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Bleiweis MS, Sharaf OM, Philip J, Peek GJ, Stukov Y, Janelle GM, Pitkin AD, Sullivan KJ, Nixon CS, Neal D, Jacobs JP. A single-institutional experience with 36 children less than 5 kilograms supported with the Berlin Heart: Comparison of congenital versus acquired heart disease. Cardiol Young 2024:1-8. [PMID: 38362907 DOI: 10.1017/s1047951123004134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES We reviewed outcomes in all 36 consecutive children <5 kg supported with the Berlin Heart pulsatile ventricular assist device at the University of Florida, comparing those with acquired heart disease (n = 8) to those with congenital heart disease (CHD) (n = 28). METHODS The primary outcome was mortality. The Kaplan-Meier method and log-rank tests were used to assess group differences in long-term survival after ventricular assist device insertion. T-tests using estimated survival proportions were used to compare groups at specific time points. RESULTS Of 82 patients supported with the Berlin Heart at our institution, 49 (49/82 = 59.76%) weighed <10 kg and 36 (36/82 = 43.90%) weighed <5 kg. Of 36 patients <5 kg, 26 (26/36 = 72.22%) were successfully bridged to transplantation. (The duration of support with ventricular assist device for these 36 patients <5 kg was [days]: median = 109, range = 4-305.) Eight out of 36 patients <5 kg had acquired heart disease, and all eight [8/8 = 100%] were successfully bridged to transplantation. (The duration of support with ventricular assist device for these 8 patients <5 kg with acquired heart disease was [days]: median = 50, range = 9-130.) Twenty-eight of 36 patients <5 kg had congenital heart disease. Eighteen of these 28 [64.3%] were successfully bridged to transplantation. (The duration of support with ventricular assist device for these 28 patients <5 kg with congenital heart disease was [days]: median = 136, range = 4-305.) For all 36 patients who weighed <5 kg: 1-year survival estimate after ventricular assist device insertion = 62.7% (95% confidence interval = 48.5-81.2%) and 5-year survival estimate after ventricular assist device insertion = 58.5% (95% confidence interval = 43.8-78.3%). One-year survival after ventricular assist device insertion = 87.5% (95% confidence interval = 67.3-99.9%) in acquired heart disease and 55.6% (95% confidence interval = 39.5-78.2%) in CHD, P = 0.036. Five-year survival after ventricular assist device insertion = 87.5% (95% confidence interval = 67.3-99.9%) in acquired heart disease and 48.6% (95% confidence interval = 31.6-74.8%) in CHD, P = 0.014. CONCLUSION Pulsatile ventricular assist device facilitates bridge to transplantation in neonates and infants weighing <5 kg; however, survival after ventricular assist device insertion in these small patients is less in those with CHD in comparison to those with acquired heart disease.
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Affiliation(s)
- Mark S Bleiweis
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Omar M Sharaf
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Joseph Philip
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Giles J Peek
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Yuriy Stukov
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Gregory M Janelle
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Andrew D Pitkin
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Kevin J Sullivan
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Connie S Nixon
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Dan Neal
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, Departments of Surgery, Pediatrics, and Anesthesiology, University of Florida, Gainesville, FL, USA
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Schramm JE, Dykes JC, Hopper RK, Feinstein JA, Rosenthal DN, Kameny RJ. Pulmonary Vasodilator Therapy in Pediatric Patients on Ventricular Assist Device Support: A Single-Center Experience and Proposal for Use. ASAIO J 2023; 69:1025-1030. [PMID: 37556563 DOI: 10.1097/mat.0000000000002023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
Pediatric precapillary pulmonary hypertension can develop in response to systemic atrial hypertension. Systemic atrial decompression following ventricular assist device (VAD) implantation may not sufficiently lower pulmonary vascular resistance (PVR) to consider heart transplant candidacy. Prostacyclins have been used in adult VAD patients with success, but pediatric data on safety and efficacy in this population are limited. We sought to describe our center's experience to show its safety and to present our current protocol for perioperative use. We reviewed our use of prostacyclin therapy in pediatric patients on VAD support with high PVR from 2016 to 2021. Of the 17 patients who met inclusion, 12 survived to transplant and 1 is alive with VAD in situ . All patients survived posttransplant. With continuous intravenous (IV) epoprostenol or treprostinil therapy, there were no bleeding complications or worsening of end-organ function. A significant reduction was observed in vasoactive inotropic scores by 49% in the first 24 hours post-prostacyclin initiation. The proportion of patients surviving to transplant in this high-risk cohort is favorable. In conclusion, prostacyclins may be safe to use in patients with elevated PVR as part of their VAD and transplant course and may provide a transplant option in those otherwise not candidates.
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Affiliation(s)
- Jennifer E Schramm
- From the Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John C Dykes
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Rachel K Hopper
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
| | - Rebecca J Kameny
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California
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Konstantinov IE, Cooper DKC, Adachi I, Bacha E, Bleiweis MS, Chinnock R, Cleveland D, Cowan PJ, Fynn-Thompson F, Morales DLS, Mohiuddin MM, Reichart B, Rothblatt M, Roy N, Turek JW, Urschel S, West L, Wolf E. Consensus statement on heart xenotransplantation in children: Toward clinical translation. J Thorac Cardiovasc Surg 2023; 166:960-967. [PMID: 36184321 PMCID: PMC10124772 DOI: 10.1016/j.jtcvs.2022.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Igor E Konstantinov
- Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, Mass
| | - Iki Adachi
- Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Emile Bacha
- Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, NY
| | | | | | - David Cleveland
- Department of Surgery, University of Alabama, Birmingham, Ala
| | - Peter J Cowan
- Immunology Research Centre, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | | | - David L S Morales
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Muhammad M Mohiuddin
- Program in Cardiac Xenotransplantation, University of Maryland School of Medicine, Baltimore, Md
| | - Bruno Reichart
- Transregional Collaborative Research Center, Walter Brendel Centre of Experimental Medicine, Ludwig Maximilians University, Munich, Germany
| | | | - Nathalie Roy
- Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Joseph W Turek
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Simon Urschel
- Pediatric Cardiac Transplantation Program, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Lori West
- Pediatric Cardiac Transplantation Program, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada; Canadian Donation and Transplantation Research Program, Alberta Transplant Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Eckhard Wolf
- Gene Center and Department of Veterinary Sciences, Ludwig Maximilians University, Munich, Germany
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Kozik D, Alsoufi B. Pediatric mechanical circulatory support - a review. Indian J Thorac Cardiovasc Surg 2023; 39:80-90. [PMID: 37525715 PMCID: PMC10386992 DOI: 10.1007/s12055-023-01499-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
The history of mechanical circulatory support began in 1953, as the first heart-lung machine enabled surgeons to perform complex open heart surgery. Heart failure is more prevalent in adults than pediatric patients which has led to the development of devices for adults with end-stage heart failure at a faster pace. Pediatric mechanical circulatory support has been derived from adult durable devices and subsequently applied in the adolescent population. The application of adult devices in children is inherently problematic due to size mismatch, especially in smaller patients. There has been an increasing interest in developing durable pumps that are appropriate for children for several reasons, with the primary factor being the number of children with end-stage heart failure far exceeding the number of potential donors. Mechanical circulatory support (MCS) for children can be divided into short-term temporary support and long-term durable support. The goal of this review is to discuss the devices available for the pediatric population and review the options for support in complex patients including single-ventricle anatomy, biventricular support, and total artificial heart options. We will also briefly discuss the Pumps for Kids, Infants, and Neonates (PumpKIN) Trial and MCS registries, including the Advanced Cardiac Therapies Improving Outcomes Network (ACTION).
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Affiliation(s)
- Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY USA
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Shinkawa T, Ichihara Y, Saito S, Ishido M, Inai K, Niinami H. Ventricular assist device for end-stage adult congenital heart disease patients: Current status. J Cardiol 2023; 81:378-384. [PMID: 36152979 DOI: 10.1016/j.jjcc.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/14/2022] [Indexed: 11/24/2022]
Abstract
As long-term surgical outcome of congenital heart disease has continued to improve, most pediatric patients with congenital heart disease are able to reach adulthood. However, adult congenital heart disease (ACHD) patients have increased risk of arrhythmia, valvular diseases, infectious endocarditis, and heart failure. The end-stage ACHD patients with advanced heart failure may require mechanical circulatory support to improve the heart failure symptoms or to recover from circulatory collapse, and may eventually aim to heart transplant or destination therapy. In general, long-term mechanical support for dilated cardiomyopathy or ischemic cardiomyopathy has been achieved with left ventricular assist device with excellent survival outcomes and improved quality of life. However, the ventricular assist device for end-stage ACHD patients can be challenging due to patient-specific anatomical feature, multiple histories of surgical and catheter-based interventions and possible multiple end-organ dysfunctions, and offered less frequently compared to non-ACHD patients. The Interagency Registry for Mechanically Assisted Circulatory Support data published recently showed that ACHD patients receiving long-term mechanical circulatory support consisted <1 % of all registrants and had higher mortality after mechanical support than non-ACHD patients. However, the ACHD patients supported with left ventricular assist device had similar survival with non-ACHD patients and a large proportion of the mortality difference between ACHD and non-ACHD patients seemed to result from operative and perioperative factors. Therefore, the ventricular assist device therapy can be an excellent treatment for selected ACHD patients. In this paper, we describe the current status of ventricular assist device support for end-stage ACHD patients and consideration to the future.
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Affiliation(s)
- Takeshi Shinkawa
- Tokyo Women's Medical University, Department of Cardiovascular Surgery, Tokyo, Japan.
| | - Yuki Ichihara
- Tokyo Women's Medical University, Department of Cardiovascular Surgery, Tokyo, Japan
| | - Satoshi Saito
- Tokyo Women's Medical University, Department of Cardiovascular Surgery, Tokyo, Japan
| | - Mikiko Ishido
- Tokyo Women's Medical University, Department of Pediatric and Adult Congenital Cardiology, Tokyo, Japan
| | - Kei Inai
- Tokyo Women's Medical University, Department of Pediatric and Adult Congenital Cardiology, Tokyo, Japan
| | - Hiroshi Niinami
- Tokyo Women's Medical University, Department of Cardiovascular Surgery, Tokyo, Japan
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Bleiweis MS, Philip J, Peek GJ, Stukov Y, Janelle GM, Pitkin AD, Sullivan KJ, Nixon CS, Sharaf OM, Neal D, Jacobs JP. A Single-Institutional Experience with 36 Children Smaller Than 5 Kilograms Supported with the Berlin Heart Ventricular Assist Device (VAD) over 12 Years: Comparison of Patients with Biventricular versus Functionally Univentricular Circulation. World J Pediatr Congenit Heart Surg 2023; 14:117-124. [PMID: 36798022 DOI: 10.1177/21501351221146150] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVES We reviewed outcomes in all 36 consecutive children <5 kg supported with the Berlin Heart pulsatile ventricular assist device (VAD) at the University of Florida, comparing those with univentricular circulation (n = 23) to those with biventricular circulation (n = 13). METHODS The primary outcome was mortality. Kaplan-Meier methods and log-rank tests were used to assess group differences in long-term survival after VAD insertion. T-tests using estimated survival proportions and standard errors were used to compare groups at specific time points. RESULTS Of all 82 patients ever supported with Berlin Heart at our institution, 49 (49/82 = 59.76%) weighed <10 kg and 36 (36/82 = 43.90%) weighed <5 kg. Of these 36 patients who weighed <5 kg, 26 (26/36 = 72.22%) were successfully bridged to transplantation. Of these 36 patients who weighed <5 kg, 13 (13/36 = 36.1%) had biventricular circulation and were supported with 12 biventricular assist devices (BiVADs) and 1 left ventricular assist device (LVAD) (Age [days]: median = 67, range = 17-212; Weight [kilograms]: median = 4.1, range = 3.1-4.9), while 23 (23/36 = 63.9%) had univentricular circulation and were supported with 23 single ventricle-ventricular assist devices (sVADs) (Age [days]: median = 25, range = 4-215; Weight [kilograms]: median = 3.4, range = 2.4-4.9). Of 13 biventricular patients who weighed <5 kg, 12 (12/23 = 92.3%) were successfully bridged to cardiac transplantation. Of 23 functionally univentricular patients who weighed <5 kg, 14 (14/23 = 60.87%) were successfully bridged to cardiac transplantation. For all 36 patients who weighed <5 kg: 1-year survival estimate after VAD insertion = 62.7% (95% confidence interval [CI] = 48.5%-81.2%) and 5-year survival estimate after VAD insertion = 58.5% (95% CI = 43.8%-78.3%). One-year survival after VAD insertion: 84.6% (95% CI = 67.1%-99.9%) in biventricular patients and 49.7% (95% CI = 32.3%-76.4%) in univentricular patients, P = 0.018. Three-year survival after VAD insertion: 84.6% (95% CI = 67.1%-99.9%) in biventricular patients and 41.4% (95% CI = 23.6%-72.5%) in univentricular patients, P = 0.005. CONCLUSION Pulsatile VAD facilitates bridge to transplantation in neonates and infants weighing <5 kg; however, survival after VAD insertion in these small patients is less in those with univentricular circulation in comparison to those with biventricular circulation.
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Affiliation(s)
- Mark S Bleiweis
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Joseph Philip
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Giles J Peek
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Yuriy Stukov
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Gregory M Janelle
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Andrew D Pitkin
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Kevin J Sullivan
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Connie S Nixon
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Omar M Sharaf
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Dan Neal
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, Departments of Surgery and Pediatrics, 3463University of Florida, Gainesville, FL, USA
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7
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Ventricular assist device support for failing Glenn circulation: Impact of concomitant Fontan completion in select patients. J Heart Lung Transplant 2022; 42:637-644. [PMID: 36610928 DOI: 10.1016/j.healun.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 11/18/2022] [Accepted: 12/04/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Ventricular assist device (VAD) support for failing Glenn circulation represents a unique challenge. METHODS We conducted a retrospective review of clinical outcomes in patients with VAD support for failing Glenn circulation between 2010 and 2020 at a tertiary pediatric institution. RESULTS Ten patients were included: INTERMACS profiles were 1 in 3 patients and 2 in 7 patients. The median age, weight, and body surface area were 3.2 years, 13.0 kg, and 0.5 m2, respectively. Seven patients (70%) were implanted with continuous-flow devices and 3 with para-corporeal devices. Nine patients (90%) received heart transplant, with a median support duration of 77 days. Four (67%) out of 6 patients supported with discharge-capable devices were managed as outpatients. Post-transplant survival was 100%, with a median (range) follow up duration of 3.5 (1.8-11.9) years. There were 3 neurologic complications in 3 patients (0.9 events per patient-year); 2 intraoperative events (fatal hypoxia and symptomatic embolic stroke) and 1 postoperative (asymptomatic subarachnoid hemorrhage). Pump thrombosis occurred in one patient (0.3 events per patient-year), requiring pump exchange at day 65. Five patients (50%) received concomitant Fontan completion (fenestrated in 1). The Fontan-upgraded patients (vs Glenn) tended to be larger (median (range): 15.9 (12.6-22.9) vs 9.1 (7.7-22.8) kg), older (4.7 (3.1-6.5) vs 1.1 (0.9-10.1) years) and had a higher PaO2/FiO2 ratio (192 (52-336) vs 76 (59-78) mm Hg) on postoperative day 1. CONCLUSION Our experience suggests the feasibility of durable VAD support for failing Glenn circulation. Concomitant Fontan completion may be considered in select patients to improve oxygen delivery.
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Gorbea M, Duarte IM, Reisch JS, Hernandez J. Perioperative Outcomes in Patients With Failing Single-Ventricle Physiology Undergoing Ventricular Assist Device Placement: A Single Institutional Experience. J Cardiothorac Vasc Anesth 2022; 36:4347-4356. [PMID: 36050214 DOI: 10.1053/j.jvca.2022.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To address the current lack of specified data existing regarding the perioperative characteristics and outcomes in a novel patient population, which may bridge the current understanding of how patient characteristics and perioperative management may influence the postoperative hospital course before cardiac transplantation. DESIGN A retrospective electronic chart review included all patients with failing single- ventricle (SV) physiology receiving ventricular assist device (VAD) support at a high-volume pediatric VAD center between April 5, 2010, and December 1, 2020, using institution-based electronic medical records for retrospective analysis. SETTING At a single pediatric hospital. PARTICIPANTS Fourteen pediatric patients with failing SV physiology receiving ventricular assist device therapy (SVAD). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Preoperative, intraoperative, and postoperative patient demographic and medical data were obtained from prior inpatient progress notes, laboratory values, anesthetic records, cardiac catheterization reports, echocardiography reports, and postoperative surgical notes entered during inpatient encounters at the time of SVAD placement. Between April 5, 2010, and December 1, 2020, 16 VAD device implants supported 14 pediatric patients with failing SV physiology. Most patients presented with a preoperative diagnosis of hypoplastic left heart syndrome (N = 9, 64.3%). A total of 6 patients expired on VAD therapy (43%), 7 (50%) survived to receive a cardiac transplant, and 1 patient currently remains on device therapy. CONCLUSION Although our institutional approach represents a single perspective, we anticipate that our experience institutional experience may prove helpful to others caring for peditric patients with single ventricle physiology undergoing ventricular assist device placement and promote collaborative efforts to improve their care.
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Affiliation(s)
- Mikel Gorbea
- The University of Texas Southwestern Medical Center Department of Anesthesiology and Pain Management at Children's Medical Center of Dallas, Dallas, TX.
| | - Ingrid Moreno Duarte
- The University of Texas Southwestern Medical Center Department of Anesthesiology and Pain Management at Children's Medical Center of Dallas, Dallas, TX
| | - Joan S Reisch
- The University of Texas Southwestern Medical Center Department of Anesthesiology and Pain Management at Children's Medical Center of Dallas, Dallas, TX
| | - Jennifer Hernandez
- The University of Texas Southwestern Medical Center Department of Anesthesiology and Pain Management at Children's Medical Center of Dallas, Dallas, TX
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Konstantinov IE. Supporting univentricular heart in biventricular circulation. JTCVS Tech 2022; 18:108-109. [PMID: 37096111 PMCID: PMC10122128 DOI: 10.1016/j.xjtc.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Igor E Konstantinov
- Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia
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10
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Friedland-Little JM, Joong A, Shugh SB, O'Connor MJ, Bansal N, Davies RR, Ploutz MS. Patient and Device Selection in Pediatric MCS: A Review of Current Consensus and Unsettled Questions. Pediatr Cardiol 2022; 43:1193-1204. [PMID: 35325280 DOI: 10.1007/s00246-022-02880-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/15/2022] [Indexed: 01/24/2023]
Abstract
The field of pediatric ventricular assist device (VAD) support has expanded significantly over the past 20 years, with one third of pediatric heart transplant recipients currently being bridged to transplant with a VAD. Despite increased pediatric VAD utilization, however, there remains little formalized guidance for patient or device selection. The population of children with advanced heart failure is quite heterogeneous, and the available data suggest that VAD outcomes vary significantly based upon patient size, anatomy, level of illness, and type of device implanted. In an effort to better understand current practice patterns and identify populations for whom there does not appear to be a consensus approach to achieving optimal VAD outcomes, the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) has surveyed clinical decision-making among member sites and conducted a review of the available literature regarding patient population-specific VAD outcomes and center-specific practices related to patient and device selection. Rather than aiming to provide clinical guidelines, this document offers an overview of contemporary approaches to patient and device selection, highlighting specific populations for whom there is not a consensus approach to achieving reliably good VAD outcomes, as these populations may benefit most from future research and quality improvement efforts directed toward identifying best practice.
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Affiliation(s)
| | - Anna Joong
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Svetlana B Shugh
- Heart Institute, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Matthew J O'Connor
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Neha Bansal
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ryan R Davies
- UT Southwestern Medical Center and Children's Health, Dallas, TX, USA
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11
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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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Bleiweis MS, Peek GJ, Philip J, Fudge JC, Sullivan KJ, Co-Vu J, DeGroff C, Vyas HV, Gupta D, Shih R, Pietra BBA, Fricker FJ, Cruz Beltran SC, Arnold MA, Wesley MC, Pitkin AD, Hernandez-Rivera JF, Lopez-Colon D, Barras WE, Stukov Y, Sharaf OM, Neal D, Nixon CS, Jacobs JP. A Comprehensive Approach to the Management of Patients With HLHS and Related Malformations: An Analysis of 83 Patients (2015-2021). World J Pediatr Congenit Heart Surg 2022; 13:664-675. [PMID: 35511494 DOI: 10.1177/21501351221088030] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Some patients with hypoplastic left heart syndrome (HLHS) and HLHS-related malformations with ductal-dependent systemic circulation are extremely high-risk for Norwood palliation. We report our comprehensive approach to the management of these patients designed to maximize survival and optimize the utilization of donor hearts. Methods: We reviewed our entire current single center experience with 83 neonates and infants with HLHS and HLHS-related malformations (2015-2021). Standard-risk patients (n = 62) underwent initial Norwood (Stage 1) palliation. High-risk patients with risk factors other than major cardiac risk factors (n = 9) underwent initial Hybrid Stage 1 palliation, consisting of application of bilateral pulmonary bands, stent placement in the patent arterial duct, and atrial septectomy if needed. High-risk patients with major cardiac risk factors (n = 9) were bridged to transplantation with initial combined Hybrid Stage 1 palliation and pulsatile ventricular assist device (VAD) insertion (HYBRID + VAD). Three patients were bridged to transplantation with prostaglandin. Results: Overall survival at 1 year = 90.4% (75/83). Operative Mortality for standard-risk patients undergoing initial Norwood (Stage 1) Operation was 2/62 (3.2%). Of 60 survivors: 57 underwent Glenn, 2 underwent biventricular repair, and 1 underwent cardiac transplantation. Operative Mortality for high-risk patients with risk factors other than major cardiac risk factors undergoing initial Hybrid Stage 1 palliation without VAD was 0/9: 4 underwent transplantation, 1 awaits transplantation, 3 underwent Comprehensive Stage 2 (with 1 death), and 1 underwent biventricular repair. Of 9 HYBRID + VAD patients, 6 (67%) underwent successful cardiac transplantation and are alive today and 3 (33%) died while awaiting transplantation on VAD. Median length of VAD support was 134 days (mean = 134, range = 56-226). Conclusion: A comprehensive approach to the management of patients with HLHS or HLHS-related malformations is associated with Operative Mortality after Norwood of 2/62 = 3.2% and a one-year survival of 75/83 = 90.4%. A subset of 9/83 patients (11%) were stabilized with HYBRID + VAD while awaiting transplantation. VAD facilitates survival on the waiting list during prolonged wait times.
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Affiliation(s)
- Mark S Bleiweis
- Department of Surgery, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA.,Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Giles J Peek
- Department of Surgery, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA.,Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Joseph Philip
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - James C Fudge
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Kevin J Sullivan
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA.,Department of Anesthesia, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Jennifer Co-Vu
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Curt DeGroff
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Himesh V Vyas
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Dipankar Gupta
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Renata Shih
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Biagio Bill A Pietra
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Frederick Jay Fricker
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Susana C Cruz Beltran
- Department of Anesthesia, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Michael A Arnold
- Department of Anesthesia, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Mark C Wesley
- Department of Anesthesia, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Andrew D Pitkin
- Department of Anesthesia, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Jose F Hernandez-Rivera
- Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Dalia Lopez-Colon
- Department of Surgery, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA.,Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Wendy E Barras
- Department of Surgery, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Yuriy Stukov
- Department of Surgery, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Omar M Sharaf
- Department of Surgery, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA.,Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Dan Neal
- Department of Surgery, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Connie S Nixon
- Department of Surgery, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA.,Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
| | - Jeffrey P Jacobs
- Department of Surgery, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA.,Department of Pediatrics, Congenital Heart Center, 3463University of Florida, Gainesville, FL, USA
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Bleiweis MS, Stukov Y, Philip J, Peek GJ, Pitkin AD, Sullivan KJ, Neal D, Jacobs JP. Analysis of 82 Children Supported with Pulsatile Paracorporeal Ventricular Assist Device: Comparison of Patients with Biventricular versus Univentricular Circulation. Semin Thorac Cardiovasc Surg 2022; 35:367-376. [DOI: 10.1053/j.semtcvs.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 11/11/2022]
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Palliation + VAD insertion in 15 Neonates and Infants with Functionally Univentricular Circulation. Ann Thorac Surg 2022; 114:1412-1418. [PMID: 35304109 DOI: 10.1016/j.athoracsur.2022.02.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/03/2022] [Accepted: 02/09/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND We report fifteen high-risk neonates and infants with functionally univentricular circulation stabilized with initial surgical palliation + VAD insertion (PALLIATION+VAD) in preparation for transplantation. METHODS Fifteen univentricular patients with ductal-dependent systemic circulation (8 HLHS, 1 HLHS-related malformation: 7 neonates, 2 infants) or ductal-dependent pulmonary circulation (HRHS: 5 neonates, 1 infants) presented with anatomical and/or physiological features associated with increased risk for conventional univentricular palliation (large coronary sinusoids with ventricular dependent coronary circulation, severe systemic atrioventricular valvar regurgitation, cardiogenic shock, or restrictive atrial septum). PALLIATION+VAD for ductal-dependent systemic circulation: VAD insertion + application of bilateral pulmonary bands, stent placement in the arterial duct, and atrial septectomy if needed. PALLIATION+VAD for ductal-dependent pulmonary circulation: VAD insertion + either stent placement in the arterial duct or systemic-to-pulmonary artery shunt with pulmonary arterioplasty if needed. RESULTS At PALLIATION+VAD, median age = 20 days (range=13-143); median weight = 3.25 kilograms (range=2.43-4.2). Ten patients survive (67%) and five patients died (33%). Nine survivors are at home doing well after successful transplantation and one survivor is doing well in the ICU on VAD support awaiting transplantation. Only 2/10 survivors (20%) required intubation > 10 days after PALLIATION+VAD. In fourteen patients no longer on VAD, median length of VAD support was 136 days (range=56-223 days). CONCLUSIONS High-risk neonates with functionally univentricular hearts who are suboptimal candidates for conventional palliation can be successfully stabilized with pulsatile VAD insertion along with initial palliation while awaiting cardiac transplantation; these patients may be extubated and optimized for transplantation while on VAD.
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Townsend M, Jeewa A, Adachi I, Al Aklabi M, Honjo O, Armstrong K, Buchholz H, Conway J. Ventricular Assist Device Use in Single Ventricle Circulation. Can J Cardiol 2022; 38:1086-1099. [DOI: 10.1016/j.cjca.2022.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 01/09/2023] Open
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Reid CS, Kaiser HA, Heinisch PP, Bruelisauer T, Michel S, Siepe M. Ventricular assist device for Fontan: who, when and why? Curr Opin Anaesthesiol 2022; 35:12-17. [PMID: 34812751 DOI: 10.1097/aco.0000000000001078] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Since the advent of the Fontan palliation, survival of patients with univentricular congenital heart disease has increased significantly. These patients will, however, ultimately develop heart failure requiring advanced therapies such as heart transplantation. As wait times are long, mechanical circulatory support (MCS) is an attractive therapy, both for bridge to transplantation and destination therapy in patients not suitable for transplantation. This review aims to summarize current thinking about how to determine which patients would benefit from a ventricular assist device (VAD), the optimal time for implantation and which device should be considered. RECENT FINDINGS VAD implantation in end-stage Fontan is still in its infancy; however, case reports and research interest have increased extensively in the past few years. Mortality is significantly higher than in noncongenital heart disease patients. Implantation in patients with primarily systolic dysfunction is indicated, whereas patients with increased transpulmonary gradient may not benefit from a single-VAD solution. When possible, implantation should occur prior to clinical decompensation with evidence of end-organ damage, as outcomes at this point are worse. SUMMARY Fontan patients demonstrating signs of heart failure should be evaluated early and often for feasibility and optimal timing of VAD implantation. The frequency of this procedure will likely increase significantly in the future.
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Affiliation(s)
- Catherine S Reid
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heiko A Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Anaesthesiology and Intensive Care Medicine, Hirslanden Klinik Aarau, Hirslanden Group, Aarau, Switzerland
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thomas Bruelisauer
- German Heart Center Berlin, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Sebastian Michel
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Bleiweis MS, Fudge JC, Peek GJ, Vyas HV, Cruz Beltran S, Pitkin AD, Sullivan KJ, Hernandez-Rivera JF, Philip J, Jacobs JP. Ventricular assist device support in neonates and infants with a failing functionally univentricular circulation. JTCVS Tech 2021; 13:194-204. [PMID: 35711213 PMCID: PMC9195634 DOI: 10.1016/j.xjtc.2021.09.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/10/2021] [Indexed: 11/03/2022] Open
Abstract
Some neonates with functionally univentricular hearts are at extremely high risk for conventional surgical palliation. Primary cardiac transplantation offers the best option for survival of these challenging neonates; however, waitlist mortality must be minimized. We have developed a comprehensive strategy for the management of neonates with functionally univentricular hearts that includes the selective use of conventional neonatal palliation in standard-risk neonates, hybrid approaches in neonates with elevated risk secondary to a noncardiac etiology, and neonatal palliation combined with insertion of a single ventricular assist device (VAD) in neonates with elevated risk secondary to a cardiac etiology. Here we describe our selection criteria, technical details, management strategies, pitfalls, and current outcomes for neonates with functionally univentricular hearts supported with a VAD. Our experience shows that extremely high-risk neonates with functionally univentricular hearts who are poor candidates for conventional palliation can be successfully stabilized with concomitant palliation and pulsatile VAD insertion while awaiting cardiac transplantation.
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Deshpande SR, Slepian MJ, Alsoufi B. HeartWare HVAD Market Withdrawal and Impact on the Pediatric Field. ASAIO J 2021; 67:825-826. [PMID: 34339397 DOI: 10.1097/mat.0000000000001538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Shriprasad R Deshpande
- From the Pediatric Cardiology, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Marvin J Slepian
- Department of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
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