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Shin H, Baek JS, Kim MJ, Cha S, Yu JJ. Pacemaker-Related Factors and Outcomes of Fontan Patients - Impact of Paced QRS Duration. Circ J 2024; 88:642-648. [PMID: 38267052 DOI: 10.1253/circj.cj-23-0491] [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] [Indexed: 01/26/2024]
Abstract
BACKGROUND Permanent pacemaker (PPM) implantation has been identified as a risk factor for morbidity and mortality after Fontan operation. This study investigated the factors associated with outcomes in patients with Fontan physiology who underwent PPM implantation.Methods and Results: We retrospectively reviewed 508 patients who underwent Fontan surgery at Asan Medical Center between September 1992 and August 2022. Of these patients, 37 (7.3%) received PPM implantation. Five patients were excluded, leaving 32 patients, of whom 11 were categorized into the poor outcome group. Poor outcomes comprised death, heart transplantation, and "Fontan failure". Clinical, Fontan procedure-related, and PPM-related factors were compared between the poor and good outcome groups. Ventricular morphology, Fontan procedure-associated factors, pacing mode, high ventricular pacing rate, and time from first arrhythmia to PPM implantation did not differ significantly between the 2 groups. However, the poor outcome group exhibited a significantly longer mean paced QRS duration (P=0.044). Receiver operating characteristic curve analysis revealed a paced QRS duration cut-off value of 153 ms with an area under the curve of 0.73 (P=0.035). CONCLUSIONS A longer paced QRS duration was associated with poor outcomes, indicating its potential to predict adverse outcomes among Fontan patients.
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Affiliation(s)
- Hyewon Shin
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
| | - Jae Suk Baek
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
| | - Mi Jin Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
| | - Seulgi Cha
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
| | - Jeong Jin Yu
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
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2
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Avesani M, Sabatino J, Borrelli N, Cattapan I, Leo I, Pelaia G, Moscatelli S, Bianco F, Bassareo P, Martino F, Leonardi B, Oreto L, Guccione P, Di Salvo G. The mechanics of congenital heart disease: from a morphological trait to the functional echocardiographic evaluation. Front Cardiovasc Med 2024; 11:1301116. [PMID: 38650919 PMCID: PMC11033364 DOI: 10.3389/fcvm.2024.1301116] [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: 09/24/2023] [Accepted: 03/28/2024] [Indexed: 04/25/2024] Open
Abstract
Advances in pediatric cardiac surgery have resulted in a recent growing epidemic of children and young adults with congenital heart diseases (CHDs). In these patients, congenital defects themselves, surgical operations and remaining lesions may alter cardiac anatomy and impact the mechanical performance of both ventricles. Cardiac function significantly influences outcomes in CHDs, necessitating regular patient follow-up to detect clinical changes and relevant risk factors. Echocardiography remains the primary imaging method for CHDs, but clinicians must understand patients' unique anatomies as different CHDs exhibit distinct anatomical characteristics affecting cardiac mechanics. Additionally, the use of myocardial deformation imaging and 3D echocardiography has gained popularity for enhanced assessment of cardiac function and anatomy. This paper discusses the role of echocardiography in evaluating cardiac mechanics in most significant CHDs, particularly its ability to accommodate and interpret the inherent anatomical substrate in these conditions.
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Affiliation(s)
- Martina Avesani
- Division of Paediatric Cardiology, Department of Women’s and Children’s Health, University Hospital of Padua, Padua, Italy
| | - Jolanda Sabatino
- Paediatric Cardiology and Congenital Heart Disease Unit, Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, A.O. dei Colli, Monaldi Hospital, Naples, Italy
| | - Irene Cattapan
- Division of Paediatric Cardiology, Department of Women’s and Children’s Health, University Hospital of Padua, Padua, Italy
| | - Isabella Leo
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Giulia Pelaia
- Paediatric Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Sara Moscatelli
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom
- Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Francesco Bianco
- Department of Pediatrics and Congenital Cardiac Surgery and Cardiology, Ospedali Riuniti, Ancona, Italy
| | - PierPaolo Bassareo
- Department of Cardiology, Mater Misericordiae University Hospital and Our Lady’s Children’s Hospital, University College of Dublin, Crumlin, Ireland
| | - Francesco Martino
- Department of Internal Clinical, Anesthesiological and Cardiovascular Sciences, La Sapienza University, Rome, Italy
| | - Benedetta Leonardi
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesu Children’s Hospital and Research Institute, IRCCS, Rome, Italy
| | - Lilia Oreto
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Children’s Hospital, Taormina, Italy
| | - Paolo Guccione
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesu Children’s Hospital and Research Institute, IRCCS, Rome, Italy
| | - Giovanni Di Salvo
- Division of Paediatric Cardiology, Department of Women’s and Children’s Health, University Hospital of Padua, Padua, Italy
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3
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Schamroth Pravda N, Richter I, Blieden L, Dadashev A, Vig S, Yehuda D, Razon Y, Machtei A, Sudri O, Schwartz E, Schamroth Pravda M, Kolker S, Kornowski R, Hirsch R. Long-Term Outcomes and Characteristics Associated With Mortality of Adult Patients Post Fontan Surgery: 27-Year Single-Center Experience. Am J Cardiol 2023; 207:392-398. [PMID: 37782970 DOI: 10.1016/j.amjcard.2023.08.176] [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: 07/09/2023] [Revised: 08/27/2023] [Accepted: 08/27/2023] [Indexed: 10/04/2023]
Abstract
Data on the characteristics and long-term outcomes of patients who underwent Fontan surgery and surviving into adulthood are limited. We aimed to describe our center's long-term experience with this unique patient population. Included were adult patients who had undergone Fontan surgery and were followed up at our Adult Congenital Heart Disease clinic between the years 1994 and 2021. We describe cardiac and noncardiac morbidities, medical treatment, laboratory data, echocardiographic characteristics, and all-cause mortality. The primary outcome was a composite of heart failure hospitalizations or death. A total of 107 patients who underwent Fontan surgery were followed up during the study period; 46.7% were male. The mean age at time of Fontan was 7.4 ± 6.2 years and the mean age at the last follow-up or at the time of an outcome event was 35.0 ± 8.0 years (range 21.1 to 62.8). At the last documented follow-up, 74.7% of the cohort were in New York Heart Association functional class I/II. The common morbidities included atrial arrythmias (37%) and stroke (17%). The primary outcome occurred in 17.7%. By the end of the study period, 9.3% of the patients in the cohort died. In a multivariate logistic regression analysis, controlling for gender, age, and Fontan type, worse functional class at the last follow-up (New York Heart Association III/IV vs I/II) was significantly associated with the risk of the primary outcome (odds ratio 34.57, 95% confidence interval 6.728 to 177.623, p <0.001). In conclusion, long-term outcomes of patients surviving into adulthood with a Fontan circulation is encouraging. Most of these patients achieve good functional cardiovascular status, despite the complex anatomy and a substantial burden of co-morbid conditions, specifically, atrial arrythmias and thrombotic events. Functional class was independently associated with heart failure hospitalizations and mortality.
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Affiliation(s)
- Nili Schamroth Pravda
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ilan Richter
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Cardiology & Interventional Cardiology Unit, Rabin Medical Center, Petach Tikva, Israel
| | - Leonard Blieden
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Dadashev
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shahar Vig
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Yehuda
- Internal medicine B, Beilinson Hospital, Petach Tikva, Israel
| | - Yaron Razon
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Paediatric Cardiology, Assuta Ashdod Medical Center, Ashdod, Israel
| | - Ayelet Machtei
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Schneider Children's Hospital, Petach Tikva, Israel
| | - Omri Sudri
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Schwartz
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Shimon Kolker
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Cardiology & Interventional Cardiology Unit, Rabin Medical Center, Petach Tikva, Israel
| | - Rafael Hirsch
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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4
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Ferrari MR, Schäfer M, Hunter KS, Di Maria MV. Central Venous Waveform Patterns in the Fontan Circulation Independently Contribute to the Prediction of Composite Survival. Pediatr Cardiol 2023:10.1007/s00246-023-03268-w. [PMID: 37773462 DOI: 10.1007/s00246-023-03268-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/07/2023] [Indexed: 10/01/2023]
Abstract
It is well appreciated that the Fontan circulation perturbs central venous hemodynamics, with elevated pressure being the clearest change associated with Fontan comorbidities, such as Fontan-associated liver disease (FALD) and protein-losing enteropathy (PLE). Our group has better quantity of these venous perturbations through single- and multi-location analyses of flow waveforms obtained from magnetic resonance imaging of Fontan patients. Here, we determine if such analyses, which yield principal components (PC) that describe flow features, are associated with Fontan survival. Patients with a Fontan circulation (N = 140) that underwent free-breathing and mechanically ventilated cardiac MRI were included in this study. Standard volumetric and functional hemodynamics, as well as flow analysis principal components, were subjected to univariate and bivariate Cox regression analyses to determine composite clinical outcome, including plastic bronchitis, PLE, and referral and receipt of transplant. Unsurprisingly, ventricular function measures of ejection fraction (EF; HR = 0.88, p < 0.0001), indexed end-systolic volume (ESVi; HR 1.02, p < 0.0001), and indexed end-diastolic volume (EDVi; HR = 1.02, p = 0.0007) were found as specific predictors of clinical events, with specificities uniformly > 0.75. Additionally a feature of IVC flow (PC2) indicating increased flow in systole was found as a highly sensitive predictor (HR = 0.851, p = 0.027, sensitivity 0.93). In bivariate prediction, combinations of ventricular function (EF, ESVi, EDVi) with this IVC flow feature yielded best overall prediction of composite outcome. This suggests that central venous waveform analysis relays additional information about Fontan patient survival and that coupling sensitive and specific measures in bivariate analysis is a useful approach for obtaining superior prediction of survival.
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Affiliation(s)
- Margaret R Ferrari
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 East 16Th Ave, Aurora, CO, 80045, USA
| | - Kendall S Hunter
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Michael V Di Maria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 East 16Th Ave, Aurora, CO, 80045, USA.
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Wernovsky G, Ozturk M, Diddle JW, Muñoz R, d'Udekem Y, Yerebakan C. Rapid bilateral pulmonary artery banding: A developmentally based proposal for the management of neonates with hypoplastic left heart. JTCVS OPEN 2023; 14:398-406. [PMID: 37425468 PMCID: PMC10328842 DOI: 10.1016/j.xjon.2023.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 07/11/2023]
Affiliation(s)
- Gil Wernovsky
- Division of Cardiology, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
- Division of Cardiac Critical Care, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Mahmut Ozturk
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - J. Wesley Diddle
- Division of Cardiac Critical Care, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Ricardo Muñoz
- Division of Cardiac Critical Care, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
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6
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Das B, Deshpande S, Akam-Venkata J, Shakti D, Moskowitz W, Lipshultz SE. Heart Failure with Preserved Ejection Fraction in Children. Pediatr Cardiol 2023; 44:513-529. [PMID: 35978175 DOI: 10.1007/s00246-022-02960-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/22/2022] [Indexed: 11/27/2022]
Abstract
Diastolic dysfunction (DD) refers to abnormalities in the mechanical function of the left ventricle (LV) during diastole. Severe LVDD can cause symptoms and the signs of heart failure (HF) in the setting of normal or near normal LV systolic function and is referred to as diastolic HF or HF with preserved ejection fraction (HFpEF). Pediatric cardiologists have long speculated HFpEF in children with congenital heart disease and cardiomyopathy. However, understanding the risk factors, clinical course, and validated biomarkers predictive of the outcome of HFpEF in children is challenging due to heterogeneous etiologies and overlapping pathophysiological mechanisms. The natural history of HFpEF varies depending upon the patient's age, sex, race, geographic location, nutritional status, biochemical risk factors, underlying heart disease, and genetic-environmental interaction, among other factors. Pediatric onset HFpEF is often not the same disease as in adults. Advances in the noninvasive evaluation of the LV diastolic function by strain, and strain rate analysis with speckle-tracking echocardiography, tissue Doppler imaging, and cardiac magnetic resonance imaging have increased our understanding of the HFpEF in children. This review addresses HFpEF in children and identifies knowledge gaps in the underlying etiologies, pathogenesis, diagnosis, and management, especially compared to adults with HFpEF.
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Affiliation(s)
- Bibhuti Das
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA.
| | - Shriprasad Deshpande
- Department of Pediatrics, Children's National Hospital, The George Washington University, Washington, DC, USA
| | - Jyothsna Akam-Venkata
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Divya Shakti
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - William Moskowitz
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Steven E Lipshultz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Oishei Children's Hospital, Buffalo, NY, 14203, USA
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Bartczak-Rutkowska A, Tomkiewicz-Pająk L, Kawka-Paciorkowska K, Bajorek N, Ciepłucha A, Ropacka-Lesiak M, Trojnarska O. Pregnancy Outcomes in Women after the Fontan Procedure. J Clin Med 2023; 12:jcm12030783. [PMID: 36769431 PMCID: PMC9917923 DOI: 10.3390/jcm12030783] [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: 12/29/2022] [Revised: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Women with single ventricle physiology after the Fontan procedure, despite numerous possible complications, can reach adulthood and give birth. Pregnancy poses a hemodynamic burden for distorted physiology of Fontan circulation, but according to the literature, it is usually well tolerated unless the patient is a "failing" Fontan. Our study aimed to assess maternal and fetal outcomes in patients after the Fontan procedure followed up in two tertiary Polish medical centers. We retrospectively evaluated all pregnancies in women after the Fontan procedure who were followed up between 1995-2022. During the study period, 15 women after the Fontan procedure had 26 pregnancies. Among 26 pregnancies, eleven ended with miscarriages, and 15 pregnancies resulted in 16 live births. Fetal complications were observed in 9 (56.3%) live births, with prematurity being the most common complication (n = 7, 43.8%). We recorded 3 (18.8%) neonatal deaths. Obstetrical complications were present in 6 (40%) out of 15 completed pregnancies-two (13.3%) cases of abruptio placentae, two (13.3%) pregnancies with premature rupture of membranes, and two (13.3%) patients with antepartum hemorrhage. There was neither maternal death nor heart failure decompensation during pregnancy. In two (13.3%) women, atrial arrhythmia developed. One (6.7%) patient in the second trimester developed ventricular arrhythmia. None of the patients suffered from systemic thromboembolism during pregnancy. Pregnancy in women after the Fontan procedure is well tolerated. However, it is burdened by a high risk of miscarriage and multiple obstetrical complications. These women require specialized care provided by both experienced cardiologists and obstetricians.
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Affiliation(s)
| | | | | | - Natalia Bajorek
- Department of Medical Education, Centre for Innovative Medical Education, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Aleksandra Ciepłucha
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland
| | - Mariola Ropacka-Lesiak
- Department of Perinatology and Gynecology, Poznan University of Medical Sciences, 60-535 Poznan, Poland
| | - Olga Trojnarska
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland
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Peck D, Averin K, Khoury P, Veldhuis G, Alsaied T, Lubert AM, Hirsch R, Whiteside WM, Veldtman G, Goldstein BH. Occult Diastolic Dysfunction and Adverse Clinical Outcomes in Adolescents and Young Adults With Fontan Circulation. J Am Heart Assoc 2022; 12:e026508. [PMID: 36565206 PMCID: PMC9973593 DOI: 10.1161/jaha.122.026508] [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: 12/25/2022]
Abstract
Background In Fontan circulation, diastolic dysfunction portends a worse clinical outcome but may be concealed during routine assessment. Invasive evaluation with rapid volume expansion (RVE) can identify patients with occult diastolic dysfunction (ODD). We sought to evaluate the association between ODD and adverse clinical outcomes at medium-term follow-up. Methods and Results We conducted a single-center observational study of patients with Fontan circulation who underwent clinical catheterization with RVE from 2012 to 2017. ODD was defined as post-RVE end-diastolic pressure ≥15 mm Hg. A composite adverse clinical outcome included mortality, cardiac transplant, ventricular assist device, plastic bronchitis, protein-losing enteropathy, arrhythmia, stroke/thrombus, or cardiac-related hospital admission. Proportional hazards regression was used to compare the ODD-positive and ODD-negative groups for risk of the composite adverse clinical outcome. Eighty-nine patients with Fontan circulation (47% female patients) were included at a median age of 14 years. ODD was identified in 31%. Fontan duration was longer in the ODD group (P=0.001). The composite adverse clinical outcome occurred more frequently in the ODD group (52 versus 26%, P=0.03) during a median follow-up duration of 2.9 years after catheterization. ODD (hazard ratio [HR], 2.68 [95% CI, 1.28-5.66]; P=0.02) and Fontan duration (HR, 1.07 [95% CI, 1.02-1.12]; P=0.003) were associated with the composite adverse clinical outcome. When stratified by Fontan duration, ODD remained significantly associated with the hazard of adverse clinical outcomes in patients with a Fontan duration ≥10 years (HR, 2.57 [95% CI, 1.03-6.57]; P=0.04). Conclusions Cardiac catheterization with rapid volume expansion reveals a significant incidence of ODD, which relates to Fontan duration. ODD is associated with an increased hazard of adverse clinical outcomes during medium-term follow-up, especially in patients with longer Fontan duration. ODD may portend a worse prognosis in Fontan circulation.
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Affiliation(s)
- Daniel Peck
- The Heart Institute, Cincinnati Children’s Hospital Medical CenterDepartment of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
| | - Konstantin Averin
- Division of Cardiology, Department of PediatricsUniversity of AlbertaEdmontonAB
| | - Philip Khoury
- The Heart Institute, Cincinnati Children’s Hospital Medical CenterDepartment of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
| | - Grant Veldhuis
- The Heart Institute, Cincinnati Children’s Hospital Medical CenterDepartment of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
| | - Tarek Alsaied
- The Heart Institute, Cincinnati Children’s Hospital Medical CenterDepartment of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH,Heart Institute, UPMC Children’s Hospital of PittsburghDepartment of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPA
| | - Adam M. Lubert
- The Heart Institute, Cincinnati Children’s Hospital Medical CenterDepartment of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
| | - Russel Hirsch
- The Heart Institute, Cincinnati Children’s Hospital Medical CenterDepartment of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
| | | | - Gruschen Veldtman
- Heart Center, King Faisal Specialist Hospital and Research CenterRiyadhSaudi Arabia
| | - Bryan H. Goldstein
- The Heart Institute, Cincinnati Children’s Hospital Medical CenterDepartment of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH,Heart Institute, UPMC Children’s Hospital of PittsburghDepartment of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPA
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