Angira Patel - Academia.edu (original) (raw)

Papers by Angira Patel

Pediatric heart transplantation as a field has evolved over the last 50 years and is now a widely... more Pediatric heart transplantation as a field has evolved over the last 50 years and is now a widely accepted therapy for children with end-stage heart failure. The major ethical principles that guide equitable allocation of organs include utility, justice, and respect for autonomy. In this chapter, we discuss historical perspectives, current state of the field, and explore how ethical principles guide recipient selection and donor allocation. Additionally, other ethical themes that are discussed include: surgical innovation and informed consent; psychosocial issues in transplantation; quality of life and end of life care; genetic anomalies and developmental delay; and regulatory aspects of organ donation. Finally, we discuss recently published cases related to pediatric heart transplantation that highlight ethical conflicts, offer an ethical analysis, and suggest potential solutions.

Journal of Hospital Medicine, 2020

Circulation, 2020

Introduction: While valve-sparing repair is ideal for Tetralogy of Fallot (TOF), it’s durability ... more Introduction: While valve-sparing repair is ideal for Tetralogy of Fallot (TOF), it’s durability and which patients may benefit from a transannular patch remains unclear. To this end, we reviewed our experience with valve-sparing TOF repair. Methods: Retrospective review was performed of all primary TOF operations at our institution from 1/2008 to 12/2018. Standard demographic, operative, and echo data were collected, along with clinical outcomes. Transannular patch and valve-sparing repair groups were then compared. Results: Sixty-eight patients underwent TOF repair with a mean age of 4.1±2.2 months and weight of 5.7±1.8 kg. There was no difference in age or weight between patients who underwent a transannular patch repair and valve-sparing repair (Table). There was also no difference in the frequency of hypercyanotic spells or beta-blocker use. As expected the pre-operative pulmonary valve size and z-score were significantly different between groups. Bypass times were longer in th...

The Annals of Thoracic Surgery, 2020

BACKGROUND Given recent reports of percutaneous closure of sinus venosus atrial septal defects (S... more BACKGROUND Given recent reports of percutaneous closure of sinus venosus atrial septal defects (SVASD), we reviewed our experience with surgical repair. Due to the high incidence of arrhythmias with the two-patch technique, since 2001 we have used either one-patch repairs or the Warden procedure. METHODS A retrospective review was performed of pediatric patients undergoing SVASD at our institution from 1/1/1990 to 7/1/2018. Standard demographic data such as echocardiographic and cross-sectional imaging, along with operative details, and clinical echocardiographic outcomes were collected. RESULTS The cohort included 144 patients with a median age of 4.3 (8.5) years. Inferior SVASD was present in 24 patients (17%). A single autologous untreated pericardial patch was used for 114 patients (79%), a two-patch technique in 20 patients (14%, last performed in 2000), and a Warden procedure in 10 patients (7%). Median length-of-stay was 4 (2) days. On echocardiogram follow-up no patient had pulmonary vein stenosis. One patient who had the Warden procedure required a balloon dilation of the superior caval vein 2 years postoperatively and a stent 3 years later. Two-patch patients were substantially less likely to be in normal sinus rhythm (41%) on postoperative ECGs compared to the other two techniques (81% one-patch and 89% Warden, p=0.02). CONCLUSIONS The great majority of patients with SVASD can be successfully repaired with a single patch of autologous pericardium. We transitioned to using either a single pericardial patch or the Warden procedure resulting in a higher frequency of normal sinus rhythm on postoperative ECGs.

Journal of the American College of Cardiology, 2020

Current Pediatrics Reports, 2020

Pediatric Cardiology, 2018

Quantification guidelines for pediatric echocardiograms were published in 2010 establishing conse... more Quantification guidelines for pediatric echocardiograms were published in 2010 establishing consensus regarding standard measurements. However, a standard protocol for performance and analysis of pediatric echocardiograms was not defined. This study aims to identify practice variations among pediatric laboratories. A survey was sent to 85 North American pediatric laboratory directors. The survey included 29 questions assessing: demographics, methods of image acquisition, parameters routinely evaluated and reported, and methods used to assess chamber sizes, valves, and ventricular function. There were 47/85 (55%) responses; 83% were academic centers and 77% in an urban setting. Wide variations exist in acquisition method (clips versus sweeps) and color scale settings. The most commonly used methods for left ventricular (LV) function are M-mode shortening fraction, qualitative assessment, and Doppler Tissue Imaging. The most commonly used parameter for right ventricular function is qualitative. LV mass is routinely measured by the majority of centers with variations in methods of calculation. Conversely, while a minority measure left atrial volume, there is consensus regarding the preferred method. While multiple techniques exist for assessing valves, qualitative assessment is reported to be the preferred method. Despite quantification guidelines, there is a lack of uniformity in performance and analysis of pediatric echocardiograms. Further studies are needed to determine why variations exist and whether development of consensus guidelines might improve interpretation, consistency and quality of reports, patient care, and provide a standardized system allowing for comparative research among centers.

Echocardiography (Mount Kisco, N.Y.), Oct 1, 2018

Kawasaki disease (KD) is a vasculitis that affects medium-sized arteries and can lead to coronary... more Kawasaki disease (KD) is a vasculitis that affects medium-sized arteries and can lead to coronary artery aneurysms. KD should be considered in any infant presenting with prolonged fever. Delaying treatment beyond Day 10 of fever portends a high risk of coronary artery aneurysms. Echocardiography is often necessary to diagnose KD in young infants who frequently present without classic physical examination findings. We report on a case of KD with giant aneurysms in a 2-month-old infant. A combination of transthoracic echocardiography and CT angiography was utilized in the diagnosis as well as in the management of this infant.

The Journal of Heart and Lung Transplantation, 2015

Purpose: Severe renal dysfunction may be prohibitive to HT. However, the acceptable threshold is ... more Purpose: Severe renal dysfunction may be prohibitive to HT. However, the acceptable threshold is not well defined. CKD staging has prognostic implications for the adult population, however, its influence on pediatric recipients is unknown and may be an important consideration in patient selection. Methods: 3241 HT pts were identified from UNOS (1987-2011) & stratified by CKD stage using the MDRD formula as the UNOS registry does not capture variables for pediatric GFR calculators. Exclusions: age > 17y, re-HT, multiorgan transplant/listing, & patients lost to follow-up (FU). Survival was censored at 12y & multivariate Cox proportional hazard regression models were adjusted for age, sex, diabetes, race, ischemic time, dialysis, ischemic etiology, life support, wait time & HLA mismatch. Results: CKD stages 1 (n= 2854) & 2 (n= 188) were most prevalent compared to CKD 3 (n= 71), 4 (n= 15) & 5 (113). 1066 died during the study period (31%, 45%, 55%, 67% & 45% for CKD 1-5 respectively). Crude survival is shown in Figure. Unadjusted HR for all-cause mortality (compared to CKD 1) was: CKD 2 [1.38 (1.09-1.74)*], CKD 3 [1.89 (1.36-2.62)*]; CKD 4 [2.36 (1.23-4.56)*]; CKD 5 [1.99 (1.47-2.68)*]. Adjusted multivariate analysis showed: Stage 2 [1.16 (0.87-1.53)**]; Stage 3 [1.95 (1.33-2.86)*]; Stage 4 [3.93 (1.92-8.04)*]; Stage 5 [1.91 (1.35-2.71)*]. Conclusion: CKD stage is an independent predictor of mortality post HT in pediatric recipients. CKD stages 2-5 have significantly worse outcomes than CKD stage 1. MDRD may be useful for risk stratification in pediatric recipients. Further studies are warranted.*p < 0.001; **p= NS

The Annals of Thoracic Surgery, 2016

World journal for pediatric & congenital heart surgery, 2014

Although thrombus formation following myocardial infarction in adults is well known, intracardiac... more Although thrombus formation following myocardial infarction in adults is well known, intracardiac thrombosis in children is uncommon. We report the case of a large left ventricular thrombus in an infant with ischemic cardiomyopathy secondary to anomalous origin of the left coronary artery from the pulmonary artery. Given its mobility and protrusion across the aortic valve, the patient underwent urgent thrombus removal through a transaortic approach. There were no embolic or neurologic complications. This case highlights that thrombectomy may be performed safely and successfully in critically ill pediatric patients.

Pediatric Transplantation, 2010

CD can be a cause of diarrhea in pediatric heart transplant recipients. Fulminant colitis can dev... more CD can be a cause of diarrhea in pediatric heart transplant recipients. Fulminant colitis can develop in immunocompromised patients with CD and progress to toxic megacolon. We report a case of a 10-yr-old girl who developed CD diarrhea and subsequently fulminant colitis with clinical signs and symptoms of abdominal compartment syndrome. She was taken to the operating room emergently and found to have toxic megacolon. She underwent a sub-total abdominal colectomy and end-ileostomy, and made a rapid recovery. Rapid recognition of the severity of the disease in the post-operative transplant patient is imperative as abdominal compartment syndrome may develop requiring surgical management. In pediatric heart transplant patients with diarrhea, we recommend a heightened clinical awareness with aggressive treatment given the risk of progression to fulminant CD and toxic megacolon.

Pediatric Cardiology, 2008

Catheterization and Cardiovascular Interventions, 2006

Intracardiac echocardiography (ICE) is increasingly replacing transesophageal echocardiography (T... more Intracardiac echocardiography (ICE) is increasingly replacing transesophageal echocardiography (TEE) as the primary imaging technique to guide device closure of atrial septal defects (ASD). Owing to the length of the procedure, the use of TEE requires general anesthesia. Investigators have reported the usefulness of ICE in adults and children. However, little is known about the use of ICE in children whose weight is &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;15 kg. Therefore, this study examines the use of ICE guided secundum ASD closure in children &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;15 kg. Nineteen patients with a median age of 3.1 years (range 1.8-4.8), and median weight of 13.2 kg (range 8.0-14.4) underwent transcatheter occlusion (Amplatzer occluder) of a secundum ASD using ICE guidance. ICE was performed using an Acunav catheter. The ICE catheter (10 F shaft) was introduced into an 11 F sheath in a contralateral femoral vein. Diagnostic as well as periprocedure imaging was obtained. Sixteen patients had single, and three had multiple defects. Median defect size as measured by ICE was 16 mm (range 2.5-25). The median balloon stretched diameter (obtained in eight patients) was 18 mm (range 10-21); the median size of the defect for these eight patients was 15 mm (range of 8-20). Both techniques for measuring the defect correlated well with r = 0.94. The ASD occluder size ranged from 7 to 26 mm with a median of 18 mm. The procedure was successful in 16 patients who had a device implanted and no residual shunt. ASD occlusion was not attempted in two patients due to deficient rims and in one patient, the attempt failed due to left atrial disk prolapse through the ASD. Four patients experienced transient complications during the catheter procedure, including supra ventricular tachycardia, sinus bradycardia, and two with complete heart block (resolving with device removal); all had subsequent successful device placement. No complications were attributed to the use of ICE and specifically, no vascular injury was noted. Comparable to results with larger patients, ICE provides adequate imaging (preprocedure diagnosis and periprocedure guidance) during device occlusion of secundum ASDs with no significant complications. Thus, ICE can successfully be used in the closure of ASD in smaller patients (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;15 kg) and eliminate the need for endotracheal intubation.

The Annals of Thoracic Surgery, 2014