Choledochocele or type III choledochal cyst is a rare abnormality of obscure etiology that consis... more Choledochocele or type III choledochal cyst is a rare abnormality of obscure etiology that consists of cystic or diverticular dilatation of the terminal intramural portion of the common bile duct protruding into the duodenum. It should be considered in the differential diagnosis of otherwise unexplained biliary colic or recurrent pancreatitis--particularly after cholecystectomy. An intraluminal duodenal filling defect on barium study that opacifies during cholangiography or endoscopic retrograde cholangiopancreatography is diagnostic. We present one case of choledochocele in which the first use of the biliary scintigraphic (HIDA) scan for diagnosis is demonstrated. An additional 47 cases found in the literature are reviewed and a new anatomic classification of choledochoceles is proposed as a guide for treatment. Treatment options are partial excision of the cyst, sphincterotomy, or both.
World Journal for Pediatric and Congenital Heart Surgery
The European Congenital Heart Surgeons Association (ECHSA) Congenital Database (CD) is the second... more The European Congenital Heart Surgeons Association (ECHSA) Congenital Database (CD) is the second largest clinical pediatric and congenital cardiac surgical database in the world and the largest in Europe, where various smaller national or regional databases exist. Despite the dramatic increase in interventional cardiology procedures over recent years, only scattered national or regional databases of such procedures exist in Europe. Most importantly, no congenital cardiac database exists in the world that seamlessly combines both surgical and interventional cardiology data on an international level; therefore, the outcomes of surgical and interventional procedures performed on the same or similar patients cannot easily be tracked, assessed, and analyzed. In order to fill this important gap in our capability to gather and analyze information on our common patients, ECHSA and The Association for European Paediatric and Congenital Cardiology (AEPC) have embarked on a collaborative effo...
Purpose:Transposition of great arteries with intact ventricular septum and left ventricular outfl... more Purpose:Transposition of great arteries with intact ventricular septum and left ventricular outflow tract obstruction (TGA + IVS + LVOTO) is uncommon. We reviewed operations performed in patients with TGA + IVS + LVOTO in the European Congenital Heart Surgeons Association Congenital Database (ECHSA-CD).Methods:All 109 patients with a diagnosis of TGA + IVS + LVOTO in ECHSA-CD who underwent cardiac surgery during a 21-year period (01/2000-02/2021, inclusive) were included. Preoperative variables, operative data, and postoperative outcomes were collected.Results:These 109 patients underwent 176 operations, including 37 (21.0%) arterial switch operations (ASO), 26 (14.2%) modified Blalock-Taussig-Thomas shunts (MBTTS), 11 (6.2%) Rastelli operations, and 13 (7.3%) other palliative operations (8 superior cavopulmonary anastomosis[es], 4 Fontan, and 1 other palliative procedure). Of 37 patients undergoing ASO, 22 had a concomitant procedure.There were 68 (38.6%) reoperations, including 11...
Seminars in Thoracic and Cardiovascular Surgery, 2020
Aorto-ventricular tunnel (AoVT), a rare congenital anomaly, is a channel originating in the ascen... more Aorto-ventricular tunnel (AoVT), a rare congenital anomaly, is a channel originating in the ascending aorta just above the sinotubular junction and leading to the cavity of the left ventricle (AoLVT), or, rarely, the right (AoRVT). This study reviews our collective 30-year experience with the surgical treatment of AoVT. Data was submitted by 15 participating centers on 42 patients who underwent correction of AoVT between 1987 and 2018. Of these, 36 had AoLVT, and six AoRVT. The tunnel originated above the right coronary sinus in 28 (77.8%) patients. For AoLVT, most operations were performed early (median age 25 days, range: 1 day-25 years). In contrast, AoRVT was diagnosed and repaired later (median age 6years, range: 1 month-12 years). Surgically important coronary ostial displacement was common. Patch closure of the aortic orifice only was the commonest surgical repair for AoLVT (23 patients), while in AoRVT, both orifices or only the ventricular one was closed. Aortic valvar insufficiency (AI), severe or moderate, coexisted in 11 (30.5%) patients with AoLVT, and aortic valvuloplasty was performed in 8, mainly due to aortic valve stenosis. AI at discharge ranged from trivial to mild in almost all patients. Early mortality was 7.14%, with 3 patients with AoLVT succumbing to cardiac failure. There were two early reoperations and one late death. AoVT is a rare malformation. AoLVT usually necessitates surgery in early life. AoRVT is rarer, diagnosed and repaired later in life. Surgical repair by patch closure, with concomitant aortic valve repair as needed, is associated with good results.
Background and aim: Advances in paediatric cardiac surgical and medical care have led to vastly i... more Background and aim: Advances in paediatric cardiac surgical and medical care have led to vastly increased survival of patients with congenital heart disease (CHD). We would like to explore and analyse data from the European Congenital Heart Surgeons Association (ECHSA) database with the aim of evaluating the risk of surgery for treating adult patients with CHD. Methods: We included in our study data from 19589 surgical procedures. We excluded 1389 procedured including hemodynamic procedures, anesthesiologist procedures). Outcome included early and late mortality according to the main surgical procedure. Results: fx1 Conclusions: Surgical risk for adult patients with CHD is low, either considering early and late mortality. Mortality continue to be high for particular categories of patients.
World Journal for Pediatric and Congenital Heart Surgery
Background Congenital heart surgery databases are tools for internal programmatic evaluation, ben... more Background Congenital heart surgery databases are tools for internal programmatic evaluation, benchmarking institutional results to multi-institutional aggregate data, and research. Therefore, it is essential to ensure the completeness and accuracy of data. This study analyzes the results of ten years of on-site source data verification of the European Congenital Heart Surgeons Association Congenital Heart Surgery Database (ECHSA CHSD). Methods All data forms verified between 2009 and 2018 were analyzed. The data form consists of 12 data elements: dates of birth, admission, surgery, discharge, and death; weight; case category; cardiopulmonary bypass time; aortic cross-clamp time; validation rules; diagnoses; and procedures. Descriptive data calculation and rates of completeness and accuracy were determined. The trend of error rate of seven centers with ≥5 visits was analyzed. Results Sixty-nine on-site verification visits took place at 17 centers. A total of 26,245 cases were verifi...
Revista portuguesa de cirurgia cardio-torácica e vascular : órgão oficial da Sociedade Portuguesa de Cirurgia Cardio-Torácica e Vascular
Atrial septal defect (ASD), one of the commonest congenital heart lesions, is asymptomatic in mos... more Atrial septal defect (ASD), one of the commonest congenital heart lesions, is asymptomatic in most cases and therefore remains undiagnosed until adulthood in a significant number of patients. Despite the employment of transcatheter modalities in its treatment, surgery remains a reliable alternative. This study summarizes our experience in surgical correction of ASD in adult patients. Over a 9-year period (September 1997-August 2006), 171 patients, 73 males and 98 females, aged 18-72 (median 35) years, underwent surgical repair of ASDs'. Of these, 141 patients (82%) had ASD of the secundum type and 30 (18%) sinus venosus ASD with partial anomalous pulmonary venous connection (PAPVC). Fifteen patients with different principal diagnoses and concomitant ASD's were excluded, as were those with ostium primum ASDs'. Eighty six patients (50%) were asymptomatic and 11 (6.4%) had established arrhythmias. Two patients had recurrent lesions, 5 had a previously failed attempted trans...
World Journal for Pediatric and Congenital Heart Surgery, 2020
The coronavirus disease 2019 (COVID-19) pandemic currently gripping the globe is impacting the en... more The coronavirus disease 2019 (COVID-19) pandemic currently gripping the globe is impacting the entire health care system with rapidly escalating morbidities and mortality. Although the infectious risk to the pediatric population appears low, the effects on children with congenital heart disease (CHD) remain poorly understood. The closure of congenital heart surgery programs worldwide to address the growing number of infected individuals could have an unintended impact on future health for COVID-19-negative patients with CHD. Pediatric and congenital heart surgeons, given their small numbers and close relationships, are uniquely positioned to collectively assess the impact of the pandemic on surgical practice and care of children with CHD. We present the results of an international survey sent to pediatric and congenital heart surgeons characterizing the early impact of COVID-19 on the care of patients with CHD.
World Journal for Pediatric and Congenital Heart Surgery, 2021
First, I would like to thank Jose Fragata for his most kind, generous, and favorably exaggerated ... more First, I would like to thank Jose Fragata for his most kind, generous, and favorably exaggerated introduction. Jose’s leadership of the European Congenital Heart Surgeons Association (ECHSA) as its immediate past president has been landmark. Succeeding him as President of ECHSA has been the greatest honor of my professional life. It remains a daunting task to even attempt to match his contributions. In thinking about my presentation today, I have tried to look toward what the future might bring, not just for ECHSA, but for all of our subspecialty of congenital heart surgery. Stimulated by my experience of close collaboration with the Artificial Intelligence (AI) team of Professor Dimitris Bertsimas at the Massachusetts Institute of Technology (MIT), during this past year, working on machine learning (ML) tools to analyze congenital heart surgery data, I decided to attempt to provide you with an overview of the fantastic opportunities and challenges provided to our field by the explosive progress of AI. Of course, I wish to emphasize at the outset that I am by no means an expert on AI. Therefore, this presentation provides only the perspective of a clinical pediatric cardiac surgeon wondering if and how the impressive achievements and capabilities of AI could be harnessed for the benefit of our patients. Some 50 years ago, Dr William Schwartz, in his paper entitled “Medicine and the Computer—the Promise and Problems of Change,” published in the New England Journal of Medicine (NEJM), predicted that “Computing science will probably exert its major effects by augmenting and, in some cases, largely replacing the intellectual functions of the physician.” As I will be showing you, this prediction has been proven largely correct, and, in fact, the potential impact of artificial intelligence in medicine is in fact even bolder: Increasingly, the dream of AI in Medicine is becoming to create a virtual global team of medical experts, holding the ever expanding accumulated wisdom of the decisions of millions of physicians, regarding the medical issues and resulting outcomes of billions of patients. This virtual global team should then be able to support the decisions of every physician with real-time personalized advice on the diagnosis, management, and actual therapeutic interventions for each patient. Before we consider whether such far-reaching promise is conceivably possible, some definitions are in order. Artificial Intelligence is defined by Encyclopedia Britannica in an arguably circular manner as “the ability of a digital computer or a computer-controlled robot to perform tasks commonly associated with intelligent beings.” This term was coined by John McCarthy in preparation for a Dartmouth Summer Research Project in 1965: “The study is to proceed on the basis that every aspect of learning or any other feature of intelligence can in principle be so precisely described that a machine can be made to simulate it.” Thus, pivotal in all the achievements of AI has been the development of what has become known as ML, which is the application of AI systems to learn and improve from experience without being explicitly programed. Humans can learn to make general complex associations from small amounts of data (eg, a toddler learning to recognize a cat), whereas machines require many more examples and do not have common sense, they do not have what the philosopher of science Michael Polanyi described as tacit or implicit understanding. Yet, although machines do need massive amounts of data to learn from, their ability to absorb such data is practically limitless, and they do not tire. Of course, there are too many types of machine learning for a nonexpert to understand, but it is useful to distinguish between two general categories: In the “supervised models,” data sets are prepared and labeled by humans according to predefined categories, and the relevant algorithms are designed to orient only to categories and concepts prespecified by us. In “unsupervised” models, pattern recognition is allowed to develop freely within the data, with algorithms learning without human-provided guidance. Interestingly, the subject of whether machines can be made to think has been considered in the 17th century by the French philosopher René Descartes, in his 1637 book Discourse on the Method of Rightly Conducting One’s Reason and Seeking the Truth in the Sciences, famous for the quote “Cogito, ergo sum” (I think, therefore I am). Descartes seems to have predicted that machines could be constructed to perform some tasks as well as or better than humans, but, he felt they could neither be made to
World Journal for Pediatric and Congenital Heart Surgery, 2021
The optimal training of the highly specialized congenital heart surgeon is a long and complex pro... more The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve th...
Choledochocele or type III choledochal cyst is a rare abnormality of obscure etiology that consis... more Choledochocele or type III choledochal cyst is a rare abnormality of obscure etiology that consists of cystic or diverticular dilatation of the terminal intramural portion of the common bile duct protruding into the duodenum. It should be considered in the differential diagnosis of otherwise unexplained biliary colic or recurrent pancreatitis--particularly after cholecystectomy. An intraluminal duodenal filling defect on barium study that opacifies during cholangiography or endoscopic retrograde cholangiopancreatography is diagnostic. We present one case of choledochocele in which the first use of the biliary scintigraphic (HIDA) scan for diagnosis is demonstrated. An additional 47 cases found in the literature are reviewed and a new anatomic classification of choledochoceles is proposed as a guide for treatment. Treatment options are partial excision of the cyst, sphincterotomy, or both.
World Journal for Pediatric and Congenital Heart Surgery
The European Congenital Heart Surgeons Association (ECHSA) Congenital Database (CD) is the second... more The European Congenital Heart Surgeons Association (ECHSA) Congenital Database (CD) is the second largest clinical pediatric and congenital cardiac surgical database in the world and the largest in Europe, where various smaller national or regional databases exist. Despite the dramatic increase in interventional cardiology procedures over recent years, only scattered national or regional databases of such procedures exist in Europe. Most importantly, no congenital cardiac database exists in the world that seamlessly combines both surgical and interventional cardiology data on an international level; therefore, the outcomes of surgical and interventional procedures performed on the same or similar patients cannot easily be tracked, assessed, and analyzed. In order to fill this important gap in our capability to gather and analyze information on our common patients, ECHSA and The Association for European Paediatric and Congenital Cardiology (AEPC) have embarked on a collaborative effo...
Purpose:Transposition of great arteries with intact ventricular septum and left ventricular outfl... more Purpose:Transposition of great arteries with intact ventricular septum and left ventricular outflow tract obstruction (TGA + IVS + LVOTO) is uncommon. We reviewed operations performed in patients with TGA + IVS + LVOTO in the European Congenital Heart Surgeons Association Congenital Database (ECHSA-CD).Methods:All 109 patients with a diagnosis of TGA + IVS + LVOTO in ECHSA-CD who underwent cardiac surgery during a 21-year period (01/2000-02/2021, inclusive) were included. Preoperative variables, operative data, and postoperative outcomes were collected.Results:These 109 patients underwent 176 operations, including 37 (21.0%) arterial switch operations (ASO), 26 (14.2%) modified Blalock-Taussig-Thomas shunts (MBTTS), 11 (6.2%) Rastelli operations, and 13 (7.3%) other palliative operations (8 superior cavopulmonary anastomosis[es], 4 Fontan, and 1 other palliative procedure). Of 37 patients undergoing ASO, 22 had a concomitant procedure.There were 68 (38.6%) reoperations, including 11...
Seminars in Thoracic and Cardiovascular Surgery, 2020
Aorto-ventricular tunnel (AoVT), a rare congenital anomaly, is a channel originating in the ascen... more Aorto-ventricular tunnel (AoVT), a rare congenital anomaly, is a channel originating in the ascending aorta just above the sinotubular junction and leading to the cavity of the left ventricle (AoLVT), or, rarely, the right (AoRVT). This study reviews our collective 30-year experience with the surgical treatment of AoVT. Data was submitted by 15 participating centers on 42 patients who underwent correction of AoVT between 1987 and 2018. Of these, 36 had AoLVT, and six AoRVT. The tunnel originated above the right coronary sinus in 28 (77.8%) patients. For AoLVT, most operations were performed early (median age 25 days, range: 1 day-25 years). In contrast, AoRVT was diagnosed and repaired later (median age 6years, range: 1 month-12 years). Surgically important coronary ostial displacement was common. Patch closure of the aortic orifice only was the commonest surgical repair for AoLVT (23 patients), while in AoRVT, both orifices or only the ventricular one was closed. Aortic valvar insufficiency (AI), severe or moderate, coexisted in 11 (30.5%) patients with AoLVT, and aortic valvuloplasty was performed in 8, mainly due to aortic valve stenosis. AI at discharge ranged from trivial to mild in almost all patients. Early mortality was 7.14%, with 3 patients with AoLVT succumbing to cardiac failure. There were two early reoperations and one late death. AoVT is a rare malformation. AoLVT usually necessitates surgery in early life. AoRVT is rarer, diagnosed and repaired later in life. Surgical repair by patch closure, with concomitant aortic valve repair as needed, is associated with good results.
Background and aim: Advances in paediatric cardiac surgical and medical care have led to vastly i... more Background and aim: Advances in paediatric cardiac surgical and medical care have led to vastly increased survival of patients with congenital heart disease (CHD). We would like to explore and analyse data from the European Congenital Heart Surgeons Association (ECHSA) database with the aim of evaluating the risk of surgery for treating adult patients with CHD. Methods: We included in our study data from 19589 surgical procedures. We excluded 1389 procedured including hemodynamic procedures, anesthesiologist procedures). Outcome included early and late mortality according to the main surgical procedure. Results: fx1 Conclusions: Surgical risk for adult patients with CHD is low, either considering early and late mortality. Mortality continue to be high for particular categories of patients.
World Journal for Pediatric and Congenital Heart Surgery
Background Congenital heart surgery databases are tools for internal programmatic evaluation, ben... more Background Congenital heart surgery databases are tools for internal programmatic evaluation, benchmarking institutional results to multi-institutional aggregate data, and research. Therefore, it is essential to ensure the completeness and accuracy of data. This study analyzes the results of ten years of on-site source data verification of the European Congenital Heart Surgeons Association Congenital Heart Surgery Database (ECHSA CHSD). Methods All data forms verified between 2009 and 2018 were analyzed. The data form consists of 12 data elements: dates of birth, admission, surgery, discharge, and death; weight; case category; cardiopulmonary bypass time; aortic cross-clamp time; validation rules; diagnoses; and procedures. Descriptive data calculation and rates of completeness and accuracy were determined. The trend of error rate of seven centers with ≥5 visits was analyzed. Results Sixty-nine on-site verification visits took place at 17 centers. A total of 26,245 cases were verifi...
Revista portuguesa de cirurgia cardio-torácica e vascular : órgão oficial da Sociedade Portuguesa de Cirurgia Cardio-Torácica e Vascular
Atrial septal defect (ASD), one of the commonest congenital heart lesions, is asymptomatic in mos... more Atrial septal defect (ASD), one of the commonest congenital heart lesions, is asymptomatic in most cases and therefore remains undiagnosed until adulthood in a significant number of patients. Despite the employment of transcatheter modalities in its treatment, surgery remains a reliable alternative. This study summarizes our experience in surgical correction of ASD in adult patients. Over a 9-year period (September 1997-August 2006), 171 patients, 73 males and 98 females, aged 18-72 (median 35) years, underwent surgical repair of ASDs'. Of these, 141 patients (82%) had ASD of the secundum type and 30 (18%) sinus venosus ASD with partial anomalous pulmonary venous connection (PAPVC). Fifteen patients with different principal diagnoses and concomitant ASD's were excluded, as were those with ostium primum ASDs'. Eighty six patients (50%) were asymptomatic and 11 (6.4%) had established arrhythmias. Two patients had recurrent lesions, 5 had a previously failed attempted trans...
World Journal for Pediatric and Congenital Heart Surgery, 2020
The coronavirus disease 2019 (COVID-19) pandemic currently gripping the globe is impacting the en... more The coronavirus disease 2019 (COVID-19) pandemic currently gripping the globe is impacting the entire health care system with rapidly escalating morbidities and mortality. Although the infectious risk to the pediatric population appears low, the effects on children with congenital heart disease (CHD) remain poorly understood. The closure of congenital heart surgery programs worldwide to address the growing number of infected individuals could have an unintended impact on future health for COVID-19-negative patients with CHD. Pediatric and congenital heart surgeons, given their small numbers and close relationships, are uniquely positioned to collectively assess the impact of the pandemic on surgical practice and care of children with CHD. We present the results of an international survey sent to pediatric and congenital heart surgeons characterizing the early impact of COVID-19 on the care of patients with CHD.
World Journal for Pediatric and Congenital Heart Surgery, 2021
First, I would like to thank Jose Fragata for his most kind, generous, and favorably exaggerated ... more First, I would like to thank Jose Fragata for his most kind, generous, and favorably exaggerated introduction. Jose’s leadership of the European Congenital Heart Surgeons Association (ECHSA) as its immediate past president has been landmark. Succeeding him as President of ECHSA has been the greatest honor of my professional life. It remains a daunting task to even attempt to match his contributions. In thinking about my presentation today, I have tried to look toward what the future might bring, not just for ECHSA, but for all of our subspecialty of congenital heart surgery. Stimulated by my experience of close collaboration with the Artificial Intelligence (AI) team of Professor Dimitris Bertsimas at the Massachusetts Institute of Technology (MIT), during this past year, working on machine learning (ML) tools to analyze congenital heart surgery data, I decided to attempt to provide you with an overview of the fantastic opportunities and challenges provided to our field by the explosive progress of AI. Of course, I wish to emphasize at the outset that I am by no means an expert on AI. Therefore, this presentation provides only the perspective of a clinical pediatric cardiac surgeon wondering if and how the impressive achievements and capabilities of AI could be harnessed for the benefit of our patients. Some 50 years ago, Dr William Schwartz, in his paper entitled “Medicine and the Computer—the Promise and Problems of Change,” published in the New England Journal of Medicine (NEJM), predicted that “Computing science will probably exert its major effects by augmenting and, in some cases, largely replacing the intellectual functions of the physician.” As I will be showing you, this prediction has been proven largely correct, and, in fact, the potential impact of artificial intelligence in medicine is in fact even bolder: Increasingly, the dream of AI in Medicine is becoming to create a virtual global team of medical experts, holding the ever expanding accumulated wisdom of the decisions of millions of physicians, regarding the medical issues and resulting outcomes of billions of patients. This virtual global team should then be able to support the decisions of every physician with real-time personalized advice on the diagnosis, management, and actual therapeutic interventions for each patient. Before we consider whether such far-reaching promise is conceivably possible, some definitions are in order. Artificial Intelligence is defined by Encyclopedia Britannica in an arguably circular manner as “the ability of a digital computer or a computer-controlled robot to perform tasks commonly associated with intelligent beings.” This term was coined by John McCarthy in preparation for a Dartmouth Summer Research Project in 1965: “The study is to proceed on the basis that every aspect of learning or any other feature of intelligence can in principle be so precisely described that a machine can be made to simulate it.” Thus, pivotal in all the achievements of AI has been the development of what has become known as ML, which is the application of AI systems to learn and improve from experience without being explicitly programed. Humans can learn to make general complex associations from small amounts of data (eg, a toddler learning to recognize a cat), whereas machines require many more examples and do not have common sense, they do not have what the philosopher of science Michael Polanyi described as tacit or implicit understanding. Yet, although machines do need massive amounts of data to learn from, their ability to absorb such data is practically limitless, and they do not tire. Of course, there are too many types of machine learning for a nonexpert to understand, but it is useful to distinguish between two general categories: In the “supervised models,” data sets are prepared and labeled by humans according to predefined categories, and the relevant algorithms are designed to orient only to categories and concepts prespecified by us. In “unsupervised” models, pattern recognition is allowed to develop freely within the data, with algorithms learning without human-provided guidance. Interestingly, the subject of whether machines can be made to think has been considered in the 17th century by the French philosopher René Descartes, in his 1637 book Discourse on the Method of Rightly Conducting One’s Reason and Seeking the Truth in the Sciences, famous for the quote “Cogito, ergo sum” (I think, therefore I am). Descartes seems to have predicted that machines could be constructed to perform some tasks as well as or better than humans, but, he felt they could neither be made to
World Journal for Pediatric and Congenital Heart Surgery, 2021
The optimal training of the highly specialized congenital heart surgeon is a long and complex pro... more The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve th...
Uploads
Papers by George Sarris