1
|
Latus H, Born D, Shehu N, Stern H, Hager A, Georgiev S, Tanase D, Meierhofer C, Ewert P, Eicken A, Tutarel O. Favorable Atrial Remodeling After Percutaneous Pulmonary Valve Implantation and Its Association With Changes in Exercise Capacity and Right Ventricular Function. J Am Heart Assoc 2021; 10:e021416. [PMID: 34612047 PMCID: PMC8751879 DOI: 10.1161/jaha.121.021416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Right atrial (RA) dilatation and impaired right ventricular (RV) filling are common in patients with RV outflow tract dysfunction. We aimed to study potential correlations between atrial function with clinically relevant hemodynamic parameters and to assess the predictive impact of atrial performance on the recovery of exercise capacity and RV pump function after percutaneous pulmonary valve implantation (PPVI). Methods and Results Altogether, 105 patients with right ventricular outflow tract dysfunction (median age at PPVI, 19.2 years; range, 6.2–53.4 years) who underwent cardiac magnetic resonance imaging before and 6 months after PPVI were included. RA and left atrial maximal and minimal volumes as well as atrial passive and active emptying function were assessed from axial cine slices. RA emptying function was inversely related to invasive RV end‐diastolic pressure, and RA passive emptying correlated significantly with peak oxygen uptake. After PPVI, a significant decrease in RA minimum volume was observed, whereas RA passive emptying function improved, and RA active emptying function decreased significantly. Patients with predominant right ventricular outflow tract stenosis showed more favorable changes in RA active and left atrial passive emptying than those with primary volume overload. None of the RA and left atrial emptying parameters was predictive for recovery of peak oxygen uptake or RV ejection fraction. Conclusions In patients with right ventricular outflow tract dysfunction, impaired RA emptying assessed by cardiac magnetic resonance imaging was associated with increased RV filling pressures and lower exercise capacity. PPVI leads to a reduction in RA size and improved passive RA emptying function. However, RA function was not associated with improved exercise performance and RV pump function.
Collapse
Affiliation(s)
- Heiner Latus
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany
| | - Danik Born
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany
| | - Nerejda Shehu
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany
| | - Heiko Stern
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany
| | - Stainimir Georgiev
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany
| | - Daniel Tanase
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany
| | - Christian Meierhofer
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany.,German Centre for Cardiovascular Research (DZHK) Partner Site Munich Heart Alliance Munich Germany
| | - Andreas Eicken
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany
| | - Oktay Tutarel
- Department of Congenital Heart Disease and Pediatric Cardiology German Heart Centre MunichTechnical University of Munich Munich Germany.,German Centre for Cardiovascular Research (DZHK) Partner Site Munich Heart Alliance Munich Germany
| |
Collapse
|
2
|
Use of Speckle Tracking Echocardiography to Assess Left Ventricular Systolic Function in Patients with Surgically Repaired Tetralogy of Fallot: Global and Segmental Assessment. Pediatr Cardiol 2018; 39:1669-1675. [PMID: 30105466 DOI: 10.1007/s00246-018-1950-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Abstract
Patients with repaired Tetralogy of Fallot (rToF) can have significant right and left ventricular dysfunction which can impact clinical outcome. Conventional echocardiographic evaluation using ejection fraction can be limited in detecting early stages of deteriorating left ventricular (LV) systolic function. Speckle-tracking echocardiography (STE) provides a promising emerging tool for early detection of LV systolic dysfunction. The aim of this cross-sectional study is to evaluate the left ventricular global and regional function using STE in rToF patients with preserved left ventricular ejection fraction to detect early signs of LV dysfunction. The study is a retrospective review of the medical records and transthoracic echocardiograms of rTOF patients who were seen in the pediatric cardiology clinic at our institution from August 2016 till May 2018. The rTOF group was compared with a matched healthy control group. Offline strain analysis of TTE studies was completed in each subject according to mode set by the American Society of Echocardiography. Twenty-two patients with rTOF and 22 age-matched controls (rTOF 18.7 ± 6 years and control 14.6 ± 9.6 years, P value 0.19) were included during the study period. The rTOF group consisted of 12 males and 10 females, whereas the control group consisted of 15 males and 7 females. There was no significant difference in terms of LV ejection fraction using both 2-chamber as well as 4-chamber views. Global LV longitudinal strain was significantly lower in the rTOF group compared with the control group (rTOF - 15.92 ± 3.16 vs control - 22.79 ± 2.45, P value 0.00). All 17 segments showed significantly lower longitudinal strains in rTOF group compared with the control group. Global circumferential left ventricle strain was significantly lower in the rTOF patients compared with the control group (- 17.24 ± 5.86 vs - 22.74 ± 3.99, P value 0.001). 13 out of 16 segments had lower circumferential strains in the rTOF patients compared with controls. Asymptomatic surgically repaired TOF patients exhibited abnormal segmental and global left ventricle longitudinal and circumferential strains despite having normal left ventricle ejection fraction. Our findings suggest subclinical damage to the left ventricle systolic function post-surgical repair of TOF. 2-D speckle-tracking echocardiography may be used as a valuable method in the early recognition of left myocardial systolic function impairment in patients after TOF repair. The application of this method to guide clinical decision and management of rTOF patients such as earlier pulmonary valve replacement or risk stratification for sudden cardiac death needs further investigation.
Collapse
|
3
|
Hae Kim C, Wang S, Park JB, Jung KH, E Yoon Y, Lee SP, Kim HK, Kim YJ, Cho GY, Sohn DW. Assessing Impact of High-Dose Pitavastatin on Carotid Artery Elasticity with Speckle-Tracking Strain Imaging. J Atheroscler Thromb 2018. [PMID: 29515050 PMCID: PMC6224202 DOI: 10.5551/jat.42861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
AIM Speckle-tracking imaging has been introduced for the precise assessment of vessel mechanics. However, there are no data on the role of this imaging tool in assessing the changes in vasculature with statin therapy, which is known to enhance vascular elasticity. METHODS This study was a prospective study including 48 statin-naïve patients (age, 58.2±8.4 years; 29.2% male) with hypercholesterolemia. Circumferential carotid artery strain (CAS) and stiffness index (β2) were measured using speckle-tracking imaging before and after 3 months of high-dose pitavastatin treatment (4 mg daily). For the comparison, we measured conventional carotid elasticity parameters and intima-media thickness using B-mode ultrasound at the same time points. RESULTS Compared with baseline, there was significant improvement in circumferential CAS (2.98%±1.18% to 3.40%±1.43%, p=0.008) and β2 (0.19±0.07 to 0.17±0.08, p=0.047) after statin therapy. Contrariwise, there were no significant changes in all conventional carotid elasticity metrics and intima-media thickness. When stratifying patients into two subgroups by 10 year atherosclerotic cardiovascular disease (ASCVD) risk, speckle-tracking-derived circumferential CAS and β2 improved significantly only in patients with ASCVD risk ≥ 7.5%. CONCLUSIONS Short-term treatment with high-dose pitavastatin improved carotid artery elasticity measured by speckle-tracking method, but not conventional parameters by B-mode ultrasound. Speckle-tracking-based measurements may allow the early noninvasive assessment of statin effects on vascular function in hypercholesterolemic patients.
Collapse
Affiliation(s)
- Chee Hae Kim
- Division of Cardiology, Seoul National University College of Medicine.,Cardiovascular Center, Seoul National University Hospital
| | - Shuang Wang
- Department of Cardiology, Xiangtan Central Hospital
| | - Jun-Bean Park
- Division of Cardiology, Seoul National University College of Medicine.,Cardiovascular Center, Seoul National University Hospital
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital
| | - Yeonyee E Yoon
- Division of Cardiology, Seoul National University College of Medicine.,Cardiovascular Center, Seoul National University Bundang Hospital
| | - Seung-Pyo Lee
- Division of Cardiology, Seoul National University College of Medicine.,Cardiovascular Center, Seoul National University Hospital
| | - Hyung-Kwan Kim
- Division of Cardiology, Seoul National University College of Medicine.,Cardiovascular Center, Seoul National University Hospital
| | - Yong-Jin Kim
- Division of Cardiology, Seoul National University College of Medicine.,Cardiovascular Center, Seoul National University Hospital
| | - Goo-Yeong Cho
- Division of Cardiology, Seoul National University College of Medicine.,Cardiovascular Center, Seoul National University Bundang Hospital
| | - Dae-Won Sohn
- Division of Cardiology, Seoul National University College of Medicine.,Cardiovascular Center, Seoul National University Hospital
| |
Collapse
|
4
|
Ferrara F, Gargani L, Ostenfeld E, D'Alto M, Kasprzak J, Voilliot D, Selton-Suty C, Vriz O, Marra AM, Argiento P, Stanziola AA, Cittadini A, D'Andrea A, Bossone E. Imaging the right heart pulmonary circulation unit: Insights from advanced ultrasound techniques. Echocardiography 2017; 34:1216-1231. [DOI: 10.1111/echo.13594] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Francesco Ferrara
- Heart Department; Cardiology Division; “Cava de' Tirreni and Amalfi Coast” Hospital; University of Salerno; Salerno Italy
| | - Luna Gargani
- Institute of Clinical Physiology - C.N.R.; Pisa Italy
| | - Ellen Ostenfeld
- Department of Clinical Sciences Lund; Clinical Physiology and Skane University Hospital; Lund University; Lund Sweden
| | - Michele D'Alto
- Department of Cardiology; Second University of Naples; Napoli Italy
| | - Jaroslaw Kasprzak
- Department of Cardiology; Bieganski Hospital; Medical University of Lodz; Lodz Poland
| | - Damien Voilliot
- Cardiology Service; Institute Lorrain du Cœur et des Vaisseaux; Centre Hospitalier Universitaire de Nancy; Vandœuvre-lès-Nancy France
| | - Christine Selton-Suty
- Cardiology Service; Institute Lorrain du Cœur et des Vaisseaux; Centre Hospitalier Universitaire de Nancy; Vandœuvre-lès-Nancy France
| | - Olga Vriz
- Cardiology and Emergency Department; Hospital of San Daniele del Friuli; Udine Italy
| | | | - Paola Argiento
- Department of Cardiology; Second University of Naples; Napoli Italy
| | - Anna A. Stanziola
- Department of Respiratory Diseases; Monaldi Hospital; University “Federico II,”; Naples Italy
| | - Antonio Cittadini
- Department of Translational Medical Sciences; University Federico II of Naples; Naples Italy
| | | | - Eduardo Bossone
- Heart Department; Cardiology Division; “Cava de' Tirreni and Amalfi Coast” Hospital; University of Salerno; Salerno Italy
| |
Collapse
|
5
|
Pagourelias ED, Daraban AM, Mada RO, Duchenne J, Mirea O, Cools B, Heying R, Boshoff D, Bogaert J, Budts W, Gewillig M, Voigt JU. Right ventricular remodelling after transcatheter pulmonary valve implantation. Catheter Cardiovasc Interv 2017; 90:407-417. [PMID: 28296032 DOI: 10.1002/ccd.26966] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 12/13/2016] [Accepted: 01/16/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To define the optimal timing for percutaneous pulmonary valve implantation (PPVI) in patients with severe pulmonary regurgitation (PR) after Fallot's Tetralogy (ToF) correction. BACKGROUND PPVI among the aforementioned patients is mainly driven by symptoms or by severe right ventricular (RV) dilatation/dysfunction. The optimal timing for PPVI is still disputed. METHODS Twenty patients [age 13.9 ± 9.2 years, (range 4.3-44.9), male 70%] with severe PR (≥3 grade) secondary to previous correction of ToF, underwent Melody valve (Medtronic, Minneapolis, MN) implantation, after a pre-stent placement. Full echocardiographic assessment (traditional and deformation analysis) and cardiovascular magnetic resonance evaluation were performed before and at 3 months after the intervention. 'Favorable remodelling' was considered the upper quartile of RV size decrease (>20% in 3 months). RESULTS After PPVI, indexed RV effective stroke volume increased from 38.4 ± 9.5 to 51.4 ± 10.7 mL/m2 , (P = 0.005), while RV end-diastolic volume and strain indices decreased (123.1 ± 24.1-101.5 ± 18.3 mL/m2 , P = 0.005 and -23.5 ± 2.5 to -21 ± 2.5%, P = 0.002, respectively). After inserting pre-PPVI clinical, RV volumetric and deformation parameters in a multiple regression model, only time after last surgical correction causing PR remained as significant regressor of RV remodelling [R2 = 0.60, beta = 0.387, 95%CI(0.07-0.7), P = 0.019]. Volume reduction and functional improvement were more pronounced in patients treated with PPVI earlier than 7 years after last RV outflow tract (RVOT) correction, reaching close-to-normal values. CONCLUSIONS Early PPVI (<7 years after last RVOT operation) is associated with a more favorable RV reverse remodelling toward normal range and should be considered, before symptoms or RV damage become apparent. © 2017 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
| | - Ana M Daraban
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, 3000, Belgium
| | - Razvan O Mada
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, 3000, Belgium
| | - Jürgen Duchenne
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, 3000, Belgium
| | - Oana Mirea
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, 3000, Belgium
| | - Bjorn Cools
- Department of Pediatric Cardiology, University Hospital Leuven, Leuven, 3000, Belgium
| | - Ruth Heying
- Department of Pediatric Cardiology, University Hospital Leuven, Leuven, 3000, Belgium
| | - Derize Boshoff
- Department of Pediatric Cardiology, University Hospital Leuven, Leuven, 3000, Belgium
| | - Jan Bogaert
- Department of Radiology, University Hospital Leuven, Leuven, 3000, Belgium
| | - Werner Budts
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, 3000, Belgium
| | - Marc Gewillig
- Department of Pediatric Cardiology, University Hospital Leuven, Leuven, 3000, Belgium
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, 3000, Belgium
| |
Collapse
|
6
|
Wehman B, Sharma S, Pietris N, Mishra R, Siddiqui OT, Bigham G, Li T, Aiello E, Murthi S, Pittenger M, Griffith B, Kaushal S. Mesenchymal stem cells preserve neonatal right ventricular function in a porcine model of pressure overload. Am J Physiol Heart Circ Physiol 2016; 310:H1816-26. [PMID: 27106046 DOI: 10.1152/ajpheart.00955.2015] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/12/2016] [Indexed: 11/22/2022]
Abstract
Limited therapies exist for patients with congenital heart disease (CHD) who develop right ventricular (RV) dysfunction. Bone marrow-derived mesenchymal stem cells (MSCs) have not been evaluated in a preclinical model of pressure overload, which simulates the pathophysiology relevant to many forms of CHD. A neonatal swine model of RV pressure overload was utilized to test the hypothesis that MSCs preserve RV function and attenuate ventricular remodeling. Immunosuppressed Yorkshire swine underwent pulmonary artery banding to induce RV dysfunction. After 30 min, human MSCs (1 million cells, n = 5) or placebo (n = 5) were injected intramyocardially into the RV free wall. Serial transthoracic echocardiography monitored RV functional indices including 2D myocardial strain analysis. Four weeks postinjection, the MSC-treated myocardium had a smaller increase in RV end-diastolic area, end-systolic area, and tricuspid vena contracta width (P < 0.01), increased RV fractional area of change, and improved myocardial strain mechanics relative to placebo (P < 0.01). The MSC-treated myocardium demonstrated enhanced neovessel formation (P < 0.0001), superior recruitment of endogenous c-kit+ cardiac stem cells to the RV (P < 0.0001) and increased proliferation of cardiomyocytes (P = 0.0009) and endothelial cells (P < 0.0001). Hypertrophic changes in the RV were more pronounced in the placebo group, as evidenced by greater wall thickness by echocardiography (P = 0.008), increased cardiomyocyte cross-sectional area (P = 0.001), and increased expression of hypertrophy-related genes, including brain natriuretic peptide, β-myosin heavy chain and myosin light chain. Additionally, MSC-treated myocardium demonstrated increased expression of the antihypertrophy secreted factor, growth differentiation factor 15 (GDF15), and its downstream effector, SMAD 2/3, in cultured neonatal rat cardiomyocytes and in the porcine RV myocardium. This is the first report of the use of MSCs as a therapeutic strategy to preserve RV function and attenuate remodeling in the setting of pressure overload. Mechanistically, transplanted MSCs possibly stimulated GDF15 and its downstream SMAD proteins to antagonize the hypertrophy response of pressure overload. These encouraging results have implications in congenital cardiac pressure overload lesions.
Collapse
Affiliation(s)
- Brody Wehman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Sudhish Sharma
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Nicholas Pietris
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rachana Mishra
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Osama T Siddiqui
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Grace Bigham
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Tieluo Li
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Emily Aiello
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Sarah Murthi
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Mark Pittenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Bartley Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Sunjay Kaushal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
| |
Collapse
|
7
|
Clinical Application of Strain Imaging. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0140-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
8
|
Chowdhury SM, Hijazi ZM, Fahey JT, Rhodes JF, Kar S, Makkar R, Mullen M, Cao QL, Shirali GS. Speckle-Tracking Echocardiographic Measures of Right Ventricular Function Correlate With Improvement in Exercise Function After Percutaneous Pulmonary Valve Implantation. J Am Soc Echocardiogr 2015; 28:1036-44. [PMID: 26117295 DOI: 10.1016/j.echo.2015.05.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Speckle-tracking echocardiographic (STE) measures of right ventricular (RV) function appear to improve after transcatheter pulmonary valve implantation (TPVI). Measures of exercise function, such as ventilatory efficiency (the minute ventilation [VE]/carbon dioxide production [VCO2] slope), have been shown to be prognostic of mortality in patients who may require TPVI. The aim of this study was to evaluate the correlation between STE measures of RV function and changes in VE/VCO2 after TPVI. METHODS Speckle-tracking echocardiography and cardiopulmonary exercise testing were performed at baseline and 6 months after TPVI in 24 patients from four centers. Conventional echocardiographic measures of RV function were also assessed. Echocardiographic and exercise stress test results were interpreted by single blinded observers at separate core laboratories. RESULTS All patients demonstrated relief of pulmonary regurgitation and stenosis after TPVI. Improvements in RV longitudinal strain (-16.9 ± 3.5% vs -19.7 ± 4.3%, P < .01) and strain rate (-0.9 ± 0.4 vs. -1.2 ± 0.4 s(-1), P < .01) were noted. The VE/VCO2 slope improved (32.4 ± 5.7 vs 31.5 ± 8.8, P = .03). No other significant echocardiographic or exercise changes were found. On multivariate regression, the change in VE/VCO2 was independently associated with change in RV longitudinal early diastolic strain rate (P < .001) and tricuspid A velocity (P < .001). Preintervention RV longitudinal strain was found to be a predictor of change in VE/VCO2 after TPVI (r = -0.60, P < .001). CONCLUSIONS STE measures of RV function appear to hold the potential for use as predictors of improved outcomes in patients requiring TPVI. Future studies should directly assess the prognostic significance of STE measures of RV function in this population.
Collapse
Affiliation(s)
- Shahryar M Chowdhury
- Department of Pediatrics, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina.
| | - Ziyad M Hijazi
- Department of Pediatrics, Sidra Medical and Research Center, Doha, Qatar
| | - John T Fahey
- Department of Pediatrics, Yale-New Haven Hospital, New Haven, Connecticut
| | - John F Rhodes
- Department of Pediatrics, Miami Children's Hospital, Miami, Florida
| | - Saibal Kar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Raj Makkar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Mullen
- Department of Medicine, The Heart Hospital, London, United Kingdom
| | - Qi-Ling Cao
- Rush Center for Congenital & Structural Heart Disease, Rush University Medical Center, Chicago, Illinois
| | - Girish S Shirali
- The Ward Family Heart Center, Children's Mercy Hospital, Kansas City, Missouri
| |
Collapse
|