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Lohr D, Kollmann A, Bille M, Terekhov M, Elabyad I, Hock M, Baltes S, Reiter T, Schnitter F, Bauer WR, Hofmann U, Schreiber LM. Precision imaging of cardiac function and scar size in acute and chronic porcine myocardial infarction using ultrahigh-field MRI. COMMUNICATIONS MEDICINE 2024; 4:146. [PMID: 39026075 PMCID: PMC11258271 DOI: 10.1038/s43856-024-00559-y] [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: 11/25/2022] [Accepted: 06/24/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND 7 T cardiac magnetic resonance imaging (MRI) studies may enable higher precision in clinical metrics like cardiac function, ventricular mass, and more. Higher precision may allow early detection of functional impairment and early evaluation of treatment responses in clinical practice and pre-clinical studies. METHODS Seven female German Landrace pigs were scanned prior to and at three time points (3-4 days, 7-10 days, and ~60 days) post myocardial infarction using a whole body 7 T system and three radiofrequency (RF) coils developed and built in-house to accompany animal growth. RESULTS The combination of dedicated RF hardware and 7 T MRI enables a longitudinal study in a pig model of acute and chronic infarction, providing consistent blood tissue contrast and high signal-to-noise ratio (SNR) in measurements of cardiac function, as well as low coefficients of variation (CoV) for ejection fraction (CoVintra-observer: 2%, CoVinter-observer: 3.8%) and infarct size (CoVintra-observer: 8.4%, CoVinter-observer: 3.8%), despite drastic animal growth. CONCLUSIONS Best results are achieved via manual segmentation. We define state-of-the-art procedures for large animal studies at 7 T.
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Affiliation(s)
- David Lohr
- Comprehensive Heart Failure Center (CHFC), Chair of Molecular and Cellular Imaging, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Alena Kollmann
- Comprehensive Heart Failure Center (CHFC), Chair of Molecular and Cellular Imaging, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maya Bille
- Comprehensive Heart Failure Center (CHFC), Chair of Molecular and Cellular Imaging, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maxim Terekhov
- Comprehensive Heart Failure Center (CHFC), Chair of Molecular and Cellular Imaging, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ibrahim Elabyad
- Comprehensive Heart Failure Center (CHFC), Chair of Molecular and Cellular Imaging, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Michael Hock
- Comprehensive Heart Failure Center (CHFC), Chair of Molecular and Cellular Imaging, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Steffen Baltes
- Comprehensive Heart Failure Center (CHFC), Chair of Molecular and Cellular Imaging, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Theresa Reiter
- Comprehensive Heart Failure Center (CHFC), Chair of Molecular and Cellular Imaging, University Hospital Wuerzburg, Wuerzburg, Germany
- Department of Internal Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Florian Schnitter
- Department of Internal Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Wolfgang Rudolf Bauer
- Department of Internal Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ulrich Hofmann
- Department of Internal Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Laura Maria Schreiber
- Comprehensive Heart Failure Center (CHFC), Chair of Molecular and Cellular Imaging, University Hospital Wuerzburg, Wuerzburg, Germany.
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Lloyd MS, Tomashitis BM, Garcia M. Percutaneous Transpericardial Permanent Pacing in a Woman With Fontan Circulation. JACC Clin Electrophysiol 2024; 10:1508-1509. [PMID: 38520438 DOI: 10.1016/j.jacep.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 03/25/2024]
Affiliation(s)
- Michael S Lloyd
- Section of Clinical Cardiac Electrophysiology, Emory University, Atlanta, Georgia, USA.
| | - Brett M Tomashitis
- Section of Clinical Cardiac Electrophysiology, Emory University, Atlanta, Georgia, USA
| | - Mariana Garcia
- Section of Cardiovascular Imaging, Emory University, Atlanta, Georgia, USA
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Clark BC, Berul CI. Emerging Technologies for the Smallest Patients. Card Electrophysiol Clin 2023; 15:505-513. [PMID: 37865523 DOI: 10.1016/j.ccep.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Pediatric and congenital heart disease patients may require cardiac implantable electronic device implantation, inclusive of pacemaker, ICD, and implantable cardiac monitor, for a variety of etiologies. While leads, generators, and monitors have decreased in size over the years, they remain less ideal for the smallest patients. The potential for a miniature pacemaker, fetal micropacemaker, improving leadless technology, and rechargeable devices creates hope that the development of pediatric-focused devices will increase. Further, alternative approaches that avoid the need for a transvenous or surgical approach may add more options to the toolbox for the pediatric and congenital electrophysiologist.
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Affiliation(s)
- Bradley C Clark
- Division of Pediatric Cardiology, Department of Pediatrics, Masonic Children's Hospital, University of Minnesota Medical School, 2450 Riverside Avenue South, AO-405, Minneapolis, MN 55454, USA.
| | - Charles I Berul
- Division of Cardiology, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Avenue, NW, Washington, DC 20010, USA
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Kumthekar RN, Opfermann JD, Mass P, Contento JM, Berul CI. Percutaneous epicardial pacing in infants using direct visualization: A feasibility animal study. J Cardiovasc Electrophysiol 2023; 34:1452-1458. [PMID: 37172303 DOI: 10.1111/jce.15926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/20/2023] [Accepted: 04/29/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND Pacemaker implantation in infants and small children is limited to epicardial lead placement via open chest surgery. We propose a minimally invasive solution using a novel percutaneous access kit. OBJECTIVE To evaluate the acute safety and feasibility of a novel percutaneous pericardial access tool kit to implant pacemaker leads on the epicardium under direct visualization. METHODS A custom sheath with optical fiber lining the inside wall was built to provide intrathoracic illumination. A Veress needle inside the illumination sheath was inserted through a skin nick just to the left of the xiphoid process and angled toward the thorax. A needle containing a fiberscope within the lumen was inserted through the sheath and used to access the pericardium under direct visualization. A custom dilator and peel-away sheath with pre-tunneled fiberscope was passed over a guidewire into the pericardial space via modified Seldinger technique. A side-biting multipolar pacemaker lead was inserted through the sheath and affixed against the epicardium. RESULTS Six piglets (weight 3.7-4.0 kg) had successful lead implantation. The pericardial space could be visualized and entered in all animals. Median time from skin nick to sheath access of the pericardium was 9.5 (interquartile range [IQR] 8-11) min. Median total procedure time was 16 (IQR 14-19) min. Median R wave sensing was 5.4 (IQR 4.0-7.3) mV. Median capture threshold was 2.1 (IQR 1.7-2.4) V at 0.4 ms and 1.3 (IQR 1.2-2.0) V at 1.0 ms. There were no complications. CONCLUSION Percutaneous epicardial lead implantation under direct visualization was successful in six piglets of neonatal size and weight with clinically acceptable acute pacing parameters.
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Affiliation(s)
- Rohan N Kumthekar
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Justin D Opfermann
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Paige Mass
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia, USA
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Jacqueline M Contento
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia, USA
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Charles I Berul
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
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Haxel CS, Johnson JN, Hintz S, Renno MS, Ruano R, Zyblewski SC, Glickstein J, Donofrio MT. Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery. Pediatrics 2022; 150:189887. [PMID: 36317976 DOI: 10.1542/peds.2022-056415c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated. METHODS Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management. RESULTS Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization. CONCLUSIONS Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.
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Affiliation(s)
- Caitlin S Haxel
- The University of Vermont Children's Hospital, Burlington, Vermont
| | | | - Susan Hintz
- Stanford University, Lucille Salter Packard Children's Hospital, Palo Alto, California
| | - Markus S Renno
- University Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Julie Glickstein
- Columbia University Vagelos School of Medicine, Morgan Stanley Children's Hospital, New York, New York
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Chang P, Beach C, Vinocur J, Das S. Expanding the Reach of Pediatric Transcatheter Pacing. J Innov Card Rhythm Manag 2021; 12:4487-4492. [PMID: 33939789 PMCID: PMC8081454 DOI: 10.19102/icrm.2021.120408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abiri P, Yousefi A, Abiri A, Gudapati V, Ding Y, Nguyen KL, Abiri A, Markovic D, Tai YC, Hsiai TK. A Multi-Dimensional Analysis of a Novel Approach for Wireless Stimulation. IEEE Trans Biomed Eng 2020; 67:3307-3316. [PMID: 32248088 DOI: 10.1109/tbme.2020.2983443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The elimination of integrated batteries in biomedical implants holds great promise for improving health outcomes in patients with implantable devices. However, despite extensive research in wireless power transfer, achieving efficient power transfer and effective operational range have remained a hindering challenge within anatomical constraints. OBJECTIVE We hereby demonstrate an intravascular wireless and batteryless microscale stimulator, designed for (1) low power dissipation via intermittent transmission and (2) reduced fixation mechanical burden via deployment to the anterior cardiac vein (ACV, ∼3.8 mm in diameter). METHODS We introduced a unique coil design circumferentially confined to a 3 mm diameter hollow-cylinder that was driven by a novel transmitter-based control architecture with improved power efficiency. RESULTS We examined wireless capacity using heterogenous bovine tissue, demonstrating >5 V stimulation threshold with up to 20 mm transmitter-receiver displacement and 20° of misalignment. Feasibility for human use was validated using Finite Element Method (FEM) simulation of the cardiac cycle, guided by pacer phantom-integrated Magnetic Resonance Images (MRI). CONCLUSION This system design thus enabled sufficient wireless power transfer in the face of extensive stimulator miniaturization. SIGNIFICANCE Our successful feasibility studies demonstrated the capacity for minimally invasive deployment and low-risk fixation.
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Clark BC, Kumthekar R, Mass P, Opfermann JD, Berul CI. Chronic performance of subxiphoid minimally invasive pericardial Model 20066 pacemaker lead insertion in an infant animal model. J Interv Card Electrophysiol 2019; 59:13-19. [PMID: 31612301 DOI: 10.1007/s10840-019-00626-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/10/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe chronic performance of subxiphoid minimally invasive pacemaker lead insertion in a piglet model. METHODS Minimally invasive pacemaker lead implantation was performed through a 10-mm incision under direct visualization using the PeriPath port. Epicardial access was obtained and the commercially available Medtronic Model 20066 pacemaker lead was inserted into the pericardial space and epicardial fixation was performed using the side-action helix. The lead was connected to a pacemaker generator in a para-rectus pocket. Animals underwent a 12-14-week observation period and lead impedances, R-wave amplitudes, and ventricular capture thresholds were tested biweekly. After the survival period, animals were euthanized and gross and histopathology were performed. RESULTS Subxiphoid minimally invasive pacemaker lead placement was performed in 8 animals (median 4.9 kg) with 100% acute success. Median procedure time was 65 min (IQR 60.5-77). At implant, median lead impedance was 650 Ω (IQR 244-984), R-wave amplitude 11.1 mV (IQR 8-12.3), and ventricular capture threshold 1.5 V @ 0.4 ms (IQR 1-2.6). Over a median survival period of 13 weeks, there was a median lead impedance change of + 262 Ω (IQR 5.3-618.3), R-wave change of - 4.5 mV (IQR - 7.1-- 2.7) and capture threshold change (1.0 ms) of + 1.5 V (IQR 0-3.3). At autopsy, epicardial fixation sites showed fibrovascular proliferation and minimal chronic inflammation. CONCLUSIONS Subxiphoid pericardial pacemaker placement is safe and effective in a piglet model. Further study and development of leads designed for pericardial placement are warranted.
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Affiliation(s)
- Bradley C Clark
- Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA. .,Albert Einstein College of Medicine, Bronx, NY, USA.
| | | | - Paige Mass
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, DC, USA
| | - Justin D Opfermann
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, DC, USA
| | - Charles I Berul
- Children's National Medical Center, Washington, DC, USA.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, DC, USA.,George Washington University School of Medicine, Washington, DC, USA
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Quast AFB, Beurskens NE, Ebner A, Wasley R, Vehmeijer JT, Marcovecchio A, Sanghera R, Knops RE, Burke MC. Feasibility of an Entirely Extracardiac, Minimally Invasive,Temporary Pacing System. Circ Arrhythm Electrophysiol 2019; 12:e007182. [DOI: 10.1161/circep.119.007182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
A completely extracardiac pacing system provides the potential for clinical advantages over existing device alternatives that require intravascular, endocardial, or epicardial contact. Preliminary studies evaluating the feasibility of cardiac pacing with a lead in the anterior mediastinum, outside the pericardium and circulatory system have been completed. These studies examined (1) the anatomic access route, (2) the usability of a delivery tool to facilitate lead placement, and (3) the pacing performance of the extracardiac lead.
Methods:
Feasibility evaluations included (1) a retrospective computed tomography analysis to characterize anatomic variations related to lead access, (2) accessing the anterior mediastinum in cadavers and human subjects using a custom delivery tool, and (3) acute clinical pacing performance.
Results:
Major findings: (1) A total of 166 (95%) out of 174 patients had a viable lead access path through the fourth, fifth, or sixth intercostal space. (2) Access to the targeted implant location using a delivery tool was successful in all 5 cadavers and 3 humans without use of fluoroscopy and with an average lead delivery time of 121±52 s. No damage to the lung, pericardium, heart, or internal thoracic vessels occurred. (3) Pacing performance was tested in 6 human subjects showing a threshold voltage of 4.7 V (2.7–6.7), threshold pulse width of 1.8 ms (1.0–2.5), and an impedance of 1205 Ω (894–1786). R-wave amplitudes measured 9.6 mV (5.6–12.0).
Conclusions:
Results support the feasibility for this completely extracardiac pacing method in a heterogeneous patient population, using a minimally invasive, parasternal, delivery approach and with adequate sensing and thresholds suited for temporary pacing.
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Affiliation(s)
- Anne-Floor B.E. Quast
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, the Netherlands (A.-F.B.E.Q., N.E.G.B., J.T.V., R.E.K., M.C.B.)
| | - Niek E.G. Beurskens
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, the Netherlands (A.-F.B.E.Q., N.E.G.B., J.T.V., R.E.K., M.C.B.)
| | | | | | - Jim T. Vehmeijer
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, the Netherlands (A.-F.B.E.Q., N.E.G.B., J.T.V., R.E.K., M.C.B.)
| | | | - Rick Sanghera
- AtaCor Medical, Inc, San Clemente, CA (A.M., R.S., M.C.B.)
| | - Reinoud E. Knops
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, the Netherlands (A.-F.B.E.Q., N.E.G.B., J.T.V., R.E.K., M.C.B.)
| | - Martin C. Burke
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, the Netherlands (A.-F.B.E.Q., N.E.G.B., J.T.V., R.E.K., M.C.B.)
- AtaCor Medical, Inc, San Clemente, CA (A.M., R.S., M.C.B.)
- CorVita Science Foundation, Chicago, IL (M.C.B.)
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Pruetz JD, Miller JC, Loeb GE, Silka MJ, Bar-Cohen Y, Chmait RH. Prenatal diagnosis and management of congenital complete heart block. Birth Defects Res 2019; 111:380-388. [PMID: 30821931 DOI: 10.1002/bdr2.1459] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 01/03/2023]
Abstract
Congenital complete heart block (CCHB) is a life-threatening medical condition in the unborn fetus with insufficiently validated prenatal interventions. Maternal administration of medications aimed at decreasing the immune response in the fetus and beta-agonists intended to increase fetal cardiac output have shown only marginal benefits. Anti-inflammatory therapies cannot reverse CCHB, but may decrease myocarditis and improve heart function. Advances in prenatal diagnosis and use of strict surveillance protocols for delivery timing have demonstrated small improvements in morbidity and mortality. Ambulatory surveillance programs and wearable fetal heart rate monitors may afford early identification of evolving fetal heart block allowing for emergent treatment. There is also preliminary data suggesting a roll for prevention of CCHB with hydroxychloroquine, but the efficacy and safety is still being studied. To date, intrauterine fetal pacing has not been successful due to the high-risk invasive placement techniques and potential problems with lead dislodgement. The development of a fully implantable micropacemaker via a minimally invasive approach has the potential to pace fetal patients with CCHB and thus delay delivery and allow fetal hydrops to resolve. The challenge remains to establish accepted prenatal interventions capable of successfully managing CCHB in utero until postnatal pacemaker placement is successfully achieved.
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Affiliation(s)
- Jay D Pruetz
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Jennifer C Miller
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Gerald E Loeb
- Department of Biomedical Engineering, University of Southern California (USC), Los Angeles, California
| | - Michael J Silka
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Yaniv Bar-Cohen
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, Keck School of Medicine of USC, Los Angeles, California
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