James E Lock

Harvard University, Cambridge, Massachusetts, United States

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Publications (370)3110.76 Total impact

  • No preview · Article · Aug 2015 · Academic medicine: journal of the Association of American Medical Colleges
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    ABSTRACT: Left atrial decompression using cardiac catheterization techniques has been described at centers with extracorporeal membrane oxygenation programs. Left atrial decompression can decrease cardiogenic edema, minimize ventricular distension, and allow myocardial recovery. We describe Boston Children's Hospital's experience with percutaneous left atrial decompression techniques, acute outcomes, and clinical impact of left atrial decompression in extracorporeal membrane oxygenation patients.
    No preview · Article · Oct 2014 · Pediatric Critical Care Medicine
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    ABSTRACT: Given the rising costs of health care in today's economic environment, the need for effective, value-driven care has never been more pressing. While the U.S. health care system strives continually to improve patient outcomes, it struggles with the inadequacies due to variation in care and the inefficiencies of unnecessary resource utilization. The tools traditionally used to study care, from retrospective studies to randomized controlled trials, may be inadequate to address the complicated, interdependent questions related to defining effective care. To overcome the deficiencies of these traditional tools and better optimize our health care system, a new kind of methodology is required-one that integrates the functionality of previously existing tools in a novel way.Standardized Clinical Assessment and Management Plans (SCAMPs) were designed to accomplish this goal. A SCAMP is a care pathway, designed by clinicians, to guide medical decision making around a particular disorder. SCAMPs are unique in that they invite knowledge-based diversions from their recommendations and are accompanied by data collection and continuous improvement processes. Through these mechanisms, SCAMPs successfully reduce practice variation, optimize resource use, and create an integrated medical learning system which overcomes many of the inadequacies of traditional research tools. As such, the SCAMP paradigm may represent an important breakthrough in the effort to define and implement effective health care.
    No preview · Article · Oct 2014 · Academic medicine: journal of the Association of American Medical Colleges
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    ABSTRACT: Objectives Peripheral pulmonary artery stenosis (PPS) is a heterogeneous disease associated with numerous clinical or syndromic disorders including Williams syndrome. Previous studies focusing on patients with Williams syndrome have documented spontaneous improvement in branch pulmonary artery (PA) stenosis and right ventricular pressure. The goal of this study is to identify angiographic evidence of spontaneous occlusion or loss of segmental PAs in patients with PPS.Methods Patients undergoing serial catheterization for PPS at Boston Children's Hospital between 1999 and 2014 were selected. Patients with structural heart disease such as tetralogy of Fallot, truncus arteriosus, transposition of the great arteries, or single ventricle were excluded. Hemodynamic data were extracted from catheterization reports, all available angiograms were reviewed, and evidence of segmental PA loss was documented based on defined angiographic criteria.ResultsForty-two patients were included in the study. Each patient underwent an average of 5 catheterizations over the 15-year study period. The average RV pressure at initial catheterization was near systemic levels. Evidence of segmental PA loss was present in 40% of patients. Almost 30% of patients with vessel loss demonstrated loss at their initial catheterization, and 65% of patients experienced loss of multiple vessels over time. Patients with vessel loss tended to be older at initial catheterization and have higher average RV pressures at their most recent catheterization than those without vessel loss.Conclusions Progressive segmental PA loss in patients with systemic arteriopathy and PPS has not been well described previously. In this cohort, segmental PA loss occurred in 40% of patients, resulting in persistently elevated PA pressures relative to patients who did not develop vessel loss. These findings highlight the importance of surveillance in this population of patients with systemic arteriopathy and severe PPS.
    No preview · Article · Sep 2014 · Congenital Heart Disease
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    ABSTRACT: Background: Fetal aortic valvuloplasty can be performed for severe midgestation aortic stenosis in an attempt to prevent progression to hypoplastic left heart syndrome (HLHS). A subset of patients has achieved a biventricular (BV) circulation after fetal aortic valvuloplasty. The postnatal outcomes and survival of the BV patients, in comparison with those managed as HLHS, have not been reported. Methods and results: We included 100 patients who underwent fetal aortic valvuloplasty for severe midgestation aortic stenosis with evolving HLHS from March 2000 to January 2013. Patients were categorized based on postnatal management as BV or HLHS. Clinical records were reviewed. Eighty-eight fetuses were live-born, and 38 had a BV circulation (31 from birth, 7 converted after initial univentricular palliation). Left-sided structures, namely aortic and mitral valve sizes and left ventricular volume, were significantly larger in the BV group at the time of birth (P<0.01). After a median follow-up of 5.4 years, freedom from cardiac death among all BV patients was 96±4% at 5 years and 84±12% at 10 years, which was better than HLHS patients (log-rank P=0.04). There was no cardiac mortality in patients with a BV circulation from birth. All but 1 of the BV patients required postnatal intervention; 42% underwent aortic or mitral valve replacement. On the most recent echocardiogram, the median left ventricular end-diastolic volume z score was +1.7 (range, -1.3 to +8.2), and 80% had normal ejection fraction. Conclusions: Short- and intermediate-term survival among patients who underwent fetal aortic valvuloplasty and achieved a BV circulation postnatally is encouraging. However, morbidity still exists, and ongoing assessment is warranted.
    Full-text · Article · Jul 2014 · Circulation
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    ABSTRACT: The objective of this study was to describe our single-institution experience with prenatal atrial septal stent placement for fetuses with hypoplastic left heart syndrome and an intact atrial septum (HLHS/IAS). Infants born with HLHS/IAS are at high risk for neonatal death, despite maximal postnatal therapy. Prenatal atrial septoplasty by static balloon dilation has been effective in decompressing the left atrium in utero, but several factors have limited the size of septal defects. We attempted to overcome the limitations of balloon septoplasty using transcatheter atrial septal stents. All records from our institution of fetuses with HLHS/IAS that underwent prenatal atrial septal stent placement were reviewed, including operative notes and echocardiograms. Nine fetuses between 24 and 31 weeks gestation with HLHS/IAS underwent attempted fetal atrial septal stent placement. A stent was deployed across the atrial septum in five fetuses, with four fetuses demonstrating flow across the stent at the time of intervention. In four cases, stent placement failed due to malposition or embolization, but in three of the four cases, atrial balloon septoplasty at the same in-utero procedure successfully and acutely decompressed the left atrium. There were no maternal complications. There was one fetal demise. The remaining 8 fetuses survived to delivery, but four died in the neonatal period (2 of which had been stented). Ultrasound-guided atrial septal stent placement is feasible in some fetuses with HLHS/IAS. Visualization of the septum and catheter tip is critical to technical success. Additional experience is necessary to determine the clinical impact of this intervention. © 2013 Wiley Periodicals, Inc.
    Full-text · Article · Jul 2014 · Catheterization and Cardiovascular Interventions
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    Anna Hallbergson · James E. Lock · Audrey C. Marshall
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    ABSTRACT: Objectives We have taken a novel approach using oral rapamycin – sirolimus – as a medical adjunct to percutaneous therapy in patients with in-stent stenosis and high risk of right ventricular failure. Background Peripheral pulmonary artery stenosis can result in right ventricular hypertension, dysfunction, and death. Percutaneous pulmonary artery angioplasty and stent placement acutely relieve obstructions, but patients frequently require re-interventions due to re-stenosis. In patients with tetralogy of Fallot or arteriopathy, the problem of in-stent stenosis contributes to the rapidly recurrent disease. Methods Rapamycin was administered to 10 patients (1.5–18 years) with peripheral pulmonary stenosis and in-stent stenosis and either right ventricular hypertension, pulmonary blood flow maldistribution, or segmental pulmonary hypertension. Treatment was initiated around the time of catheterisation and continued for 1–3 months. Potential side-effects were monitored by clinical review and blood tests. Results Target serum rapamycin level (6–10 ng/ml) was accomplished in all patients; eight of the nine patients who returned for clinically indicated catheterisations demonstrated reduction in in-stent stenosis, and eight of the 10 patients experienced no significant side-effects. Among all, one patient developed diarrhoea requiring drug discontinuation, and one patient experienced gastrointestinal bleeding while on therapy that was likely due to an indwelling feeding tube and this patient tolerated rapamycin well following tube removal. Conclusions Our initial clinical experience supports that patients with peripheral pulmonary artery stenosis can be safely treated with rapamycin. Systemic rapamycin may provide a novel medical approach to reduce in-stent stenosis.
    Preview · Article · Apr 2014 · Journal of the American College of Cardiology
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    Preview · Article · Apr 2014 · Journal of the American College of Cardiology
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    ABSTRACT: The short-term surgical results for mixed aortic valve disease (MAVD) and the long-term effects on the left ventricle (LV) are unknown. Retrospective review identified patients with at least both moderate aortic stenosis (AS) and aortic regurgitation (AR) before surgical intervention. A one-to-one comparison cohort of patients with MAVD not referred for surgical intervention was identified. The 45 patients in this study underwent surgical management for MAVD. A control group of 45 medically managed patients with MAVD also was identified. Both groups had elevated LV end-diastolic volume (EDV), elevated LV mass, a normal LV mass:volume ratio (MVR), and a normal ejection fraction. Both groups had diastolic dysfunction shown by early diastolic pulsed-Doppler mitral inflow/early diastolic tissue Doppler velocity z-score. The LV end-diastolic pressure (EDP) was correlated with age (R = 0.4; p = 0.03) and LV MVR (R = 0.4; p = 0.03) but not with AS, AR, or the score combining gradient and LV size. As shown by 6- to 12-month postoperative echocardiograms, aortic valve gradients and AR significantly improved (gradient 65 ± 17 to 28 ± 18 mmHg, p = 0.01; median regurgitation grade moderate to mild; p < 0.01), LV EDV normalized, and LV mass significantly improved (p < 0.01). Diastolic dysfunction was unchanged. Symptoms did not correlate with any measured parameter, but the preoperative symptoms resolved. In conclusion, despite diastolic dysfunction, systolic function is invariably preserved, and symptoms are not correlated with aortic valve function or LV EDP. Current surgical practice preserves LV mechanics and results in short-term improvement in valve function and symptoms.
    Full-text · Article · Feb 2014 · Pediatric Cardiology
  • Anna Hallbergson · James E Lock · Audrey C Marshall
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    ABSTRACT: Peripheral and central pulmonary artery (PA) stenoses can result in right ventricular hypertension, dysfunction, and death. Percutaneous PA angioplasty and stent placement relieve obstruction acutely, but patients frequently require reintervention. Within a heterogeneous patient population with PA stents referred for catheterization because of noninvasive signs of PA obstruction, we have observed that in-stent stenosis (ISS) occurs commonly in some groups, challenging previous reports that this phenomenon occurs infrequently. We set out to evaluate the incidence and demographics of patients with previous PA stent placement who develop ISS. Consecutive patients with previously placed stents presenting for catheterization and undergoing PA angiography were reviewed (104 patients, 124 cases). We defined ISS angiographically, as a 25% narrowing of the contrast-filled lumen relative to the fluoroscopically apparent stent diameter at any site along the length of the stent. For inclusion, we required that the stenotic segment be narrower or equal in size to the distal vessel. ISS was diagnosed in 24% of patients, with the highest incidence among patients with tetralogy of Fallot and multiple aortopulmonary collaterals, Williams syndrome, or Alagille syndrome. In conclusion, ISS after PA stent placement is a more frequent problem than previously reported, and patients with inherently abnormal PAs are disproportionately affected. Increased clinical surveillance after stent placement and investigation of innovative preventive strategies may be indicated.
    No preview · Article · Feb 2014 · The American journal of cardiology
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    ABSTRACT: The options for mitral valve replacement in children with irreparable mitral valve disease have been limited to fixed-diameter prostheses that do not accommodate for somatic growth. We have modified an externally stented bovine jugular vein graft (Melody valve) for implantation in this cohort. Because it is not a fixed-diameter prosthesis, we hypothesized that the valve can be expanded in the catheterization laboratory as the child grows. The medical records of patients who had undergone Melody valve implantation in the mitral or left atrioventricular valve position from 2010 to 2013 were reviewed. Eleven patients had undergone Melody valve implantation at a median age of 7 months (range, 2-28). The techniques of valve modification and implantation included stent shortening, adding a pericardial sewing cuff, intraoperative balloon expansion, and fixation of the distal stent to the inferior left ventricle wall. The valve was competent, with a low gradient acutely postoperatively in all patients. One patient died, and one required permanent pacemaker implantation. One patient developed valve dysfunction and required explantation. Two patients without a pericardial sewing cuff developed paravalvular leaks. One patient who had not undergone distal stent fixation developed left ventricular outflow tract obstruction. Three patients who had undergone subsequent catheter-based balloon expansion of the valve have continued to demonstrate acceptable valvular function. The Melody valve has demonstrated acceptable short-term function. Implantation techniques to prevent left ventricular outflow tract obstruction (suture fixation of the distal stent) and paravalvular leaks (the addition of a pericardial cuff) should be considered. The Melody valve can be percutaneously expanded as the child grows.
    No preview · Article · Dec 2013 · The Journal of thoracic and cardiovascular surgery
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    ABSTRACT: Background: Angioplasty and stent placement in right ventricle-to-pulmonary artery (RV-PA) conduits have been shown to prolong the functional lifespan of a conduit. Safety and efficacy of angioplasty of obstructed RV-PA homografts using ultra-noncompliant (UNC) or ultrahigh-pressure balloons are unknown. Methods and results: From 2004 to 2012, 70 patients underwent 76 procedures for angioplasty of RV-PA homografts with UNC Atlas balloons. The UNC group was compared with a partially contemporaneous control cohort of 81 patients who underwent 84 angioplasty procedures with conventional balloons. Acute hemodynamic changes after angioplasty of homografts with UNC balloons included significantly reduced RV:Ao pressure ratio (P=0.02) and right ventricular outflow tract gradients (P≤0.001). Balloon waist resolution was more frequently achieved with UNC balloons (P=0.04), and balloon rupture occurred less often (P<0.001). Conduit tears of any severity occurred in 22% of patients overall and were more common in the UNC group (P=0.001). Patients with any conduit tear had significantly greater reduction in their RV:Ao pressure ratio (P<0.001) and right ventricular outflow tract gradient (P=0.004) than those with no tear. There were 4 unconfined tears, all in the UNC group, with no acute decompensations or deaths and only 1 patient who required surgical management. Conclusions: RV-PA conduit tears are common in patients undergoing angioplasty, but clinically important tears, which only occurred during UNC angioplasty in this series, were uncommon. UNC balloons can be used to good effect with significant reduction in right ventricular outflow tract gradient and the RV:Ao ratio when compared with conventional balloons.
    Preview · Article · Nov 2013 · Circulation Cardiovascular Interventions
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    ABSTRACT: Standardization of care can reduce practice variation, optimize resource utilization, and improve clinical outcomes. We have created a standardized clinical assessment and management plan (SCAMP) for patients having balloon aortic valvuloplasty (BAV) for congenital aortic stenosis (AS). This study compares acute outcomes of BAV at our institution before and after introduction of this SCAMP. In this retrospective matched cohort study, each SCAMP patient was matched to four historical controls. Outcomes were categorized based on the combination of residual AS and aortic regurgitation (AR) as: (1) Optimal: gradient ≤35 mm Hg and trivial or no AR; (2) Adequate: gradient ≤35 mm Hg and mild AR; (3) Inadequate: gradient >35 mm Hg and/or moderate or severe AR. All 23 SCAMP patients achieved a residual AS gradient ≤35 mm Hg; the median residual AS gradient for the SCAMP group was lower (25 [10-35] mm Hg) than in matched controls (30 [0-65] mm Hg; P = 0.005). The two groups did not differ with regard to degree of AR grade after BAV. Compared with controls, SCAMP patients were more likely to have an optimal result and less likely to have an inadequate result (52% vs. 34% and 17% vs. 45%, respectively; P = 0.02) CONCLUSIONS: A SCAMP for BAV resulted in optimal acute results in half of the initial 23 patients enrolled, and outcomes in this group were better than those of matched historical controls. Whether these improved acute outcomes translate into better long-term outcomes for this patient population remains to be seen.
    No preview · Article · Oct 2013 · Congenital Heart Disease
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    ABSTRACT: Background: The Melody transcatheter pulmonary valve (TPV) was approved for implantation in obstructed right ventricular outflow tract conduits in 2010 after a multicenter trial demonstrating improvements in conduit obstruction, regurgitation, and right ventricular pressure. A recognized risk and contraindication to TPV implantation is the demonstration of coronary artery (CA) compression during balloon angioplasty or stent placement in the overlying conduit. This study is the first to characterize the risk of CA compression in this population. Methods and results: From 2007 to 2012, 404 patients underwent 407 catheterizations for potential TPV implantation (median age, 18 years) at 4 centers. Three hundred forty-three patients (85%) underwent valve implantation. Twenty-one patients (5%) had evidence of CA compression with simultaneous right ventricular outflow tract angioplasty and CA angiography. Sixty-eight patients (17%) had abnormal CA anatomy. Fifteen of 21 (71%) patients with CA compression had abnormal CA anatomy. Eight patients with tetralogy of Fallot and 7 patients with transposition of the great arteries demonstrated compression. Of the 34 patients with tetralogy of Fallot and abnormal CA, 7 (21%) demonstrated CA compression. Conclusions: CA compression following TPV implantation can be catastrophic. CA compression was observed in 5% of patients during test balloon angioplasty. No patients in this study developed clinically apparent CA compression after TPV implantation. CA compression was significantly associated with the presence of abnormal CA anatomy, especially in patients with tetralogy of Fallot or transposition of the great arteries. Preimplantation coronary angiography with simultaneous test angioplasty is an important step to evaluate for the presence of CA compression during TPV implantation.
    No preview · Article · Sep 2013 · Circulation Cardiovascular Interventions
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    ABSTRACT: Background: Angioplasty and stent implantation have become accepted therapies for isolated peripheral pulmonary stenosis, and have been shown to increase vessel diameter and reduce right ventricular (RV) pressure acutely in patients with pulmonary artery (PA) stenosis. The purpose of this study was to assess long-term outcomes after primary transcatheter therapy for peripheral pulmonary stenosis. Methods and results: We studied 69 patients who underwent primary transcatheter intervention for severe isolated peripheral pulmonary stenosis at ≤ 5 years of age. Genetic/syndromic diagnoses included Williams syndrome (n=23), non-Williams familial arteriopathy (n=12), and Alagille syndrome (n=3). At the initial PA intervention, median RV:aortic pressure ratio decreased from 1.00 to 0.88 (median decrease, 0.18; P<0.001). Patients with a higher preintervention RV:aortic pressure ratio had a greater reduction (P<0.001). During follow-up (median, 8.5 years), 10 patients died, 5 from complications of PA catheterization (all before 1998). Thirteen patients underwent surgical PA intervention, most within 1 year and along with repair of supravalvar aortic stenosis. Freedom from any PA reintervention was 38 ± 6% at 1 year and 22 ± 6% at 5 years. The median RV:aortic pressure ratio decreased from 1.0 at baseline to 0.53 at the most recent catheterization (P<0.001), and 82% of patients with available clinical follow-up were asymptomatic. Conclusions: Transcatheter therapy for infants with severe peripheral pulmonary stenosis has become safer, regardless of genetic condition. Coupled with reintervention and surgical relief in selected cases, RV:aortic pressure ratios decrease substantially and most patients are asymptomatic at late follow-up.
    Preview · Article · Aug 2013 · Circulation Cardiovascular Interventions
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    ABSTRACT: Background: Midaortic syndrome is often associated with refractory hypertension. The aim of our study was to better understand the short- and medium-term outcomes in this patient population utilizing a multidisciplinary management approach. Methods: We conducted a review of patients with midaortic syndrome treated at our institution over the past 30 years. Results: Fifty-three patients presented at a median age of 6.7 years (birth to 28.7 years). Thirty-five patients (66 %) underwent invasive management (percutaneous techniques: 21; surgical techniques: 5; both: 9). Percutaneous interventions were acutely successful in decreasing the gradient across the obstruction and degree of luminal stenosis. However, freedom from reintervention was 58 % at 1 year and 33 % at 5 years. Freedom from reintervention after a surgical procedure was longer: 83 % at 1 year and 72 % at 10 years. At the most recent follow-up, the majority of patients (69 %) were normotensive. The median duration between time of presentation and achievement of blood pressure control was 5.7 (0.4-21.1) years. The median number of anti-hypertensive medications was 1 (0-5). Conclusions: A multidisciplinary management strategy which couples comprehensive medical management with catheter-based and surgical interventions can lead to adequate blood pressure control and preservation of end-organ function in patients with midaortic syndrome.
    Preview · Article · Jun 2013 · Pediatric Nephrology
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    ABSTRACT: Background: Percutaneous pulmonary valve implantation using a stent-based bioprosthetic valve provides an alternative to surgery in select patients. Systemic infections in Melody valve-implanted patients with and without identified valve involvement have been reported, yet the incidence is unknown, and risk factors remain unidentified. Methods and results: Between 2007 and 2012, a total of 147 consecutive patients with congenital heart disease underwent Melody percutaneous pulmonary valve implantation at our institution. Demographic and clinical variables were collected at baseline and at follow-up and analyzed as predictors. The occurrence of bloodstream infection (BSI), defined as a bacterial infection treated with ≥4 weeks of antibiotics, served as our primary outcome. The mean age at implantation for the study population was 21.5±11 years, and tetralogy of Fallot was the cardiac condition in 59%. During a median follow-up of 19 months, 14 patients experienced BSI (9.5%; 95% confidence interval, 5.3%-15%). Of these, 4 (2.7%) patients had Melody valve endocarditis. Two patients died during the event, neither of whom had known valve involvement. The median procedure to infection time was 15 months (range, 1-56). In univariate analysis, male sex, previous endocarditis, in situ stents in the right ventricular outflow tract, and presence of outflow tract irregularities at the implant site were associated with BSI occurrence. Conclusions: In this cohort, 9.5% of patients who underwent Melody percutaneous pulmonary valve implantation experienced subsequent BSI, occurring 1 to 56 months after implant, and 2.7% of patients had prosthetic endocarditis. Our findings suggest that patient and nonvalve anatomic factors may be associated with BSI after percutaneous pulmonary valve implantation.
    Preview · Article · Jun 2013 · Circulation Cardiovascular Interventions
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    ABSTRACT: Variability in medical practice in the United States leads to higher costs without achieving better patient outcomes. Clinical practice guidelines, which are intended to reduce variation and improve care, have several drawbacks that limit the extent of buy-in by clinicians. In contrast, standardized clinical assessment and management plans (SCAMPs) offer a clinician-designed approach to promoting care standardization that accommodates patients' individual differences, respects providers' clinical acumen, and keeps pace with the rapid growth of medical knowledge. Since early 2009 more than 12,000 patients have been enrolled in forty-nine SCAMPs in nine states and Washington, D.C. In one example, a SCAMP was credited with increasing clinicians' rate of compliance with a recommended specialist referral for children from 19.6 percent to 75 percent. In another example, SCAMPs were associated with an 11-51 percent decrease in total medical expenses for six conditions when compared with a historical cohort. Innovative tools such as SCAMPs should be carefully examined by policy makers searching for methods to promote the delivery of high-quality, cost-effective care.
    Full-text · Article · May 2013 · Health Affairs
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    ABSTRACT: Risk factors for developing systemic-to-pulmonary artery collaterals (SPCs) in hypoplastic left heart syndrome (HLHS) are unknown. We performed a retrospective case-control study to identify risk factors for developing a profuse SPC burden in HLHS. Angiograms of 439 patients with HLHS (performed <2 years of age) were reviewed using a previously published angiographic grading scale to identify cases (profuse SPC burden, n = 20) and controls (no or minimal SPC burden, n = 35). In univariate analyses, profuse SPC burden was associated with mitral atresia and aortic atresia subtype (MA/AA) (65% vs 14%, p <0.0001), use of a Sano shunt (70% vs 37%, p = 0.03), longer log-transformed durations of intensive care unit stay (p = 0.02), hospital stay (p = 0.002), pleural drainage (p = 0.008) after stage 1 palliation, lower oxygen saturation at discharge after stage 1 palliation (82 ± 4 vs 85 ± 4%, p = 0.03), and a history of severe shunt obstruction (37% vs 11%, p = 0.04). In a multivariate logistic regression model, profuse SPC burden was associated with MA/AA subtype (odds ratio 6.6), Sano shunt type (odds ratio 8.6), and log-transformed duration of hospital stay after stage 1 (odds ratio 7.9, model p <0.0001, area under the curve 0.88). Nonassociated parameters included fetal aortic valve dilation, severe cyanotic episodes, number of days with open sternum or number of additional exploratory thoracotomies after stage 1 palliation, pulmonary vein stenosis, and restrictive atrial septal defect. In conclusion, in the present case-control study of patients with HLHS, the development of a profuse SPC burden was associated with MA/AA subtype, Sano shunt type, and longer duration of hospital stay after stage 1 palliation.
    Full-text · Article · Apr 2013 · The American journal of cardiology
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    Preview · Article · Mar 2013 · Journal of the American College of Cardiology

Publication Stats

16k Citations
3,110.76 Total Impact Points


  • 1987-2015
    • Harvard University
      Cambridge, Massachusetts, United States
  • 1985-2014
    • Boston Children's Hospital
      • • Department of Cardiac Surgery
      • • Children's Hospital Primary Care Center
      Boston, Massachusetts, United States
  • 1986-2012
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 1986-2010
    • Harvard Medical School
      • Department of Pediatrics
      Boston, Massachusetts, United States
  • 2006
    • University of Oulu
      • Department of Obstetrics and Gynaecology
      Uleoborg, Northern Ostrobothnia, Finland
  • 1994-1995
    • Children's Hospital of Richmond
      Ричмонд, Virginia, United States
  • 1993
    • Children's National Medical Center
      • Division of Cardiology
      Washington, Washington, D.C., United States
    • Valley Children's Hospital
      Мадера, California, United States
  • 1992
    • American College of Cardiology
      Washington, Washington, D.C., United States
  • 1991
    • Texas Children's Hospital
      Houston, Texas, United States
  • 1990
    • University of South Alabama
      Mobile, Alabama, United States
  • 1988
    • American Heart Association
      Dallas, Texas, United States
  • 1984-1988
    • Children's Hospital & Medical Center
      Omaha, Nebraska, United States
  • 1978-1988
    • University of Minnesota Duluth
      Duluth, Minnesota, United States
  • 1978-1980
    • SickKids
      • Division of Cardiology
      Toronto, Ontario, Canada