109 results on '"Ralph S. Mosca"'
Search Results
2. Periscopic technique in Norwood operation is associated with better preservation of early ventricular function
- Author
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Sujata Chakravarti, David M. Williams, Puneet Bhatla, Brandon Winston, Catherine Bull, Luv Makadia, Richard G. Ohye, T.K. Susheel Kumar, Ralph S. Mosca, and James C. Nielsen
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,RV-PA-C, right ventricle to pulmonary artery conduit ,periscopic technique ,PT, periscope technique ,RV function ,Ventriculotomy ,Hypoplastic left heart syndrome ,symbols.namesake ,Norwood ,Internal medicine ,medicine.artery ,EDA, end diastolic area ,medicine ,echocardiography ,Congenital: Norwood Procedure ,Fisher's exact test ,RV to PA conduit ,Ejection fraction ,business.industry ,HLHS, hypoplastic left heart syndrome ,MBTT, modified Blalock-Taussig-Thomas ,FAC, fraction area change ,medicine.disease ,Norwood Operation ,TT, traditional technique ,RV, right ventricle ,medicine.anatomical_structure ,Ventricle ,Pulmonary artery ,symbols ,Cardiology ,Surgery ,Tricuspid Valve Regurgitation ,business - Abstract
Objective Although the right ventricle (RV) to pulmonary artery conduit in stage 1 Norwood operation results in improved interstage survival, the long-term effects of the ventriculotomy used in the traditional technique remain a concern. The periscopic technique (PT) of RV to pulmonary artery conduit placement has been described as an alternative technique to minimize RV injury. A retrospective study was performed to compare the effects of traditional technique and PT on ventricular function following Norwood operation. Methods A retrospective study of all patients who underwent Norwood operation from 2012 to 2019 was performed. Patients with baseline RV dysfunction and significant tricuspid valve regurgitation were excluded. Prestage 2 echocardiograms were reviewed by a blinded experienced imager for quantification of RV function (sinus and infundibular RV fractional area change) as well as for regional conduit site wall dysfunction (normal or abnormal, including hypokinesia, akinesia, or dyskinesia). Wilcoxon rank-sum tests were used to assess differences in RV infundibular and RV sinus ejection fraction and the Fisher exact test was used to assess differences in regional wall dysfunction. Results Twenty-two patients met inclusion criteria. Eight underwent traditional technique and 14 underwent PT. Median infundibular RV fractional area change was 49% and 37% (P = .02) and sinus RV fractional area change was 50% and 41% for PT and traditional technique (P = .007) respectively. Similarly qualitative regional RV wall function was better preserved in PT (P = .002). Conclusions The PT for RV to pulmonary artery conduit in Norwood operation results in better preservation of early RV global and regional systolic function. Whether or not this benefit translates to improved clinical outcome still needs to be studied.
- Published
- 2021
3. Femoral artery homograft for coronary artery plasty following arterial switch operation
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Charles Ma, Dan G. Halpern, Jodi L. Feinberg, David Y.T. Chen, Ralph S. Mosca, Puneet Bhatla, and T.K. Susheel Kumar
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.anatomical_structure ,business.industry ,Internal medicine ,medicine.artery ,Cardiology ,Congenital: Transposition of the Great Arteries: Case Report ,Medicine ,Surgery ,Femoral artery ,business ,Artery - Published
- 2020
4. Surgical Management of Giant Intrapericardial Teratoma Encasing the Coronary Artery
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James C. Nielsen, Michelle Ramirez, Emina Hodzic, Madhu Sharma, Tk Susheel Kumar, Jason C. Fisher, Ralph S. Mosca, Puneet Bhatla, Prashant K. Minocha, and Margret Magid
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Surgical resection ,medicine.medical_specialty ,business.industry ,Infant, Newborn ,Teratoma ,General Medicine ,Coronary Vessels ,Surgery ,Heart Neoplasms ,medicine.anatomical_structure ,Intrapericardial teratoma ,Pediatrics, Perinatology and Child Health ,Medicine ,Humans ,Cardiology and Cardiovascular Medicine ,business ,Pericardium ,Artery - Abstract
Intrapericardial teratomas are rare, predominantly benign tumors that warrant surgical resection in the neonatal period because of their potential detrimental effects on the cardiorespiratory system. Surgical resection can be a challenge when the tumor encases and obscures a coronary artery. Adherence to certain operative principles is necessary to achieve successful outcomes.
- Published
- 2021
5. Commentary: Tetralogy of Fallot: Will time tell?
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Ralph S. Mosca
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,General surgery ,medicine ,Surgery ,Cardiology and Cardiovascular Medicine ,medicine.disease ,business ,Tetralogy of Fallot - Published
- 2020
6. Altering management decisions with gained anatomical insight from a 3D printed model of a complex ventricular septal defect
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Ralph S. Mosca, Puneet Bhatla, and Justin T. Tretter
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Heart Septal Defects, Ventricular ,Models, Anatomic ,Cardiac Catheterization ,medicine.medical_specialty ,3d printed ,Decision Making ,Computed tomography ,Cardiac catheterisation ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,0502 economics and business ,Humans ,Medicine ,Medical physics ,Cardiac Surgical Procedures ,Surgical repair ,medicine.diagnostic_test ,business.industry ,05 social sciences ,Infant, Newborn ,Disease Management ,General Medicine ,Infant newborn ,Surgery ,Tomography x ray computed ,Echocardiography ,Printing, Three-Dimensional ,Pediatrics, Perinatology and Child Health ,050211 marketing ,Tomography, X-Ray Computed ,Cardiology and Cardiovascular Medicine ,business - Abstract
Rapid prototyping is quickly gaining utility in various complex forms of CHD. In properly selected cases, these printed models provide detailed anatomical understanding that help guide potential surgical and cardiac catheterisation interventions. We present a case of a tunnel-like ventricular septal defect referred for surgical repair, where the decision to obtain a three-dimensional printed model helped in better understanding of the anatomy, leading to delaying, and hopefully avoiding altogether, surgical repair.
- Published
- 2016
7. Utility and Scope of Rapid Prototyping in Patients with Complex Muscular Ventricular Septal Defects or Double-Outlet Right Ventricle: Does it Alter Management Decisions?
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Piers Barker, Nicole Wake, Sujata Chakravarti, Shi Joon Yoo, Puneet Bhatla, Ralph S. Mosca, Achi Ludomirsky, Justin T. Tretter, Michael Argilla, Doff B. McElhinney, and Larry A. Latson
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Heart Septal Defects, Ventricular ,Male ,Models, Anatomic ,Rapid prototyping ,medicine.medical_specialty ,Heart disease ,Decision Making ,030204 cardiovascular system & hematology ,Surgical planning ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,Imaging, Three-Dimensional ,0302 clinical medicine ,Double outlet right ventricle ,medicine ,Humans ,Cardiac Surgical Procedures ,Child ,medicine.diagnostic_test ,business.industry ,Infant ,Heart ,Magnetic resonance imaging ,Vascular surgery ,medicine.disease ,Magnetic Resonance Imaging ,Double Outlet Right Ventricle ,Surgery ,Cardiac surgery ,medicine.anatomical_structure ,Ventricle ,Child, Preschool ,Printing, Three-Dimensional ,Pediatrics, Perinatology and Child Health ,Female ,Tomography, X-Ray Computed ,Cardiology and Cardiovascular Medicine ,business - Abstract
Rapid prototyping facilitates comprehension of complex cardiac anatomy. However, determining when this additional information proves instrumental in patient management remains a challenge. We describe our experience with patient-specific anatomic models created using rapid prototyping from various imaging modalities, suggesting their utility in surgical and interventional planning in congenital heart disease (CHD). Virtual and physical 3-dimensional (3D) models were generated from CT or MRI data, using commercially available software for patients with complex muscular ventricular septal defects (CMVSD) and double-outlet right ventricle (DORV). Six patients with complex anatomy and uncertainty of the optimal management strategy were included in this study. The models were subsequently used to guide management decisions, and the outcomes reviewed. 3D models clearly demonstrated the complex intra-cardiac anatomy in all six patients and were utilized to guide management decisions. In the three patients with CMVSD, one underwent successful endovascular device closure following a prior failed attempt at transcatheter closure, and the other two underwent successful primary surgical closure with the aid of 3D models. In all three cases of DORV, the models provided better anatomic delineation and additional information that altered or confirmed the surgical plan. Patient-specific 3D heart models show promise in accurately defining intra-cardiac anatomy in CHD, specifically CMVSD and DORV. We believe these models improve understanding of the complex anatomical spatial relationships in these defects and provide additional insight for pre/intra-interventional management and surgical planning.
- Published
- 2016
8. Surgical planning for a complex double-outlet right ventricle using 3D printing
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Sathish Chikkabyrappa, Ralph S. Mosca, Justin T. Tretter, Sujata Chakravarti, and Puneet Bhatla
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Models, Anatomic ,medicine.medical_specialty ,Heart Ventricles ,medicine.medical_treatment ,3D printing ,030204 cardiovascular system & hematology ,Surgical planning ,Preoperative care ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,Imaging, Three-Dimensional ,0302 clinical medicine ,Double outlet right ventricle ,Preoperative Care ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Medical physics ,Cardiac catheterization ,Surgical repair ,Surgical approach ,business.industry ,Models, Cardiovascular ,Equipment Design ,medicine.disease ,Double Outlet Right Ventricle ,Surgery ,Printing, Three-Dimensional ,Computer-Aided Design ,Surgical simulation ,Cardiology and Cardiovascular Medicine ,business - Abstract
Rapid prototyping may be beneficial in properly selected cases of complex congenital heart disease, providing detailed anatomical understanding that helps to guide potential surgical and cardiac catheterization interventions. We present a case of double-outlet right ventricle, where the decision to obtain a three-dimensional printed model helped for better understanding of the anatomy, with the additional advantage of surgical simulation in planning the surgical approach and type of surgical repair.
- Published
- 2017
9. From Eye Wash to Cardiac Modeling
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Ralph S. Mosca
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Pulmonary and Respiratory Medicine ,Heart Septal Defects, Ventricular ,medicine.medical_specialty ,Heart septal defect ,business.industry ,MEDLINE ,General Medicine ,030204 cardiovascular system & hematology ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,030228 respiratory system ,Internal medicine ,medicine ,Cardiology ,Humans ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Published
- 2018
10. Ubiquitin C-Terminal Hydrolase 1 and Phosphorylated Axonal Neurofilament Heavy Chain in Infants Undergoing Cardiac Surgery: Preliminary Assessment as Potential Biomarkers of Brain Injury
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Ralph S. Mosca, Sathish Chikkabyrappa, Sunil P. Malhotra, Amanda Mastrippolito, Timothy Lee, Sujata Chakravarti, Diane Reformina, and Gerry Shaw
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Male ,medicine.medical_specialty ,Neurofilament ,Ubiquitin C-Terminal Hydrolase ,Enzyme-Linked Immunosorbent Assay ,Pilot Projects ,030204 cardiovascular system & hematology ,Pharmacology ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Postoperative Complications ,Ubiquitin ,law ,Neurofilament Proteins ,Hydrolase ,Cardiopulmonary bypass ,medicine ,Humans ,Prospective Studies ,Cardiopulmonary Bypass ,Spectroscopy, Near-Infrared ,biology ,business.industry ,Infant, Newborn ,Infant ,General Medicine ,Cardiac surgery ,Circulatory Arrest, Deep Hypothermia Induced ,Brain Injuries ,Pediatrics, Perinatology and Child Health ,biology.protein ,Deep hypothermic circulatory arrest ,Phosphorylation ,Surgery ,Female ,Cardiology and Cardiovascular Medicine ,business ,Ubiquitin Thiolesterase ,030217 neurology & neurosurgery ,Biomarkers - Abstract
Background: There are no reliable markers to assess brain injury in neonates following cardiac surgery. We examine ubiquitin C-terminal hydrolase 1 (UCHL1) and phosphorylated axonal neurofilament heavy chain (pNF-H), neuronal-specific biomarkers released following axonal and cortical injury, in neonates undergoing cardiac surgery involving cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). Methods: Twenty-six patients younger than three months were prospectively enrolled (CPB only, n = 12 and DHCA, n = 14). Healthy newborns (n = 22) served as the control. Blood samples were collected preoperatively and postoperatively upon intensive care unit admission (hour 0) and subsequently at 12, 24, 36, and 48 hours. Serum was tested for UCHL1 and pNF-H using enzyme-linked immunosorbent assay. Concomitant arterial blood gas, lactate, and cerebral near-infrared spectroscopy (NIRS) monitoring were performed. Results: Ubiquitin C-terminal hydrolase 1 showed a significant rise at 0 hours in the DHCA group compared to baseline (74.9 ± 13.7 pg/mL vs 33.9 ± 37.3 pg/mL, P < .0001). Levels returned to baseline at 12 hours. There was an early rise in UCHL1 at 0 hours in the CPB group, P = .09. Phosphorylated axonal neurofilament heavy chain was decreased at 0 hours in both the CPB and DHCA groups compared to baseline, P = .06. There was no difference between control and baseline levels of UCHL1 ( P = .9) or pNF-H ( P = .77). Decreased NIRS was observed in the DHCA group at 0 hours (57.3 ± 10.5) versus baseline (64.2 ± 12.3), but not significant ( P = .21). There was no correlation between biomarkers and NIRS at 0 hours. Conclusion: A rapid rise in UCHL1 levels was observed in the DHCA group, suggesting that it may be a marker for acute brain injury. Follow-up with neurodevelopmental studies is ongoing.
- Published
- 2018
11. Commentary: The Achilles' heel of the stage 1 palliation
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Ralph S. Mosca
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Heel ,business.industry ,medicine.medical_treatment ,Femoral vein ,MEDLINE ,Surgery ,medicine.anatomical_structure ,medicine.artery ,Pulmonary artery ,medicine ,Norwood procedure ,Stage (cooking) ,Cardiology and Cardiovascular Medicine ,business - Published
- 2019
12. Retrograde transcatheter device closure of a complex paravalvular leak after bioprosthetic pulmonary valve replacement in a pediatric patient
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Sathish Chikkabyrappa, Doff B. McElhinney, and Ralph S. Mosca
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medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,medicine.medical_treatment ,General Medicine ,030204 cardiovascular system & hematology ,eye diseases ,Surgery ,03 medical and health sciences ,Pediatric patient ,0302 clinical medicine ,Internal medicine ,Congenital pulmonary valve stenosis ,Angiography ,medicine ,Cardiology ,Radiology, Nuclear Medicine and imaging ,sense organs ,030212 general & internal medicine ,Paravalvular leak ,Cardiology and Cardiovascular Medicine ,business ,Bioprosthetic pulmonary valve replacement ,Cardiac catheterization - Abstract
We report a case of retrograde transcatheter device closure of a complex paravalvular leak (PVL) after bioprosthetic pulmonary valve replacement (PVR) in a 13-year-old patient with congenital pulmonary valve stenosis. There are prior reports of pulmonary PVL closure after PVR in adults (Seery and Slack, Congenit Heart Dis 2014;9:E19-F22), but indications for and technical considerations in PVL closure after bioprosthetic PVR, particularly in children, are not well defined. © 2015 Wiley Periodicals, Inc.
- Published
- 2015
13. Anomalous aortic origin of a coronary artery: 90% of optimal therapy is 50% improved technology
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Ralph S. Mosca
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Aorta ,business.industry ,Coronary Vessel Anomalies ,Coronary Vessel Anomaly ,MEDLINE ,030204 cardiovascular system & hematology ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Text mining ,Internal medicine ,Anomalous aortic origin of a coronary artery ,medicine.artery ,medicine ,Cardiology ,Humans ,Surgery ,030212 general & internal medicine ,Prospective Studies ,Cardiology and Cardiovascular Medicine ,business ,Prospective cohort study - Published
- 2017
14. Cardiac Function After Tetralogy of Fallot/Complete Atrioventricular Canal Repair
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Jennifer Tingo, Betul Yilmaz, Paul J. Chai, Stéphanie Levasseur, Jan M. Quaegebeur, Jeffrey D. Dayton, Emile A. Bacha, Ralph S. Mosca, Marc Najjar, and Elizabeth H. Stephens
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Cardiac function curve ,Male ,medicine.medical_specialty ,Time Factors ,Heart Ventricles ,030204 cardiovascular system & hematology ,03 medical and health sciences ,Primary repair ,0302 clinical medicine ,Internal medicine ,Medicine ,Humans ,Ventricular Function ,Cardiac Surgical Procedures ,Tetralogy of Fallot ,Retrospective Studies ,business.industry ,Heart Septal Defects ,Infant ,Mitral Valve Insufficiency ,General Medicine ,medicine.disease ,Pulmonary Valve Insufficiency ,Treatment Outcome ,030228 respiratory system ,Echocardiography ,Child, Preschool ,Pediatrics, Perinatology and Child Health ,Cardiology ,Atrioventricular canal ,Surgery ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background: Repair of complete atrioventricular canal (CAVC) with tetralogy of Fallot (TOF) is a challenging operation increasingly being performed as a complete, primary repair in infancy. Previous studies have focused on perioperative outcomes; however, midterm valve function, ventricular function, and residual obstruction have received little attention. Methods: We retrospectively reviewed 20 patients who underwent CAVC/TOF repair (January 2005 to December 2014). A two-patch repair was used in all patients to correct the CAVC defect. Tetralogy of Fallot repair included transannular patch in 11 (65%) patients and valve-sparing in 6 (35%) patients. Results: The average age at surgery was 72 ± 122 weeks, 40% were male, and 80% had trisomy 21. Mean echo follow-up was 3.0 ± 3.0 years. There were no in-hospital or late mortalities. The rate of reoperation was 20%. At the latest follow-up, moderate left atrioventricular valve regurgitation was present in three (15%) patients and mild stenosis present in seven (35%) patients. One (5%) patient had moderate right ventricular outflow tract (RVOT) obstruction. The valve-sparing population was smaller at the time of surgery than the non-valve-sparing cohort (body surface area: 0.28 ± 0.04 vs 0.42 ± 0.11, P = .002) and less likely to have had a previous shunt (0% vs 64%, P = .01). Among the valve-sparing patients (six), at the latest follow-up, moderate pulmonary insufficiency was present in two (33%) patients. Conclusion: Repair of CAVC concomitant with TOF can be performed with low mortality and acceptable perioperative morbidity. Management of the RVOT remains a challenge for the long term.
- Published
- 2017
15. Shunt right or left? Decision 2016
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Ralph S. Mosca
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Fistula ,business.industry ,Heart Ventricles ,MEDLINE ,030204 cardiovascular system & hematology ,Pulmonary Artery ,medicine.disease ,Shunt (medical) ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,030228 respiratory system ,medicine.artery ,Pulmonary artery ,Medicine ,Humans ,Cardiology and Cardiovascular Medicine ,business - Published
- 2016
16. Super Glenn: Able to Defeat Recalcitrant Pulmonary Vascular Adversaries?
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Ralph S. Mosca
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,MEDLINE ,General Medicine ,030204 cardiovascular system & hematology ,Fontan procedure ,03 medical and health sciences ,0302 clinical medicine ,Text mining ,030228 respiratory system ,Medicine ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Intensive care medicine - Published
- 2018
17. TRANSTHORACIC TRANSCATHETER APPROACH FOR THE EXCLUSION OF A PSEUDOANEURYSM IN A FONTAN PATIENT
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Ralph S. Mosca, Puneet Bhatla, Hannah L. Tredway, Nicole Perry, Michael Argilla, Xingchen Mai, and Dan G. Halpern
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congenital, hereditary, and neonatal diseases and abnormalities ,medicine.medical_specialty ,business.industry ,Status post ,medicine.disease ,Transcatheter approach ,Surgery ,Pseudoaneurysm ,Great arteries ,cardiovascular system ,Medicine ,cardiovascular diseases ,Tricuspid atresia ,Cardiology and Cardiovascular Medicine ,business - Abstract
Surgically corrected congenital heart defects may result in unique long-term complications. An 18 year old man with tricuspid atresia, normally related great arteries, and ventricular septal defect (VSD), status post a staged surgical palliation culminating in an extra-cardiac Fontan, presented
- Published
- 2019
18. Periscope Modification of Right Ventricle-to-Pulmonary Artery Shunt in Norwood Operation
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Masaki Tsukashita M.D. and Ralph S. Mosca
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Heart Ventricles ,Hemodynamics ,Pulmonary Artery ,Norwood Procedures ,Hypoplastic left heart syndrome ,Prosthesis Implantation ,Pseudoaneurysm ,Electrical conduit ,medicine.artery ,Internal medicine ,Hypoplastic Left Heart Syndrome ,Humans ,Medicine ,cardiovascular diseases ,business.industry ,Anastomosis, Surgical ,Suture Techniques ,medicine.disease ,Norwood Operation ,Surgery ,Shunt (medical) ,surgical procedures, operative ,medicine.anatomical_structure ,Ventricle ,Pulmonary artery ,cardiovascular system ,Cardiology ,Cardiology and Cardiovascular Medicine ,business - Abstract
Given the purported hemodynamic advantages of the right ventricle (RV) to pulmonary artery (PA) conduit, many surgeons have adopted it as their preferred source of pulmonary blood flow during stage I palliation for hypoplastic left heart syndrome. Potential disadvantages of the RV-PA shunt include ventricular dysfunction, pseudoaneurysm formation, arrhythmia, and conduit obstruction, which can lead to a higher rate of unplanned reinterventions. The "dunk" technique was described to reduce the RV incision and proximal conduit obstruction; however, insertion of the ringed graft from the epicardium can be cumbersome and risk RV injury. We introduce a simplified, alternative method of placing the conduit, which we call the periscope technique, whereby the graft is withdrawn from within the RV cavity.
- Published
- 2014
19. Procalcitonin as a biomarker of bacterial infection in pediatric patients after congenital heart surgery
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Sujata Chakravarti, Diane Reformina, Timothy Lee, Puneet Bhatla, Sunil P. Malhotra, and Ralph S. Mosca
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medicine.medical_specialty ,lcsh:Diseases of the circulatory (Cardiovascular) system ,congenital heart surgery ,lcsh:Medicine ,030204 cardiovascular system & hematology ,Procalcitonin ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,procalcitonin (PCT) ,law ,Interquartile range ,parasitic diseases ,Cardiopulmonary bypass ,Medicine ,030212 general & internal medicine ,Receiver operating characteristic ,business.industry ,lcsh:R ,lcsh:RJ1-570 ,Retrospective cohort study ,lcsh:Pediatrics ,Cardiac surgery ,medicine.disease ,infection ,Surgery ,Systemic inflammatory response syndrome ,pediatric ,lcsh:RC666-701 ,Pediatrics, Perinatology and Child Health ,Biomarker (medicine) ,Original Article ,cardiopulmonary bypass (CPB) ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background: Bacterial infection (BI) after congenital heart surgery (CHS) is associated with increased morbidity and is difficult to differentiate from systemic inflammatory response syndrome caused by cardiopulmonary bypass (CPB). Procalcitonin (PCT) has emerged as a reliable biomarker of BI in various populations. Aim: To determine the optimal PCT threshold to identify BI among children suspected of having infection following CPB. Setting and Design: Single-center retrospective observational study. Materials and Methods: Medical records of all the patients admitted between January 2013 and April 2015 were reviewed. Patients in the age range of 0-21 years of age who underwent CHS requiring CPB in whom PCT was drawn between postoperative days 0-8 due to suspicion of infection were included. Statistical Analysis: The Wilcoxon rank-sum test was used for nonparametric variables. The diagnostic performance of PCT was evaluated using a receiver operating characteristic (ROC) curve. Results: Ninety-eight patients were included. The median age was 2 months (25th and 75th interquartile of 0.1-7.5 months). Eleven patients were included in the BI group. The median PCT for the BI group (3.42 ng/mL, 25th and 75th interquartile of 2.34-5.67) was significantly higher than the median PCT for the noninfected group (0.8 ng/mL, 25th and 75th interquartile 0.38-3.39), P = 0.028. The PCT level that yielded the best compromise between the sensitivity (81.8%) and specificity (66.7%) was 2 ng/mL with an area under the ROC curve of 0.742. Conclusion: A PCT less than 2 ng/mL makes BI unlikely in children suspected of infection after CHS.
- Published
- 2016
20. Repair of Truncus Arteriosus With Interrupted Aortic Arch
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Ralph S. Mosca
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,Internal medicine ,Interrupted aortic arch ,cardiovascular system ,Cardiology ,medicine ,Surgery ,Cardiology and Cardiovascular Medicine ,medicine.disease ,business ,Truncus arteriosus - Published
- 2010
21. Surgical repair in neonatal life of cardiac haemangiomas diagnosed prenatally
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Ralph S. Mosca, Yasutaka Hirata, and Jayendra Sharma
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Adult ,Male ,medicine.medical_specialty ,Pediatrics ,Prenatal diagnosis ,Pericardial effusion ,Ultrasonography, Prenatal ,Resection ,Diagnosis, Differential ,Heart Neoplasms ,Young Adult ,Pregnancy ,Fetal hydrops ,Humans ,Medicine ,Cardiac Surgical Procedures ,Surgical repair ,business.industry ,General Medicine ,Antenatal ultrasound ,medicine.disease ,Surgery ,Fetal Diseases ,Neonatal life ,Pediatrics, Perinatology and Child Health ,Female ,Good prognosis ,Hemangioma ,Cardiology and Cardiovascular Medicine ,business - Abstract
Although cardiac tumours are rare, such tumours are increasingly being diagnosed with increasing frequency and great accuracy by antenatal ultrasound. Cardiac haemangiomas account for less than one-twentieth of all primary cardiac tumours, with most being diagnosed in the neonatal period. We report 3 instances of successful neonatal resection of cardiac haemangioma subsequent to prenatal diagnosis. Such diagnosis is important in perinatal management, since early surgical intervention provides a good prognosis.
- Published
- 2009
22. Persistent Antegrade Pulmonary Blood Flow Post-Glenn Does Not Alter Early Post-Fontan Outcomes in Single-Ventricle Patients
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Karen Altmann, Ralph S. Mosca, Jan M. Quaegebeur, Ashwin Prakash, Robert G. Gray, Ismee A. Williams, and Jonathan M. Chen
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Heart Defects, Congenital ,Pulmonary and Respiratory Medicine ,Thorax ,Cardiac Catheterization ,Pulmonary Circulation ,Heart Ventricles ,medicine.medical_treatment ,Hemodynamics ,Fontan Procedure ,medicine.artery ,medicine ,Humans ,Retrospective Studies ,Cardiac catheterization ,Lung ,business.industry ,Respiratory disease ,Infant, Newborn ,Infant ,Blood flow ,medicine.disease ,medicine.anatomical_structure ,Echocardiography ,Ventricle ,Child, Preschool ,Anesthesia ,Pulmonary artery ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background The bidirectional Glenn cavopulmonary anastomosis (BDG) represents the standard interim procedure in treatment of patients with single-ventricle physiology. Anterograde pulmonary blood flow (APBF) maintained after BDG has been shown both to improve and to complicate postoperative clinical course. We studied its effects on outcome after BDG and eventual Fontan completion. Methods From November 1995 to November 2005, 60 patients underwent BDG and Fontan. All patients had APBF from the ventricle to the pulmonary artery at time of BDG. In group 1 (n = 39) APBF was maintained after BDG, whereas APBF was interrupted at BDG in group 2 (n = 21). Cardiac catheterization data, interstage morbidity, and postoperative outcome variables were recorded. Results Pre-BDG hemodynamics differed only in that the mean pulmonary artery pressure was higher in group 2 (17.0 ± 4.4 mm Hg) than in group 1 (13.8 ± 4.5 mm Hg; p = 0.03). There were no differences between groups 1 and 2 in BDG outcome variables. At pre-Fontan catheterization, group 1 had higher mean pulmonary artery pressure (13.3 versus 10.9 mm Hg, p = 0.01), arterial oxygen saturation (85.8 versus 80.9%, p = 0.0001), and fewer collateral vessels were coil embolized than in group 2 (0.9 versus 1.6, p = 0.02). Mean ventricular end-diastolic pressure was similar between groups. The Nakata index in group 1 remained stable from pre-BDG to pre-Fontan (348 versus 391, p = 0.24), but it decreased in group 2 (375 versus 227, p = 0.046). Conclusions Patients with anterograde pulmonary blood flow after BDG had a modest increase in pulmonary artery growth and arterial oxygen saturations, and decreased collateral vessel formation. This did not, however, confer additional benefit on outcome after BDG or on eventual Fontan completion.
- Published
- 2007
23. Cardiac retransplantation in high risk pediatric patients
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Seema Mital, Daphne T. Hsu, Jonathan M. Chen, Jan M. Quaegebeur, Linda J. Addonizio, Ralph S. Mosca, Jacqueline M. Lamour, and Marc E. Richmond
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Heart transplantation ,Transplantation ,medicine.medical_specialty ,Allograft failure ,business.industry ,medicine.medical_treatment ,Panel reactive antibody ,Retrospective cohort study ,Surgery ,Impaired renal function ,El Niño ,Pediatrics, Perinatology and Child Health ,medicine ,Graft survival ,business - Abstract
Cardiac retransplantation is often the only therapy to treat GV or other causes of allograft failure. Previous reports of retransplantation have conflicting results. In this series of 18 re-transplants in 16 patients from 1984-2005, indications for retransplantation were: GV (67%); GV with cellular rejection (28%); acute graft failure (2.5%); and chronic graft failure (2.5%). Mean age at retransplantation was 12.3 (range: 0.7-22) years with a mean primary graft survival of 5.3 years (range: 8 days-10.5 years). There was no short-term mortality with only three deaths at 4, 10, and 16 years post-retransplantation. Fourteen of 18 patients had risk factors for adverse outcomes following retransplantation: ECMO support in one patient prior to retransplantation; impaired renal function in three patients; elevated panel reactive antibody screen in seven patients; a history of PTLD in five patients; and a recent episode of rejection (13-36 days) in four patients. One-, five- and ten-year survival after retransplantation was 100%, 83% and 66%, respectively, comparable to survival after primary transplantation. Freedom from rejection was not significantly different between primary and retransplantations. All patients who underwent treatment for PTLD had excellent results after retransplantation with one recurrence 16 months after retransplant. Overall, patients had excellent survival after retransplantation even in those with risk factors for poor outcome.
- Published
- 2007
24. Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard--neither Minotaur nor Midas
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Ralph S. Mosca
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Pulmonary and Respiratory Medicine ,Pediatrics ,medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,medicine.disease ,Fontan Procedure ,Norwood Procedures ,Hypoplastic left heart syndrome ,Surgery ,Fontan procedure ,03 medical and health sciences ,0302 clinical medicine ,030228 respiratory system ,Hypoplastic Left Heart Syndrome ,Medicine ,Humans ,Norwood procedure ,Cardiology and Cardiovascular Medicine ,business - Published
- 2015
25. Anomalous Aortic Origin of a Coronary Artery Is Not Always a Surgical Disease
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Colin K.L. Phoon and Ralph S. Mosca
- Subjects
medicine.medical_specialty ,Coronary Vessel Anomalies ,Disease ,030204 cardiovascular system & hematology ,Sudden cardiac death ,Lesion ,03 medical and health sciences ,Incomplete knowledge ,0302 clinical medicine ,Internal medicine ,medicine ,Humans ,030212 general & internal medicine ,Sinus (anatomy) ,business.industry ,Patient Selection ,Sinus of Valsalva ,medicine.disease ,Surgery ,Natural history ,medicine.anatomical_structure ,Death, Sudden, Cardiac ,Anomalous aortic origin of a coronary artery ,Pediatrics, Perinatology and Child Health ,Cardiology ,Stents ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Anomalous aortic origin of the coronary artery (AAOCA) from the opposite sinus of Valsalva with an interarterial course has become a high-profile lesion as a result of its association with sudden cardiac death in otherwise young and healthy individuals. Despite our incomplete knowledge of its pathophysiology and natural history, surgical intervention is often recommended. Evidence now shows AAOCA to be relatively common, with lower than previously suspected rates of sudden cardiac death. Analysis of this information reveals that AAOCA is not always a surgical disease. Future multi-institutional studies will continue to define those subgroups best served by observation or surgery.
- Published
- 2015
26. Pulmonary valve replacement after repair of tetralogy of Fallot: Evolving strategies
- Author
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Ralph S. Mosca
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Palliative care ,Treatment outcome ,MEDLINE ,030204 cardiovascular system & hematology ,Prosthesis Design ,03 medical and health sciences ,0302 clinical medicine ,Pulmonary Valve Replacement ,medicine ,Prosthesis design ,Humans ,Cardiac Surgical Procedures ,Tetralogy of Fallot ,Prosthetic valve ,Heart Valve Prosthesis Implantation ,Pulmonary Valve ,business.industry ,Palliative Care ,medicine.disease ,Pulmonary Valve Insufficiency ,Surgery ,Treatment Outcome ,030228 respiratory system ,Heart Valve Prosthesis ,Cardiology and Cardiovascular Medicine ,business - Published
- 2015
27. TGA/VSD/LVOTO: Evolution of surgical therapy
- Author
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Ralph S. Mosca
- Subjects
Pulmonary and Respiratory Medicine ,Heart Septal Defects, Ventricular ,Heart Valve Prosthesis Implantation ,medicine.medical_specialty ,business.industry ,Transposition of Great Vessels ,Surgery ,Blood Vessel Prosthesis ,Pulmonary Valve Stenosis ,Surgical therapy ,Blood Vessel Prosthesis Implantation ,Heart Valve Prosthesis ,Medicine ,Humans ,Abnormalities, Multiple ,Cardiology and Cardiovascular Medicine ,business - Published
- 2015
28. Adult-age donors offer acceptable long-term survival to pediatric heart transplant recipients: An analysis of the United Network of Organ Sharing database
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Mark J. Russo, Robert Sorabella, Ralph S. Mosca, Faisal H. Cheema, Timothy P. Martens, Seema Mital, Jonathan M. Chen, Ryan R. Davies, and Isaac George
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Adult ,Male ,Pulmonary and Respiratory Medicine ,United Network for Organ Sharing ,Thorax ,medicine.medical_specialty ,Pediatrics ,Adolescent ,MEDLINE ,Adult age ,Long term survival ,medicine ,Humans ,Child ,Intensive care medicine ,Survival analysis ,business.industry ,Patient Selection ,Age Factors ,Middle Aged ,Survival Analysis ,Tissue Donors ,Transplantation ,El Niño ,Heart Transplantation ,Female ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Abstract
ObjectivesA critical shortage of donor organs has caused many centers to use less restrictive donor criteria, including the use of adult-age donors for pediatric recipients. The purpose of this study is (1) to describe the supply of pediatric (0-18 years) heart donors, (2) to explore the relationship between donor age and long-term survival, and (3) to define threshold age ranges associated with decreased long-term survival.MethodsThe United Network of Organ Sharing provided deidentified patient-level data. Primary analysis focused on 1887 heart transplant recipients aged 9 to 18 years undergoing transplantation from October 1, 1987, to September 25, 2005. Kaplan-Meier analysis and log-rank tests were used in time-to-event analysis. Receiver operating characteristic curves and stratum-specific likelihood ratios were generated to compare survival at various donor age thresholds.ResultsThe number of pediatric donors decreased (P < .001) over the study period, particularly from 1993 (n = 640) through 2004 (n = 432). Among recipients aged 9 to 18 years, univariate analysis demonstrated a statistically significant (P < .001) inverse relationship between donor age and survival. Stratum-specific likelihood ratio analysis generated 3 strata for donor age: the low-risk, intermediate-risk, and high-risk groups consisted of donors aged 13 years or younger (n = 611, 32.41%), 14 to 51 years (n = 1258, 66.7%), and 52 years and older (n = 16, 0.85%), respectively. In the low-risk, intermediate-risk, and high-risk groups median survival was 4069 days (11.1 years), 3495 days (9.57 years), and 1197 days (3.28 years), respectively.ConclusionsAlthough donors aged 13 years or less offer pediatric recipients the best chance for achieving long-term survival, donors aged 14 to 51 years offer good outcomes to pediatric recipients. Consideration should be given to expanded use of well-selected adult-age donors for pediatric recipients.
- Published
- 2006
29. Superior outcomes for repair in infants and neonates with tetralogy of Fallot with absent pulmonary valve syndrome
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Jan M. Quaegebeur, Ralph S. Mosca, Julie S. Glickstein, William E. Hellenbrand, Jonathan M. Chen, Renee Margossian, and Michelle L. Mercando
- Subjects
Male ,Reoperation ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.medical_treatment ,Pulmonary insufficiency ,Angioplasty ,medicine.artery ,Humans ,Medicine ,Tetralogy of Fallot ,Pulmonary Valve ,Respiratory distress ,business.industry ,Infant, Newborn ,Infant ,Recovery of Function ,Perioperative ,medicine.disease ,Survival Analysis ,Surgery ,Catheter ,Treatment Outcome ,medicine.anatomical_structure ,Child, Preschool ,Pulmonary valve ,Pulmonary artery ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Objective Primary repair of tetralogy of Fallot with absent pulmonary valve syndrome has been associated with significant mortality, particularly for neonates in respiratory distress. Controversy persists regarding the method of establishing right ventricle–pulmonary artery continuity. Methods Anatomic and demographic parameters were evaluated for patients undergoing repair of tetralogy of Fallot with absent pulmonary valve syndrome from 1990 to 2005, as were perioperative and late postoperative parameters (airway complications, reoperation or catheter-based intervention, and mortality). Results Twenty-three patients underwent repair. Median age was 15 days (range 2-1154 days). Patients were followed up for 5.3 ± 3.9 years. Seventeen (85%) required preoperative ventilatory assistance. One patient died within 24 hours; 1 patient died 8 months postoperatively. Four patients received valved homografts, and the remainder had valveless connections. All patients underwent reduction pulmonary arterioplasty and mobilization, unifocalization (in 3), and ventricular septal defect closure. Valveless connection recipients had a transannular hood. No patient underwent a Lecompte maneuver. Four patients underwent reoperation for conversion to valveless connection (n = 1), reduction arterioplasty (n = 1), and repair of pulmonary stenosis (n = 2). Three patients required catheter-based intervention, with balloon angioplasty (n = 3) and stent placement (n = 1); 2 now demonstrate equal quantitative lung perfusion. No patient has had significant debility from airway compromise. All patients demonstrate free pulmonary insufficiency and good biventricular function. Conclusions We report excellent overall survival (89%) and low postoperative morbidity for neonates and infants undergoing primary repair of tetralogy of Fallot with absent pulmonary valve syndrome. Our recent experience supports the use of a valveless right ventricle–pulmonary artery connection, which, combined with catheter-based intervention, reduces the likelihood of reoperation necessitated by homograft placement.
- Published
- 2006
30. Truncus Arteriosus Associated with Interrupted Aortic Arch in 50 Neonates: A Congenital Heart Surgeons Society Study
- Author
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Andrew S. Mackie, Gary K. Lofland, Christopher A. Caldarone, Brian W. McCrindle, Eugene H. Blackstone, Tara Karamlou, William G. Williams, Ralph S. Mosca, and Igor E. Konstantinov
- Subjects
Heart Septal Defects, Ventricular ,Male ,Reoperation ,Pulmonary and Respiratory Medicine ,Aortic arch ,medicine.medical_specialty ,Persistent truncus arteriosus ,Aorta, Thoracic ,Comorbidity ,Constriction, Pathologic ,Pulmonary Artery ,Cohort Studies ,Ductus arteriosus ,Internal medicine ,medicine.artery ,Prevalence ,medicine ,Humans ,Abnormalities, Multiple ,Prospective Studies ,Ductus Arteriosus, Patent ,Societies, Medical ,Subclavian artery ,Aorta ,Arterial trunk ,business.industry ,Interrupted aortic arch ,Infant, Newborn ,Infant ,Thoracic Surgery ,medicine.disease ,Combined Modality Therapy ,Heart Valves ,Respiration, Artificial ,Survival Analysis ,Truncus Arteriosus, Persistent ,Surgery ,Survival Rate ,Transplantation ,Treatment Outcome ,medicine.anatomical_structure ,Prostaglandins ,Cardiology ,Heart Transplantation ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
Background. Patients with both interrupted aortic arch (IAA) and truncus arteriosus (TA) have worse outcomes than those with either lesion in isolation. We determined outcomes and associated factors in this rare group. Methods. From 1987 to 1997, 50 (11%) of 472 neonates with IAA were identified with TA. Site of aortic arch interruption was distal to the left subclavian artery in 16% and between the left common carotid and subclavian artery in 84%. From the common arterial trunk, the pulmonary arteries arose from a main pulmonary trunk in 46%, common orifice in 22%, and separate orifices in 32%. At presentation, truncal valve stenosis was present in 12% and regurgitation in 22%. Results. There were 34 deaths, with a single early hazard phase. Overall survival from admission was 44%, 39%, and 31% at 6 months, 1 year, and 10 years, respectively. One patient had primary cardiac transplantation and 4 died without any intervention. The IAA repair alone was performed in 7 patients, with single stage repair of both IAA and TA in 38 patients. Associated factors for overall time-related death include female gender (p < 0.001), type III TA (p < 0.001) and one institution (low-risk; p < 0.001). Results improved somewhat over time (p < 0.001). At 5 years after IAA repair only 28% were alive without arch repair intervention, and at 5 years after TA repair only 18% were alive without conduit reoperation. Conclusions. The combination of IAA and TA carries high early mortality, with high risk of reinterventions in survivors. One stage repair of both TA and IAA is the optimal management.
- Published
- 2006
31. Early Complete Atrioventricular Canal Repair Yields Outcomes Equivalent to Late Repair
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Anjali Chelliah, Paul J. Chai, Elizabeth H. Stephens, Emile A. Bacha, Ralph S. Mosca, Halit Yerebakan, Jan M. Quaegebeur, Ali Ibrahimiye, Betul Yilmaz, Stéphanie Levasseur, and Jonathan M. Chen
- Subjects
Pulmonary and Respiratory Medicine ,Male ,medicine.medical_specialty ,Time Factors ,New York ,Ventricular outflow tract obstruction ,law.invention ,Postoperative Complications ,law ,medicine ,Cardiopulmonary bypass ,Humans ,Cardiac Surgical Procedures ,Retrospective Studies ,Atrioventricular valve ,business.industry ,Mortality rate ,Incidence ,Infant, Newborn ,Infant ,Retrospective cohort study ,Perioperative ,medicine.disease ,Surgery ,Survival Rate ,Treatment Outcome ,Echocardiography ,Atrioventricular canal ,Female ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,Trisomy ,business ,Endocardial Cushion Defects ,Follow-Up Studies - Abstract
Background Repair of complete atrioventricular canal early in infancy has traditionally carried greater morbidity and mortality than repair performed later. However, an individualized anatomy-based repair may give young infants outcomes that are equivalent to older patients. Methods We retrospectively reviewed 139 patients who underwent complete atrioventricular canal repair from January 2005 to December 2012. An individualized approach was used: 2-patch repair was performed in 98 patients for large ventricular septal defects and a modified single-patch ("Australian technique") was used in 41 for "shallow" ventricular septal defects. Results The average age was 25.5 ± 3.9 weeks, 50% were boys, and 78% had trisomy 21. Mean follow-up was 5.1 ± 0.2 years, with 100% completeness of data. There were 3 in-hospital deaths (2.1%) and 1 late death (0.7%). A permanent pacemaker was required in 2 patients (1.4%). The rate for left atrioventricular valve reoperation was 8% at a mean of 211 ± 238 days after the original repair (range, 6 to 682 days). Compared with patients aged older than 3 months, the 39 patients (28%) who were younger than 3 months had similar perioperative courses and rate of reoperation. Compared with patients with an Australian repair, the 98 patients (71%) with a 2-patch repair were more likely to have trisomy 21 and had slightly increased cardiopulmonary bypass and cross-clamp times but similar outcomes. Multivariate analysis showed postoperative left atrioventricular valve regurgitation greater than 2 and left ventricular outflow tract obstruction were significant risk factors for reoperation on the left atrioventricular valve (both p Conclusions Repair of complete atrioventricular canal using an individualized surgical approach yields reoperation and early mortality rates similar for younger infants compared with older infants, obviating the need to delay operation in symptomatic patients.
- Published
- 2014
32. Pulmonary position cryopreserved homografts: Durability in pediatric Ross and non-Ross patients
- Author
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Karen Altmann, Welton M. Gersony, Chava Khan, David E. Solowiejczyk, Ralph S. Mosca, Ehud Krongrad, Elif Seda Selamet Tierney, Jan M. Quaegebeur, Howard D. Apfel, and Laura Bevilacqua
- Subjects
Pulmonary and Respiratory Medicine ,Thorax ,medicine.medical_specialty ,Ventricular Outflow Obstruction ,Blood Vessel Prosthesis Implantation ,Risk Factors ,Blood vessel prosthesis ,parasitic diseases ,Humans ,Medicine ,In patient ,Child ,Lung ,Potential risk ,business.industry ,Graft Survival ,Graft Occlusion, Vascular ,Infant, Newborn ,Infant ,Implant failure ,Blood Vessel Prosthesis ,Prosthesis Failure ,Surgery ,body regions ,Treatment Outcome ,surgical procedures, operative ,medicine.anatomical_structure ,El Niño ,Child, Preschool ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Objective The purpose of this study was to evaluate the outcome and risk factors for implant failure in pediatric patients who underwent pulmonary position homograft placement for right ventricular outflow tract obstruction compared with conduit placement as a component of the Ross operation. Actuarial 5-year survivals for cryopreserved right ventricle-to-pulmonary artery homografts range from 55% to 94% at all ages. It is not known whether there is a difference in homograft durability when utilized for right ventricular outflow tract obstruction or as part of the Ross operation. Methods The records of all pediatric patients receiving a right ventricle-to-pulmonary artery homograft from July 1989 through October 2003 were reviewed. Ninety-eight consecutive patients were studied (26 Ross, 72 non-Ross). In addition to Ross versus non-Ross comparisons, other potential risk factors for homograft failure analyzed included age at operation, follow-up time, type of surgery, and homograft type and size. Results Ross and non-Ross patients were comparable in age at the time of the operation and follow-up time. Homograft failure rates were 12% and 51% for Ross and non-Ross patients, respectively. Freedom from reintervention was 93% in the Ross and 66% in the non-Ross group at 5 years (P = .019). On multivariate analysis, non-Ross operation and age less than 2 years were significant predictors of homograft failure. Conclusions 1. Pediatric patients undergoing the Ross operation have longer homograft survival than pediatric patients treated for right ventricular outflow tract obstruction, independent of age. 2. Homografts placed in patients less than 2 years of age have shorter homograft survival.
- Published
- 2005
33. The effect of repair technique on postoperative right-sided obstruction in patients with truncus arteriosus
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Ralph S. Mosca, Jan M. Quaegebeur, Ryan R. Davies, Michelle L. Mercando, Jonathan M. Chen, William E. Hellenbrand, and Julie S. Glickstein
- Subjects
Thorax ,Reoperation ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Persistent truncus arteriosus ,Pulmonary Artery ,law.invention ,law ,Hypothermia, Induced ,medicine.artery ,Cardiopulmonary bypass ,medicine ,Ventricular outflow tract ,Humans ,Cardiac Surgical Procedures ,Retrospective Studies ,Cardiopulmonary Bypass ,business.industry ,Infant, Newborn ,Infant ,Retrospective cohort study ,Perioperative ,medicine.disease ,Truncus Arteriosus, Persistent ,Surgery ,Catheter ,Treatment Outcome ,Pulmonary Veins ,Anesthesia ,Pulmonary artery ,business ,Cardiology and Cardiovascular Medicine - Abstract
Objectives We reviewed our experience with repair of truncus arteriosus to assess the effect of type of right ventricular outflow tract reconstruction on perioperative morbidity, survival, and freedom from catheter-based interventions and reoperation. Methods Patients undergoing repair of truncus arteriosus from June 1990 through February 2004 were evaluated on the basis of operative procedure regarding preoperative and postoperative variables, the need for postoperative catheter-based intervention or reoperation, and survival on the basis of univariate, multivariable, and actuarial analyses. Results Of 54 study patients, 15 (28%) received a valved homograft, and 39 (72%) received a direct connection with a variety of hood materials. Five (9.1%) patients died. Valved homograft recipients were more likely to require reoperation than patients receiving direct connections (40% vs 15%, P = .046); however, valved homograft and direct connection recipients had a similar incidence of the combined end point of reoperation or catheter-based intervention (40.0% vs 37.5%, P = .865). Univariate and multivariable modeling demonstrated use of valved homografts or direct connections with an autologous pericardial hood to be predictive of the need for later catheter-based intervention or reoperation. Actuarial analysis demonstrated a trend toward improved outcomes in the direct connection group and within the direct connection cohort, a statistically significant difference on the basis of hood type. Conclusions Although the direct connection technique might not prevent later catheter-based intervention, it does reduce the need for reoperation. Outcomes among direct connection recipients were associated with hood type: polytetrafluoroethylene hoods (W. L. Gore & Associates, Inc, Tempe, Ariz) had the lowest rate of reintervention, and untreated autologous pericardial hoods had the highest rate of reintervention. We report excellent outcomes with primary repair of truncus arteriosus. Where anatomically appropriate, we advocate the direct connection technique.
- Published
- 2005
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34. A Unique ALCAPA Variant in a Neonate
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Anne J.L. Chun, Colin K.L. Phoon, Ralph S. Mosca, Robert Adams, Deane E. Smith, Marci Bendel, and Michael Argilla
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,Right pulmonary artery ,Main Pulmonary Artery ,Left coronary artery ,medicine.anatomical_structure ,Internal medicine ,medicine.artery ,Pulmonary artery ,medicine ,Cardiology ,Surgery ,Circumflex ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly present in approximately one in 300,000 live births. Here, we present a unique ALCAPA variant identified in a neonate. The left anterior descending artery originated posterolaterally on the main pulmonary artery, and the circumflex originated separately from the distal right pulmonary artery. doi: 10.1111/jocs.12079 (J Card Surg 2013;28:306–308)
- Published
- 2013
35. Early and medium-term results for repair of ebstein anomaly
- Author
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Pamela A. Mazzeo, Kimara L. Targoff, Jonathan M. Chen, Ralph S. Mosca, Karen Altmann, Jan M. Quaegebeur, and Beth F. Printz
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Adult ,Male ,Reoperation ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Time Factors ,Adolescent ,Radiofrequency ablation ,Heart Ventricles ,New York ,Regurgitation (circulation) ,Severity of Illness Index ,law.invention ,Postoperative Complications ,law ,Internal medicine ,Severity of illness ,Humans ,Ventricular Function ,Medicine ,cardiovascular diseases ,Child ,Tricuspid valve ,business.industry ,Infant ,Middle Aged ,Survival Analysis ,Tricuspid Valve Insufficiency ,Surgery ,Ebstein Anomaly ,Clinical trial ,Treatment Outcome ,medicine.anatomical_structure ,Echocardiography ,Ventricle ,Child, Preschool ,Circulatory system ,Adjunctive treatment ,cardiovascular system ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
Objectives We evaluated the early and medium-term single-center results for primary repair of Ebstein anomaly in both adults and children. Methods The records were reviewed of patients undergoing repair of Ebstein anomaly at the Children's Hospital of New York from September 1990 to September 2002. Functional, demographic, and echocardiographic parameters were studied both preoperatively and postoperatively, along with functional status and adverse events. The repair technique involved vertical plication of the atrialized ventricle and valve leaflet reimplantation after clockwise rotation. Results A total of 25 patients (19 children and 6 adults) underwent repair. The average age was 14.2 ± 15.9 years, and the average follow-up was 4.1 ± 3.4 years. Three patients required reoperation for right ventricular overload (1 child) and progressive, severe tricuspid regurgitation (2 adults); both adults received tricuspid valve replacements, one at 4 years and the other at 8 years post-repair. Three patients had radiofrequency ablation procedures performed intraoperatively. Ten patients (40%) had moderate-to-severe tricuspid regurgitation perioperatively. However, 18 children (95%) and 5 adults (83%) demonstrated significant improvement in exercise capacity late postoperatively. Two children died suddenly 11 months and 4 years after repair. Discussion Ebstein repair has good functional outcomes in children despite residual tricuspid regurgitation, likely because of reduction in right ventricular volume loading and relative annular and ventricular plasticity. Adult patients did not demonstrate the same durability of valve repair and frequently required tricuspid valve replacement. Intraoperative radiofrequency ablation represents an important adjunctive treatment for intractable arrhythmias, which may now represent relative indications for operative intervention.
- Published
- 2004
36. Primary cardiac precursor B lymphoblastic lymphoma in a child
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Benjamin J. Lentzner, Ralph S. Mosca, Deepa Bassi, and Bachir Alobeid
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medicine.medical_specialty ,business.industry ,Cardiac Neoplasm ,Lymphoblastic lymphoma ,Primary Cardiac Lymphoma ,General Medicine ,Disease ,Precursor B-Lymphoblastic Lymphoma ,medicine.disease ,Pathology and Forensic Medicine ,Surgery ,Right atrial mass ,Rare case ,medicine ,Vomiting ,Radiology ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business - Abstract
We describe an extremely rare case of primary cardiac precursor B lymphoblastic lymphoma (B-LBL) in a 10-year-old boy who presented with nonspecific complaints of fatigue and vomiting for 2 weeks and an episode of syncope. Chest X-ray showed cardiomegaly and echocardiography revealed a large right atrial mass, which was successfully resected. Pathology showed precursor B-LBL arising in the heart and there was no evidence of disease at any extracardiac site. A brief review of the literature is also presented.
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- 2004
37. Echocardiographic analysis of ventricular geometry and function during repair of congenital septal defects
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Cecily G. Gallup, Jan M. Quaegebeur, Alan D. Weinberg, Brianne F. Blumenthal, April J Zhu, Rowan Walsh, Joseph P. Hart, Henry M. Spotnitz, Ralph S. Mosca, Santos E. Cabreriza, Beth F. Printz, Daphne T. Hsu, and David Park
- Subjects
Heart Defects, Congenital ,Pulmonary and Respiratory Medicine ,congenital, hereditary, and neonatal diseases and abnormalities ,medicine.medical_specialty ,Diastole ,Afterload ,Internal medicine ,Humans ,Medicine ,cardiovascular diseases ,Interventricular septum ,Child ,Stroke ,Ultrasonography ,Body surface area ,Intraoperative Care ,Ejection fraction ,business.industry ,Infant ,medicine.disease ,Preload ,medicine.anatomical_structure ,Child, Preschool ,Congenital Septal Defect ,cardiovascular system ,Cardiology ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Abstract
This study investigated changes in left ventricular (LV) geometry and systolic function after corrective surgery for atrial (ASD) and ventricular septal defects (VSD).Transesophageal LV short-axis echocardiograms were recorded before and after operative repair of ASD (n = 11) and VSD (n = 7). Preload was measured using LV end-diastolic area indexed for body surface area. Measurements of septal-freewall (D1) and anterior-posterior (D2) endocardial diameters were used to assess LV symmetry from D1/D2. Systolic indices included stroke area, area ejection fraction, and fractional shortening.Preload, stroke area, area ejection fraction, and fractional shortening of D1 increased after ASD repair but decreased after VSD repair (p0.05). End-diastolic symmetry increased after ASD closure and decreased after VSD closure (p0.05). Increases in stroke area and ejection fraction after ASD correction primarily reflected increased shortening of D1. A positive correlation was found overall between percent change in end-diastolic area (EDA) and percent change in area ejection fraction (r(2) = 0.80, p0.0001, n = 18).Preload was the primary determinant of changes in LV function in this series of ASD and VSD repairs. Intraoperative changes in position of the interventricular septum affected systolic and diastolic LV symmetry and septal free wall shortening. Additional studies are needed to define changes in afterload and contractility as well as diastolic compliance and systolic mechanics.
- Published
- 2004
38. Cardiopulmonary bypass, cardioplegia, confocal inspection…?
- Author
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Ralph S. Mosca
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Cardiopulmonary Bypass ,business.industry ,Myocardium ,Confocal ,030204 cardiovascular system & hematology ,01 natural sciences ,law.invention ,010309 optics ,03 medical and health sciences ,0302 clinical medicine ,law ,Internal medicine ,0103 physical sciences ,Heart Arrest, Induced ,Cardiopulmonary bypass ,Cardiology ,Humans ,Medicine ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Published
- 2016
39. Use of extracorporeal life support as a bridge to pediatric cardiac transplantation
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Joseph R. Custer, Dennis C. Crowley, Ralph S. Mosca, Richard G. Ohye, Robert J. Gajarski, Alicia Valentini, Thomas J. Kulik, Frank W. Moler, and Edward L. Bove
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Pulmonary and Respiratory Medicine ,endocrine system ,medicine.medical_specialty ,Time Factors ,Databases, Factual ,genetic structures ,medicine.medical_treatment ,Population ,Extracorporeal ,Extracorporeal Membrane Oxygenation ,Extracorporeal membrane oxygenation ,Humans ,Medicine ,Renal Insufficiency ,education ,Dialysis ,Heart Failure ,Heart transplantation ,Transplantation ,education.field_of_study ,business.industry ,Infant ,medicine.disease ,eye diseases ,Surgery ,Life support ,Heart Transplantation ,Cardiology and Cardiovascular Medicine ,business ,Life Support Systems ,Kidney disease - Abstract
Background Extracorporeal life support (ECLS) has been used for post-cardiotomy rescue, but its use as a bridge to heart transplantation (OHT) in patients with post-surgical or end-stage ventricular failure remains controversial. Methods Records were reviewed for patients receiving ECLS for ventricular failure from January 1991 to August 2001. Patients listed for OHT were analyzed separately. Listing for OHT requirements were improbable myocardial recovery, absence of contraindications (central nervous system damage, high pulmonary resistance, ongoing infection, etc.), and parental consent. Outcome variables included patient demographics, diagnosis, days from ECLS initiation to United Network for Organ Sharing (UNOS) listing (latency), list time, renal function, and survival to discharge. Results Of 145 patients with ventricular failure who received ECLS, 21 pediatric patients were UNOS listed. Of 124 non-listed patients, 57 (46%) survived to discharge. All but 3 survivors were separated from ECLS in ≤7 days. Twelve underwent OHT and 10 survived to discharge (list time, 6 days; median ECLS time, 14 days). Five had ECLS discontinued without undergoing OHT (1 later underwent OHT, 2 survived to discharge). Five experienced complications while receiving ECLS and died without undergoing OHT. Six of 9 patients who required dialysis for renal failure died. Of 11 infants listed, 4 were weaned from ECLS without undergoing OHT (2 survived to discharge), 5 had OHT (ECLS support, 4 days; 4 survived to discharge) and 2 died (ECLS support, 16 and 47 days). Conclusions (1) Extracorporeal life support can be used as a bridge to OHT (even among the infant population) for at least 2 weeks with acceptable survival and hospital discharge rates, and (2) renal insufficiency with the concomitant requirement for dialysis decreases the likelihood of survival before and after OHT.
- Published
- 2003
40. Albumin versus crystalloid prime solution for cardiopulmonary bypass in young children
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Terri Voepel-Lewis, Edward L. Bove, Lori Q. Riegger, Alan R. Tait, Shobha Malviya, Thomas J. Kulik, and Ralph S. Mosca
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Hematocrit ,Weight Gain ,Critical Care and Intensive Care Medicine ,Statistics, Nonparametric ,law.invention ,Osmotic Pressure ,law ,Albumins ,Cardiopulmonary bypass ,Humans ,Medicine ,Colloids ,Prospective Studies ,Mechanical ventilation ,Analysis of Variance ,Cardiopulmonary Bypass ,medicine.diagnostic_test ,business.industry ,Infant, Newborn ,Albumin ,Infant ,Perioperative ,Surgery ,Cardiac surgery ,Treatment Outcome ,Child, Preschool ,Anesthesia ,Female ,business ,Packed red blood cells ,Fluid balance - Abstract
Objective: To determine the effects of adding 5% albumin to the cardiopulmonary bypass prime on perioperative fluid status and fluid management in young children. Design: Prospective randomized study. Setting: Single university hospital. Patients: Pediatric patients of
- Published
- 2002
41. A retrospective review of three antibiotic prophylaxis regimens for pediatric cardiac surgical patients
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Ralph S. Mosca, Kevin O. Maher, Kristen VanderElzen, Edward L. Bove, Thomas J. Kulik, and Carol E. Chenoweth
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Heart disease ,medicine.drug_class ,medicine.medical_treatment ,Antibiotics ,Cefazolin ,Drug Administration Schedule ,Postoperative Complications ,Vancomycin ,Sepsis ,medicine ,Humans ,Surgical Wound Infection ,Cardiac Surgical Procedures ,Antibiotic prophylaxis ,Retrospective Studies ,Chemotherapy ,business.industry ,Infant ,Antibiotic Prophylaxis ,medicine.disease ,Thoracostomy ,Surgery ,Thoracotomy ,Gentamicin ,Gentamicins ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Optimal antimicrobial prophylaxis for the pediatric cardiac surgical patient is unknown. We have reviewed our experience with more than 4,000 pediatric cardiac surgical patients at the University of Michigan to evaluate antibiotic prophylaxis regimens.Three antibiotic prophylaxis protocols were serially used during a 6-year period: Protocol 1 (n = 786): cefazolin was administered before operation and continued as long as thoracostomy tubes or central venous catheters were present; Protocol 2 (n = 1095): cefazolin was discontinued 48 hours postoperatively, regardless of the presence of tubes or catheters; Protocol 3 (n = 2039): cefazolin was continued as long as thoracostomy tubes were present, but not for central venous catheters. Patients with an open chest postoperatively received vancomycin and gentamicin until chest closure. This was identical during all three protocols. We retrospectively determined the rate of surgical site infections and unrelated bloodstream infections (the latter for both cardiac medical and surgical patients) for the three protocols.Surgical site infections per 100 operations for protocols 1, 2, and 3 was 2.04, 6.58, and 1.67, respectively (p0.05 for protocol 2 versus protocols 1 and 3). The mean age of patients with a surgical site infection ranged from 12 to 15.4 months. Patients with an open chest had a higher rate of surgical site infection (18.8% for protocol 2 and 9.3% for protocol 3). Bloodstream infections per 1,000 patient days for protocols 1, 2, and 3 were 2.18, 6.51, and 5.02, respectively (p0.05 protocol 1 versus protocols 2 and 3).These data suggest that pediatric cardiac surgical patients may benefit from prophylactic antibiotics as long as thoracostomy tubes are in place.
- Published
- 2002
42. Tetralogy of Fallot: Total Correction
- Author
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Ralph S. Mosca
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,congenital, hereditary, and neonatal diseases and abnormalities ,business.industry ,Ventricular Outflow Obstruction ,medicine.disease ,Muscle hypertrophy ,Septal band ,medicine.anatomical_structure ,Right ventricular hypertrophy ,Pulmonary valve ,Internal medicine ,Cardiology ,cardiovascular system ,Medicine ,Ventricular outflow tract ,Surgery ,cardiovascular diseases ,business ,Cardiology and Cardiovascular Medicine ,Tetralogy of Fallot - Abstract
he events that give rise to the c1evelol)iiieiit of the T constellation of lesions that we refer to as tetralogj of Fallot are still micertain. Regardless of the true teleological cause, it is hel1)ful for the surgeon to approach this defect as resulting from anterocephalad deviation of the ventricular outlet septum. "monology with sequellae." The resulting malalignment ventricular septal defect (VSD), aortic override, ancl right ventricular outflow tract ol~struction are thus easily understood. The right ventricular hypertrophy can he appreciated as secondary to the VSD and right ventricular outflow tract ohstructioii. Right ventricular outflow obstruction is increased by hypertrophy of the anterior limb of the septal ]land, anomalous anterior muscular bands, and outlet septum as well as pulmonary valve and arterial anomalies (Fig I). Classically the VSD is circular, juxtaaortic, and nonrestrictive and results from the malalignment of the parietal extension of the infundibular and trabecular septae. As such, the defect lies between the infundibular septum and is cradled by the anterior and posterior limbs of the septal band (Fig 11).
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- 2002
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43. Complete Repair of Tetralogy of Fallot in the Neonate
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Edward L. Bove, Jennifer C. Hirsch, and Ralph S. Mosca
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Male ,Reoperation ,medicine.medical_specialty ,Time Factors ,Pulmonary insufficiency ,Postoperative Complications ,Risk Factors ,medicine.artery ,Scientific Papers ,medicine ,Humans ,Ventricular outflow tract ,Survival rate ,Retrospective Studies ,Tetralogy of Fallot ,Pulmonary artery stenosis ,business.industry ,Infant, Newborn ,Perioperative ,medicine.disease ,Surgery ,Survival Rate ,Pulmonary artery ,Female ,business ,Pulmonary atresia ,Follow-Up Studies - Abstract
Objective To review more than a decade of experience with complete repair of tetralogy of Fallot (TOF) in neonates at the University of Michigan; to assess early and late survival, perioperative complications, and the incidence of reoperation; and to analyze patient, procedural, and morphologic risk factors to determine their effects on outcome. Background Data Palliation of TOF with systemic-to-pulmonary artery shunts has been the accepted standard for symptomatic neonates and infants. Complete repair has traditionally been reserved for infants older than 6 months of age because of the perception that younger and smaller infants face an unacceptably high surgical risk. Results A retrospective review from August 1988 to November 1999 consisted of 61 consecutive symptomatic neonates with TOF who underwent complete repair. Thirty-one patients had TOF with pulmonary stenosis, 24 had TOF with pulmonary atresia, and 6 had TOF with nonconfluent pulmonary arteries. The mean age at repair was 16 ± 13 days, and the mean weight was 3.2 ± 0.7 kg. Before surgery, 36 patients were receiving an infusion of prostaglandin, 26 were mechanically ventilated, and 11 required inotropic support. Right ventricular outflow tract obstruction was managed with a transannular patch in 49 patients and a right ventricle-to-pulmonary artery conduit in 12. Cardiopulmonary bypass time averaged 71 ± 26 minutes. Hypothermic circulatory arrest was used in 52 patients (mean 38 ± 12 minutes). After cardiopulmonary bypass, the average intraoperative right/left ventricular pressure ratio was 55% ± 13%. There were no new clinically apparent neurologic sequelae after repair. The postoperative intensive care unit stay was 9.1 ± 8 days, with 6.8 ± 7 days of mechanical ventilation. There was one hospital death from postoperative necrotizing enterocolitis on postoperative day 71 and four late deaths, only one of which was cardiac-related. Actuarial survival was 93% at 5 years. Follow-up was available for all 60 hospital survivors and averaged 62 months (range 1-141 months). Twenty-two patients required a total of 24 reoperations at an average interval of 26 months after repair. Indications for reoperation included right ventricular outflow tract obstruction (19), branch pulmonary artery stenosis (11), severe pulmonary insufficiency (4), and residual ventricular septal defect (1). The 1-month, 1-year, and 5-year freedom from reoperation rates were 100%, 89%, and 58%, respectively. Conclusions Complete repair of TOF in the neonate is associated with excellent intermediate-term survival. Although the reoperation rate is significant, this is to be expected with the complex right ventricular outflow tract and pulmonary artery anatomy seen in symptomatic neonates and the need for conduit replacement in patients with TOF with pulmonary atresia.
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- 2000
44. Serial blood lactate measurements predict early outcome after neonatal repair or palliation for complex congenital heart disease
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John R. Charpie, Thomas J. Kulik, Mary K. Dekeon, Ralph S. Mosca, Caren S. Goldberg, and Edward L. Bove
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Heart Defects, Congenital ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Time Factors ,Palliative care ,Heart disease ,medicine.medical_treatment ,Sensitivity and Specificity ,law.invention ,Extracorporeal Membrane Oxygenation ,Predictive Value of Tests ,law ,Extracorporeal membrane oxygenation ,Humans ,Medicine ,Decompensation ,Lactic Acid ,Prospective Studies ,Prospective cohort study ,business.industry ,Palliative Care ,Infant, Newborn ,medicine.disease ,Intensive care unit ,Surgery ,Cardiac surgery ,Treatment Outcome ,Predictive value of tests ,Anesthesia ,Cardiology and Cardiovascular Medicine ,business - Abstract
Objectives: Neonates with congenital heart disease may appear hemodynamically stable after operation and then suddenly experience catastrophic decompensation. An improved means of predicting which infants will suddenly die in the early postoperative period may lead to lifesaving interventions. Studies indicate that blood lactate level is proportional to tissue oxygen debt, but information linking lactate levels with outcome in infants after operation is limited. We sought to determine whether a change in lactate level over time was predictive of a poor outcome defined as death within the first 72 hours or the need for extracorporeal membrane oxygenation. Methods: To test this hypothesis, we studied prospectively 46 infants who were less than 1 month old and were undergoing complex cardiac surgical palliation or repair. Postoperative arterial oxygen saturation, bicarbonate, and lactate levels were recorded on admission to the intensive care unit and every 3 to 12 hours for the first 3 days. Results: Thirty-seven patients had a good outcome, and 9 patients had a poor outcome. Mean initial lactate level was significantly greater in patients with a poor outcome (9.4 ± 3.8 mmol/L) than in patients with a good outcome (5.6 ± 2.1 mmol/L; P =.03). However, an elevated initial lactate level of more than 6 mmol/L had a low positive predictive value (38%) for poor outcome. In contrast, a change in lactate level of 0.75 mmol/L per hour or more was associated with a poor outcome (P
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- 2000
45. Use of a Single Coil Transvenous Electrode with an Abdominally Placed Implantable Cardioverter Defibrillator in Children
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Sarah LeRoy, Gerald A. Serwer, Peter S. Fischbach, Ralph S. Mosca, Macdonald Dick, and Ian H. Law
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Male ,medicine.medical_specialty ,Adolescent ,Heart Ventricles ,medicine.medical_treatment ,Long QT syndrome ,Cardiomyopathy ,Diaphragmatic breathing ,Electrocardiography ,Internal medicine ,Abdomen ,Humans ,Medicine ,Thoracotomy ,Child ,Electrodes ,Tetralogy of Fallot ,Equipment Safety ,business.industry ,Transvenous electrode ,General Medicine ,Implantable cardioverter-defibrillator ,medicine.disease ,Defibrillators, Implantable ,Surgery ,Treatment Outcome ,Child, Preschool ,Tachycardia, Ventricular ,Cardiology ,Female ,Implant ,Cardiology and Cardiovascular Medicine ,business - Abstract
FISCHBACH, P.S., ET AL.: Use of a Single Coil Transvenous Electrode with an Abdominally Placed Im-plantable Cardioverter Defibrillator in Children. While transvenous defibrillaior electrode placementavoiding a thoracotomy is preferable, electrode size, a large intercoil spacing, and the need for subclavic-ular device placement preclude this approach in mo.'it children. We investigated a single RV coil to an ab-dominally placed active can ICD device. Five children ages 8-16 years (weight 21-50 kg. mean 35 kg) un-derwent ICD placement. Placement of a single coil Medtronic model 6932 or 6943 electrode was performedvia the left subclavian vein approach and the electrode positioned in the HV apex with the coil lying alongthe RV diaphragmatic surface. The ICD (Medtronic Micro Jewel II model 7223Cx) was implanted in a leftabdominal pocket with the lead tunneled from the infraclavicular region to the pocket. Implant DFTs were^ 15 f using a biphasic waveform. DFTs rechecked within 3-month postimplant were unchanged. Leadimpedance at implant ranged from 38 to 56 fl, mean 51 fl. Follow-up was 3-21 months (total 82 months)with no electrode dislodgment. lead fractures, or inappropriate discharges. Two of the five patients havehad successful appropriate ICD discharges. Transvenous ICD electrode placement can be performed inchildren as small as 20 kg with the device implanted in a cosmetically acceptable abdominal pocket thatis well tolerated. Fxcellent DFTs can be achieved. This approach avoids a thoracotomy in all hut thesmallest child, does not require subclavicular placement of the device, and avoids use of a second in-travascular coil. (PACE 2000; 23:884-887)defibrillator, children, arrhythmia, abdominal implantIntroductionThe value of implantable cardioverter defibril-lators [ICDs) as a lifesaving intervention has beonpreviously demonstrated in the pediatric popula-tion/ The experience with ICDs in this age group islimited, accounting for less than 1% of all im-planted devices.^ Similar to the indications for de-vice implantation in adult patients as outlined re-cently by the American College of Cardiology andthe American Heart Association,^ the need for anICD in the pediatric population arises from one ofthree causes: (1) primary electrical disease [con-genital long QT syndrome, idiopathic ventricularfibrillation fVF]); (2) cardiomyopathy [arrhythmo-genic right ventricular dysplasia, hypertrophic, di-lated); and [3) following repair of congenital heartdisease (tetralogy of Fallot, transposition of thegreat arteries). Previously, the size of the transve
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- 2000
46. A successful neonatal repair of congenital aortic aneurysm with cleft sternum
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Ralph S. Mosca, Yasutaka Hirata, Charles C. Marboe, and Marc S. Arkovitz
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Pulmonary and Respiratory Medicine ,Sternum ,medicine.medical_specialty ,Aortic Aneurysm, Thoracic ,medicine.diagnostic_test ,business.industry ,Bronchotomy ,Remission Induction ,Infant, Newborn ,Thoracic Surgical Procedures ,Anastomosis ,medicine.disease ,Surgery ,Aortic aneurysm ,Pneumonia ,Foreign body aspiration ,Bronchoscopy ,medicine ,Humans ,Female ,Foreign body ,Cardiology and Cardiovascular Medicine ,business - Abstract
minal obstruction may occur. Recurrent suppurative pneumonia can occur due to obstruction. Our patient aspirated a chicken bone 4 years previously and underwent several rigid bronchoscopy attempts to extract the foreign body. She was admitted to the Istanbul Medical School after an episode of pneumonia and had dyspnea and audible wheezing because of near total airway obstruction diagnosed via bronchoscopy. Ibrahim Sersar and colleagues reported a series of 3300 patients, 3 of whom required bronchotomy because extraction of the inhaled foreign body failed. In another study, 164 patients underwent bronchoscopy for foreign body aspiration, and 6% of patients required surgical extraction. Early bronchoscopy has high successful rates in the extraction of foreign bodies. Bronchotomy is usually enough to extract the foreign body, which was performed after early bronchoscopy. Because of the delay in extraction, our patient required an extended operation, a segmental main bronchial resection with supra-aortic anastomosis. After unsuccessful attempts, a bronchotomy would have been a less-invasive procedure for this patient. Thus, we advise an early operation for organic foreign bodies.
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- 2009
47. Staged palliation of single ventricle with Levo-transposition of the great arteries
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Ralph S. Mosca
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medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,levo-Transposition of the great arteries ,medicine.disease ,Surgery ,law.invention ,Shunting ,Fontan procedure ,medicine.anatomical_structure ,Ventricle ,Great arteries ,law ,Heart failure ,Internal medicine ,Pediatrics, Perinatology and Child Health ,medicine ,Cardiopulmonary bypass ,Cardiology ,Ventricular inversion ,Cardiology and Cardiovascular Medicine ,business - Abstract
Patients born with single ventricle and L-transposition of the great arteries present challenging medical and surgical management problems. This defect is characterized by a wide variation in cardiac morphology and physiology. The clinical spectrum can range from cyanosis due to pulmonary outflow obstruction and venoarterial shunting to congestive heart failure from pulmonary over-circulation and systemic outflow tract obstruction. To avoid major operations in ill neonates and infants, earlier surgical treatment strategies concentrated on less invasive procedures that did not require cardiopulmonary bypass. Because of relatively poor initial results and a small number of patients presenting later as good candidates for the Fontan procedure, more elaborate initial palliative operations have been used. Despite their increasing complexity, these procedures more completely address the underlying anatomic and physiologic problems and have accounted for steadily improved patient survival.
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- 1999
48. Tricuspid Valvuloplasty in Hypoplastic Left Heart Syndrome
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Edward L. Bove and Ralph S. Mosca
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congenital, hereditary, and neonatal diseases and abnormalities ,medicine.medical_specialty ,Atrioventricular valve ,Tricuspid valve ,business.industry ,Tricuspid insufficiency ,Tricuspid valvuloplasty ,medicine.disease ,Hypoplastic left heart syndrome ,Surgery ,medicine.anatomical_structure ,Ventricle ,Internal medicine ,Pediatrics, Perinatology and Child Health ,cardiovascular system ,medicine ,Cardiology ,In patient ,cardiovascular diseases ,Tricuspid Valve Regurgitation ,Cardiology and Cardiovascular Medicine ,business - Abstract
Tricuspid valve regurgitation is a common finding in patients with hypoplastic left heart syndrome undergoing staged surgical reconstruction and can result from either abnormal valve morphology or incomplete leaflet coaptation due to annular dilatation. Significant tricuspid insufficiency imposes an additional volume load on the right ventricle and may have an important effect on survival. The spectrum of tricuspid valve anatomy found in hypoplastic left heart syndrome and surgical techniques available for the repair of atrioventricular valves are discussed. Tricuspid valvuloplasty during either the hemi-Fontan or Fontan stages of reconstruction carries a high success rate and is associated with improved right ventricular function. Copyright 1999 by W.B. Saunders Company
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- 1999
49. Neopulmonary reconstruction: Operam do
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Ralph S. Mosca
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Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Exercise Tolerance ,business.industry ,Pulmonary Artery ,Surgery ,Arterial Switch Operation ,medicine ,Humans ,Female ,Cardiology and Cardiovascular Medicine ,business - Published
- 2015
50. Resting coronary flow and coronary flow reserve in human infants after repair or palliation of congenital heart defects as measured by positron emission tomography
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Ralph S. Mosca, Thomas J. Kulik, Jon P. Donnelly, Barry L. Shulkin, David M. Raffel, James R. Corbett, and Edward L. Bove
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Heart Defects, Congenital ,Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Adenosine ,Palliative care ,Heart disease ,Hypoplastic left heart syndrome ,Lesion ,Coronary circulation ,Ammonia ,Coronary Circulation ,Internal medicine ,Hypoplastic Left Heart Syndrome ,medicine ,Humans ,Nitrogen Radioisotopes ,business.industry ,Palliative Care ,Infant, Newborn ,Infant ,Coronary flow reserve ,Heart ,medicine.disease ,medicine.anatomical_structure ,Ventricle ,Case-Control Studies ,Cardiology ,Female ,Surgery ,Radiopharmaceuticals ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Perfusion ,Tomography, Emission-Computed - Abstract
Objective: Coronary physiology in infants with congenital heart disease remains unclear. Our objective was to better understand coronary physiology in infants with congenital heart disease. Methods: We used positron emission tomography with nitrogen 13–labeled ammonia to measure myocardial perfusion at rest and with adenosine (142 μg/kg/min × 6 minutes) in five infants after anatomic repair of a congenital heart lesion (group I), and in five infants after Norwood palliation for hypoplastic left heart syndrome (group II). The groups were matched for age, weight, and time from the operation. Results: Resting coronary flow in the left ventricle in group I was 1.8 ± 0.2 ml/min/gm; resting flow in the right ventricle in group II was 1.0 ± 0.3 ml/min/gm ( p = 0.003). Coronary flow with adenosine was 2.6 ± 0.5 ml/min/gm in group I and 1.5 ± 0.7 ml/min/gm in group II ( p = 0.02). Absolute coronary flow reserve was the same in both groups (1.5 ± 0.2 in group I vs 1.6 ± 0.3 in group II, p = 0.45). Oxygen delivery was reduced in group II compared with group I at rest (16.1 ± 4.2 ml/min/100 gm vs 28.9 ± 4.42 ml/min/100 gm, p = 0.02) and with adenosine (25.5 ± 8.1 ml/min/100 gm vs 42.3 ± 5.8 ml/min/100 gm, p = 0.02). Conclusions: Infants with repaired heart disease have higher resting flow and less coronary flow reserve than previously reported for adults. After Norwood palliation, infants have less perfusion and oxygen delivery to the systemic ventricle than do infants with a repaired lesion. This may in part explain why the outcome for patients with Norwood palliation is less favorable than for others. (J Thorac Cardiovasc Surg 1998;115:103-10)
- Published
- 1998
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