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Preliminary analysis of arrhythmias after the Fontan operation with extracardiac conduit compared with intra-atrial lateral tunnel symptoms depression vs alzheimer's 100 mg clozapine with amex. Bless the babies: one hundred fifteen late survivors of heart rransplantation during the first year of life. Intermediate term results of infant orthotopic cardiac transplantation from two centers. Cardiac transplantation for hypoplastic left heart syndrome: a modified technique. Transplantation as a primary treatment for hypoplastic left heart syndrome: intermediate-term results. The relationship of postoperative electrographic seizures to neurodevelopmental outcome at 1 year of age after neonatal and infant cardiac surgery. The quest to optimize neurodevelopmental outcomes in neonatal arch reconstruction: the perfusion techniques we use and why we believe in them. Neurodevelopmental outcome in preschool survivors of complex congenital heart disease: Implications for clinical practice. Developmental outcome of patients with hypoplastic left heart syndrome treated with heart transplantation. Implementation of a routine developmental follow-up program for children with congenital heart disease: early results. Neurologic and developmental morbidity in children with complex congenital heart disease [see comment]. Quality of lifein children with heart disease as perceived by children and parents. Quality of life and perceived health status in surviving adults with univentricular heart [see comment]. Physical activity levels in children and adolescents are reduced after the Fontan procedure, independent of exercise capacity, and are associated with lower perceived general health. Parent- versus child-reported functional health status after the Fontan procedure. Without treatment, about 30% of these infants die in the first week of life, 50% within the first month, 70% within 6 months, and 90% within the first year. Today, aggressive medical and surgical interventions in the neonate can provide >90% early and midterm survival and, for many patients, the prospect of a vigorous adolescent and adult life. Although earlier epidemiologic and genetic surveys suggested some other associations, for example, increased prevalence in infants of diabetic mothers or prenatal exposure to sexhormone therapy, these have not been confirmed. Normally and abnormally related great arteries customarily are designated in terms of their ventriculoarterial connections or alignments, that is, normal, transposed, double-outlet right or left ventricle, and anatomically corrected malposition. The modifying term complete by present classification and nomenclature is redundant; however, it has, by common usage, come to indicate that the transposed great arteries are physiologically uncorrected, that is, that systemic venous blood flows predominantly to the aorta and pulmonary venous blood to the pulmonary artery. It should be recognized, however, that both the physiologically uncorrected and physiologically corrected transposition hearts are morphologically complete transpositions; that is, both great arteries are completely (or predominantly) misplaced across the ventricular septum and arise from morphologically inappropriate ventricles and thus have discordant ventriculoarterial connections. Using the segmental (atria, ventricles, arteries) approach and the situs-independent dextro-In) and levo-u.

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Certain characteristic features of this condition seen at surgery have been described (93) mood disorder lamps buy clozapine with visa. During ventricular contraction, a visible "dimple" in the ordinarily smooth right ventricular surface strongly suggests the presence of an obstructing muscle bundle. Results were favorable in the short term, but concerns about long-term stent integrity will need to be evaluated in a larger group of patients before this approach can be considered a reasonable alternative to surgery in standard risk patients (94). Angiocardiography Right ventricular angiography is an excellent method to demonstrate the anatomy of this lesion and always should be performed when a significant intraventricular pressure gradient is detected. Cases presenting with intact ventricular septum may in fact have had spontaneous closure of a ventricular septal defect. The need for reoperation for recurrent obstruction is exceedingly uncommon if adequate resection of the anomalous bundles is achieved (89). Although rare, familial and nonfamilial cases of isolated peripheral pulmonary stenosis with no underlying syndrome also have been described (102). The remainder of the trunk of the main pulmonary artery arises from the common truncus arteriosus. The proximal segments of the right and left branch pulmonary arteries are derived from the sixth branchial arches on either side. The distal portion of the right sixth arch disappears completely, whereas the one on the left persists as the ductus arteriosus and later as the ligamentum arteriosus. It appears that multiple factors and many types of pathologic changes may produce narrowing of the branch pulmonary artery. When pulmonary artery stenosis is associated with significant intracardiac anomalies, the pathogenesis is likely to be developmental in origin. Certain teratogenic agents may interfere with the development of any of the components of the pulmonary arterial tree and may lead to atresia, hypoplasia, or stenosis. Relatively discrete branch stenosis can be seen in association with ductal closure, especially in cyanotic heart disease. A genetic deletion mapped to chromosome 7 resulting in abnormal elastin production was found in most patients with Williams syndrome (103). A deletion in chromosome 20 appears to be responsible for Alagille syndrome, but the resulting biochemical abnormality has not been identified (104). Several families with multiple relatives affected with Noonan syndrome have had the genetic mutation mapped to chromosome 12, and missense mutations in a specific gene on this chromosome are now known to account for more than 50% of cases (9,105). These genetic abnormalities can arise as sporadic mutations or can be familial with autosomal dominant inheritance. In approximately two-thirds of cases, the stenoses involved the main pulmonary trunk, its bifurcation, or its main branches. When the stenosis is localized, dilation of the vessel distal to the narrowing is usually present. With long segment constrictions, only minimal poststenotic dilation, if any, is seen, and no dilation at all is noted with the hypoplastic form.

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In other cases klinische depression test 50 mg clozapine mastercard, if the four-chamber view is inadequate, a full-volume data set can be acquired from the parasternal long-axis view; however, this images the leaflets in a lateral plane, which provides lower image resolution. At one end of the spectrum are asymptomatic infants or children who have a heart murmur detected on routine examination. Physical findings of M5 include a middiastolic murmur and a late diastolic murmur during atrial systole. These murmurs are low pitched and better appreciated with the bell rather than the diaphragm of the stethoscope. Unlike adults with rheumatic mitral stenosis 51 invariably is not increased in intensity. Mitral regurgitation results in a high-pitched pansystolic 51-coincident murmur that may make it difficult to appreciate the first and second heart sounds. Hepatomegaly and increased work of breathing are other physical findings that may be present in children with either M5 or regurgitation. Clicks may be followed by a high-pitched late systolic murmur of mitral regurgitation, heard best at the left lower sternal border or apex. For example, standing results in decreased left ventricular preload, resulting in prolapse that occurs earlier in systole with a click(s) that are close to 51. However, squatting increases preload and delays the prolapse, resulting in the click moving closer to 52. Oximetry may show mild desaturation in the setting of pulmonary edema or may indicate the presence of a left-to-right shunt. Hemodynamic assessment may show pulmonary hypertension, elevated pulmonary capillary wedge pressures, and left atrial hypertension with elevated "A" waves. One exception is with supra-annular prosthetic stenosis, where the "V" wave is larger than the "A" wave and the left ventricular end-diastolic pressure is often elevated (65). Angiography is associated with significant risk in patients with pulmonary hypertension and should be avoided unless balloon valvuloplasty is planned. Catheterization of a child with mitral regurgitation, even severe regurgitation, is not routinely indicated prior to surgical intervention but may be helpful in patients with pulmonary hypertension or mixed obstruction and regurgitation. Findings will include elevated left ventricular end diastolic pressure, elevated left atrial pressure with large "V" waves, and increased pulmonary capillary wedge pressure. However, chest radiography is reasonable prior to surgical or catheter interventions. Patients with mild or moderate stenosis typically do not warrant surgical or catheter intervention but may benefit from diuretic therapy. Endocarditis prophylaxis is not required unless the patient has a prosthetic valve (67) but good dental hygiene and regular dental follow-up are important. However, hemodynamic assessment may be valuable in children with mitral disease associated with other lesions.

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Quality control of the data collection process can involve multiple strategies of data monitoring depression definition synonyms purchase 25 mg clozapine with visa. Other monitoring procedures may be initiated before a block of data collection has begun, or carried out on working databases after data entry is complete. Such methods include duplicate analysis testing of the data collection process, or software checks for absent, incorrect, or falsified fields in a working database (Table 78. Data editing is the process of correcting errors or absences in data as detected by data monitoring. In order to avoid undermining the integrity of the data collection process, any data editing procedures must be standardized in the operations manual before the start of the study, and clearly documented when performed. Trial monitoring for safety and efficacy should be conducted by allowing preliminary or interim analyses of subject characteristics and safety and efficacy outcomes to be performed as data are being collected. Role in Standardization Allows all adjudication to be performed by a handful of individuals under highly standardized conditions. Type of Core lab Centralized laboratory Staffed by a small number of highly trained, fully blinded technicians. Receives collected data from separate trial centerts), is responsible for final adjudication and analysis of all outcomes. Responsible for verifying outcomes adjudicated and reported by individual trial centers, by ensuring each decision meets a specific set of protocolspecified criteria. Interim analyses should be specified in advance and lead to adjustment in initial sample size estimation. Having interim analyses performed and reviewed by an independent body also carries the benefit of maintaining any investigator blindness in a trial, since results analysis and review may require knowledge of treatment assignments. Bodies responsible for performing this analysis may be a preappointed, independent review committee, or simply the institutional review board of a singlecenter study. The decision to prematurely stop a study before completion is informed by data monitoring and interim analyses, which may identify exceptional information that may warrant stopping a study, such as clear excessive benefit or harm related to the study intervention (Table 78. Conversely, unnecessarily stopping a study can be very costly in terms of wasted resources, and may invalidate any useful results emerging before the study was stopped. Therefore, careful consideration and weighing of all possible risks and benefits must be done by qualified individuals before the decision to prematurely stop a study is made (Table 78. Ideally, thresholds of benefit or risk should be prespecified in advance of any interim analysis, preferably in the design or operationalization stages of trial development. Assessment of excessive risks or benefits that may warrant early stopping of the trial. Purpose Minimizes data entry errors, since data are fresh, still have clear context.

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Toyama (36) also reported that at least five cases have had no congenital cardiac malformations anxiety knee pain order cheap clozapine on-line. The abdominal form of ectopia cordis has been extremely rare in some reviews and appears to represent a diaphragmatic defect with continued migration of the heart into the abdominal cavity. In some cases, the patients were apparently healthy, had no other cardiac disease, and died as adults. Congenital deficienciesin the parietal pericardium: a review with 2 new cases including successful diagnosis by plain roentgenography. Extrathoracic heart (ectopiacordis):report of two cases and review of the literature. A criss-cross heart: Detailed anatomic description and discussion of morphogenesis. Diseases of the Endocardium, Myocardium, and Pericardium Hypertrophic Cardiomyopathy Barry J. Maron ardiomyopathies, or primary diseases of the myocardium, are not uncommon in infants and children. In the process, the disease acquired a confusing array of names, all presumably describing the same clinical entity. These primary abnormalities include increased overall mitral leaflet area (up to twice normal) owing largely to elongation of the leaflets (37) and, with considerable diversity, an increased size of both anterior and posterior leaflets. Of note, many of these myocytes do not show normal parallel alignment, but are arranged in a chaotic, disorganized fashion at oblique and perpendicular angles to each other. These vessels are characterized by thickening of the arterial wall with increased intimal or medial components and apparent narrowing of the lumen. F: Extensive scarring of ventricular septum that is transmural in distribution, characteristic of the end-stage phase. The relationship of obstruction specifically to sudden cardiac death is much weaker, encumbered by particularly low positive-predictive value (59). Magnitude of the outflow gradient is directly related to duration of mitral-septal contact with prolonged contact throughout midsystole indicative of marked obstruction. Estimation of the magnitude of outflow obstruction is made conventionally with continuous wave Doppler (60), which obviates the need for diagnostic cardiac catheterization. Alternatively, the outflow gradient and murmur can be augmented by circumstances that decrease arterial pressure or ventricular volume. Subpulmonic gradients represent a form of fixed obstruction due to exaggerated hypertrophy of right ventricular musculature that projects into the relatively small outflow tract. Conversely, diastolic dysfunction may be present in the absence of both symptoms and outflow obstruction and unrelated to the severity or distribution of ventricular hypertrophy (70). However, variable and age-related penetrance can occasionally result in delayed expression of the phenotype into the third decade of life, or potentially even later (77).

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Unrepaired young adult patients with a univentricular heart have a poor prognosis bipolar depression in the elderly clozapine 50 mg purchase mastercard. Patients who have undergone the Fontan procedure have now entered their fourth decade of life. In such patients, both the benefits and long-term sequelae associated with this palliation are often seen. The Fontan circulation is dependent upon some degree of systemic venous hypertension at the expense of pulmonary hypo perfusion. This hemodynamic derangement, along with multiple prior surgeries, extensive suture lines and intracardiac scarring, chronic cyanosis for a period of time, all contribute to potential complications in the adult patient that are listed below. Protein losing enteropathy Cyanotic Adult Multiple medical problems occur as a result of chronic cyanosis. The hematologic manifestations include thrombocytopenia, erythrocytosis, thromboemboli, iron deficiency, and bleeding complications. It seems paradoxical that cyanotic patients may suffer thromboembolic events but develop bleeding issues as well. Embolic events are from derangements in the coagulation pathway whereas bleeding diatheses are secondary to platelet dysfunction and thrombocytopenia (68). Thus, there is no agreement as to whether cyanotic patients should receive antiplatelet agents or systemic anticoagulation. The decision to initiate aspirin or coumadin therapy is individually based and many times driven by a documented thromboembolic event or discontinued after a clinically significant bleeding episode, for example, hemoptysis. Neurologic events include cerebral abscesses, hemorrhage, and thromboemboli from right-to-left intracardiac shunting. Therefore, air filters should always be placed on intravenous lines to prevent paradoxical air embolization. Symptoms may include headache, dizziness, fatigue, dyspnea, mental status changes, and paresthesias. Symptoms may be exacerbated at lower levels of hematocrit when iron deficiency is present. The loss of a significant amount of protein via the gastrointestinal tract leads to symptoms of peripheral edema, fatigue, pleural and pericardial effusions, ascites, and chronic diarrhea (165). The etiology is not known but thought to be secondary to elevated systemic venous pressures. Current treatment strategies have included a high protein diet, afterload reduction therapy, inotropic agents, heparin, albumin infusion, octreotide, prednisone, and creation of an atrial fenestration (165,167).

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It also is possible to estimate cardiac output by planimiterization of the pulsed Doppler aortic waveforms with respect to space and time anxiety burning sensation buy generic clozapine 100 mg line. Newer studies, especially in adult patients, and a few in the pediatric population, have used Doppler tissue analysis to evaluate wall contractile function and diastolic function. Because many of these patients cannot exercise physically, dobutamine stress echo studies may provide information regarding myocardial performance, especially in patients with borderline normal resting studies. These studies should be performed carefully, recognizing that atrial and ventricular tachyarrhythmias could occur during such stress testing. Specific abnormalities are discussed below with respect to findings in particular lesions. Holter Monitoring Twenty-four-hour electrocardiography gives insight into arrhythmias and disorders of conduction seen in patients who are often asymptomatic. It also allows measurement of heart rate variability in patients with disordered automaticity. More recently, the sphericity index, derived from comparing the long-axis left ventricular dimensions in diastole and systole with the chord from the mitral annulus to the apex in diastole and systole, has been used to quantify the myopathy. The amount of dystrophin expressed also can be determined by cardiac biopsy, but this is not a common or practical approach. It also is important to note that skeletal and cardiac muscle may exhibit paradoxical clinical responses. This probably accounts for the uncommon presence of symptoms and signs of clinical heart failure, which often do not manifest without a catastrophic event, such as a life-threatening pulmonary infection. The disease usually is not recognized until about 3 years of age because the affected boys run and jump poorly and cannot keep up with other children in normal play activity. Through such recognition, the Muscular Dystrophy Association is sponsoring a multicenter trial of early diagnosis and natural history in infants. They usually climb stairs one step at a time rather than alternating from step to step. Facial injuries can result from forward falls because the arms are too weak to brace against the fall. To get up from the floor, boys roll to a prone position, spread their legs for balance, first lift their buttocks and then "walk" their hands up their legs (Gower sign). Walking becomes increasingly difficult about age 10, and without intervention, most of these patients will become wheelchair dependent by about age 12. On physical examination, certain features are easily recognized and include the following: enlarged (hypertrophied, not "pseudohypertrophied") calf muscles that feel rubbery on palpation; weak neck muscles that cannot raise the head from supine, especially if the neck is first hyperextended; and weakness of proximal muscles of varying degrees, always worse than distal muscle. Late in the course, all muscle function is impaired except for minimal hand movement. Diaphragm and intercostal muscles are compromised, leading to poor cough, aspiration, and predisposition to pneumonia. Death has historically occurred sometime in the early twenties, although aggressive and early use of nocturnal ventilatory support may have created a significant impact in extending life expectancy (15).

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The predisposition to cardiovascular disease in patients with diabetes cannot be overemphasized anxiety scale clozapine 25 mg buy without a prescription. However, if the progression of atherosclerosis is similar to that seen in adults, it can be anticipated that these patients may develop clinically apparent cardiovascular disease as early as their late thirties and early forties. Unfortunately, because so little is known about the progression of cardiovascular disease in young patients with type 2 diabetes, it is difficult to make evidencebased decisions regarding the optimum clinical strategies to prevent cardiovascular disease. Both groups also had decreased diastolic function when compared to lean controls with the greatest decrease in those with type 2 diabetes. This suggests that more research is needed to understand additional factors that may be related to this process. It is also important to evaluate cardiovascular risk factors in patients with diabetes and treat those risk factors when present. Cigarette Smoking Cigarette smoking is a major independent risk factor for cardiovascular disease (40). In adolescents, atherosclerotic lesions have been seen with increased prevalence in cigarette smokers as young as 15 years of age. Chronic cigarette smoking may lead to injury of the endothelium, which serves as the nidus for the development of atherosclerosis. It has been estimated that of smoking-related deaths, cardiovascular disease is involved in over one-third, and this process often begins early in life (43). Most individuals who become regular smokers initiate cigarette smoking in childhood and adolescence. During the period from 1997 to 2003, overall smoking prevalence declined in high school students from >27% to 22 % (44). Unfortunately, the prevalence of smoking in girls has increased over time, so now the prevalence is closer to equal for boys and girls (45). In 2009, the prevalence of cigarette smoking in adolescent high school students was 17. The major influences on initiation of smoking appear to be parents and peers smoking regularly (47,48). It has been shown that parent discussion of smoking, rules against smoking, and punishment for use of cigarettes all have a beneficial effect on decreasing adolescent smoking (48,49). Of greatest importance is that adolescents are significantly less likely to initiate smoking when parents quit smoking (50). Studies have also demonstrated an inverse association between physical activity and smoking, suggesting that an increased level of physical activity may protect against smoking initiation (51). Efforts of prevention should begin in elementary and middle school students because many children are already experimenting with cigarette smoking by age 10 years (52). Exposure to environmental tobacco smoke may also be associated with increased risk of cardiovascular disease.

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The selection of a specific drug depends upon the primary goal of therapy bipolar depression and anger clozapine 25 mg order without a prescription, underlying or associated conditions, and whether or not the treatment is acute or chronic in nature. One approach to classifying vasodilators groups the drug classes according to their major mechanism of action (Table 79. Another method is to group drugs according to their predominant site of action (predominately venous, arteriolar, or balanced; Table 79. Depending on the therapeutic goals, one may select an agent that has predominant effects on venous capacitance, arteriolar resistance, or both. Thiazide Diuretics Thiazides inhibit sodium and chloride transport in the distal convoluted tubule of the nephron. Thiazide diuretics have been available for many years and there is broad experience with these agents. Hydrochlorothiazide and chlorothiazide are the primary drugs in this class used in children with cardiovascular disease. In this situation, they may be used in combination with a loop diuretic and/or a potassiumsparing agent. Adverse effects of thiazides include hypokalemia, hyperuricemia, and hypercalcemia. Nonrenal effects of thiazide diuretics that have been described in older patients and adults include carbohydrate intolerance and adverse effects on plasma cholesterol and triglycerides. The extent and implications of potential disturbances in cholesterol, lipoproteins, and triglycerides have not been determined in young children. Nitric Oxide-Modifying Drugs Relaxation of vascular smooth muscle by drugs in this class is mediated by nitric oxide. It exhibits several thiazide properties although it does not have a classic thiazide structure. Nitroglycerin Nitroglycerin relaxes smooth muscle in the cardiovascular, respiratory, and gastrointestinal systems. At the usual therapeutic concentrations, the predominant site of action is the venous vascular bed. Nitroglycerin has been largely replaced by other agents, but is sometimes administered after cardiac surgery. At low doses, there is little effect on systemic vascular resistance, systemic arterial pressure, or heart rate. However, higher doses can produce arteriolar dilation with hypotension and reflex tachycardia. Patients with decreased intravascular volume (low preload) may respond adversely to nitroglycerin because a further decline in filling pressure may significantly reduce cardiac output. Overdose causes hypotension and tachycardia, which respond quickly to a reduction in dose or cessation of the infusion. Inhibition of this phosphodiesterase results in pulmonary vasodilation and will also increase the efficacy of inhaled nitric oxide (48,68,69). Orally administered sildenafil has been shown to be effective in treating persistent pulmonary hypertension in newborns and is well tolerated.

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A main coronary branch coursing anterior to the pulmonary trunk was found in 96% of the specimens bipolar depression cycling discount 100 mg clozapine otc, and a large coronary branch crossing the right ventricular outflow tract was found in 61 % of the specimens. From their study of 62 patients, they concluded: (a) the proximal coronary pattern at the aortic sinus depends on the aortopulmonary rotation, (b) the peripheral coronary pattern depends on the atrial situs and apical position or the so-called apicocaval ipsilaterality, as well as the ventricular looping (38). A good understanding of the type and degree of variability of the coronary anatomy in patients with congenitally corrected transposition is crucial in the era of "double switch" surgical approaches to these patients. The degree of malalignment is related to the size of the left ventricular outflow tract and the pulmonary trunk. They showed that patients with congenitally corrected transposition and a normal conduction system were frequently characterized by the presence of pulmonary atresia or significant pulmonary stenosis. These anatomical variants resulted in a lesser degree of atrial and ventricular septal malalignment. It is thought that the normal conduction tissue is "in addition to" rather than "instead of" the abnormal anterior conduction system. In childhood, the timing and severity of symptoms, in general, reflects the associated lesions. The extensive works done by Anderson, Becker, Losekoot, and others, have elucidated the presence of normal and abnormal conduction tissue (17,39-42). The latter is located anterosuperiorly in the area lateral to the pulmonarymitral valve continuity, underneath the opening of the right atrial appendage. The bundle then courses onto the upper interventricular septum from which it descends and branches. Clearly, the position of the heart within the thorax does not influence the P-wave vector or axis. The electrical activation of the ventricles in the normal heart begins in the interventricular septum and is directed from left to right and in a slightly anterior direction as well. With ventricular inversion, both its surfaces and ventricular bundle branches are inverted, and thus the sequence of initial activation is oriented from right to left and usually in a more superior and anterior direction. This results in a reversal of the normal Q wave pattern in the precordial leads: Q waves are present in the right precordial leads but are absent in the left precordial leads. This pattern of reversal is appreciated less commonly when the heart is right-sided or when there are confounding associated lesions producing pressure or volume overload (15). The most important feature is the increasing prevalence of complete heart block in the corrected transposition population during follow-up, with an estimated rate of 2 % per year after diagnosis (45,46). Despite the development of surgical techniques to reduce the incidence of complete heart block at surgery, this problem continues to be significant and progressive (47).

Zapotek, 39 years: While focal constriction has been reported, the constrictive process usually involves the entire pericardium.

Umul, 45 years: H1Nl 6 Epstein-Barr virus Human herpesvirus Chest Radiography Chest radiography is routinely performed in the evaluation of patients with clinical suspicion of myocarditis.

Ashton, 28 years: Surveillance for transplant coronary artery disease in infant, child and adolescent heart transplant recipients: an intravascular ultrasound study.

Yasmin, 34 years: The 2006 American College of Cardiology/American Heart Association Task Force Report Guidelines for the Management of Patients with Valvular Heart Disease (8) recommends the guidelines for grading the severity of aortic stenosis according to the Doppler-derived gradients.

Malir, 58 years: Blockade of presynaptic az-adrenergic receptors may contribute to the tachycardia and arrhythmias that occur at high doses of phentolamine.

Arakos, 53 years: Some have speculated that the pulmonary valve, if subjected to low pressure for many years, may be susceptible to neoaortic regurgitation following anatomic correction.

Copper, 60 years: Intravenous sildenafil is a potent pulmonary vasodilator in children with congenital heart disease.

Pranck, 37 years: Rhabdomyomas often are classified as hamartomas, with an inability of cells to undergo mitotic division (80,85).

Rhobar, 32 years: However, most importantly, the "reassuring" peripheral oxygen saturation may be associated with paradoxically low oxygen delivery, particularly to the brain.

Darmok, 24 years: Poorly constructed aim statements speak of improving failed processes, but do not define how much improvement is expected and by when the improvement is expected.

Knut, 63 years: As long as intercirculatory mixing and systemic arterial oxygen saturation are satisfactory and the peak systolic pulmonary artery pressure is low, intracardiac surgery can be safely delayed with careful follow-up regarding the pulmonary artery.

Kelvin, 62 years: Most recently, there is increased interest and investigation into the use of non-heart-beating heart donors after cardiocirculatory death as an additional source of donors for both adults and children (85,86).