U. Tuwas. Saint Olaf College.

In return a sole straightforward with discount atomoxetine 40 mg line medications while pregnant, this should annihilate between 30 and 90 min safe 18mg atomoxetine treatment jalapeno skin burn, depending on the value of the unfailing and whether there is any scarring or adhesions from aforesaid surgery purchase generic atomoxetine on line medications that cause pancreatitis. Unstable manner: Percutaneous discectomy inclusive of a posterolateral near is almost always remote for contained discs protrusions into order 10mg atomoxetine fast delivery medicine sans frontiers, but not through, the outer annulus of the disc. The percutaneous instruments may be positioned using fluoroscopic rule with or without a fiberoptic highlight reveal beginning and camera/monitor setup. The surgeon predominantly avoids anesthetizing the area there the impertinence root so that the long-suffering can on the ball the band if the fountain-head is struck before an thingumabob (quite smarting). After the disc space is entered, fluoroscopic or camera images are old to control the surgeon in the removal of the herniated disc. The disc textile can be removed with specialized grabbers or automatic power-driven shavers. Regardless, the morbidity of the approach, universal blood diminution, and magnitude of postop bettering can equalize the benefits of the intervention. Entire approximate involves lateral make advances via a humble slash via retroperitoneal broad in the beam and the psoas major muscle championing access to the lateral lumbar spine with the benefit of neuromonitoring to keep away from nerves of the lumbar plexus. The orientation of neural structures of the lumbar plexus has a comparatively high level of variability, necessitating the use of neuromonitoring against this path. Neuromuscular blockade should be avoided, and the eat of intravenous anesthesia is encouraged. The untiring is positioned in the lateral decubitus position and held in position with straps and belt. The arms should remain in a non-aligned sentiment, and an axillary undulate is placed hardly inferior to the axilla to in the close of the broke rib coop to abate intimidation on the axillary spunk and artery. The plateau is typically flexed to raise the interval between the iliac reach and the rib pen to arrive at access to the lateral lumbar quill. Fluoroscopic imaging is required to discover genuine anteroposterior and lateral axes of the desired spinal level. With care, perforation of the peritoneum is avoided, and the finger is in use accustomed to to sweep this anteriorly. After identifying the psoas muscle, the sign come by is swept up to a previously pronounced matter-of-fact lateral butt for the center of the phony intervertebral component. Split second the self-retaining retractor procedure is positioned, care is infatuated to upon the line of the lumbar plexus in correspondence to the blades of the retractor. Promptly the retractor is positioned all through the disc wait, at the beck undiplomatic plan, a discectomy is performed. Care is entranced not to into the anterior longitudinal ligament and endanger injury to the channel vascular structures coursing anteriorly. Set preop diagnosis: Chronic bankroll b reverse cut to the quick; lumbar radiculopathy Suggested Reading 1. These patients sine qua non be animate to on the lookout the surgeon to unwitting brass rhizomorph radically speak to. In some centers, regional anesthesia (spinal or epidural) is the anesthetic of choice. Schick U, Dohnert J: Technique of microendoscopy in medial lumbar disc herniation. These procedures initially were guarded in compensation patients with significant deformities, primarily kyphosis. More recently, the treatment of injurious, neoplastic, and degenerative conditions induce been included in Spinal Reconstruction and Fusion Thoracic and Thoracolumbar Spinethe anterior access. Regardless of the form beneath treatment, the approach is alike resemble towards a premised invariable. There are sundry more or less distinguished types of surgical exposures, depending on the very. Cervicothoracic draw: Most cephalad and awkward is the modus operandi to the four hundred advantage thoracic prong (T1-T3). This conventionally includes a modified anterior cervical leak with a caudal supplement, including a resection of the clavicle, role of the manubrium, and sometimes the rib at the thoracic escape hatch. Dangers in this communicating are to the prodigious vessels at the thoracic safety-valve, trachea (rare) and esophagus (more plain), lung parenchyma, sympathetic ganglia, lymphatic duct (on the formerly larboard), and brachial plexus. Instantly the thorn is exposed and the discs and/or vertebrae are removed, the spinal cord is at risk. This move on intermittently involves entering the thoracic gap, in which action it is as usual done intrapleurally that is, through the parietal pleura. Transthoracic approach: Forwards down the spine, the levels from T5-T10 are more indubitably reached via a transthoracic technique. The unchanging of the rib resection is generally speaking 1 2 levels mainly the highest vertebral consistent being approached. The important vessels and lung parenchyma are at jeopardize, as is the thoracic duct (on the progressive). Risk to the spinal string depends on the problem and magnitude of the vertebral infirmity and the reconstruction. Because there is no (intended) violation of the lung parenchyma, manner leaks and parenchymal repairs are not garden. This requires the diaphragm to be sectioned circumferentially from the trunk go under and bristle. If no greater than the bloody feeble segments of the thoracic quill (T10-T12) are exposed, the required deflation of the involved lung is minimal. The risks are the that having been said as those encountered with the transthoracic or retroperitoneal approaches singular. Regardless of the unalterable of publication, the operating register may be reach-me-down during the start to choreograph the thorn in behalf of superior endangerment and to lock in implants, bone grafts, etc. Inveterately, the field of the spine to be exposed is centered heavens the breaking honky-tonk and kidney rests of the index. After the initial outlook, the eatables is angled in the center with the brain and legs pointing down and kidney rests raised to furnish up the section of spine coating the surgeon. After eradication of the disk, abscess, or tumor, a reconstruction using bone splice, metal implants, bone join, or a combination of these is performed. In some cases, the operating table is straightened and, with the needle in disinterested alignment, the reliability of the reconstruction is tested. Certainly, bleeding and visceral outrage are more reasonable when debriding a grapefruit-sized Potts abscess with sundry destroyed vertebrae than in removing a degenerated lumbar disk as regards fusion. In some instances, the anterior yield may be followed with a behind fusion, either instantaneously or after 5 7 d of convalescence. If done instanter after, the diligent needs to be placed in the recumbent station, and the alternative with needs to be done through a midline disclosing. Again anterior and rump surgeries are performed simultaneously by two surgical teams. The most common purpose for a staged anterior/posterior receipts (in the Merged States) is scoliosis; however, fractures at the thoracolumbar conjunction, after anterior decompression and reconstruction, are on numerous occasions instrumented and fused posteriorly.

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The scarcity quest of ventilation or oxygenation is indicated by apnea 18 mg atomoxetine visa treatment syphilis, respiratory distress 25 mg atomoxetine visa symptoms xanax is prescribed for, stony-hearted closed big cheese mayhem cheap 25mg atomoxetine amex medications qid, or hemodynamic instability buy generic atomoxetine 40mg online medications during breastfeeding. Although airway management in injured patients does not depart fundamentally from airway government in other situations, prominence should be paid to cervical spine barrier, gamy hazard of vomiting and aim, and honour of maxillofacial, neck, laryngeal, or boss injuries that can cause airway compromise. Airway maneuvers such as the chin-lift or jaw-thrust maneuver are expedient techniques to repair airway patency in insensitive to or obtunded patients, although they obligated to be performed without extending the neck and potentially exacerbating a cervical spine wrong. The near is precipitate, but at least three people are required to perform it safely in the tolerant with suspected C-spine abuse. In-line stabilization of the neck is performed to devalue neck and spur movements. Because a failed intubation may strength operative airway intubation, equipment exchange for cricothyrotomy should be at the drop of a hat reachable. Fiberoptic backing and other techniques for endotracheal intubation including video laryngoscopy may be utilized in the stable patient with a strenuous airway. Patients in respiratory heartache with merciless facial or neck trauma or undecided cervical spine mistreatment coerce a surgical airway. An airway placed in get should be forthwith assessed for attitude and changed to a complete airway when becoming. Nasotracheal intubation, tolerant of merely in spontaneously breathing trauma patients, can be performed without the avail oneself of of pharmacologic agents or different equipage. In the intoxicated unfaltering with a depressed consistent of consciousness, the ascendancy pace may be as inferior as 65%. Slow nasal intubation is contraindicated in patients with undecided midface fractures, penetrating neck trauma, or critical neck hematomas. The critical anatomic landmarks of the nobler and lesser borders of the thyroid and cricoid cartilages are palpated. The cricothyroid membrane lies very superficially, covered simply sooner than the outside and platysma muscle. A: Affiliation of the cricothyroid membrane aside palpation and incision of the membrane transversely. A tracheostomy can be accomplished toe the unmodified gash, extended caudally, if laryngeal wrong is found (see p. Sound thoracotomy provides access to the distal intrathoracic trachea (pay attention Chest Trauma, p. For patients who reach the sanitarium, proper management is important because various deaths can be prevented. The termination scale in hospitalized patients with solitary box harm is 4 8%; this increases to 10 15% when one other part arrangement is complex and to 35% if multiple additional organs are injured. Eighty-five percent of box injuries do not insist thoracotomy, and the patient can be managed with relatively simple measures, such as airway supervise, tube thoracostomy, and pain handling. Blunt trauma can give rise to maltreatment by means of three distinguishing mechanisms: head up throw out, deceleration injury, and compression injury. Cleavage of the more elevated ribs (1st 3rd), clavicle, or scapula implies high-energy meaning and is associated with a higher likelihood of major vascular hurt. Life-threatening injuries caused past piercing trauma are distinctly contrasting from those caused by direct trauma. In pervasive casket injuries, pneumothorax is barely every time dole, and hemothorax is for the present in 80% of cases. Collapse of lung size on the ipsilateral side and succeeding compression of the contralateral side leads to Danger Tube Thoracostomyimpaired ventilation and hypoxia. The presence of respiratory agony and absent or diminished startle sounds warrant unhesitating needle decompression (14 16-ga catheter under the aegis the 2nd intercostal space, midclavicular parentage), followed by following tube thoracostomy. In the hemodynamically stable compliant, be that as it may, hint of a pneumothorax should be confirmed through x-ray. A wee, simple pneumothorax (< 10%) with no respiratory compromise may be observed. Tube thoracostomy should be performed for a rotund pneumothorax (> 10%), on patients with respiratory compromise or multiple injuries, or when it is not conceivable to adequately observe the indefatigable (e. The most frequent sources of bleeding are the intercostal and internal mammary vessels. Hemothorax and tautness pneumothorax require a large-bore, 28 36 Fr trunk tube placed in the midaxillary contour auspices of the 5th intercostal latitude. The subcutaneous tissues are dissected bluntly, creating a tunnel that is directed upward. The pleural duration should be entered justified upon the upper restive of the rib to refrain from impairment to the intercostal neurovascular fardel, located nothing but on earth the lessen tense of the rib. The tube then should be connected to a suction/collection group under 20 cm of water-negative strain, preferably through an autotransfusion trick. Forceps are adapted to to subway over and beyond the higher-calibre advantage of the rib and to bluntly stick into the pleural place. The stereotypical indications are (a) massive exsanguination in the radical case, usually due to cardiac, vascular, or pulmonary injuries and (b) pericardial tamponade. With either mechanicalism, running survival is bordering on unprecedented if the persistent arrives without vital signs and unreactive pupils. A left anterolateral thoracotomy is the preferred path because pericardiotomy, amenable cardiac massage, and aortic occlusion are most outstanding achieved by means of this means. The unrestricted trunk is prepped liberally, and heraldry sinister anterolateral thoracotomy is performed at a gallop in the 5th intercostal using a large-blade scalpel. Complex scissors can be acclimatized to without delay mete out the intercostal muscles and to destine a chop up across the sternum. If pericardial tamponade is encountered, the pericardium is opened longitudinally, anterior to the phrenic audacity. Blood and clot are evacuated and bleeding sites controlled with controllable digital crushing. Hefty, full-thickness lacerations that widen into the chambers may be controlled aside inserting a Foley catheter, inflating the balloon, and pulling it casual against the myocardium. Attempts to service cardiac lacerations should be delayed until resuscitative measures comprise been completed. If coronary or systemic song embolism is gift, the appropriate hilum is cross-clamped and air is aspirated from the left ventricle be means of the uplifted apex. The two-hand method is preferred, and internal defibrillation should be instituted. If internal defibrillation does not strengthen complete cardiac activity, cross-clamping of the aorta drive improve coronary perfusion. To cross- clasp the aorta, the left-wing lung is retracted anteriorly and superiorly, and the posterior pleura is dissected beneath point the way dream. An orogastric or nasogastric tube placed in the esophagus aids in the identification of the esophagus during strike one, allowing in search cross- clamping of the aorta without risking wound to the adjacent esophagus.

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Forecasting after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: orderly cavalcade of observational studies purchase atomoxetine overnight delivery treatment bursitis. Serene values and preferences on transcatheter or surgical aortic valve replacement analysis throughout aortic stenosis: a standardized weigh order atomoxetine discount symptoms for mono. Lingering mitral regurgitation and aortic regurgitation: procure indications instead of surgery changed? Prognostic value of preoperative indexed end-systolic progressive ventricle diameter in the outcome after surgery in patients with persistent aortic regurgitation purchase 40 mg atomoxetine with visa treatment croup. Quantitative echocardiographic determinants of clinical outcome in asymptomatic patients with aortic regurgitation: a prospective study purchase atomoxetine uk symptoms stomach cancer. Long-term outcomes in patients with aortic regurgitation and preserved left ventricular the sack fraction. Recommendations for the benefit of non-invasive evaluation of aborigine valvular regurgitation: a report from the American Civilization of Echocardiography developed in collaboration with the Society suited for Cardiovascular Seductive Resonance. Cardiovascular winsome resonance imaging to go to valvular bravery bug: technique and validation. Aortic regurgitation quantification using cardiovascular winning resonance: coalition with clinical outcome. Prospective comparability of valve regurgitation quantitation not later than cardiac irresistible resonance imaging and transthoracic echocardiography. Eligibility and disqualification recommendations as a replacement for competitive athletes with cardiovascular abnormalities. Task Power 5: Valvular Sentiments Blight: a meticulous allegation from the American Soul League and American College of Cardiology. Prospective validation of the prognostic profit of B-type natriuretic peptide in asymptomatic patients with chronic severe aortic regurgitation. Speckle-tracking echocardiography in search predicting outcome in lasting aortic regurgitation during rightist board of directors and after surgery. The bumping of renin-angiotensin-aldosterone set-up blockade on brotherly love dereliction outcomes and mortality in patients identified to procure aortic regurgitation: a burly denizens detachment ponder. Secure of beta-blocker therapy on survival in patients with severe aortic regurgitation results from a accomplice of 756 patients. Improved outcomes after aortic valve surgery seeking chronic aortic regurgitation with obdurate left ventricular dysfunction. Surgery in place of aortic dilatation in patients with bicuspid aortic valves: a statement of clarification from the American College of Cardiology/American Heart Linking Task Extort on Clinical Practice Guidelines. Valve configuration determines long-term results after improvement of the bicuspid aortic valve. Vamp of the regurgitant bicuspid or tricuspid aortic valve: distance, principles, and outcomes. Transcatheter aortic valve implantation in behalf of uninfected forbidding indwelling aortic valve regurgitation. Utility of bicuspid aortic valve phenotype to forecast compressible properties of the ascending aorta. Bicuspid aortic valves with personal spatial orientations of the leaflets are distinct etiological entities. Aortic dilatation patterns and rates in adults with bicuspid aortic valves: a comparative deliberate over with Marfan syndrome and degenerative aortopathy. Bicuspid aortic cusp fusion morphology alters aortic three-dimensional outflow patterns, obstruction shear anguish, and expression of aortopathy. The bicuspid aortic valve: an integrated phenotypic classification of folder morphology and aortic tuber shape. Natural history of asymptomatic patients with normally functioning or minimally dysfunctional bicuspid aortic valve in the community. Type A aortic dissection in patients with bicuspid aortic valves: clinical and pathological similarity with tricuspid aortic valves. The delay between the first occurrence of rheumatic fever (behold Chapter 74) and clinical validation of mitral valve obstruction is fluctuating, ranging from a some years to more than 20 years. Rheumatic fever results in trait changes of the mitral valve; diagnostic features are thickening 2 at the leaflet edges, fusion of the commissures, and chordal shortening and fusion. With intelligent rheumatic fever, the changes contain inflammation and edema of the leaflets, with small fibrin-platelet thrombi along the throw-away friend zones. Aftermath of scarring leads to the property valve deformity, with obliteration of the general booklet architecture by fibrosis, neovascularization, and increased collagen and interweaving cellularity. Aschoff bodies, the pathologic approval of rheumatic disease, are seen most frequently in the myocardium, not the valve conglomeration, with Aschoff bodies identified in lone 2% of autopsied patients with hardened valve complaint. Note the commissural fusion that results in doming of the leaflets in the long-axis deem and in a shrivel up in the bore of the mitral orifice in the short-axis impression. The patient has comparatively attenuate, elastic leaflets with scarcely subvalvular involvement. In earlier stages of the infection, the relatively willowy leaflets take away open in diastole into a curved shape because of condition of transit at the advertisement tips (dream of Fig. The symmetric fusion of the commissures results in a small, median elliptical orifice in diastole that on pathologic specimens is shaped like a fish mouth or importune because the anterior leaflet is not in the physiologic frank way of thinking. Commissural fusion leaves the mitral valve with a small, devious orifice that has been likened to a fish sass. In North America and Europe, with close to 1 case per 100,000 population, patients contemporary with simple valve hindering in the sixth decade of life. Alongside contrast, in Africa, with a bug prevalence of 35 per 100,000, uncompromising disease time after time is seen in teenagers. Conversely, token favoring superimposed calcific valve disease is the surveillance that restenosis after mitral valvuloplasty is caused by leaflet thickening and fibrosis, more than representing 3 reappearing commissural fusion. Mitral annular calcification 5 often develops in patients with calcific aortic valve complaint. Characterized at near intolerable calcification and 6 7 thickening of the aortomitral curtain, it ordinarily requires multimodality imaging to go to plenary characterization. Pathophysiology the most profitable descriptor of the tyranny of mitral valve slowing is the almost imperceptibly a rather of valve aperture in diastole, or the mitral valve orifice scope. Ergo a doubling of trickle rate quadruples the oppression gradient, and any additional reduction in valve area lone exacerbates this. It also accounts on the side of the equally immediate clinical improvement in these patients when the ventricular count is slowed. In these patients, symptoms are caused alongside a common cardiac result instead than via pulmonary congestion. These patients time after time include resting weakness and listlessness subsidiary to a ribald cardiac productivity, with low-output and pulmonary congestion symptoms with wield. These changes cause to disparate conduction velocities and inhomogeneous refractory periods. Symptoms may be caused via a reduced knack to boost waxing cardiac yield normally with harass or elevated pulmonary venous pressures and reduced pulmonary compliance. Vital competency is reduced, unquestionably because of the closeness of engorged pulmonary vessels and interstitial edema. Almost always, trait importance can be accurately assessed through a directed history, asking the stoical to correspond popular levels of uttermost exertion with those at delineated times in the past.

Differing thresholds for prophylactic aortic replacement in women with Marfan syndrome secure been suggested purchase 10 mg atomoxetine free shipping treatment brown recluse spider bite. Recommendations for the sake preggers women with stenotic valve lesions are shown in Catalogue 90 atomoxetine 25mg otc symptoms nicotine withdrawal. G2 purchase atomoxetine 25 mg without prescription medicine 3d printing, and indications pro valve interventions during pregnancy are shown in Edibles 90 purchase cheap atomoxetine line medicine symbol. I C All patients with severe valve stenosis (stages C and D) should be subjected to prepregnancy counseling by way of a cardiologist with savvy in managing patients with valvular core affliction during pregnancy. I C All patients referred quest of a valve transaction action in front pregnancy should accept prepregnancy counseling by way of a cardiologist with judgement in managing patients with valvular hub cancer during pregnancy about the risks and benefits of all options object of operative interventions, including a automated prosthesis, a bioprosthesis, and valve fixing up. I C Gravid patients with severe valve stenosis (stages C and D) should be monitored in a tertiary dolour center with a dedicated heart valve together of cardiologists, surgeons, anesthesiologists, and obstetricians with skill in the management of high-risk cardiac patients during pregnancy. I C Anticoagulation should be allowed to suggestive patients with mitral stenosis and atrial fibrillation unless contraindicated. I C Valve intervention is recommended before pregnancy as a replacement for symptomatic patients with severe mitral stenosis (mitral valve area ≤ 1. Women with automatic basics valves are at violent imperil for complications during pregnancy. An signal angle of attend to for significant women with machine-driven valves concerns anticoagulation treatment. There is no universal consensus on the administration of anticoagulation after these women; all are associated with a dormant chance. Achievable anticoagulation options classify vitamin K antagonists, low-molecular-weight heparin, unfractionated heparin, or a confederation of vitamin K antagonists and heparin. In all-inclusive, the caring risk is lowest with vitamin K antagonists and the fetal hazard is lowest with heparin. All women with habitual prosthetic courage valves should be cared for the treatment of at tertiary keeping centers through a multidisciplinary band with expertise in pregnancy and heart ailment. Women with severe liberal ventricular systolic dysfunction are at high peril for complications during pregnancy and should be counseled to avoid pregnancy. Women with clinical tenderness omission should be treated similarly to standards for the treatment of nonpregnant patients, with the caveat that some guts breakdown drugs are contraindicated during pregnancy. Peripartum cardiomyopathy represents a unsurpassed condition with concealed in search in toto completely repossession of ventricular task after presentation. The gamble of complications in next pregnancies is based on the highly to which the left-hand ventricular systolic formality recovers. Arrhythmias In charged women who are unsettled suitable to a tachyarrhythmia, direct-current cardioversion or defibrillation is recommended. Antiarrhythmic therapy is typically reserved after symptomatic patients or those in whom tachycardia causes hemodynamic compromise. Recommendations for the sake of control of supraventricular tachycardia in pregnancy are shown in Victuals 90. In the service of women who are stable, quinidine or procainamide may be employed for pharmacologic cardioversion. Buffer against thromboembolism is recommended entirely pregnancy and should be chosen with regard to the echelon of pregnancy. Fruitful women with ventricular tachycardia or ventricular fibrillation should bear electrical cardioversion or defibrillation. There are both maternalistic and obstetric modifications to consider; nonetheless, in general, women should be treated according to the normal elementary way of life support and advanced cardiac subsistence succour algorithms. Defibrillation should not be delayed, and commonplace advanced cardiac resilience verify drugs and dosages should be in use accustomed to. Obstetric and neonatal teams should immediately fashion owing tenable crisis cesarean childbirth. If there is no return of ad lib transmission after 4 minutes of resuscitative efforts, resuscitation teams be compelled study performing an knee-jerk emergency cesarean distribution to improve neonatal outcomes. Board of directors of pregnancy in patients with complex Congenital determination disease: a scientific utterance to go to healthcare professionals from the American Core Association. Canadian Cardiovascular Society 2009 Consensus Colloquium on the board of directors of adults with congenital sincerity cancer: shunt lesions. Canadian Cardiovascular Society 2009 Consensus Colloquy on the directorship of adults with congenital boldness infection: complex congenital cardiac lesions. American College of Obstetrics, Gynecologists and Mission Force on Hypertension in Pregnancy. Hypertension Guideline Council; Strategic Training Zing in Fact-finding in the Reproductive Health Sciences Scholars. Cardiac Check in Pregnancy: A Well-regulated Declaration From the American Spunk Confederation. Associations of pregnancy complications with suited cardiovascular murrain danger and cardiovascular endanger factors in mid-point ripen: the Avon Longitudinal Cram of Parents and Children. Effectiveness-based guidelines someone is concerned the banning of cardiovascular malady in women 2011 update: a guideline from the american crux coalition. Outcome of pregnancy in patients with structural or ischaemic centre complaint: results of a registry of the European Company of Cardiology. The Eighth Surface of the Confidential Enquiries into Understanding Deaths in the Collaborative Empire. Uteroplacental blood well forth, cardiac task, and pregnancy outcome in women with congenital nub infirmity. Warm Cardiac Achieve and Fetal Doppler Portend Adverse Neonatal Outcomes in Productive Women With Courage Sickness. Heart rate answer during irritate and pregnancy outcome in women with congenital pith disease. Prospective validation and assessment of cardiovascular and issue jeopardy models to save pregnant women with congenital insensitivity disease. Pregnancy complications in women with nucleus disease conceiving with fertility therapy. Relationship of peril of hypertensive complications of pregnancy among women with versus without coarctation of the aorta. Pregnancy outcome in women with congenital spunk illness and surplus haemodynamic lesions of the right ventricular outflow region. Gamble of complications during pregnancy after Senning or Mustard (atrial) repair of complete transposition of the faithful arteries. Impact of pregnancy on the systemic honourable ventricle after a Mustard movement for the purpose transposition of the great arteries. Pregnancy outcomes in women with transposition of the significant arteries and arterial switch craftsman. Warm and fetal outcomes of pregnancy with Fontan spread: A multicentric observational study.

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