CHD Intervention Featured Articles of April 2017

Cardiac Catheterization Reviews of April 2017 Manuscripts

 

Tricuspid Regurgitation Does Not Impact Right Ventricular Remodeling After Percutaneous Pulmonary Valve Implantation.

Tanase D, Ewert P, Georgiev S, Meierhofer C, Pabst von Ohain J, McElhinney DB, Hager A, Kühn A, Eicken A.

JACC Cardiovasc Interv. 2017 Apr 10;10(7):701-708. doi: 10.1016/j.jcin.2017.01.036.

 

Take Home Points:

 

  • Percutaneous pulmonary valve implantation (PPVI) improves right ventricular (RV) size and exercise performance regardless of the severity of tricuspid regurgitation (TR).
  • Severity of TR improves following PPVI, and therefore the presence of significant TR should not preclude attempts at PPVI.

 

Whiteside, WendyComment from Dr. Wendy Whiteside (Cincinnati), section editor of Congenital Heart Disease Interventions Journal Watch:  Percutaneous pulmonary valve implantation (PPVI) has become the therapy of choice for treatment of RV outflow tract (RVOT) conduit dysfunction.  In patients presenting for PPVI, TR is a frequent associated finding, occurring in as many as 1/3 of patients.  There are multiple etiologies and mechanisms for TR in these patients, including annular dilation in the setting of a dilated right ventricle, valvar dysplasia, or surgical or pacemaker lead disruption, however the presence of significant TR may impact the decision to perform pulmonary valve replacement via a percutaneous or surgical approach and may affect the ability for the RV to remodel following pulmonary valve replacement.  If significant TR is present and the tricuspid valve is felt to require surgical intervention at the time of valve replacement, these patients may be referred exclusively for surgical intervention without consideration for a less invasive approach.  However, if the TR can be improved just by improving the RVPA conduit dysfunction and subsequent RV remodeling, these patients may be able to have a less invasive percutaneous procedure rather than a surgical one.

 

To investigate the impact of moderate or severe TR on RV remodeling after PPVI, Tanase et al conducted a matched cohort study comparing patients who underwent percutaneous pulmonary valve implantation (PPVI) either with significant TR (moderate or severe) or without significant TR, assessing the outcomes of TR severity by echocardiogram, RV size by cardiac MRI, and exercise performance by objective measures from cardiopulmonary exercise testing.

 

Among the 173 patients at their center who underwent PPVI over an 8-year period, patients with moderate to severe TR by echocardiographic criteria were identified, and represented 13% of their PPVI population.  Ultimately, the study included 18 patients with RVOT dysfunction and significant TR and 18 matched control subjects with RVOT dysfunction but no TR.  Patients were matched to have the same pulmonary valve pathology (primary stenosis, insufficiency, mixed), similar indexed RV end-diastolic volume, and similar NYHA functional classification).  Data were obtained at baseline, 6 months post-PPVI, and at latest follow-up (median of 6.5 years post-PPVI, range 8 months to 9.3 years).  All patients with significant TR were identified by serial echocardiography (looking back at least 8 years prior to PPVI) and found to have gradually increasing TR over time with no patients having a sudden increase in TR after surgery to suggest a primary anatomic valve issue.

 

Median patient age was 22±8 years, majority had NYHA functional class II symptoms, median peak oxygen uptake (VO2 peak) was 28.5 mlO2/kg/min, and median RVEDVi was 100 ml/m2 (range 61-185 ml/m2).  After PPVI, the degree of TR improved in 15 of 18 patients (83%) and was unchanged in the remaining 3 patients at 6-month follow-up.  At latest follow-up, no patient had significant TR (15 trivial and 3 mild).  There was a significant decrease in RVEDVi from pre- to post-PPVI with no difference between TR groups.  Similarly, while VO2 increased following PPVI, there was no difference in this increase between TR groups.  Tanase et al therefore conclude that in most patients with RVOT conduit dysfunction and significant TR, PPVI leads to a reduction in TR.  PPVI also decreases RV volume and improves exercise tolerance without a difference between baseline TR severity groups

 

These findings help to provide insight into a clinically very meaningful question—whether the presence of significant TR in a patient with a dysfunctional RVOT conduit should play into the decision for type and timing of intervention.  While they provide convincing evidence to suggest that secondary TR will improve following PPVI, there some important limitations to consider. The mechanism of TR is an important variable in the ability to improve TR.  Tanase et al attempted to exclude patients with a primary tricuspid valve abnormality (by showing a slow progression of TR over time in the included study patients).  Generalizing these results, therefore, to patients with primary valve abnormalities (dysplastic or surgically manipulated valves) should be done with caution.  Secondly, the median RVEDVi of included patients is small (100 ml/m2) and may not be representative of most PPVI populations.  This may lessen the effect of the additional volume load of TR on RV remodeling following PPVI.  Despite these limitations and small patient size, this study is of interest and should be considered in decision making for patients with RVOT conduit dysfunction and concomitant TR.

 

 

 

 

 

 

Impacts of early cardiac catheterization for children with congenital heart disease supported by extracorporeal membrane oxygenation.

Kato A, Lo Rito M, Lee KJ, Haller C, Guerguerian AM, Sivarajan VB, Honjo O.

Catheter Cardiovasc Interv. 2017 Apr;89(5):898-905. doi: 10.1002/ccd.26632. Epub 2016 Jul 14.

PMID: 27416545

 

Take Home Points:

  • Early catheterization is associated with shorter duration of ECMO support and higher survival probability at 30 days after ECMO cannulation.
  • ECMO-related end-organ dysfunction is a significantly poor prognostic factor for successful decannulation.

 

Averin , KonstantinCommentary from Dr. Konstantin Averin (Edmonton), section editor of Congenital Heart Disease Interventions Journal Watch: Extracorporeal membrane oxygenation (ECMO) has been widely used in the pediatric population for cases of peri-operative hemodynamic instability, failure to wean from cardiopulmonary bypass, and cardiopulmonary resuscitation. Cardiac catheterization in patients on ECMO support poses significant challenges but can potentially be useful in improving clinical outcomes. This single center retrospective cohort study focused on patients with congenital heart disease (CHD) and hypothesized that timing of cardiac catheterization may be a predictor of clinical outcomes. The specific aims of the study were: (1) to analyze the institution’s experience with cardiac catheterization on pediatric patients with CHD supported by cardiac ECMO and (2) to determine factors associated with successful weaning from ECMO and short-term outcomes.

 

Three hundred and forty-two patients required ECMO support between 2000 and 2014. Of these, 47 underwent 49 cardiac catheterizations that met inclusion criteria with a median patient age of 65 days and median weight 4.2kg. ECMO was successfully weaned in 33 patients (70%) after a median support time of 4 days with 51% of patients surviving to hospital discharge. Cardiac catheterizations were performed a median of 1 day after ECMO initiation and during 27 of them an intervention was performed (balloon/stent angioplasty and balloon atrial septostomy). There was no procedure related mortality but 9 (18%) procedure-related serious complications with 8 occurring during interventional catheterization (pulmonary artery rupture, stent dislodgement, arrhythmia, pulmonary hemorrhage, and sheath tip migration). In a multivariate analysis, absence of renal or respiratory complications were prognostic of successful ECMO weaning. Kaplan-Meier analysis demonstrated that patient who underwent earlier catheterization (<48 hours after cannulation) had a higher survival probability at 30 days after ECMO cannulation compared with late catheterization.

 

The authors conclude that early cardiac catheterization in pediatric patients with CHD who require ECMO support may be associated with better short-term survival. Early cardiac catheterization should be considered in this cohort, especially if there are unresolved anatomic or physiologic questions. The absence of ECMO-related complications is a predictor for successful weaning off ECMO.

cath 1 april

 

 

Impact of imaging approach on radiation dose and associated cancer risk in children undergoing cardiac catheterization.

Hill KD, Wang C, Einstein AJ, Januzis N, Nguyen G, Li JS, Fleming GA, Yoshizumi TK.

Catheter Cardiovasc Interv. 2017 Apr;89(5):888-897. doi: 10.1002/ccd.26630. Epub 2016 Jun 17.

PMID: 27315598

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Take Home Points:

  • Congenital cardiac catheterizations utilize much higher doses of ionizing radiation than other imaging modalities, such as computed tomography, increasing the lifetime cancer risk for patients
  • Traditional measures of radiation exposure (air kerma or dose-area product) do not accurately measure the true tissue exposure to radiation
  • Altering the methods of image acquisition (collimation, magnification, minimizing source to image distance, removal of antiscatter grids, lower acquisition frame rates) lead to marked variation in effective radiation doses and are easily modifiable by the interventional cardiologist

 

Seckler, MikeCommentary from Dr. Michael Seckeler (Tucson), section editor of Congenital Heart Disease Interventions Journal Watch: The authors have undertaken a very important study for any practitioner who utilizes ionizing radiation for imaging pediatric patients. Using two patient phantoms representing a newborn and a 5-year-old child, they systematically compared the relative effects of different alterable parameters of fluoroscopic imaging used in standard congenital catheterization laboratories on effective radiation doses in the phantoms. In addition, they were able to estimate lifetime cancer risks based on the effective radiation doses. This is the first study to look at this in pediatric patients.

 

The modifiable factors included collimation, magnification, minimizing source to image distance, removal of antiscatter grids and lower acquisition frame rates. These were tested in various combinations and effective radiation doses measured. Optimizing the imaging for minimal radiation exposure (lower magnification, maximal collimation, lowest source to image distance, removal of antiscatter grids and lower acquisition frame rates) all led to significant reductions in the effective radiation doses and lower predicted lifetime cancer risks (Figure 1).

 

The authors do report several limitations to their conclusions. First, optimizing the radiation exposure does not always lead to the best image quality, which has the potential to compromise patient safety during a procedure. However, by highlighting how each of several different factors can improve radiation exposure, this data will allow interventional cardiologists to make as many modifications as possible to find the optimal balance between safety and image quality. Second, the radiation exposures were derived from phantoms and mathematical simulations; however, the intention was not to provide exact doses, but the relative changes in exposure with changes in imaging modality.

This is a very important paper for our field and provides tools to help interventional cardiologists minimize the radiation exposure for our patients.

cath 2 april

CHD Interventions April 2017

 

  1. Real-time three dimensional CT and MRI to guide interventions for congenital heart disease and acquired pulmonary vein stenosis.

Suntharos P, Setser RM, Bradley-Skelton S, Prieto LR.

Int J Cardiovasc Imaging. 2017 Apr 28. doi: 10.1007/s10554-017-1151-x. [Epub ahead of print]

PMID: 28455631

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  1. Clinical Trial Principles and Endpoint Definitions for Paravalvular Leaks in Surgical Prosthesis: An Expert Statement.

Ruiz CE, Hahn RT, Berrebi A, Borer JS, Cutlip DE, Fontana G, Gerosa G, Ibrahim R, Jelnin V, Jilaihawi H, Jolicoeur EM, Kliger C, Kronzon I, Leipsic J, Maisano F, Millan X, Nataf P, O’Gara PT, Pibarot P, Ramee SR, Rihal CS, Rodes-Cabau J, Sorajja P, Suri R, Swain JA, Turi ZG, Tuzcu EM, Weissman NJ, Zamorano JL, Serruys PW, Leon MB; Paravalvular Leak Academic Research Consortium..

J Am Coll Cardiol. 2017 Apr 25;69(16):2067-2087. doi: 10.1016/j.jacc.2017.02.038. Review.

PMID: 28427582

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  1. In vivo intracardiac vector velocity imaging using phased array transducers for pediatric cardiology.

Fadnes S, Wigen M, Nyrnes SA, Lovstakken L.

IEEE Trans Ultrason Ferroelectr Freq Control. 2017 Apr 24. doi: 10.1109/TUFFC.2017.2689799. [Epub ahead of print]

PMID: 28436859

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  1. Prediction of adverse events after catheter-based procedures in adolescents and adults with congenital heart disease in the IMPACT registry.

Stefanescu Schmidt AC, Armstrong A, Kennedy KF, Nykanen D, Aboulhosn J, Bhatt AB.

Eur Heart J. 2017 Apr 18. doi: 10.1093/eurheartj/ehx200. [Epub ahead of print]

PMID: 28430913

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  1. Clinical Trial Principles and Endpoint Definitions for Paravalvular Leaks in Surgical Prosthesis: An Expert Statement.

Ruiz CE, Hahn RT, Berrebi A, Borer JS, Cutlip DE, Fontana G, Gerosa G, Ibrahim R, Jelnin V, Jilaihawi H, Jolicoeur EM, Kliger C, Kronzon I, Leipsic J, Maisano F, Millan X, Nataf P, O’Gara PT, Pibarot P, Ramee SR, Rihal CS, Rodes-Cabau J, Sorajja P, Suri R, Swain JA, Turi ZG, Tuzcu EM, Weissman NJ, Zamorano JL, Serruys PW, Leon MB; of the Paravalvular Leak Academic Research Consortium..

Eur Heart J. 2017 Apr 18. doi: 10.1093/eurheartj/ehx211. [Epub ahead of print]

PMID: 28430909

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  1. Cell Therapy Trials in Congenital Heart Disease.

Oh H.

Circ Res. 2017 Apr 14;120(8):1353-1366. doi: 10.1161/CIRCRESAHA.117.309697. Review.

PMID: 28408455

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  1. A systematic review of 3-D printing in cardiovascular and cerebrovascular diseases.

Sun Z, Lee SY.

Anatol J Cardiol. 2017 Apr 10. doi: 10.14744/AnatolJCardiol.2017.7464. [Epub ahead of print]

PMID: 28430115 Free Article

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  1. Avoidable costs of stenting for aortic coarctation in the United Kingdom: an economic model.

Salcher M, Mcguire A, Muthurangu V, Kelm M, Kuehne T, Naci H; CARDIOPROOF..

BMC Health Serv Res. 2017 Apr 10;17(1):258. doi: 10.1186/s12913-017-2215-2.

PMID: 28395657 Free PMC Article

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  1. Coincidental Significant Tricuspid Regurgitation at the Time of Right Ventricle-to-Pulmonary Artery Conduit Intervention: Should We Address it, Ignore it, or Take a More Nuanced Approach?

Hebson CL, Ephrem G, Rodriguez FH 3rd.

JACC Cardiovasc Interv. 2017 Apr 10;10(7):709-711. doi: 10.1016/j.jcin.2017.02.032. No abstract available.

PMID: 28385409

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  1. Coronary Sinus Defect Following Transcatheter Closure of ASD Using Amplatzer Septal Occluder: Potential Erosion by the Device.

Mohammad Nijres B, Al-Kubaisi M, Bokowski J, Abdulla RI, Awad S.

Pediatr Cardiol. 2017 Apr 10. doi: 10.1007/s00246-017-1613-x. [Epub ahead of print]

PMID: 28396933

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  1. Impacts of early cardiac catheterization for children with congenital heart disease supported by extracorporeal membrane oxygenation.

Kato A, Lo Rito M, Lee KJ, Haller C, Guerguerian AM, Sivarajan VB, Honjo O.

Catheter Cardiovasc Interv. 2017 Apr;89(5):898-905. doi: 10.1002/ccd.26632. Epub 2016 Jul 14.

PMID: 27416545

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  1. Patent foramen ovale with right atrial septal pouch.

Kijima Y, Bokhoor P, Tobis JM.

Catheter Cardiovasc Interv. 2017 Apr;89(5):E169-E171. doi: 10.1002/ccd.26357. Epub 2015 Dec 29.

PMID: 26711371

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  1. In-hospital cost comparison between percutaneous pulmonary valve implantation and surgery.

Andresen B, Mishra V, Lewandowska M, Andersen JG, Andersen MH, Lindberg H, Døhlen G, Fosse E.

Eur J Cardiothorac Surg. 2017 Apr 1;51(4):747-753. doi: 10.1093/ejcts/ezw378.

PMID: 28007875 Free PMC Article

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  1. Evolution of hybrid interventions for congenital heart disease.

Agrawal H, Alkashkari W, Kenny D.

Expert Rev Cardiovasc Ther. 2017 Apr;15(4):257-266. doi: 10.1080/14779072.2017.1307733. Epub 2017 Mar 23. Review.

PMID: 28293976

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  1. Minimally invasive endoscopic surgery versus catheter-based device occlusion for atrial septal defects in adults: reconsideration of the standard of care.

Schneeberger Y, Schaefer A, Conradi L, Brickwedel J, Reichenspurner H, Kozlik-Feldmann R, Detter C.

Interact Cardiovasc Thorac Surg. 2017 Apr 1;24(4):603-608. doi: 10.1093/icvts/ivw366.

PMID: 28040751

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  1. The Medtronic Micro Vascular Plug™ for Vascular Embolization in Children With Congenital Heart Diseases.

Sathanandam S, Justino H, Waller BR 3rd, Gowda ST, Radtke W, Qureshi AM.

J Interv Cardiol. 2017 Apr;30(2):177-184. doi: 10.1111/joic.12369. Epub 2017 Feb 16.

PMID: 28211168

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  1. Pulmonary artery dissection following balloon valvuloplasty in a dog with pulmonic stenosis.

Grint KA, Kellihan HB.

J Vet Cardiol. 2017 Apr;19(2):182-189. doi: 10.1016/j.jvc.2016.09.005. Epub 2016 Nov 30.

PMID: 27913078

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  1. Bronchial artery embolization for the treatment of haemoptysis in pulmonary hypertension.

Rasciti E, Sverzellati N, Silva M, Casadei A, Attinà D, Palazzini M, Galiè N, Zompatori M.

Radiol Med. 2017 Apr;122(4):257-264. doi: 10.1007/s11547-016-0714-6. Epub 2016 Dec 26.

PMID: 28025781

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  1. Three-dimensional Printed Cardiac Models: Applications in the Field of Medical Education, Cardiovascular Surgery, and Structural Heart Interventions.

Valverde I.

Rev Esp Cardiol (Engl Ed). 2017 Apr;70(4):282-291. doi: 10.1016/j.rec.2017.01.012. Epub 2017 Feb 8. English, Spanish.

PMID: 28189544

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  1. Seven Coils in 1 Heart: Therapeutic Option for Multiple VSD.

Sabiniewicz R, Weryński P.

JACC Cardiovasc Interv. 2017 Apr 24;10(8):837-838. doi: 10.1016/j.jcin.2017.02.016. Epub 2017 Mar 29. No abstract available.

PMID: 28365261

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  1. Are the AMPLATZER Duct Occluder II Additional Sizes devices dedicated only for smaller children?

Fiszer R, Chojnicki M, Szkutnik M, Haponiuk I, Chodór B, Białkowski J.

EuroIntervention. 2017 Apr 20;12(17):2100-2103. doi: 10.4244/EIJ-D-15-00238.

PMID: 27867138 Free Article

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  1. Targeted endomyocardial biopsy guided by real-time cardiovascular magnetic resonance.

Unterberg-Buchwald C, Ritter CO, Reupke V, Wilke RN, Stadelmann C, Steinmetz M, Schuster A, Hasenfuß G, Lotz J, Uecker M.

J Cardiovasc Magn Reson. 2017 Apr 19;19(1):45. doi: 10.1186/s12968-017-0357-3.

PMID: 28424090 Free PMC Article

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  1. Transcatheter closure of a residual aorto-left ventricular tunnel: report of a case with a 6-year follow-up.

Djukic M, Djordjevic SA, Dähnert I.

Cardiol Young. 2017 Apr 17:1-4. doi: 10.1017/S1047951117000701. [Epub ahead of print]

PMID: 28414001

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  1. Radiation dose reduction in pediatric great vessel stent computed tomography using iterative reconstruction: A phantom study.

den Harder AM, Suchá D, van Doormaal PJ, Budde RPJ, de Jong PA, Schilham AMR, Breur JMPJ, Leiner T.

PLoS One. 2017 Apr 14;12(4):e0175714. doi: 10.1371/journal.pone.0175714. eCollection 2017.

PMID: 28410386 Free PMC Article

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  1. Clinical Impact of Stent Implantation for Coarctation of the Aorta with Associated Hypoplasia of the Transverse Aortic Arch.

Lu WH, Fan CS, Chaturvedi R, Lee KJ, Manlhiot C, Benson L.

Pediatr Cardiol. 2017 Apr 10. doi: 10.1007/s00246-017-1611-z. [Epub ahead of print]

PMID: 28396934

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  1. Percutaneous Mechanical Circulatory Support Using Impella® Devices for Decompensated Cardiogenic Shock: A Pediatric Heart Center Experience.

Parekh D, Jeewa A, Tume SC, Dreyer WJ, Pignatelli R, Horne D, Justino H, Qureshi AM.

ASAIO J. 2017 Apr 6. doi: 10.1097/MAT.0000000000000581. [Epub ahead of print]

PMID: 28394814

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  1. Intractable Back Pain After Coil Embolization of Giant Veno-Venous Collaterals in a Patient With Fontan Circulation.

Okada S, Kamada M, Nakagawa N, Ishiguchi Y, Moritoh Y, Shohi M, Okamoto K, Hasegawa S, Ohga S.

Int Heart J. 2017 Apr 6;58(2):298-301. doi: 10.1536/ihj.16-194. Epub 2017 Mar 21.

PMID: 28320993 Free Article

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  1. Impact of imaging approach on radiation dose and associated cancer risk in children undergoing cardiac catheterization.

Hill KD, Wang C, Einstein AJ, Januzis N, Nguyen G, Li JS, Fleming GA, Yoshizumi TK.

Catheter Cardiovasc Interv. 2017 Apr;89(5):888-897. doi: 10.1002/ccd.26630. Epub 2016 Jun 17.

PMID: 27315598

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  1. Early Cardiac Catheterization Leads to Shortened Pediatric Extracorporeal Membrane Oxygenation Run Duration.

Burke CR, Chan T, Rubio AE, McMullan DM.

J Interv Cardiol. 2017 Apr;30(2):170-176. doi: 10.1111/joic.12368. Epub 2017 Mar 8.

PMID: 28271557

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  1. Percutaneous Coronary Intervention With Bioresorbable Scaffolds in a Young Child.

Nazif TM, Kalra S, Ali ZA, Karmpaliotis D, Turner ME, Starc TJ, Cao Y, Marboe CC, Collins MB, Leon MB, Kirtane AJ.

JAMA Cardiol. 2017 Apr 1;2(4):430-434. doi: 10.1001/jamacardio.2016.4954.

PMID: 28030655

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  1. Multicenter Off-Label Use of Nit-Occlud Coil in Retrograde Closure of Small Patent Ductus Arteriosus.

Zanjani KS, Sobhy R, El-Kaffas R, El-Sisi A.

Pediatr Cardiol. 2017 Apr;38(4):828-832. doi: 10.1007/s00246-017-1589-6. Epub 2017 Feb 21.

PMID: 28224170

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  1. Preprocedural Risk Assessment Prior to PPVI with CMR and Cardiac CT.

Malone L, Fonseca B, Fagan T, Gralla J, Wilson N, DiMaria M, Truong U, Browne LP.

Pediatr Cardiol. 2017 Apr;38(4):746-753. doi: 10.1007/s00246-017-1574-0. Epub 2017 Feb 16.

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