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Zhi R, Tao X, Li Q, Yu M, Li H. Association between transabdominal uterine artery Doppler and small-for-gestational-age: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23:659. [PMID: 37704965 PMCID: PMC10500919 DOI: 10.1186/s12884-023-05968-w] [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] [Received: 02/06/2023] [Accepted: 08/31/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND The association between uterine artery Doppler (UtA) measurements and small for gestational age (SGA) has not been quantitatively analyzed throughout the whole pregnancy. This systematic review and meta-analysis aims to comprehensively explore the association between UtA measurements and SGA in the first, second, and third trimesters. METHODS Studies were searched from Pubmed, Embase, Cochrane Library, and Web of Science. Weighted mean difference (WMD), odds ratio (OR), and relative risk (RR) with 95% confidence interval (CI) were used as the effect size. Heterogeneity of all effect sizes was tested and quantified using I2 statistics. Sensitivity analysis was conducted for all outcomes, and publication bias was evaluated using Begg's test. RESULTS A total of 41 studies were finally included in our meta-analysis. In the first trimester, mean PI was significantly higher in the SGA group than the non-SGA group (WMD: 0.31, 95%CI: 0.19-0.44). In the second trimester, odds of notch presence (OR: 2.54, 95%CI: 2.10-3.08), mean PI (WMD: 0.21, 95%CI: 0.12-0.30), and mean RI (WMD: 0.05, 95%CI: 0.05-0.06) were higher in the SGA group. Also, abnormal UtA measurements were associated with the increased odds of SGA (all P < 0.05). In the third trimester, PI z-score (WMD: 0.62, 95%CI: 0.33-0.91) and PI MoM (WMD: 0.08, 95%CI: 0.06-0.09) showed a significant increase in the SGA group. The odds of SGA were higher in the women with mean PI > 95% (OR: 6.03, 95%CI: 3.24-11.24). CONCLUSIONS Abnormal UtA measurements were associated with high odds of SGA, suggesting that UtA might be an adjunctive screening method for SGA in the whole pregnancy.
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Affiliation(s)
- Ruijuan Zhi
- Department of Ultrasound, The First People's Hospital of Lianyungang, No.6 Zhenhua East Road, Haizhou District, Lianyungang, 222061, P.R. China
| | - Xiangping Tao
- Department of Pediatrics, The Affiliated Lianyungang Oriental Hospital of Xuzhou Medical University, Lianyungang, 222000, P.R. China
| | - Qingtao Li
- Department of Obstetrics and Gynecology, The First People's Hospital of Lianyungang, Lianyungang, 222061, P.R. China
| | - Ming Yu
- Department of Ultrasound, The First People's Hospital of Lianyungang, No.6 Zhenhua East Road, Haizhou District, Lianyungang, 222061, P.R. China
| | - Honge Li
- Department of Ultrasound, The First People's Hospital of Lianyungang, No.6 Zhenhua East Road, Haizhou District, Lianyungang, 222061, P.R. China.
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Josowitz R, Linn R, Rychik J. The Placenta in Congenital Heart Disease: Form, Function and Outcomes. Neoreviews 2023; 24:e569-e582. [PMID: 37653088 DOI: 10.1542/neo.24-9-e569] [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: 09/02/2023]
Abstract
The maternal-fetal environment, controlled and modulated by the placenta, plays a critical role in the development and well-being of the fetus, with long-term impact through programming of lifelong health. The fetal cardiovascular system and placenta emerge at the same time embryologically, and thus placental form and function are altered in the presence of congenital heart disease (CHD). In this review, we report on what is known about the placenta from a structural and functional perspective when there is CHD. We describe the various unique pathologic findings as well as the diagnostic imaging tools used to characterize placental function in utero. With growing interest in the placenta, a standardized approach to characterizing placental pathology has emerged. Furthermore, application of ultrasonography techniques and magnetic resonance imaging now allow for insights into placental blood flow and functionality in vivo. An improved understanding of the intriguing relationship between the placenta and the fetal cardiovascular system will provide opportunities to develop novel ways to optimize outcomes. Once better understood, therapeutic modulation of placental function offered during the vulnerable period of fetal plasticity may be one of the most impactful ways to alter the course of CHD and its complications.
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Affiliation(s)
- Rebecca Josowitz
- Division of Cardiology, Fetal Heart Program, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rebecca Linn
- Division of Anatomic Pathology, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
| | - Jack Rychik
- Division of Cardiology, Fetal Heart Program, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
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3
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Galaz J, Motomura K, Romero R, Liu Z, Garcia-Flores V, Tao L, Xu Y, Done B, Arenas-Hernandez M, Kanninen T, Farias-Jofre M, Miller D, Tarca AL, Gomez-Lopez N. A key role for NLRP3 signaling in preterm labor and birth driven by the alarmin S100B. Transl Res 2023; 259:46-61. [PMID: 37121539 PMCID: PMC10524625 DOI: 10.1016/j.trsl.2023.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/02/2023]
Abstract
Preterm birth remains the leading cause of neonatal morbidity and mortality worldwide. A substantial number of spontaneous preterm births occur in the context of sterile intra-amniotic inflammation, a condition that has been mechanistically proven to be triggered by alarmins. However, sterile intra-amniotic inflammation still lacks treatment. The NLRP3 inflammasome has been implicated in sterile intra-amniotic inflammation; yet, its underlying mechanisms, as well as the maternal and fetal contributions to this signaling pathway, are unclear. Herein, by utilizing a translational and clinically relevant model of alarmin-induced preterm labor and birth in Nlrp3-/- mice, we investigated the role of NLRP3 signaling by using imaging and molecular biology approaches. Nlrp3 deficiency abrogated preterm birth and the resulting neonatal mortality induced by the alarmin S100B by impeding the premature activation of the common pathway of labor as well as by dampening intra-amniotic and fetal inflammation. Moreover, Nlrp3 deficiency altered leukocyte infiltration and functionality in the uterus and decidua. Last, embryo transfer revealed that maternal and fetal Nlrp3 signaling contribute to alarmin-induced preterm birth and neonatal mortality, further strengthening the concept that both individuals participate in the complex process of preterm parturition. These findings provide novel insights into sterile intra-amniotic inflammation, a common etiology of preterm labor and birth, suggesting that the adverse perinatal outcomes resulting from prematurity can be prevented by targeting NLRP3 signaling.
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Affiliation(s)
- Jose Galaz
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan; Division of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Kenichiro Motomura
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan
| | - Zhenjie Liu
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Valeria Garcia-Flores
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Li Tao
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Yi Xu
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Bogdan Done
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Marcia Arenas-Hernandez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Tomi Kanninen
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Marcelo Farias-Jofre
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan; Division of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Derek Miller
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Adi L Tarca
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan; Department of Computer Science, Wayne State University College of Engineering, Detroit, Michigan; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Nardhy Gomez-Lopez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Detroit, Michigan; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan; Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, Michigan.
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Perkovic-Kepeci S, Cirkovic A, Milic N, Dugalic S, Stanisavljevic D, Milincic M, Kostic K, Milic N, Todorovic J, Markovic K, Aleksic Grozdic N, Gojnic Dugalic M. Doppler Indices of the Uterine, Umbilical and Fetal Middle Cerebral Artery in Diabetic versus Non-Diabetic Pregnancy: Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1502. [PMID: 37629792 PMCID: PMC10456372 DOI: 10.3390/medicina59081502] [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: 06/21/2023] [Revised: 07/20/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: The aim of this study was to assess the differences in Doppler indices of the uterine (Ut), umbilical (UA), and middle cerebral artery (MCA) in diabetic versus non-diabetic pregnancies by conducting a comprehensive systematic review of the literature with a meta-analysis. Materials and Methods: PubMed, Web of Science, and SCOPUS were searched for studies that measured the pulsatility index (PI), resistance index (RI), and systolic/diastolic ratio index (S/D ratio) of the umbilical artery, middle cerebral artery, and uterine artery in diabetic versus non-diabetic pregnancies. Two reviewers independently evaluated the eligibility of studies, abstracted data, and performed quality assessments according to standardized protocols. The standardized mean difference (SMD) was used as a measure of effect size. Heterogeneity was assessed using the I2 statistic. Publication bias was evaluated by means of funnel plots. Results: A total of 62 publications were included in the qualitative and 43 in quantitative analysis. The UA-RI, UtA-PI, and UtA-S/D ratios were increased in diabetic compared with non-diabetic pregnancies. Subgroup analysis showed that levels of UtA-PI were significantly higher during the third, but not during the first trimester of pregnancy in diabetic versus non-diabetic pregnancies. No differences were found for the UA-PI, UA-S/D ratio, MCA-PI, MCA-RI, MCA-S/D ratio, or UtA-RI between diabetic and non-diabetic pregnancies. Conclusions: This meta-analysis revealed the presence of hemodynamic changes in uterine and umbilical arteries, but not in the middle cerebral artery in pregnancies complicated by diabetes.
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Affiliation(s)
- Sonja Perkovic-Kepeci
- General Hospital Pancevo, 26000 Pancevo, Serbia;
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (K.K.); (N.M.); (K.M.); (M.G.D.)
| | - Andja Cirkovic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (N.M.); (D.S.)
| | - Natasa Milic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (N.M.); (D.S.)
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Stefan Dugalic
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (S.D.); (M.M.)
| | - Dejana Stanisavljevic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (N.M.); (D.S.)
| | - Milos Milincic
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (S.D.); (M.M.)
| | - Konstantin Kostic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (K.K.); (N.M.); (K.M.); (M.G.D.)
| | - Nikola Milic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (K.K.); (N.M.); (K.M.); (M.G.D.)
| | - Jovana Todorovic
- Institute of Social Medicine, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Ksenija Markovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (K.K.); (N.M.); (K.M.); (M.G.D.)
| | - Natasa Aleksic Grozdic
- Institute for Process Engineering Environmental Engineering and Technical Life Sciences, Technical University of Vienna, 1180 Vienna, Austria;
| | - Miroslava Gojnic Dugalic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (K.K.); (N.M.); (K.M.); (M.G.D.)
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (S.D.); (M.M.)
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Uteroplacental-Cerebral Ratio: A Doppler Parameter for Prognostic Prediction of Late-Onset Fetal Growth Restriction: Single Center Prospective Cohort Study. J Clin Med 2022; 12:jcm12010275. [PMID: 36615075 PMCID: PMC9821135 DOI: 10.3390/jcm12010275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose: This study aimed to elucidate the accuracy of Doppler parameters in predicting the prognosis of late-onset fetal growth restriction (FGR). Methods: This was a prospective study of 114 pregnancies. Doppler parameters, including the cerebroplacental ratio and pulsatility index (PI) in the middle cerebral, umbilical, uterine artery, were recorded. The new uteroplacental−cerebro ratio (UPCR) was constructed as the ratio of (umbilical artery + mean of the left and right uterine artery) to middle cerebral artery PI. Logistic regression analyses and receiver operating characteristic curves were performed. Results: Adverse outcomes occurred in 37 (32%) neonates. The z values of the middle cerebral artery PI and cerebroplacental ratio were lower (p < 0.001), while the z values of the umbilical artery PI, mean uterine artery PI, and UPCR (p < 0.001) were higher in late-onset FGR in those with compared to those without adverse outcomes. Multivariate logistic regression revealed that only UPCR was independently associated with adverse outcomes (p < 0.001). For predicting the prognosis of late-onset FGR, UPCR showed a fair degree of accuracy (area under the curve [AUC], 0.824). Conclusion: The new UPCR, reflecting the impact of placental impedance from both fetal and maternal sides on fetal well-being, improves the accuracy of prognostic prediction for late-onset FGR.
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Amodeo S, Cavoretto PI, Seidenari A, Paci G, Germano C, Monari F, Donno V, Giambanco L, Avagliano L, Di Martino D, Fusé F, Masturzo B, Chiantera V, Facchinetti F, Ferrazzi E, Candiani M, Bulfamante G, Farina A. Second trimester uterine arteries pulsatility index is a function of placental pathology and provides insights on stillbirth aetiology: A multicenter matched case-control study. Placenta 2022; 121:7-13. [DOI: 10.1016/j.placenta.2022.02.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/21/2022] [Accepted: 02/24/2022] [Indexed: 12/21/2022]
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Redline RW. Placental pathology: Pathways leading to or associated with perinatal brain injury in experimental neurology, special issue: Placental mediated mechanisms of perinatal brain injury. Exp Neurol 2021; 347:113917. [PMID: 34748755 DOI: 10.1016/j.expneurol.2021.113917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 10/25/2021] [Accepted: 11/02/2021] [Indexed: 11/04/2022]
Abstract
Perinatal brain injury is a multifactorial process. In utero placental physiology plays a major role in neuroprotection and the normal development of the fetal central nervous system. Advances in placental pathology have clarified several specific mechanisms of injury and the histologic lesions most strongly associated with them. This review provides an updated summary of the relevant placental anatomy and physiology, the specific placental pathways leading to brain injury, the revised Amsterdam classification system for placental pathology, and the known associations of specific placental lesions with subtypes of adverse neurologic outcomes.
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Affiliation(s)
- Raymond W Redline
- Case Western Reserve University School of Medicine, Departments of Pathology and Reproductive Biology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, United States of America.
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Kidson KM, Lapinsky S, Grewal J. A Detailed Review of Critical Care Considerations for the Pregnant Cardiac Patient. Can J Cardiol 2021; 37:1979-2000. [PMID: 34534620 DOI: 10.1016/j.cjca.2021.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 01/19/2023] Open
Abstract
Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care.
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Affiliation(s)
- Kristen M Kidson
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, Vancouver, British Columbia, Canada; Department of Critical Care Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Stephen Lapinsky
- Mount Sinai Hospital and the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Jasmine Grewal
- Division of Cardiology, University of British Columbia, Pacific Adult Congenital Heart Disease Program, St Paul's Hospital, Vancouver, British Columbia, Canada.
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