Hypoplastic left heart syndrome: consensus and controversies in 2007
ABSTRACT Variability in practice can be considered to foster clinical innovation, and allow for individualized therapeutic plans and independence of practitioners. The Institute of Medicine, however, has issued a report suggesting that variability in patterns of practice are "illogical", and should be avoided whenever possible. Perhaps nowhere in the field of congenital cardiac disease is variability in practice more apparent than in the management of hypoplastic left heart syndrome. This review assesses the variability in practice at a large number of centres that manage neonates with hypoplastic left heart syndrome, with an emphasis on practice before, during, and after the first stage of the Norwood sequence of operations. We also suggest changes in future strategies for research. In March, 2007, colleagues were contacted to respond to an internet-based survey using commercially available software (www.surveymonkey.com) to collect responses about the management practices for neonates with "straight-forward" hypoplastic left heart syndrome. No attempt was made to correlate management practices with any measures of outcome, as neither the practices themselves, nor the outcomes of interest, could be externally validated. Data is reported from 52 centers thought to manage over 1000 neonates with hypoplastic left heart syndrome on an annual basis. The first stage of the Norwood sequence was "recommended" to families by approximately five-sixths (86.5%) of the centres. No centre recommended primary cardiac transplantation, a "hybrid" approach, or non-intervention. In 7 centres (14.5%), it was reported that there was discussion of some or all of the above options, but ultimately the families decided upon the appropriate strategy. Most centres preferentially used antegrade cerebral perfusion (54%) in contrast to deep hypothermia with circulatory arrest (24%), albeit that 11% of centres used a combination of these techniques and in 9% the support strategy was based on surgeon preference. The source of flow of blood for the lungs following the first stage of reconstruction was also highly variable. Of the 51 centres that responded to the question, 13 (25.5%) were participating in a multi-centric randomized clinical trial comparing the modified Blalock-Taussig shunt to the conduit placed from the right ventricle to the pulmonary arteries, the so-called "Sano" modification. Of the remaining 38 centres, 18 "usually" placed a conduit from the right ventricle to the pulmonary artery, 14 "usually" placed a modified Blalock-Taussig shunt, and at six centres, the decision was made "based upon the preference of the surgeon and/or the cardiologist". Similarly, significant variability in practice was evident in preoperative management, other surgical strategies, postoperative medical support, monitoring and discharge planning. Other than the randomized clinical trial of shunt type, no other medical or surgical management strategy was currently under investigation in a multi-centric or randomized trial in the centres who responded to the survey. The survey emphasises the extreme variability in our current practices for treatment of children with hypoplastic left heart syndrome. While there are some areas for which there is consensus in management, the majority of our practices are variable between and within centres. These results emphasize that large multicentric trials and registries are necessary to improve care, and to answer important clinical questions, emphasizing the need to shift from analysis of experiences of single centres to multi-centric and multi-disciplinary collaboration.
- [Show abstract] [Hide abstract]
ABSTRACT: Die Therapie angeborener Herzfehler wird heute in zunehmendem Maße durch das Zusammenwirken katheterinterventioneller Eingriffe und Herzoperationen geprägt. Im vorliegenden Beitrag sollen die häufigsten Herzfehler kurz erläutert sowie die aktuellen Therapieoptionen dafür dargestellt werden. Besonderes Augenmerk wird dabei auf neue Therapieverfahren speziell der interventionellen Kinderkardiologie gelegt. Zusätzlich wird auf die Kombination interventioneller und operativer Verfahren, die so genannte „Hybridoperation“, eingegangen. Abschließend werden die jüngsten Therapieentwicklungen etwa im Bereich des perkutanen Aorten- und Pulmonalklappenersatzes beschrieben. Modern therapy of congenital heart defects consists of interventional and surgical procedures. The following report provides information about the most common congenital heart defects and the corresponding therapeutic options. Furthermore, the combined application of interventional and surgical procedures, so-called hybrid procedures, is described in detail as well as the latest developments in percutaneous valve replacement therapy. SchlüsselwörterInterventionell–Therapie–Hybrideingriff–Angeborene Herzfehler–Herzklappenersatz KeywordsInterventional–Therapy–Hybrid procedure–Congenital heart defects–Prosthetic heart valveDer Radiologe 01/2011; 51(1):10-14. DOI:10.1007/s00117-010-1994-9
Conference Paper: A question-answering system in Bahasa Malaysia[Show abstract] [Hide abstract]
ABSTRACT: The authors present a prototype question-answering system named SIGMA. This system is designed and implemented for interpreting and answering Bahasa Malaysia (Malaysian language) queries in a specific domain. The independent mechanisms of the system, the parser, the analyzer, and the response generator, are described in detail. During a trial run, the system demonstrated fast response times and was able to successfully answer 87.42% of the sentences from usersTENCON '89. Fourth IEEE Region 10 International Conference; 12/1989
Conference Paper: Internet tools for engineers-a Technical Society member perspective[Show abstract] [Hide abstract]
ABSTRACT: The characteristics of the Internet are described as they impact on the use of the Internet backbone and its extensions. The use of the basic Internet tools, e-mail, FTP, and telnet as well as related services including the World Wide Web, are described with relation to different levels of Internet connectivity. Specific applications for these tools within the Technical Society environment are introduced and explained. The requirements for connecting to the Internet are discussed. A list of Internet resources is provided.Pulp and Paper Industry Technical Conference, 1996., Conference Record of 1996 Annual; 07/1996