Le Bonheur Children’s has improved outcomes for children who undergo cardiovascular surgery, thanks in large part to key quality initiatives. Those quality measures include:• Implementation of cardiopulmonary bypass strategies to optimize renal function and neurological outcomes after surgery in infants 0-60 days old. Since January 2010, only 1 percent of these Le Bonheur patients have experienced acute renal failure and 1.5 percent have experienced neurological complications, compared to the incidence rate of 6-16 percent cited in published studies. • Reduction of central line-associated bloodstream infections in the Cardiovascular and Pediatric Intensive Care units. Together, the units maintained a rate of .44 infections per 1,000 line days in 2012 – against a national benchmark of 1.85. Rates year to date through July 2013 are zero.• Aggressive steps to minimize blood loss during surgery and reduce perioperative blood transfusions in the last 18 months. More than 20 percent of heart surgeries are now bloodless.• Improving the post-operative care for patients in the CVICU with continued training — using simulations as well as didactic methods — of expert nurses and physicians trained in pediatric heart surgical care.

Quality efforts improve outcomes

Fall 2013

Heart UpdatePediatric

Referrals: 866-870-5570www.lebonheur.org/heart

A pediatric partner of The University of Tennessee Health Science Center/College of Medicine and St. Jude Children’s Research Hospital

Memphis, Tennessee

continued on page 2

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Since 2010, Le Bonheur has decreased the number of children who undergo cardiovascular surgery and make

unplanned returns to the operating room within 48 hours of the initial surgery.

Percentage of Unplanned Returns to the OR within 48 hours

of Initial Surgery

YTD Thru June

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In 2012, Le Bonheur has decreased its discharge mortality rate for children who undergo cardiovascular

surgery since 2011. In 2012, it held a rate of 2.5 percent — up against a 2012 national benchmark

of 3.2 percent (Society of Thoracic Surgery). The numbers are not risk adjusted.

30-day post-operative mortality rates for children who undergo cardiovascular surgery at

Le Bonheur Children’s continue to decrease. The numbers are not risk adjusted.

Heart Institute minimizes blood loss, reduces transfusions in surgeries

More than 20 percent of Le Bonheur’s open heart

surgeries are now bloodless, meaning no blood or blood products are given during surgery. The Heart Institute has been taking aggressive steps to minimize blood loss during surgery and reduce perioperative blood transfusions over the last 18 months.

“Blood transfusions increase a patient’s risk of developing complications; it’s like getting a mini transplant,” said Chief Perfusionist Jerry Allen,

CCP. “Blood transfusions are a known cause of whole body inflammation and have been linked to increased morbidity and mortality after cardiac surgery.”

For children weighing more than 34 pounds, more than 60 percent will have bloodless surgery, even if they have undergone previous operations during their lifetime, says Allen.

Allen’s team has focused on decreasing the cardiopulmonary bypass (CPB) circuit surface area, using shorter tube lengths

continued from page 1

Meet the TeamThe Heart Institute at Le Bonheur Children’s Hospital uses the

combined expertise of an advanced pediatric cardiac team to provide specialized care for children with congenital heart disease. Pediatric cardiologists, pediatric cardiothoracic surgeons, cardiac intensivists, pediatric intensivists and anesthesiologists make up the Heart Institute. Advanced practice nurses, perfusionists, cardiac nurses, respiratory therapists and lab and imaging technicians are specially trained in pediatric cardiology care.

Leaders of the Heart Institute include:

Chris Knott-Craig, medical director of Cardiovascular Surgery and co-director of Heart InstituteChristopher Knott-Craig, MD graduated from the University of Cape Town in South Africa and com-pleted training in cardiac surgery at the Groote Schuur Hospital in South Africa. He is board certified by the South African Medical & Dental Council in cardio-thoracic surgery. Knott-Craig is also a professor for

The University of Tennessee Health Science Center (UTHSC) School of Medicine. His areas of special focus include neonatal/infant cardiac surgery, Ebstein’s anomaly, Ross Procedure, minimally invasive valve surgery, cardiopulmonary bypass, ambulatory thoracic surgery, hyperhidrosis and pediatric congenital heart disease.

B. Rush Waller, medical director of Cardiovascular Catherization Lab; interim co-director of Heart InstituteB. Rush Waller, MD, studied at UTHSC and completed fellowships in pediatric cardiology and pediatric interventional cardiology at the Medical University of South Carolina. Waller is an associate professor at UTHSC and is board certified by the American Board of Pediatrics with a cardiology sub-

specialty. His areas of focus include interventional pediatric cardiology, including therapeutic catheterizations for critically ill neonates, critically ill preoperative patients and complex cases of adults with congenital heart disease and transcatheter closure of intracardiac shunts.

Vijay Joshi, medical director of Non-Invasive Cardiology; interim chief of Division of Pediatric Cardiology, UTHSC Department of PediatricsVijay Joshi, MD, attended medical school at the University of Vermont and completed a fellowship in pediatric cardiology at Children’s Hospital of Philadelphia. Board certified by the American Board of Pediatrics with a cardiology subspecialty, Joshi

is also an associate professor at UTHSC. His patient care emphasis is on general cardiology with focus on fetal cardiology, advanced echocardiography, cardiac MRI and exercise testing..

Mayte Figueroa, medical director of CVICUMayte Figueroa, MD, is a graduate of Mount Sinai School of Medicine. She completed fellowships in pediatric cardiology at both Mount Sinai Hospital and the Medical University of South Carolina. Figueroa is board certified in pediatrics and has a cardiology sub-specialty. She is also an associate professor at UTHSC. Her areas of focus include pediatric cardiomyopathy, cardiovascular disease, non-invasive pediatric

cardiology, pediatric cardiac critical care, pulmonary hypertension, quality improvement and simulation-based education.

Glenn Wetzel, medical director of Pediatric Electrophysiology, director of Fellowship ProgramGlenn Wetzel, MD, PhD, completed fellowship training in pediatric cardiology at University of California at Los Angeles. He is board certified by the American Board of Pediatrics and has a cardiology subspecialty. Wetzel is also a professor at UTHSC. His special interests include pediatric electrophysiology

(arrhythmias), radiofrequency ablation and cryoablation, cardiomyopathy, pediatric pacemakers and internal defibrillator devices (ICDs).

Interventional cardiologists at Le Bonheur Children’s are testing options to “unzip” small diameter stents and give infants more options for implantation.

Their study of eight popular stents found that small diameter stents can be unzipped and that stainless steel stents, of the closed cell design, were best suited to unzip. These stents unzipped predictably at twice their nominal diameter with mini-mal shortening.

“We hope this study will encourage physicians to implant small stents in growing infant blood vessels and help in the selection of the appropriate stent type,” said Shyam Sathanandam, MD, a lead author on the study.

Potential benefits of this work is that, with an unzippable stent, it may be possible to non-surgically thread a balloon catheter into the vessel and gradually dilate the stent until it unzips. Then the narrow vessel can be re-stented with a larger stent that can be re-dilated to the eventual adult vessel diameter, without removing the old stent.

In the study, small diameter stents of different design types were dilated using angioplasty balloons in vitro. Investigators performed small increment dilations in balloon size to prevent napkin ringing and then dilated the stents until they unzipped, radially fractured, or both.

Investigators measured pressures used to dilate the stent and change in length, thickness and diameter. They also calculated the hoop stress, Tresca Yield Point force when stent fractured, ratio of change in length to change in diameter and Youden’s index to determine optimal cut points for unzipping. As a next step, the inves-tigators have begun testing in a neonatal animal model to determine the safety of this technique.

Researchers on the study include Shyam Sathanandam, MD; Lauren Haddad, MD; Ranjit Philip, MD; Saradha Subramanian, MD; Dena C. Wright, RN; and Benjamin R. Waller, MD at Le Bonheur Children’s and the University of Tennessee Health Science Center. Matthew Gillespie, MD, and Jonathan J Rome, MD, of The Childen’s Hospital of Philadelphia and the University of Pennsylvania School of Medicine also worked on the research.

Study: Small diameter stents can be “unzipped”

and decreasing tubing diameters. This allows for less contact between the patient’s blood and tubing, thus reducing the risk of inflammation and other complications.

In a retrospective study presented at Le Bonheur in August, perfusionists reported that before August 2012, 50 percent of patients received two or more units of packed red blood cells during or after open heart surgery. Subsequently, using the newer, more efficient circuits, only 11 percent of patients required two or more units of blood, and in 20 percent of cases, no blood was used at all.

“Our goal here at Le Bonheur is to achieve a 90 percent bloodless surgery for patients who weigh more than 34 pounds,” said Allen. “We will continue to find ways to reduce our circuit volume by embracing new technologies and adopting new techniques in our practice.”

A. Serial dialation with incremental balloon sizes leads to unzipping of the stent without shortening. B. Dialation with a large diameter balloon

leads to “napkin-ringing” of the stent.

A B

Standardized practice and new safety measures reduced hospital-wide central line-associated bloodstream infection (CLABSI) rates at Le Bonheur Children’s by 65 percent from

2011 to 2012. The improvements have helped protect children in the hospital’s Cardiovascular Intensive Care Unit (CVICU) and Pediatric Intensive Care Unit (PICU) from central line-associated bloodstream infections for more than one year. Other inpatient units saw additional reductions in infections.

Michelle Grandberry, clinical director of Le Bonheur’s CVICU, attributes the reduction in part to a more judicious use of central lines in the CVICU. Since 2010, the team has seen a 26 percent decrease in central line usage after incorporating discussions of line necessity into daily CVICU rounds.

“The reduction of CLABSIs in the CVICU is also rooted in the desire of our front-line care team to do the right thing for the patient,” Grandberry said. “Team members are more aware of CVL, including timing of tubing, cap and dressing changes. They take the time to inspect and discuss the integrity of the central line during bedside handoff. We also have a hard stop for any dressing that is not pristine.”

She added that the reduction in rates is a great example of how the entire team has been able to work together to affect change.

The hospital had an overall 1.03 CLABSI rate for 2012 (infections per 1,000 line days); Le Bonheur’s CVICU and PICU achieved a rate of 0.44 against a national benchmark of 1.85. CVICU intensivists, cardiovascular surgeons, anesthesiologists and nurse practitioners collaborate with Quality Improvement and care providers hospital wide to develop guidelines for managing central lines and reducing CLABSIs in the CVICU. These guidelines include:

• Anesthesia implemented insertion and maintenance CVL bundles in the OR

• Added alcohol site scrub in OR for “scrubbing the hub”• Standardized scrubbing the hub at each use with 70 percent alcohol• Stopped routine blood draws from central lines; blood draws now require a physician order• Root cause analysis and event timelines for all CLABSIs• Implemented daily discussion of line necessity in CVICU rounds• Antibiotic Stewardship Program• Implemented the use of Biopatch on all patients with central lines

Central lines are inspected every two hours by the bedside nurse, and a Vascular Access Team member inspects each line every 12 hours. An additional weekly inspection is done by a CVICU staff nurse to check for integrity of the dressing, as well as making sure all CVL tubing is labeled properly. Any deficiencies are discussed immediately with the patient’s care team.

Safety, standardization improve CVICU CLABSI ratesHospital reduces central line infection rate by 65 percent

2011: Ongoing Improvements 2012: Practice Change 2013

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1

Le Bonheur’s Heart Institute – the only center in the region offering pediatric electrophysiology expertise – has taken steps to reduce the use of fluoroscopy in its catheterization

lab. Fluoroscopy, an imaging technique that uses X-rays to obtain real-time moving images of the heart’s internal structures, is often used in conjunction with 3-D mapping to help pinpoint the origin of complex arrhythmias. Fluoroscopy is most often used to help guide catheters and to confirm the correct location for invasive procedures such as radiofrequency ablation and cryoablation.

Three-dimensional mapping, a non-invasive technology, is an increas-ingly popular alternative to radiation usage. Variations of 3-D imaging have been available for use in the cath lab setting for approximately 10 years, and Le Bonheur’s electrophysiology team has been using the technology for eight years. As the 3-D technology improves and team members become increasingly

comfortable using this modality for imaging, the lab is minimizing fluoroscopy time – aiming to complete procedures with relatively low or no radiation.

“While the amount of radiation exposure during these procedures has always been relatively low, our radiation usage

now is ‘ALARA’ – as low as reasonably achievable – and there has been a definitive reduction in fluoroscopy time,” said Glenn Wetzel, MD, PhD, a Le Bonheur pediatric cardiologist and medical director of Pediatric Electrophysiology. “In addition to minimizing each patient’s radiation exposure, we have avoided such alter-natives as transesophageal echocardiogram and larger catheters placed in the leg,

which are not appropriate for most children.” Reducing radiation exposure is a key focus for all Le Bonheur

subspecialties, particularly for children with chronic conditions who require multiple scans and procedures.

Electrophysiology lab reduces fluoroscopy use

Fluoroscopy is most often used to help guide catheters and to confirm the correct location for invasive procedures such as radiofrequency ablation and cryoablation.

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Memphis, TNPermit No. 3093

848 Adams Avenue

Memphis Tennessee 38103

Pediatric Heart Update is a publication of the Heart Institute at Le Bonheur Children’s HospitalChris Knott-Craig, MD, Co-Director, Heart InstituteB. Rush Waller, MD, Interim Co-Director, Heart InstituteVijay Joshi, MD, Interim Chief, Division of Cardiology, UTHSC

Mohammed Alsheikh-Ali, MDAlex Arevalo, MDJean Ballweg, MDJohn Edney, MDMayte Figueroa, MDJason Johnson, MDRyan Jones, MDDai Kimura, MDNagendra S. Kodali, MDTK Susheel Kumar, MDKelvin Lee, MDRonak Naik, MDRanjit Philip, MDShyam Sathanandam, MDAndreas Schwingshackl, MDSamir Shah, MDGlenn Wetzel, MD, PhDAdam Willis, MDThomas Yohannan, MD

/ lebonheurchildrens@LeBonheurChild /lebonheurchildrens

Le Bonheur Heart Institute Publications and Presentations: 2012-2013PublicationsKnott-Craig CJ, Goldberg SP, Ballweg JA, Boston US. Surgical decision making in neonatal Ebstein’s anomaly: an algorithmic approach based on 48 consecutive neonates. World J Pediatric and Congenital Heart Surgery 2012; 3:16-20.

Arevalo AR, Boston US, Goldberg SP, Becker JA, Knott-Craig CJ. Starnes’ procedure in a neonate with pulmonary atresia and intact ventricular septum. Ann Thorac Surg 2012;93:1703-4.

Philip RR, Boston US, Ballweg JA, Goldberg SP, Knott-Craig CJ. Iatrogenic pseudoaneurysm of the innominate artery in a neonate. J Card Surg 2012;27,2:242-244.

Yohannan TM, Goldberg SP, Stamps JK, Mathis CA, Anthony Jr. CL, Knott-Craig CJ. Cardiac myxolipoma in a child: diagnosis and surgical management. Cong Heart Dis 2012;7,6:113-116.

Goldberg SP, Boston US, Joshi VM, Figueroa MI, Ballweg JA, Chin TK, Mathis CA, Knott-Craig CJ. Left ventriculotomy is safe in infants and young children requiring cardiac surgery. World J Pediatric and Congenital Heart Surgery 2012:3,4:459-462.

Knott-Craig CJ, Goldberg SP. Strategies to prevent complications from resternotomy [letter]. Ann Thorac Surg 2012;94:334-335.Kelsey RM, Alpert BS, Dahmer MK, Krushkal J, Quasney MW: Alpha-Adrenergic Receptor Gene Polymorphisms and Cardiovascular Reactivityto Stress in Black Adolescents and Young Adults Psychophysiology: 2012; 49:401-412.

McCarville MB, Kaste SC, Hoffer FA, Khan RB, Walton RC, Alpert BS, Furman WL, Li C, Xiong X: Contrast Enhanced Sonography of Malignant Pediatric Abdominal and Pelvic Solid Tumors: Preliminary Safety and Feasibility Data. Pediatr Radiol 2012 Jul;42(7):824-33. Epub 2012 Jan 17.

Gallick D., Friedman BA, Alpert BS, Seller JD, Quinn DE, Osborn D, members of the AAMI Sphygmomanometer Committee: Response to Blood Pressure Monitoring: Blood Press Monit 2012, 17:45.

Alpert BS. Are kiosk blood pressure readings trustworthy? Blood Press Monit 2012, 17:257-258.

Lee KC, Danton GH, Kardon RE. Three-Dimensional Computed Tomographic Analysis of a Rare Left Coronary to Left Ventricle Fistula. Pediatr Cardiol. 2012.

Kaczorowski DJ, Sathanandam S, Ravishankar C, Gillespie MJ, Montenegro LM, Gruber PJ, Spray TL, Gaynor JW, Lin KY. Coronary ostioplasty for congenital atresia of the left main coronary artery ostium. Ann Thorac Surg. 2012 Oct;94(4):1307-10. doi: 10.1016/j.athoracsur.2012.04.072. Epub 2012 Jul 25.

Polimenakos AC, Sathanandam SK, Blair C, El Zein CF, Husayni TS, Ilbawi MN. Shunt reintervention and time-related events after Norwood operation: impact of shunt strategy. Ann Thorac Surg. 2012 Nov;94(5):1551-61. doi: 10.1016/j.athoracsur.2012.04.036. Epub 2012 Jul 6.

Jones RC, Rajasekaran S, Rayburn M, Tobias JD, Kelsey RM, Wetzel GT, Cabrera AG. Initial experience with conivaptan use in critically ill infants with cardiac disease. J Pediatr Pharmacol Ther. 2012 Jan;17(1):78-83. doi: 10.5863/1551-6776-17.1.78.

Krull KR, Sabin ND, Reddick WE, Zhu L, Armstrong GT, Green DM, Arevalo AR, Krasin MJ, Srivastava DK, Robison LL, Hudson MM. Neurocognitive function and CNS integrity in adult survivors of childhood hodgkin lymphoma. J Clin Oncol. 2012 Oct 10;30(29):3618-24. doi: 10.1200/JCO.2012.42.6841. Epub 2012 Sep 4.

Armstrong GT, Plana JC, Zhang N, Srivastava D, Green DM, Ness KK, Daniel Donovan F, Metzger ML, Arevalo A, Durand JB, Joshi V, Hudson MM, Robison LL, Flamm SD. Screening adult survivors of childhood cancer for cardiomyopathy: comparison of echocardiography and cardiac magnetic resonance imaging. J Clin Oncol. 2012 Aug 10;30(23):2876-84. doi: 10.1200/JCO.2011.40.3584. Epub 2012 Jul 16.

Lee K, Danton GH, Kardon RE. Three-dimensional computed tomographic analysis of a rare left coronary artery to left ventricle fistula. Pediatr Cardiol. 2013 Mar;34(3):774-6. doi: 10.1007/s00246-012-0552-9. Epub 2012 Oct 27.

Alpert BS. Validation of the Nihon Kohden PVM-2701/Impulse-1 automated device by both AAMI (2002) and ISO standards testing. Blood Press Monit. 2012;17:207-209.

Naik R, Kunselman A, Wackerle E, Johnson G, Cyran SE, Chowdhury D. Stress echocardiography: a useful tool for children with aortic stenosis. Pediatr Cardiol. 2013 Jun;34(5):1237-43. doi: 10.1007/s00246-013-0635-2. Epub 2013 Feb 2.

Schwingshackl, A, Teng, B., Ghosh, M, and Waters, CM. Regulation of Monocyte Chemotactic Protein-1 (MCP-1) Secretion by the Two-Pore-Domain Potassium (K2P) Channel Trek-1 in Human Alveolar Epithelial Cells. Am J Translational Research 2013, (in press).

Ghosh, M., Gorantla, V., Makena, P., Luellen, C., Sinclair, SE., Schwingshackl, A., Waters, CM. Insulin like growth factor-1 stimulates differentiation of AT II cells to AT I-like cells through activation of Wnt5a. Am J Physiol Lung Cell Mol Physiol. 2013 (in press).

Figueroa MI,Sepanski R,Goldberg SP,Shah S. Improving teamwork, confidence, and collaboration among members of a pediatric cardiovascular intensive care unit multidisciplinary team using simulation-based team training. Pediatr Cardiol. 2013 Mar;34(3):612-9. doi: 10.1007/s00246-012-0506-2. Epub 2012 Sep 13.

Chan SY, Figueroa M, Spentzas T,Powell A,Holloway R, Shah S. Prospective assessment of novice learners in a simulation-based extracorporeal membrane oxygenation (ECMO) education program. Pediatr Cardiol. 2013 Mar;34(3):543-52. doi: 0.1007/s00246-012-0490-6. Epub 2012 Aug 26.

Armstrong GT, Joshi VM, Zhu L, Srivastava D, Zhang N, Ness KK, Stokes DC, Krasin MT, Fowler JA, Robison LL, Hudson MM, Green DM. Increased tricuspid regurgitant jet velocity by Doppler echocardiography in adult survivors of childhood cancer: a report from the St Jude Lifetime Cohort Study. J Clin Oncol. 2013 Feb 20;31(6):774-81. doi: 10.1200/JCO.2012.43.0702. Epub 2013 Jan 7.

Presentations Outcome of Endovascular Stents Implanted in Infants with Congenital Heart. Oral Presentation. Sathanandam SK, Sharna Basu, Yoav Dori, Mathew Gillespie, Andy Glatz, Jonathan Rome. Society for Cardiovascular Angiography and Interventions, May 10th 2012, Las Vegas, NV.

Choice of Transcatheter Occlusion Device Based on Type of Patent Ductus Arteriosus. Poster presentation. Ranjit Philip, Benjamin Rush Waller III, Sathanandams SK. 45th Annual Southeastern Pediatric Cardiology Society Meeting, Sep 2012, Atlanta,GA.

Perioperative Vasopressin results in reduced length of hospital stay after the Fontan operation. Poster Presentation: Pooja Kashyap MD, Christopher Knott-Craig MD, Steven Goldberg MD, TK Susheel Kumar MD, Michele Harris RN, Mayte Figueroa MD.   6th World Congress in Pediatric Cardiology and Cardiac Surgery, February 17-22, 2013, Cape Town, South Africa.

Management of Neontal Ebstein’s Anomaly. Oral Presentation: Christopher J. Knott-Craig, MD, 6th World Congress in Pediatric Cardiology and Cardiac Surgery, February 17-22, 2013, Cape Town, South Africa.

Practical Aspects of implementing a new clinical pathway using simulation in a pediatric cardiovascular intensive care unit. Oral presentation- Figueroa MI,Sepanski R,Goldberg SP,Shah S. 5th International Pediatric Simulation Symposia and Workshops April 23-25, 2013, New York, NY.

Multidisciplinary simulation-based training in a pediatric cardiovascular intensive care unit. Poster presentation, Figueroa MI,Sepanski R,Goldberg SP,Shah S. 5th International Pediatric Simulation Symposia and Workshops April 23-25, 2013, New York, NY.

How do I develop a simulation based Extracorporeal membrane oxygenation (ECMO) training program at my institution. Oral presentation, Chan SY, Figueroa M, Spentzas T,Powell A,Holloway R, Shah S. 5th International Pediatric Simulation Symposia and Workshops April 23-25, 2013, New York, NY.

Simulation-based training for acute ECMO emergencies. Poster presentation, Chan SY, Figueroa M, Spentzas T,Powell A,Holloway R, Shah S. 5th International Pediatric Simulation Symposia and Workshops April 23-25, 2013, New York, NY.

Interdisciplinary education for codes utilizing high fidelity simulation in a pediatric CVICU, Poster presentation, Figueroa MI,Sepanski R,Goldberg SP,Shah S. 5th International Pediatric Simulation Symposia and Workshops April 23-25, 2013 New York, NY.

Evaluation of Bumetanide Continuous Infusion in Pediatric Patients. Oral Presentation. Katie McCallister, PharmD, Mario Briceno, MD, Rebecca Chhim, PharmD, Chasity Shelton, PharmD, Mayté  Figueroa, MD, Mark Rayburn, Pharm.D.. 2013 Pediatric Pharmacy Advocacy Group Conference, May 3, 2013 Indianapolis, IN.

Unzipping of Small Diameter Stents: An In Vitro Study. Abstract Oral Presentation. Shyam Sathanandam, Mathew Gillespie, Lauren Haddad, Ranjit Philip, Saradha Subramanian, Dena Wright, Benjamin Waller III, Jonathan Rome. Society for Cardiovascular Angiography and Interventions, May 9th 2013, Orlando, FL.

Rotational Angiography in Cardiac Catheterization: Review of new protocol. Abstract Oral Presentation. Haddad L, Waller B, Wright D, Shyam Sathanandam. Society for Cardiovascular Angiography and Interventions, May 8th 2013, Orlando, FL.

Management of Ebstein’s Anomaly. Oral Presentation. Christopher J. Knott-Craig, MD, 46th Annual Southeast Pediatric Cardiovascular Society Meeting, September 20-21, 2013, Biloxi MS.

Mitral valve repair in children, Oral Presentation. Christopher J. Knott-Craig, MD, 46th Annual Southeast Pediatric Cardiovascular Society Meeting, Biloxi MS, September 20-21, 2013.

Surgical repair of neonatal Ebstein’s anomaly with Pulmonary atresia. Video presentation. Christopher J. Knott-Craig, MD., Congenital Heart Surgeons’ Society Annual Meeting, October 20-21, 2013, Chicago IL.

Use of a Proactive Protocol-based Approach to Prevention and Management of Pulmonary Hypertensive Crises Shortens Mechanical Ventilation in Post-Operative Pediatric Cardiac Patients in a Tertiary Care Center. Poster Presentation, Yohannan TM, Menendez J, Lebaroff V., Curtis P, Figueroa M. American Academy of Pediatrics National Conference and Exhibition, October 27, 2013, Orlando FL.

Book ChaptersKnott-Craig CJ, Goldberg SP. Early presentation of Ebstein’s Anomaly. In: Cruz EM, Ivy DD, Jaggers J, (eds.) Pediatric Cardiology, Cardiac Surgery, and Intensive Care. Springer-Verlag, London 2013.

Sathanandam, S. Chapter 5: Evaluation and Therapy, Neonatal Critical Heart Disease. In: Shaddy R, Rychik J, and Gleason M (eds) Pediatric Practice: Cardiology, McGraw-Hill Publishers, New York, NY, 2013.

Sathanandam, S. Chapter 5: Cardiology. In: Shah B, Lucchesi M (eds) The Atlas of Pediatric Emergency Medicine, Second Edition. McGraw-Hill Publishers, New York, NY, 2013.