 10.1177/0300060518806111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective Percutaneous cardiac catheterization has been used as a diagnostic tool and as a therapeutic option in neonates with congenital heart disease (CHD). This study aimed to evaluate the procedural and short-term follow-up data of newborns who underwent cardiac catheterization procedures. Methods This retrospective study reviewed demographic, diagnostic and clinical data from the medical records of newborns who underwent percutaneous transcatheter interventions to treat CHD. Results Forty-six newborns were included in the study. The median gestational week and weight were 35.0 weeks and 2723 g, respectively. The median time to the procedure was 7.6 days. Aortic and pulmonary balloon valvuloplasty, ductal stenting, atrial balloon/blade septostomy and coronary fistula embolization procedures were used. The overall success rate was 73.9% (34 of 46 patients) with a complication rate of 28.3% (13 of 46 patients). Eleven patients (23.9%) underwent reinterventions after initial catheterization. Five patients (10.9%) died in the first 48 h after their procedures. Conclusions Interventional cardiological procedures applied during the neonatal period provide alternative life-saving methods to surgery, especially in developing countries where surgical outcomes are poor and newborn mortality rates are high.
Collapse
Affiliation(s)
- Asli Nuriye Melekoglu
- 1 Department of Paediatrics, Division of Neonatology, Malatya Training and Research Hospital, Malatya, Turkey
| | - Osman Baspinar
- 2 Department of Paediatrics, Division of Paediatric Cardiology, Faculty of Medicine, The University of Gaziantep, Gaziantep, Turkey
| |
Collapse
|
10
|
|
11
|
Comparison of self-expandable and balloon-expanding stents for hybrid ductal stenting in hypoplastic left heart complex. Cardiol Young 2017; 27:837-845. [PMID: 28555538 DOI: 10.1017/s1047951116001347] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We aimed to compare the procedural and mid-term performance of a specifically designed self-expanding stent with balloon-expandable stents in patients undergoing hybrid palliation for hypoplastic left heart syndrome and its variants. BACKGROUND The lack of specifically designed stents has led to off-label use of coronary, biliary, or peripheral stents in the neonatal ductus arteriosus. Recently, a self-expanding stent, specifically designed for use in hypoplastic left heart syndrome, has become available. METHODS We carried out a retrospective cohort comparison of 69 neonates who underwent hybrid ductal stenting with balloon-expandable and self-expanding stents from December, 2005 to July, 2014. RESULTS In total, 43 balloon-expandable stents were implanted in 41 neonates and more recently 47 self-expanding stents in 28 neonates. In the balloon-expandable stents group, stent-related complications occurred in nine patients (22%), compared with one patient in the self-expanding stent group (4%). During follow-up, percutaneous re-intervention related to the ductal stent was performed in five patients (17%) in the balloon-expandable stent group and seven patients (28%) in self-expanding stents group. CONCLUSIONS Hybrid ductal stenting with self-expanding stents produced favourable results when compared with the results obtained with balloon-expandable stents. Immediate additional interventions and follow-up re-interventions were similar in both groups with complications more common in those with balloon-expandable stents.
Collapse
|
12
|
Department of Pediatric Cardiac Surgery in Gdansk in its new location - previous activity and perspectives for development. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 14:84-86. [PMID: 28515759 PMCID: PMC5404138 DOI: 10.5114/kitp.2017.66940] [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: 05/08/2016] [Accepted: 10/14/2016] [Indexed: 11/29/2022]
Abstract
The Department of Pediatric Cardiac Surgery in Gdansk is the only pediatric cardiac surgery center in northern Poland providing comprehensive treatment to children with congenital heart defects. The Department of Pediatric Cardiac Surgery in Gdansk currently offers a full spectrum of advanced procedures of modern cardiac surgery and interventional cardiology dedicated to patients from infancy to adolescence. January 19, 2016 marked the official opening of its new location.
Collapse
|
13
|
Ohye RG, Schranz D, D'Udekem Y. Current Therapy for Hypoplastic Left Heart Syndrome and Related Single Ventricle Lesions. Circulation 2017; 134:1265-1279. [PMID: 27777296 DOI: 10.1161/circulationaha.116.022816] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Universally fatal only 4 decades ago, the progress in the 3-stage palliation of hypoplastic left heart syndrome and related single right ventricular lesions has drastically improved the outlook for these patients. Although the stage II operation (hemi-Fontan or bidirectional Glenn) and stage III Fontan procedure have evolved into relatively low-risk operations, the stage I Norwood procedure remains one of the highest-risk and costliest common operations performed in congenital heart surgery. Yet, despite this fact, experienced centers now report hospital survivals of >90% for the Norwood procedure. This traditional 3-stage surgical palliation has seen several innovations in the past decade aimed at improving outcomes, particularly for the Norwood procedure. One significant change is a renewed interest in the right ventricle-to-pulmonary artery shunt as the source of pulmonary blood flow, rather than the modified Blalock-Taussig shunt for the Norwood. The multi-institutional Single Ventricle Reconstruction trial randomly assigned 555 patients to one or the other shunt, and these subjects continue to be followed closely as they now approach 10 years postrandomization. In addition to modifications to the Norwood procedure, the hybrid procedure, a combined catheter-based and surgical approach, avoids the Norwood procedure in the newborn period entirely. The initial hybrid procedure is then followed by a comprehensive stage II, which combines components of both the Norwood and the traditional stage II, and later completion of the Fontan. Proponents of this approach hope to improve not only short-term survival, but also potentially longer-term outcomes, such as neurodevelopment, as well. Regardless of the approach, traditional surgical staged palliation or the hybrid procedure, survivals have vastly improved, and large numbers of these patients are surviving not only through their Fontan in early childhood, but also into adolescence and young adulthood. As this population grows, it becomes increasingly important to understand the longer-term outcomes of these Fontan patients, not only in terms of survival, but also in terms of the burden of disease, neurodevelopmental outcomes, psychosocial development, and quality of life.
Collapse
Affiliation(s)
- Richard G Ohye
- From University of Michigan C. S. Mott Children's Hospital, Ann Arbor (R.G.O.); Pediatric Heart Center, Justus Liebig University Giessen, Germany (D.S.); and Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia (Y.D'U.).
| | - Dietmar Schranz
- From University of Michigan C. S. Mott Children's Hospital, Ann Arbor (R.G.O.); Pediatric Heart Center, Justus Liebig University Giessen, Germany (D.S.); and Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia (Y.D'U.)
| | - Yves D'Udekem
- From University of Michigan C. S. Mott Children's Hospital, Ann Arbor (R.G.O.); Pediatric Heart Center, Justus Liebig University Giessen, Germany (D.S.); and Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia (Y.D'U.)
| |
Collapse
|
14
|
Schranz D. Behandlungsstrategien bei Patienten mit univentrikulärem Herzen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0109-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
15
|
Ductus Arteriosus Banding to Facilitate Stenting During the Hybrid Stage I Procedure. Ann Thorac Surg 2016; 101:e133-5. [DOI: 10.1016/j.athoracsur.2015.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 09/16/2015] [Accepted: 10/07/2015] [Indexed: 12/14/2022]
|
16
|
Quality of life in adolescents and young adults with CHD is not reduced: a systematic review and meta-analysis. Cardiol Young 2016; 26:415-25. [PMID: 26561207 DOI: 10.1017/s104795111500181x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE We performed a systematic review and meta-analysis of observational studies assessing quality of life in adolescents and young adults born with CHD compared with age-matched controls. METHODS We carried out a systematic search of the literature published in Medline, Embase, PsychINFO, and the Cochrane Library's Database (1990-2013); two authors independently extracted data from the included studies. We used the Newcastle-Ottawa scale for quality assessment of studies. A random effects meta-analysis model was used. Heterogeneity was assessed using the I2-test. RESULTS We included 18 studies with 1786 patients. The studies were of acceptable-to-good quality. The meta-analysis of six studies on quality of life showed no significant difference - mean difference: -1.31; 95% confidence intervals: -6.51 to +3.89, I2=90.9% - between adolescents and young adults with CHD and controls. Similar results were found in 10 studies not eligible for the meta-analysis. In subdomains, it seems that patients had reduced physical quality of life; however, social functioning was comparable or better compared with controls. CONCLUSION For the first time in a meta-analysis, we have shown that quality of life in adolescents and young adults with CHD is not reduced when compared with age-matched controls.
Collapse
|
17
|
Grohmann J, Sigler M, Siepe M, Stiller B. A new breakable stent for recoarctation in early infancy: Preliminary Clinical Experience. Catheter Cardiovasc Interv 2016; 87:E143-50. [DOI: 10.1002/ccd.26393] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/14/2015] [Accepted: 12/13/2015] [Indexed: 12/27/2022]
Affiliation(s)
- Jochen Grohmann
- Department of Congenital Heart Defects and Pediatric Cardiology; Heart Center, University of Freiburg; Freiburg Germany
| | - Matthias Sigler
- Department of Pediatric Cardiology and Intensive Care; University Hospital Göttingen; Göttingen Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery; Heart Center, University of Freiburg; Freiburg Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology; Heart Center, University of Freiburg; Freiburg Germany
| |
Collapse
|
18
|
Alternative hybrid and staged interventional treatment of congenital heart defects in critically ill children with complex and non-cardiac problems. Wideochir Inne Tech Maloinwazyjne 2015; 10:244-56. [PMID: 26240625 PMCID: PMC4520833 DOI: 10.5114/wiitm.2015.49474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/05/2015] [Accepted: 01/25/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION An individually designed strategy of comprehensive alternative hybrid and staged interventional treatment (AHASIT) can be a reasonable alternative to conventional treatment of congenital heart defects, reduce the risk of cardiac surgery or interventions performed separately, and give an additional chance for critically ill children. AIM To present our experience and the results of AHASIT of severely ill or borderline children referred for surgery with the diagnosis of congenital heart defects. MATERIAL AND METHODS A group of 22 patients with complex cardiac and non-cardiac pathologies was retrospectively selected and analyzed. An individual preoperative severity scale was established for AHASIT patients, with one point for each of the following preoperative complications: prematurity, low body weight, cyanosis, intolerance to drug therapy, failed interventional treatment prior to admission, mechanical ventilation prior to the procedure, chronic respiratory failure and non-cardiac, mainly congenital malformations (congenital diaphragmatic hernia, lower extremity agenesia, duodenal atresia) and acquired problems (newborn edema, necrotic enterocolitis, intracranial hemorrhage, liver and renal failure, anemia and thrombocytopenia, infections or colonization with drug-resistant pathogens). RESULTS The analysis of the postoperative course showed that the patients with 5 AHASIT points or more had a more complicated postoperative course than the patients with 1 to 4 AHASIT points. CONCLUSIONS The AHASIT of pediatric congenital heart defects with complex and non-cardiac problems appeared to be an attractive option for selected severely ill patients. The strategy was found to be effective in selected neonates suffering from complex and accompanying non-cardiac pathologies, with positive final results of both cardiological intervention and planned surgery.
Collapse
|
19
|
Zhang Y, Zhang ZW, Xie YM, Wang SS, Qiu QH, Zhou YL, Zeng GH. Toxicity of nickel ions and comprehensive analysis of nickel ion-associated gene expression profiles in THP-1 cells. Mol Med Rep 2015; 12:3273-3278. [PMID: 26044615 PMCID: PMC4526064 DOI: 10.3892/mmr.2015.3878] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 04/08/2015] [Indexed: 12/27/2022] Open
Abstract
The aim of the present study was to explore the toxic effects and underlying mechanisms of nickel ions during therapeutic nickel‑based alloy‑treatment in congenital heart disease by investigating the metal‑induced cytotoxicity to the human monocyte‑derived macrophage cell line THP‑1. THP‑1 cells were treated with NiCl2·6H2O (25, 50, 100, 200, 400 and 800 µM) for 24, 48 and 72 h, respectively. MTT was applied to detect THP‑1 cell proliferation following NiCl2 treatment. Apoptosis of THP‑1 cells was quantified using flow cytometry. Illumina sequencing was used for screening the associated genes, whose mRNA expression levels were further confirmed by quantitative real‑time polymerase chain reaction. High concentrations of nickel ions had a significant suppressive effect on cell proliferation at the three concentrations investigated (200, 400 and 800 µM). Treatment with nickel ions (25‑400 µM) for 48 h reduced cell viability in a dose‑dependent manner. The mRNA expression levels of RELB, FIGF, SPI‑1, CXCL16 and CRLF2 were significantly increased following nickel treatment. The results of the present study suggested that nickel ions exert toxic effects on THP‑1 cell growth, which may indicate toxicity of the nickel ion during treatment of congenital heart disease. The identification of genes modified by the toxic effects of nickel on THP‑1 cells (EPOR, RELB, FIGF, SPI‑1, TGF‑β1, CXCL16 and CRLF2) may aid in the development of interventional measures for the treatment/prevention of nickel ion‑associated toxic effects during the treatment of congenital heart disease.
Collapse
Affiliation(s)
- Ying Zhang
- Department of Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510180, P.R. China
| | - Zhi-Wei Zhang
- Department of Pediatric Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510180, P.R. China
| | - Yu-Mei Xie
- Department of Pediatric Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510180, P.R. China
| | - Shu-Shui Wang
- Department of Pediatric Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510180, P.R. China
| | - Qing-Huan Qiu
- Department of Pediatric Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510180, P.R. China
| | - Ying-Ling Zhou
- Department of Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510180, P.R. China
| | - Guo-Hong Zeng
- Department of Pediatric Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510180, P.R. China
| |
Collapse
|
20
|
Edwards A, Veldman A, Nitsos I, Chan Y, Brew N, Teoh M, Menahem S, Schranz D, Wong FY. Percutaneous Fetal Cardiac Catheterization Technique for Stenting the Foramen Ovale in a Midgestation Lamb Model. Circ Cardiovasc Interv 2015; 8:e001967. [DOI: 10.1161/circinterventions.114.001967] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Intact or highly restricted intra-atrial septum can be reliably diagnosed in the human fetus as early as 22 to 24 weeks of gestation. Fetal interventions targeting the atrial septum have used a direct approach through the atrial wall. Here, we report stenting of the foramen ovale with a large, open-cell stent via percutaneous access through the fetal hepatic vein in a sheep model.
Methods and Results—
In 5 fetal sheep of 109 to 111 days of gestation (term, 147 days), the fetal hepatic vein was punctured percutaneously under ultrasound guidance and a 13.3-cm 14-gauge intravenous catheter was inserted. After catheterization of the inferior vena cava, right atrium, foramen ovale, and left atrium with a guidewire and 1.8F to 2.6F tapered catheter, a self-expandable, 8×12-mm flexible open-cell stent was positioned in an unrestricted foramen ovale. Flow and fetal well-being were documented for 45 minutes after the procedure. Access to the left atrium was achieved in all 5 animals and all survived. In 4 animals, the stent was successfully positioned in the foramen ovale. One fetus was born at term and euthanized on day 3: postmortem examination confirmed the patency of the stent. The other 3 fetuses were well after being monitored by ultrasound for 45 minutes. In 1 animal, the stent dislodged immediately after release obstructing the mitral valve. This fetus developed ascites and was euthanized after 4 days.
Conclusions—
It is feasible to safely advance a large diameter, self-expandable, open-cell design stent into the fetal atrial septum via a percutaneous access route through the fetal hepatic vein.
Collapse
Affiliation(s)
- Andrew Edwards
- From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen,
| | - Alex Veldman
- From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen,
| | - Ilias Nitsos
- From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen,
| | - Yuen Chan
- From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen,
| | - Nadine Brew
- From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen,
| | - Mark Teoh
- From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen,
| | - Samuel Menahem
- From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen,
| | - Dietmar Schranz
- From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen,
| | - Flora Y. Wong
- From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen,
| |
Collapse
|
21
|
Schranz D, Bauer A, Reich B, Steinbrenner B, Recla S, Schmidt D, Apitz C, Thul J, Valeske K, Bauer J, Müller M, Jux C, Michel-Behnke I, Akintürk H. Fifteen-year single center experience with the "Giessen Hybrid" approach for hypoplastic left heart and variants: current strategies and outcomes. Pediatr Cardiol 2015; 36:365-73. [PMID: 25179460 PMCID: PMC4303711 DOI: 10.1007/s00246-014-1015-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 08/22/2014] [Indexed: 11/28/2022]
Abstract
Presented is a retrospective outcome study of a 15-year single institutional experience with a contemporary cohort of patients with hypoplastic left heart syndrome and complex that underwent a "Giessen Hybrid" stage I as initial palliation. Hybrid approach consisting of surgical bilateral pulmonary artery banding and percutaneous duct stenting with or without atrial septum manipulation was developed from a rescue approach to a first-line procedure. Comprehensive Aristotle score defined pre-operative condition. Fifteen-year follow-up mortality is reported as occurring within the staged univentricular palliation or before and after biventricular repair. Hybrid stage I was performed in 154 patients; 107 should be treated by single ventricle palliation, 33 by biventricular repair (BVR), 7 received heart transplantation, and 7 were treated by comfort care, respectively. Overall 34 children died. The Aristotle score (mean value 18.2 ± 3) classified for univentricular circulations in newborns did not have statistical impact on the outcome. Two patients died during stage I (1.2%), and the interstage I mortality was 6.7%, and stage II mortality 9%, respectively. Stage III was up to now performed in 57 patients without mortality. At 1 year, the overall unadjusted survival of HLHS and variants was 84% and following BVR 89%, respectively. The Fifteen-year survival rate for HLHS and variants was 77%, with no significant impact of birth weight of less than 2.5 kg. In conclusion, Hybrid stage I fulfilled the criteria of life-saving approach. In our institution, Hybrid procedure replaced Norwood-staged palliation with a considerable mid- and long-term survival rate. Considering interstage mortality close surveillance is mandatory.
Collapse
Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385, Giessen, Germany,
| | - Anna Bauer
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Bettina Reich
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Blanka Steinbrenner
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Sabine Recla
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Dorle Schmidt
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Christian Apitz
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Josef Thul
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Klaus Valeske
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Jürgen Bauer
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Matthias Müller
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Christian Jux
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Ina Michel-Behnke
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| | - Hakan Akintürk
- Pediatric Heart Center, Justus-Liebig University, Feulgenstr. 12, 30385 Giessen, Germany
| |
Collapse
|