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Smeets GJJ, Volkers KM, Scherder EJA, Moonen XMH. Active music making and leisure activities for people with intellectual disabilities: A cluster randomized pilot study. RESEARCH IN DEVELOPMENTAL DISABILITIES 2023; 142:104606. [PMID: 37827006 DOI: 10.1016/j.ridd.2023.104606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 07/23/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
AIM A pilot cluster randomized controlled trial was performed to evaluate the effects of a music group intervention and a leisure activities group intervention on well-being, self-esteem, social acceptance, challenging behaviour and three components of executive functions (inhibitory control, cognitive flexibility and visual working memory) of adults with intellectual disabilities (ID). METHOD Twenty-nine participants living in four residential facilities for people with ID were randomized into a music or a leisure activities group intervention. Sixteen weekly sessions of one hour were performed with six to eight participants per group. Measurements were carried out at baseline, post-intervention and 11 weeks follow- up. Results were analysed with linear mixed models. RESULTS The leisure activities group intervention improved more than the music group intervention on internalizing behaviour overall and on inhibitory control at post-intervention. However, further analyses showed that this improvement was only significant in one of the two leisure activities facilities. CONCLUSION A leisure activities group intervention seems a promising intervention to improve internalizing behaviour and inhibitory control of younger adults with mild ID. Implications for the delivery of leisure activities group interventions and especially music group interventions are discussed. WHAT THIS PAPER ADDS Involvement in leisure activities of people with ID is associated with better well-being, an improvement in social skills and a reduction in emotional and behavioural problems. Active music making, as a specific form of leisure activities, seems to improve well-being, social acceptance and challenging behaviour (CB) as well. Moreover, in different (non-clinical) groups a significant effect of active music making has been found on self-esteem and executive functioning (EF). So far, little attention has been paid to the possible positive effects of active music making on adults with ID. In the current paper, a randomized controlled trial (RCT) was conducted to compare the post-intervention and follow-up measurements with baseline measurements between a music group intervention and a leisure activities group intervention on well-being, self-esteem, social acceptance, CB and EF in adults with ID. Multilevel models were used to detect possible intervention effects of 16 weekly sessions. Overall, inhibitory control and internalizing behaviour improved more amongst the participants of the leisure activities group than amongst the participants of the music group. This was mainly the case for younger participants who had mild ID. These effects are discussed and recommendations regarding the improvement of a music intervention for people with ID are presented.
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Affiliation(s)
- Gerianne J J Smeets
- Philadelphia Care Foundation, PO box 1255, 3800 BG Amersfoort, the Netherlands.
| | - Karin M Volkers
- Philadelphia Care Foundation, PO box 1255, 3800 BG Amersfoort, the Netherlands
| | - Erik J A Scherder
- Department of Clinical Neuropsychology, VU University Amsterdam, van der Boechorstraat 7, 1081 BT Amsterdam, the Netherlands
| | - Xavier M H Moonen
- Research Institute of Child Development and Education, University of Amsterdam, Postbus 15776, 1001 NG Amsterdam, the Netherlands
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Rodriguez-Gomez DA, Talero-Gutiérrez C. Effects of music training in executive function performance in children: A systematic review. Front Psychol 2022; 13:968144. [PMID: 36003104 PMCID: PMC9393548 DOI: 10.3389/fpsyg.2022.968144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
Music training has traditionally been a fundamental component of children's education across several cultures. Moreover, music training has been hypothesized to enhance the development of executive functions and improve executive performance in children. In this systematic review, we analyze the available evidence of the effects of music training on executive function performance, evaluated using validated neuropsychologic batteries and classic tasks. To achieve this objective, we performed a systematic search in three databases (PubMed, Ovid MEDLINE, and Scopus) and selected case-control or intervention studies conducted on children with neurotypical development. We analyzed 29 studies that met the inclusion criteria and observed significant heterogeneity among the music interventions and methods for assessing executive functions. The review of the available literature suggests a beneficial effect of music training in core executive function performance, primarily in inhibitory control, and to a lesser extent, in working memory and cognitive flexibility.
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Affiliation(s)
| | - Claudia Talero-Gutiérrez
- Neuroscience Research Group (NeURos), NeuroVitae Center for Neuroscience, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
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Tymofiyeva O, Gaschler R. Training-Induced Neural Plasticity in Youth: A Systematic Review of Structural and Functional MRI Studies. Front Hum Neurosci 2021; 14:497245. [PMID: 33536885 PMCID: PMC7848153 DOI: 10.3389/fnhum.2020.497245] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 12/01/2020] [Indexed: 01/17/2023] Open
Abstract
Experience-dependent neural plasticity is high in the developing brain, presenting a unique window of opportunity for training. To optimize existing training programs and develop new interventions, it is important to understand what processes take place in the developing brain during training. Here, we systematically review MRI-based evidence of training-induced neural plasticity in children and adolescents. A total of 71 articles were included in the review. Significant changes in brain activation, structure, microstructure, and structural and functional connectivity were reported with different types of trainings in the majority (87%) of the studies. Significant correlation of performance improvement with neural changes was reported in 51% of the studies. Yet, only 48% of the studies had a control condition. Overall, the review supports the hypothesized neural changes with training while at the same time charting empirical and methodological desiderata for future research.
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Affiliation(s)
- Olga Tymofiyeva
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, CA, United States
- Department of Psychology, University of Hagen, Hagen, Germany
| | - Robert Gaschler
- Department of Psychology, University of Hagen, Hagen, Germany
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Nielsen JD, Mennies RJ, Olino TM. Application of a diathesis-stress model to the interplay of cortical structural development and emerging depression in youth. Clin Psychol Rev 2020; 82:101922. [PMID: 33038741 PMCID: PMC8594424 DOI: 10.1016/j.cpr.2020.101922] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 08/28/2020] [Accepted: 09/17/2020] [Indexed: 12/21/2022]
Abstract
Cross-sectional studies in adults have long identified differences in cortical structure in adults with depression compared to healthy adults, with most studies identifying reductions in grey matter volume, cortical thickness, and surface area in primarily frontal cortical regions including the OFC, ACC, and variable sub-regions of the PFC. However, when, why, and for whom these neural correlates of depression emerge remains poorly understood, necessitating developmental study of associations between depression and cortical structure. We systematically reviewed studies examining these associations in child/adolescent samples, and applied a developmentally-focused diathesis-stress model to understand the impacts of depressogenic risk-factors and stressors on the development of structural neural correlates of depression. Cross-sectional findings in youth are generally similar to those found in adults, but vary in magnitude and direction of effects. Preliminary evidence suggests that age, sex, severity, and comorbidity moderate these associations. Longitudinal studies show depression prospectively predicting cortical structure and structure predicting emerging depression. Consistent with a diathesis-stress model, associations have been noted between risk-factors for depression (e.g., genetic risk, family risk) and environmental stressors (e.g., early life stress) and structural neural correlates. Further investigation of these associations across development with attention to vulnerability factors and stressors is indicated.
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Affiliation(s)
- Johanna D Nielsen
- Department of Psychology, Temple University, Philadelphia, PA 19122, USA..
| | - Rebekah J Mennies
- Department of Psychology, Temple University, Philadelphia, PA 19122, USA..
| | - Thomas M Olino
- Department of Psychology, Temple University, Philadelphia, PA 19122, USA..
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Tang Q, Huang Z, Zhou H, Ye P. Effects of music therapy on depression: A meta-analysis of randomized controlled trials. PLoS One 2020; 15:e0240862. [PMID: 33206656 PMCID: PMC7673528 DOI: 10.1371/journal.pone.0240862] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/04/2020] [Indexed: 01/22/2023] Open
Abstract
Background We aimed to determine and compare the effects of music therapy and music medicine on depression, and explore the potential factors associated with the effect. Methods PubMed (MEDLINE), Ovid-Embase, the Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and Clinical Evidence were searched to identify studies evaluating the effectiveness of music-based intervention on depression from inception to May 2020. Standardized mean differences (SMDs) were estimated with random-effect model and fixed-effect model. Results A total of 55 RCTs were included in our meta-analysis. Music therapy exhibited a significant reduction in depressive symptom (SMD = −0.66; 95% CI = -0.86 to -0.46; P<0.001) compared with the control group; while, music medicine exhibited a stronger effect in reducing depressive symptom (SMD = −1.33; 95% CI = -1.96 to -0.70; P<0.001). Among the specific music therapy methods, recreative music therapy (SMD = -1.41; 95% CI = -2.63 to -0.20; P<0.001), guided imagery and music (SMD = -1.08; 95% CI = -1.72 to -0.43; P<0.001), music-assisted relaxation (SMD = -0.81; 95% CI = -1.24 to -0.38; P<0.001), music and imagery (SMD = -0.38; 95% CI = -0.81 to 0.06; P = 0.312), improvisational music therapy (SMD = -0.27; 95% CI = -0.49 to -0.05; P = 0.001), music and discuss (SMD = -0.26; 95% CI = -1.12 to 0.60; P = 0.225) exhibited a different effect respectively. Music therapy and music medicine both exhibited a stronger effects of short and medium length compared with long intervention periods. Conclusions A different effect of music therapy and music medicine on depression was observed in our present meta-analysis, and the effect might be affected by the therapy process.
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Affiliation(s)
- Qishou Tang
- Bengbu Medical University, Bengbu, Anhui, China
| | - Zhaohui Huang
- Anhui Provincial Center for Women and Child Health, Hefei, Anhui, China
| | - Huan Zhou
- Bengbu Medical University, Bengbu, Anhui, China
- National Drug Clinical Trial Institution, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui, China
| | - Peijie Ye
- Bengbu Medical University, Bengbu, Anhui, China
- * E-mail:
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Wang Z, Hu JB, Ji GJ, Xu DR, Wang DD, Xi CX, Hu CC, Lu J, Du YL, Lu QQ, Huang TT, Lai JB, Chen JK, Zhou WH, Wei N, Xu Y, Wang K, Hu SH. Executive function and its relation to anatomical connectome in homosexual and heterosexual men. Quant Imaging Med Surg 2020; 10:1973-1983. [PMID: 33014729 DOI: 10.21037/qims-19-821b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Sexual orientation has been suggested to affect executive function, of which the neurobiological basis is still largely unknown. In this study, we explored the interrelationship between neuropsychological characteristics in homosexual and heterosexual men and their anatomical connectome by graph theoretical analysis. Methods Fifty-three homosexual and 47 heterosexual males underwent diffusion tensor magnetic resonance imaging (MRI) and neuropsychological assessments. Whole-brain anatomical networks were constructed using white matter tractography, performed on the diffusion tensor imaging data. Neuropsychological tests included the Wisconsin Card Sorting Test (WCST), the Continuous Performance Test (CPT) and the Trail-Making Test (TMT). Results The cognitive performance of homosexual men was significantly poorer than their heterosexual counterparts in terms of WCST total correct responses. Anatomical connectome analysis revealed a lower (P=0.001) anatomical connectivity between left PoCG and left SMG (P=0.003) in homosexual men as compared to heterosexual men. Linear regression analyses showed that the WCST total correct responses score was significantly linked with sexual orientation (P=0.001). The anatomical connectivity strength between left PoCG and left SMG was also shown to be significantly correlated with sexual orientation (P=0.039) and education (P=0.047). Conclusions Our study demonstrated the differences in the performance of WCST and anatomical connectome of large-scale brain networks between homosexual and heterosexual men, extending our understanding of the brain's circuitry and the characteristics of executive function in men of different sexual orientation.
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Affiliation(s)
- Zheng Wang
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Jian Bo Hu
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Gong Jun Ji
- Laboratory of Cognitive Neuropsychology, Department of Medical Psychology, Anhui Medical University, Hefei, China
| | - Dong Rong Xu
- Epidemiology Division & MRI Unit, Department of Psychiatry, Columbia University & New York State Psychiatric Institute, New York, NY, USA
| | - Dan Dan Wang
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Cai Xi Xi
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Chan Chan Hu
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Jing Lu
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Yan Li Du
- Zhejiang University School of Medicine, Hangzhou, China
| | - Qiao Qiao Lu
- Zhejiang University School of Medicine, Hangzhou, China
| | | | - Jian Bo Lai
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Jing Kai Chen
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Wei Hua Zhou
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Ning Wei
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Yi Xu
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
| | - Kai Wang
- Laboratory of Cognitive Neuropsychology, Department of Medical Psychology, Anhui Medical University, Hefei, China
| | - Shao Hua Hu
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,The Key Laboratory of Mental Disorder's Management of Zhejiang Province, Hangzhou, China
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Habeck C, Gazes Y, Razlighi Q, Stern Y. Cortical thickness and its associations with age, total cognition and education across the adult lifespan. PLoS One 2020; 15:e0230298. [PMID: 32210453 PMCID: PMC7094839 DOI: 10.1371/journal.pone.0230298] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/25/2020] [Indexed: 12/13/2022] Open
Abstract
Early-life education (years of schooling) has been investigated in regards to cognition, health outcomes and mortality. It has been shown to confer cognitive reserve that might lessen the impact of brain pathology and its impact on cognitive and motor functioning in a variety of neurodegenerative diseases and, for instance, to influence electrical activity [Begum, T., Reza, F., Ahmed, I., & Abdullah, J. M. (2014). Influence of education level on design-induced N170 and P300 components of event related potentials in the human brain. J Integr Neurosci, 13(1), 71–88. doi:10.1142/S0219635214500058]. On the other hand, demonstrations of a direct association between education and brain-structural measures have been more equivocal and scant. The current study sought to identify univariate cortical-thickness patterns underlying education and general intelligence after adjusting for age, gender and possible in-scanner movement in 353 individuals aged 40 to 80. We followed up this idea with multivariate analyses as well. For univariate analyses, our analyses yielded no robust associations between education and general intelligence beyond confounding effects of gender, age and extraneous in-scanner movement. A subsequent multivariate analyses showed a relationship between education and regional cortical thickness with a robust pattern of negative as well as positive loadings in several right-sided brain areas, speaking to a subtle but robust distributed effect of education on cortical thickness. Cortical thickness variance that is the residual of this education-related pattern was shown to be positively associated with age and extraneous in-scanner movement. Our study thus presents a complex picture of the association of education with regional cortical thickness: education was associated with a distributed brain-wide pattern of positive as well as negative loadings with unaccounted residuals being larger for older participants. Focal regional associations beyond demographic and age covariates were not identified.
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Affiliation(s)
- Christian Habeck
- Cognitive Neuroscience Division, Department of Neurology, Columbia University Medical Center, New York, NY, United States of America
| | - Yunglin Gazes
- Cognitive Neuroscience Division, Department of Neurology, Columbia University Medical Center, New York, NY, United States of America
| | - Qolamreza Razlighi
- Cognitive Neuroscience Division, Department of Neurology, Columbia University Medical Center, New York, NY, United States of America
| | - Yaakov Stern
- Cognitive Neuroscience Division, Department of Neurology, Columbia University Medical Center, New York, NY, United States of America
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Music-based interventions to reduce internalizing symptoms in children and adolescents: A meta-analysis. J Affect Disord 2018; 225:647-656. [PMID: 28889050 DOI: 10.1016/j.jad.2017.08.035] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 06/19/2017] [Accepted: 08/14/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Existing systematic reviews provide evidence that music therapy is an effective intervention in the treatment of children and adolescents with psychopathology. The objective of the present review was to systematically review and quantify the effects of music-based interventions in reducing internalizing symptoms (i.e., depression and anxiety) in children and adolescents using a meta-analytical approach. METHODS Databases and journals were systematically screened for studies eligible for inclusion in meta-analysis on the effects of music-based interventions in reducing internalizing symptoms. A random-effect meta-analysis using standardized mean differences (SMD) was conducted. RESULTS Five studies were included. Analysis of data from (randomized) controlled trials, yielded a significant main effect (Hedge's g = -0.73; 95%CI [-1.42;-0.04], Z = 2.08, p = 0.04, k = 5), indicating a greater reduction of internalizing symptoms in youth receiving music-based interventions (n = 100) compared to different control group interventions (n = 95). LIMITATIONS The existing evidence is limited to studies of low power and methodological quality. Included studies were highly heterogeneous with respect to the nature of the intervention, the measurements applied, the samples studied, and the study design. CONCLUSIONS Findings indicate that music-based interventions may be efficient in reducing the severity of internalizing symptoms in children and adolescents. While these results are encouraging with respect to the application of music-based intervention, rigorous research is necessary to replicate existing findings and provide a broader base of evidence. More research adopting well controlled study designs of high methodological quality is needed.
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Moon JR, Song J, Huh J, Kang IS, Park SW, Chang SA, Yang JH, Jun TG. The Relationship between Parental Rearing Behavior, Resilience, and Depressive Symptoms in Adolescents with Congenital Heart Disease. Front Cardiovasc Med 2017; 4:55. [PMID: 28944224 PMCID: PMC5596069 DOI: 10.3389/fcvm.2017.00055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 08/16/2017] [Indexed: 11/13/2022] Open
Abstract
Objectives Parental rearing behavior is one factor that influences the strength of resilience. In turn, resilience influences depression. However, it is unclear whether resilience has a mediating effect on the relationship between parental rearing and depression in adolescents with congenital heart disease (CHD). Therefore, the associations between parental rearing behavior and resilience and between rearing behavior and symptoms of depression were investigated with respect to age, gender and disease severity. Subjects and methods Patients completed a parental rearing behavior questionnaire, a resilience scale and the Children’s Depression Inventory during a routine clinic visit. Structural equation modeling with maximum likelihood estimation was used to analyze the data. Results The median age of the 180 patients included in the study was 17.8 years, and 64% were male. Lower resilience was found to be associated with overprotection, punishment, rejection, and control. There was a strong relationship between resilience and symptoms of depression. Resilience varied according to gender, age group, and disease severity. Conclusion Parental rearing behaviors such as emotional warmth, rejection, punishment, control, and overprotection have a significant influence on adolescent’s resilience. When developing intervention programs to increase resilience and reduce depression in adolescents with CHD, parenting attitudes, gender, age, and CHD severity should be considered.
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Affiliation(s)
- Ju Ryoung Moon
- Department of Nursing, Grown-Up Congenital Heart Clinic, Heart Vascular and Stroke Institute, Samsung Medical Center, Seoul, Korea
| | - Jinyoung Song
- Department of Pediatrics, Grown-Up Congenital Heart Clinic, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Huh
- Department of Pediatrics, Grown-Up Congenital Heart Clinic, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - I-Seok Kang
- Department of Pediatrics, Grown-Up Congenital Heart Clinic, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Cardiology, Grown-Up Congenital Heart Clinic, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-A Chang
- Division of Cardiology, Grown-Up Congenital Heart Clinic, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Hyuk Yang
- Department of Thoracic & Cardiovascular Surgery, Grown-Up Congenital Heart Clinic, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae-Gook Jun
- Department of Thoracic & Cardiovascular Surgery, Grown-Up Congenital Heart Clinic, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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