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Variation in care for children undergoing the Fontan operation for hypoplastic left heart syndrome
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- Aaron W. Eckhauser, Maria I. Van Rompay, Chitra Ravishankar, Jane W. Newburger, S. Ram Kumar, Christian Pizarro, Nancy Ghanayem, Felicia L. Trachtenberg, Kristin M. Burns, Garick D. Hill, Andrew M. Atz, Michelle S. Hamstra, Mjaye Mazwi, Patsy Park, Marc E. Richmond, Michael Wolf, Jeffrey D. Zampi, Jeffrey P. Jacobs, L. LuAnn Minich, for the Pediatric Heart Network Investigators
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- Journal:
- Cardiology in the Young / Volume 29 / Issue 12 / December 2019
- Published online by Cambridge University Press:
- 26 November 2019, pp. 1510-1516
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Background:
The Single Ventricle Reconstruction Trial randomised neonates with hypoplastic left heart syndrome to a shunt strategy but otherwise retained standard of care. We aimed to describe centre-level practice variation at Fontan completion.
Methods:Centre-level data are reported as median or median frequency across all centres and range of medians or frequencies across centres. Classification and regression tree analysis assessed the association of centre-level factors with length of stay and percentage of patients with prolonged pleural effusion (>7 days).
Results:The median Fontan age (14 centres, 320 patients) was 3.1 years (range from 1.7 to 3.9), and the weight-for-age z-score was −0.56 (−1.35 + 0.44). Extra-cardiac Fontans were performed in 79% (4–100%) of patients at the 13 centres performing this procedure; lateral tunnels were performed in 32% (3–100%) at the 11 centres performing it. Deep hypothermic circulatory arrest (nine centres) ranged from 6 to 100%. Major complications occurred in 17% (7–33%). The length of stay was 9.5 days (9–12); 15% (6–33%) had prolonged pleural effusion. Centres with fewer patients (<6%) with prolonged pleural effusion and fewer (<41%) complications had a shorter length of stay (<10 days; sensitivity 1.0; specificity 0.71; area under the curve 0.96). Avoiding deep hypothermic circulatory arrest and higher weight-for-age z-score were associated with a lower percentage of patients with prolonged effusions (<9.5%; sensitivity 1.0; specificity = 0.86; area under the curve 0.98).
Conclusions:Fontan perioperative practices varied widely among study centres. Strategies to decrease the duration of pleural effusion and minimise complications may decrease the length of stay. Further research regarding deep hypothermic circulatory arrest is needed to understand its association with prolonged pleural effusion.
Cardiac extracorporeal life support: state of the art in 2007
- David S. Cooper, Jeffrey P. Jacobs, Lisa Moore, Arabela Stock, J. William Gaynor, Thomas Chancy, Michael Parpard, Dee Ann Griffin, Tami Owens, Paul A. Checchia, Ravi R. Thiagarajan, Thomas L. Spray, Chitra Ravishankar
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- Journal:
- Cardiology in the Young / Volume 17 / Issue S4 / September 2007
- Published online by Cambridge University Press:
- 26 November 2007, pp. 104-115
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Mechanical circulatory support is an invaluable tool in the care of children with severe refractory cardiac and or pulmonary failure. Two forms of mechanical circulatory support are currently available to neonates, infants, and smaller children, namely extracorporeal membrane oxygenation and use of a ventricular assist device, with each technique having unique advantages and disadvantages. The intra-aortic balloon pump is a third form of mechanical support that has been successfully used in larger children, adolescents, and adults, but has limited applicability in smaller children. In this review, we discuss the current experiences with extracorporeal membrane oxygenation and ventricular assist devices in children with cardiac disease.
A variety of forms of mechanical circulatory support are available for children with cardiopulmonary dysfunction refractory to conventional management. These devices require extensive resources, both human and economic. Extracorporeal membrane oxygenation can be effectively used in a variety of settings to provide support to critically-ill patients with cardiac disease. Careful selection of patients and timing of intervention remains challenging. Special consideration should be given to children with cardiac disease with regard to anatomy, physiology, cannulation, and circuit management. Even though exciting progress is being made in the development of ventricular assist devices for long-term mechanical support in children, extracorporeal membrane oxygenation remains the mainstay of mechanical circulatory support in children with complex anatomy, particularly those needing rapid resuscitation and those with a functionally univentricular circulation.
As the familiarity and experience with extracorporeal membrane oxygenation has grown, new indications have evolved, including emergent resuscitation. This utilization has been termed extracorporeal cardiopulmonary resuscitation. The literature supporting emergent cardiopulmonary support is mounting. Reasonable survival rates have been achieved after initiation of support during active compressions of the chest following in-hospital cardiac arrest. Due to the limitations of conventional circuits for extracorporeal membrane oxygenation, some centres have developed novel systems for rapid cardiopulmonary support.
Many centres previously considered a functionally univentricular circulation to be a contraindication to extracorporeal membrane oxygenation, but improved results have been achieved recently with this complex subset of patients. The registry of the Extracorporeal Life Support Organization recently reported the outcome of extracorporeal life support used in neonates for cardiac indications from 1996 to 2000. Of the 740 neonates who were placed on extracorporeal life support for cardiac indications, 118 had hypoplastic left heart syndrome. There was no significant difference in survival between these patients and those with other defects. It is now common to use extracorporeal membrane oxygenation to support patients with a functionally univentricular circulation, and reasonable survival rates are to be expected.
Although extracorporeal membrane oxygenation has become a standard of care for many paediatric centres, its use is limited to those patients who require only short-term cardiopulmonary support. Mechanical ventricular assist devices have become standard therapy for adults with cardiac failure refractory to maximal medical management. Several devices are readily available in the United States of America for adults, but there are fewer options available to children. Over the last few years, substantial progress has been made in paediatric mechanical support. Ventricular assist devices are being used with increasing frequency in children with cardiac failure refractory to medical therapy for primary treatment as a long-term bridge to recovery or transplantation. The paracorporeal, pneumatic, pulsatile “Berlin Heart” ventricular assist device is being used with increasing frequency in Europe and North America to provide univentricular and biventricular support. With this device, a patient can be maintained on mechanical circulatory support while extubated, being mobilized, and feeding by mouth.
Mechanical circulatory support should be anticipated, and every attempt must be made to initiate support “urgently” rather than “emergently”, before the presence of dysfunction of end organs or circulatory collapse. In an emergency, these patients can be resuscitated with extracorporeal membrane oxygenation and subsequently transitioned to a long-term ventricular assist device after a period of stability.
Characterization of the melanin pigment of a cosmopolitan fungal endophyte
- Trichur S. SURYANARAYANAN, Jagadesa P. RAVISHANKAR, Govindan VENKATESAN, Thokur S. MURALI
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- Journal:
- Mycological Research / Volume 108 / Issue 8 / August 2004
- Published online by Cambridge University Press:
- 13 August 2004, pp. 974-978
- Print publication:
- August 2004
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Phyllosticta capitalensis (teleomorph Guignardia mangiferae) occurs as a foliar endophyte in woody trees belonging to different families of both temperate and tropical regions. We isolated this endophyte from plants in different habitats, such as mangroves, dry deciduous forest, moist deciduous forest and semi-evergreen forest. This endophyte was found to produce a black pigment that was characterized to be melanin based on UV-visible, IR and ESR spectra and chemical tests. Tricyclazole, a specific inhibitor of pentaketide melanin biosynthesis, inhibited synthesis of the pigment indicating it is a 1-8, dihydroxynaphthalene. This appears to be the first report of such a melanin in Phyllosticta or other foliar endophytes. Melanin in the hyphae of P. capitalensis may be responsible for the success of this fungus as a cosmopolitan endophyte, since melanin is known to enhance the survival capability of fungi in stressful environments.
Response of Mnbi-Bi Eutectic to Freezing Rate Changes
- M. Nair, T-W. Fu, W. R. Wilcox, K. Doddi, P. S. Ravishankar, D. Larson
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- Journal:
- MRS Online Proceedings Library Archive / Volume 9 / 1981
- Published online by Cambridge University Press:
- 15 February 2011, 533
- Print publication:
- 1981
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Previously we reported on a theoretical treatment of the influence on freezing rate of sudden changes in translation rate in the Bridgman-Stockbarger technique [11]. This has now been extended to consideration of a linear ramped translation rate and an oscillatory freezing rate. Oscillations above a few hertz are found to be highly damped in smalldiameter apparatus.
An experimental test was made of the theoretical predictions for a sudden change of translation rate. MnBi-Bi eutectic was solidified with current induced interface demarcation.The experimental results correspond reasonably well with theory if the silica ampoule wall is assumed either (1) to contribute only a resistance to heat exchange of sample with the furnace wall, or (2) to transmit heat effectively in the axial direction by radiation.
In an attempt to explain the fact that a finer microstructure is obtained in space, MnBi-Bi microstructure is being determined when the freezing rate is rapidly increased or decreased. Preliminary results indicate that fiber branching does not occur as readily as does fiber termination.