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© 2014, Copyright the Authors Artificial Organs © 2014 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Near Infrared Spectroscopy Monitoring in the Pediatric Cardiac Catheterization Laboratory *Ibrahim Cansaran Tanidir, *Erkut Ozturk, *Isa Ozyilmaz, *Murat Saygi, *Neslihan Kiplapinar, †Sertac Haydin, *Alper Guzeltas, and *Ender Odemis Departments of *Pediatric Cardiology and †Pediatric Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey

Abstract: Near-infrared spectroscopy (NIRS) is a noninvasive method used to evaluate tissue oxygenation. We evaluated the relationship between cerebral and renal NIRS parameters during transcatheter intervention and adverse events in the catheterization room. Between January 1 and May 31, 2012, 123 of 163 pediatric patients undergoing cardiac catheterization were followed by NIRS. All were monitored by electrocardiography, noninvasive blood pressure measurement, pulse oxymetry, initial and final blood lactate level measurement. The number of interventional procedures was 73 (59%). During the procedures, 39 patients experienced a total of 41 adverse events: 18 (19.5%) had desaturation, 10 (8.1%) arrhythmia, three (2.4%) had respiratory difficulty, six (4.8%) had a situation calling for cardiopulmonary resuscitation, three (2.4%) had anemia necessitating transfusion, and one (0.8%) had a cyanotic spell. Cranial NIRS values worsened in 12 (9.8%)

and renal measurements worsened in 13 (12.5%) patients. The sensitivity and specificity of a 9% impairment of cranial values were 90 and 61%, respectively, while the corresponding calculations for a 21% fall in renal measurements were 54% sensitivity and 90% specificity. When arrhythmia developed, NIRS values fell simultaneously, while the development of a desaturation problem was heralded by NIRS falling 10–15 s earlier than changes in pulse oxymetry; on improving saturation, NIRS returned to earlier values 10–15 s before pulse oxymetry readings. NIRS monitoring may provide an early warning with regard to complications likely to develop during a procedure.A fall of 9% in cranial NIRS values, or of 21% in renal measurements, should raise clinician awareness. Key Words: Children—Cardiac catheterization—Complication —Monitorization—Near-infrared spectroscopy.

Near-infrared spectroscopy (NIRS) is a noninvasive method used to evaluate tissue oxygenation. Initially reserved for the evaluation of cerebral oxygenation, its use has gradually been extended to various other purposes in patients of all ages. Changes in regional tissue oxygenation indicated by

NIRS indicate the state of the balance between oxygen consumption and oxygen availability for several organs simultaneously (1). A description of NIRS was first published in 1977 by Jobsis for the noninvasive, live determination of tissue oxygenation (2). Its use for the bedside evaluation of cerebral oxygenation in premature newborns was first reported by Brazy et al. in 1985 (3), after which Greeley et al. published on its use in the evaluation of cerebral oxygenation and hemodynamics in surgery for congenital heart disease, in 1991 (4). To date, reports on NIRS use have centered on the evaluation of device efficacy (5,6). As far as we could ascertain, only two publications have been dedicated to NIRS values, along with clinical observation, during pediatric cardiac catheterization, both of which were conducted in balloon valvuloplasty patients and published by de Vries et al. (7,8).

doi:10.1111/aor.12256 Received September 2013; revised October 2013. Address correspondence and reprint requests to Dr. Ibrahim Cansaran Tanidir, Department of Pediatric Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, I˙stanbul Mehmet Akif Ersoy Eg˘itim Aras¸tırma Hastanesi, I˙stasyon Mahallesi I˙stanbul Caddesi Bezirganbahçe Mevki 34303 Küçükçekmece, Istanbul, Turkey. E-mail: [email protected] Presented in part at the Ninth International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion held May 8–11, 2013 in Hershey, PA, USA. This is the thesis of Ibrahim Cansaran Tanidir. Artificial Organs 2014, 38(10):838–844

PEDIATRIC CARDIAC CATHETERIZATION AND NIRS Numerous centers currently perform interventional and diagnostic cardiac catheterization on children with congenital heart disease. The complication rate of such interventions increases inversely with patient age, but in parallel with the complexity of cardiac pathology and the number of therapeutic and diagnostic techniques. The reported total complication rate for transcatheter procedures totals 7.8– 14.7% (of which 1.8–5.7% are major complications), with an associated mortality of 0.23–0.32% (9,10). Even though complication rates for transcatheter interventional procedures have decreased from previous levels, as a result of being performed in tertiary care centers under the supervision of anesthesia experts, and with all necessary pre- and postintervention precautions, a further reduction of the adverse event rate has not been observed in recent years (9). A continued reduction of operational morbidity and mortality should now be possible, due to our advanced knowledge of complications. This study aimed to evaluate the relationship between cerebral and renal NIRS parameters during transcatheter intervention and adverse events in the catheterization room, as well as the possibility of predicting adverse events earlier than other forms of monitoring with the use of the NIRS device, and the possible help that this would provide the clinician. PATIENTS AND METHODS Patient selection Patients aged under 18 years who had undergone diagnostic or therapeutic cardiac catheterization between January and May 2012 at the Mehmet Akif Ersoy Chest, Heart and Vessel Surgery Teaching and Research Hospital, Istanbul, Turkey, were admitted into the study. Study protocol We began to record patient parameters after the patients had entered the catheterization room and had been connected to the monitors. Cranial and renal NIRS values, baseline rhythm, heart rate, pulse oxymetry, and blood pressure measurements were recorded before anesthesia induction. Following induction, it was noted whether the patients were intubated or extubated; if they had been given oxygen, their fraction of inspired oxygen (FiO2) measurement was also recorded. Before starting catheter angiography and every 10 min thereafter, the patients’ cranial and renal NIRS values, rhythm, heart rate, oxygen saturation, as measured by pulse oxymetry, FiO2, and blood pressure, as measured by either invasive, or in its absence noninvasive, moni-

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toring, were recorded. Adverse events that occurred during the intervention and all monitored vital parameters and NIRS variables during such adverse events were also recorded. In addition, in the case of an increase or fall in NIRS values, all simultaneous vital parameter measurements were also registered. Catheter angiography procedures Diagnostic and therapeutic interventional cardiac catheterization procedures were performed, according to previously described standards. A Philips FD Xper Allura FD 20/20 Biplane (Philips, Best, The Netherlands) model angiography unit was used in all operations, which were all performed in collaboration with an anesthesiologist and an anesthesia technician, with the patient under general anesthesia or deep sedation. Midazolam (Dormicum; Roche Pharmaceuticals, Nutley, NJ, USA) and/or ketamine were administered as premedication, and anesthesia was maintained during the intervention with propofol and vecuronium (Norcuron; Organon, West Orange, NJ, USA). Patients were intubated, or not, according to both the pediatric cardiologist’s preference and the patient’s specific disease and general condition. The anesthesia device used was a Dräger Fabius GS Premium (Dräger Medical AG & Co. KG, Lübeck, Germany). Pulse oxymetry readings were taken from either the Dräger Infinity Delta monitor (Dräger Medical), which was attached to the anesthesia apparatus, or a Nellcor Oximax N-560 Portable Pulse Oxymeter (Covidien, Mansfield, MA, USA). The local anesthetic used on the entry site for all interventions was prilocaine (Astra Pain Control, Sadertalje, Sweden). The contrast medium used in all interventions was iodixanol (Visipaque; GE Healthcare Bio-Sciences, Milwaukee, WI, USA). Classification of complications/adverse events Risks, any type of rhythm disturbance, respiratory disturbances (apnea, hypoventilation, superficial breathing), occurrence of age-dependent hypotension, or hypertension and desaturation, were noted during the procedures. Desaturation was defined as a fall of >5% in pulse oxymetry reading, compared with the baseline. NIRS device An INVOS 5100 C (Somanetics, Troy, MI, USA) NIRS device was used with a pediatric somasensor (Somanetics). The cranial sensor was placed on the left forehead skin, immediately below the hairline (123 patients). The renal sensor was located on the left flank at a level between T10 and L2 (103 patients). Artif Organs, Vol. 38, No. 10, 2014

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I.C. TANIDIR ET AL. TABLE 1. Patient characteristics

Age (year) Weight (kg) Height (cm) Procedure time (min) Fluoroscopy time (min)

Complication (–)

Complication (+)

P

6.72 ± 6.95 4.95 (0.93–11.28) 23.61 ± 20.33 17.25 (7.78–30.75) 106.12 ± 38.67 103 (72–138) 53.69 ± 31.47 45 (30–60) 14.48 ± 10.72 11.01 (6.31–18.96)

3.12 ± 4.9 0.6 (0.1–4.4) 11.61 ± 11.38 7 (3.9–15) 80.22 ± 32.51 67 (53.5–98.5) 64.23 ± 27.76 60 (45–90) 19.83 ± 13.1 16.21 (8.59–30.18)

0.0001

Statistical evaluation The Number Cruncher Statistical System 2007 Statistical Software (Kaysville, UT, USA) package was used for this study. In addition to descriptive statistics (mean, standard deviation, median, and interquartile range), the Mann–Whitney U-test was used for twogroup comparisons and the chi-squared test was used for categorical variables. Areas under the receiver operating characteristic (ROC) curve (AUC) were calculated from the NIRS values, and their sensitivity, specificity, positive and negative estimated value, likelihood ratio (LR) + value and intersects were calculated. Results were evaluated assuming P < 0.05 for significance and considering the 95% confidence interval (CI). RESULTS Of the 123 participants, 69 (56%) were males. In 50 (41%) cases, procedures were performed with diagnostic intent and in 73 (59%) cases were performed with therapeutic intent. A total of 47 (38%) patients were cyanotic (Table 1). Complications During the procedures, 41 complications were observed in 38 patients. These included 18 (19.5%) episodes of desaturation, 10 (8.1%) episodes of arrhythmia (four of supraventricular tachycardia [SVT]; three of second degree atrioventricular [AV] block; one of reversible complete AV block; one of intra-atrial re-entrant tachycardia [IART]; and one of asystole), six (4.9%) of hemodynamic failure or sudden asystole requiring cardiopulmonary resuscitation, three (2.4%) of bleeding necessitating transfusion, three (2.4%) of respiratory arrest with consequent intubation need, and one (0.8%) of a cyanotic spell in a patient with tetralogy of Fallot (Table 2). Arrhythmia A total of 10 patients developed arrhythmia during their procedures. Of these, eight had a fall in NIRS Artif Organs, Vol. 38, No. 10, 2014

0.0001 0.0001 0.007 0.021

values of over 9% and five of over 20%. The fall and rise in NIRS values were contemporaneous with the start of, and recovery from, arrhythmia. The renal NIRS values fell by over 22% in five of these patients. The number of patients with arrhythmia requiring intervention (medical treatment or external massage) was also five, of whom three had a greater than 20% reduction in cranial and renal NIRS values. One further patient experienced a 22% reduction in renal NIRS and 11% in cranial NIRS, and the last of the five had a 43% decrease in cranial NIRS, but only a 17% reduction in renal NIRS. The relationship between cranial and renal NIRS (start, end, min, and max) and the observed complications were evaluated, followed by that between the percentage change in these values and the complications. The percentage change between the start and end value in cranial and renal NIRS, as well as that between start and min values, was significantly higher in patients experiencing complications, compared with patients without adverse effects (P = 0.0001) (Table 3). A direct and statistically significant correlation was found between start-min change in oxygen saturation and both cranial and renal start-min change in NIRS (r = 0.462 and 0457, respectively, and P = 0.0001 for both) (Table 4). Start-end, start-max, start-min, and min-max percentage change values of both cranial (Fig. 1a) and renal (Fig. 1b) NIRS were calculated for their area

TABLE 2. Complications

Desaturation Arrhythmia Cardiac arrest Bleeding Respiratory arrest Arrhythmia and cardiac arrest Arrhythmia and desaturation Cyanotic spell

n

%

18 8 6 3 3 1 1 1

13.8 6.5 4.1 2.4 2.4 0.8 0.8 0.8

PEDIATRIC CARDIAC CATHETERIZATION AND NIRS

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TABLE 3. The relationship between cranial NIRS, renal NIRS, and complications

NIRS cranial start-min variation percentage NIRS cranial min-max variation percentage NIRS renal start-min variation percentage NIRS renal min-max variation percentage

Complication (–)

Complication (+)

P

10.56 ± 11.72 7.24 (1.9–15.81) 14.93 ± 12.23 13.2 (6.49–18.95) 8.25 ± 9.85 4.76 (0–14.57) 13.76 ± 10.45 10.53 (6.15–17.82)

30.02 ± 20.46 29.73 (12.28–46.88) 33.86 ± 19.84 32.39 (17.24–47.46) 24.45 ± 20.87 22.67 (6.67–33.33) 28.95 ± 19.7 27.78 (14.06–35.9)

0.0001

under the ROC curve. The AUC values of cranial and renal max-min and start-min NIRS percentage change are indicated in Table 5. No statistical significant difference could be detected when comparing

0.0001 0.0001 0.0001

cranial to renal NIRS start-min and min-max change (P = 0.831 and 0.986, respectively). The area under the ROC curve of cranial NIRS start-min percentage change values was 0.810 ± 0.046

TABLE 4. The relationship between changes in cranial NIRS, renal NIRS, and saturation

Saturation start-min variation percentage Saturation min-max variation percentage NIRS cranial start-min variation percentage NIRS cranial min-max variation percentage NIRS renal start-min variation percentage NIRS renal min-max variation percentage

a

r P r P r P r P r P r P

Saturation start-min variation percentage

Saturation min-max variation percentage

NIRS cranial start-min variation percentage

NIRS cranial min-max variation percentage

NIRS renal start-min variation percentage

NIRS renal min-max variation percentage

— — 0.843 0.0001 0.462 0.0001 0.444 0.0001 0.457 0.0001 0.436 0.0001

0.843 0.0001 — — 0.391 0.0001 0.392 0.0001 0.489 0.0001 0.501 0.0001

0.462 0.0001 0.391 0.0001 — — 0.924 0.0001 0.672 0.0001 0.611 0.0001

0.444 0.0001 0.392 0.0001 0.924 0.0001 — — 0.659 0.0001 0.681 0.0001

0.457 0.0001 0.489 0.0001 0.672 0.0001 0.659 0.0001 — — 0.852 0.0001

0.436 0.0001 0.501 0.0001 0.611 0.0001 0.681 0.0001 0.852 0.0001 — —

b

FIG. 1. ROC curves for start-end, start-max, start-min, and min-max percentage change values. a: Cranial NIRS values; b: Renal NIRS values. Artif Organs, Vol. 38, No. 10, 2014

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I.C. TANIDIR ET AL. TABLE 5. AUC values of cranial and renal NIRS percentage changes

For all complications

Complications without desaturation

NIRS cranial start-end variation percentage NIRS cranial start-max variation percentage NIRS cranial start-min variation percentage NIRS cranial min-max variation percentage NIRS renal start-end variation percentage NIRS renal start-max variation percentage NIRS renal start-min variation percentage NIRS renal min-max variation percentage NIRS cranial start-min variation percentage NIRS renal start-min variation percentage

(95% CI 0.729–0.875); for a >8.96 cut-off value sensitivity was 89.74, specificity was 60.71, positive estimated value was 51.5, negative estimated value was 92.7, and LR+ was 2.28 (Table 6). The area under the ROC curve of renal NIRS minmax percentage change values was 0.757 ± 0.053 (95% CI, 0.663–0.836); for a >21.33 cut-off value, sensitivity was 54.29, specificity was 89.86, positive estimated value was 73.1, negative estimated value was 79.5, and LR+ was 5.35 (Table 6). NIRS results were fully correlated with saturation values as a result of the functioning principle of the device, so complications other than desaturation were removed and the statistical evaluation repeated. The AUC of both cranial and renal NIRS start-min percentage change values was higher than 0.750 (Table 5). The area under the ROC curve of cranial NIRS start-min percentage change values was 0.786 ± 0.0667 (95% CI 0.693–0.860); specificity for a >31.94 cut-off value was 55.56, specificity was 96.43, positive estimated value was 76.9, negative estimated value was 91, and LR+ was 15.56 (Table 6). The area under the ROC curve of renal NIRS minmax percent change values was 0.791 ± 0.07 (95% CI 0.689–0.871); specificity for a >21.33 cut-off value was

AUC

SE

95% CI

0.625 0.510 0.810 0.803 0.622 0.512 0.757 0.758 0.786 0.791

0.0556 0.056 0.0456 0.0462 0.0595 0.060 0.053 0.053 0.0667 0.07

0.534–0.711 0.418–0.601 0.729–0.875 0.721–0.869 0.521–0.715 0.412–0.611 0.663–0.836 0.664–0.837 0.693–0.860 0.689–0.871

62.50, specificity was 89.86, positive estimated value was 58.8, negative estimated value was 91.2, and LR+ was 6.16 (Table 6). Pulmonary balloon valvuloplasty There was a reduction of over 9% in cranial NIRS and a decrease of over 22% in renal NIRS values in the 10 patients who underwent pulmonary balloon valvuloplasty. Desaturation (defined as a reduction of over 5% in oxygen saturation on pulse oxymetry) was present in only five of these individuals. In all patients showing desaturation, NIRS values fell 10–20 s before a reduction in pulse oxymetry readings; they also started to recover 15–20 s earlier than pulse oxymetry readings. NIRS measurements fell again with each successive balloon valvuloplasty in those patients who were repeatedly subjected to it; however, the fall during repeat angioplasty was less than during the first procedure. Cyanotic spell An 18-month-old girl with tetralogy of Fallot entered a cyanotic spell in the course of a cardiac catheterization for diagnostic purposes. The patient was receiving 100% oxygen through a mask during this procedure. Her cranial NIRS measurements fell

TABLE 6. Cranial and renal NIRS cut-off values and their sensitivity, specificity, likelihood ratios

For all complications

Complications without desaturation

NIRS cranial start-min variation percentage NIRS renal start-min variation percentage NIRS cranial start-min variation percentage NIRS renal start-min variation percentage

Cut-off value

Sensitivity

Specificity

PEV

NEV

+LR

–LR

>8.96

89.74

60.71

51.5

92.7

2.28

0.17

>21.33

54.29

89.86

73.1

79.5

5.35

0.51

>31.94

55.56

96.43

76.9

91.0

15.56

0.46

>21.33

62.50

89.86

58.8

91.2

6.16

0.42

PEV, positive estimated value; NEV, negative estimated value. Artif Organs, Vol. 38, No. 10, 2014

PEDIATRIC CARDIAC CATHETERIZATION AND NIRS 15 s before those on pulse oxymetry. The patient improved under medical treatment (volume replacement, deeper sedation, push bicarbonate, and betablocker administration), and her cranial NIRS readings increased approximately 15 s before the spell resolved. DISCUSSION The following conclusions may essentially be drawn from our study: • Complications were significantly more frequent in patients of lower age, weight, or height, and in those with longer procedure or fluoroscopy times (Table 1). • We found that NIRS readings fell in patients developing arrhythmia, which normalized after rhythm recovery, and that the reduction in NIRS values was simultaneous with the onset of arrhythmia. • Our patient with tetralogy of Fallot experienced a fall in NIRS readings prior to that of saturation values on pulse oxymetry and similarly, on exiting the spell, a recovery of NIRS readings preceding those in pulse oxymetry. • A reduction in cranial and renal NIRS values by over 9 and 21% of baseline, respectively, was shown to multiply the probability of complications by 2.3 and 5.3 (Table 6). • A reduction in cranial (exceeding 32%) and renal (over 21%) NIRS values multiplied the probability of complications other than desaturation by 13.5 and 6.1, respectively (Table 6). Complications were significantly more frequent in patients of lower age, weight, or height (Table 1), which was expected, in accordance with existing knowledge (9). It was also shown that the complication rate increased with procedure and fluoroscopy duration (Table 1). This finding may be interpreted as the risk of complication increasing along with the complexity and duration of the procedure. The complications in our study may be attributed a severity level of grade 3 or higher (major complication), according to the scale of adverse event severity we used (11). This means that the patients’ situations were likely to worsen in the absence of any treatment. Vascular damage, the most frequent complication, was not assessed in this study, which favored an investigation of major complications, and ignored those of a minor nature. Hershenson et al. (12) noted a fall in systolic blood pressure, but no obvious reduction in diastolic or mean blood pressure during SVT in patients monitored by cranial NIRS during electrophysiology

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studies. They also reported that, while there was a correlation between NIRS and the systolic, diastolic, and mean blood pressure, no obvious NIRS reduction could be observed during tachyarrhythmia. They attributed the hypotension to a volumetric loss due to atrioventricular incoordination, resulting from the independent atrial beat, and showed that blood pressure normalized upon recovery from SVT. Rhythm disorders were found in 10 of our patients, four of whom had SVT. Two of these four patients had a greater than 22% reduction in both cranial and renal NIRS during SVT, and a further patient showed a decrease in renal values only. The fourth patient did not show a marked reduction in NIRS values, and while this patient was being tested with nitric oxide (NO) for pulmonary vasoreactivity, 100% oxygen and NO had been administered. As a result, no NIRS decrease with respect to the initial values was recorded. However, there was a reduction in NIRS during SVT when compared with the measurement immediately preceding the arrhythmia. These findings differ from those reported by Hershenson et al. (12). A definite reduction in NIRS values was also observed in all cases of arrhythmia, other than SVT (complete AV block, IART, and asystole). We interpret these two results as being dependent on the patient sample. While rhythm disorders do not usually cause major problems in patients with normal hearts, they may do so in those with abnormal hemodynamics and restricted reserve capacity. Both studies showed that the reduction in NIRS values was simultaneous with the development of arrhythmia. Tobias managed to record a preoperative hypercyanotic spell in a patient with tetralogy of Fallot and reported that NIRS fell up to 15–30 s before pulse oxymetry readings (13). In our study, the fall in NIRS values of a patient with tetralogy of Fallot entering a cyanotic spell was recorded 10–15 s earlier than its manifestation on the pulse oxymeter, and the patient immediately received treatment; similarly oxygen saturation recovered on pulse oxymetry 10–15 s later than the recovery in NIRS values. Therefore, the patient’s spell could be predicted and the response to therapy could be evaluated. It is not known whether there may be a future neurodevelopmental difference between patients who showed a NIRS reduction and those who did not. These patients are being further followed up, prospectively. The only published report we identified on patients undergoing balloon valvuloplasty is that by de Vries et al. (8). Patients were divided into two groups according to the presence or absence of an intracardiac shunt. Group 1 consisted of patients with Artif Organs, Vol. 38, No. 10, 2014

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stenosis of the pulmonary trunk after a previous arterial switch procedure for transposition of the great arteries (n = 4) or congenital aortic stenosis (n = 2), while the five patients in Group 2 had congenital pulmonary stenosis and an associated interatrial communication with the potential for a right-to-left shunt. Cerebral blood flow monitoring used both middle cerebral artery (MCA) flow determination by transcranial Doppler sonography and the NIRS device to record regional tissue oxygenation. In the six Group 1 patients who had no intracardiac shunt, inflation of the balloon caused a decrease in MCA velocity (Vmca) followed by a minor decrease in regional oxygen saturation (rSO2). In Group 2, consisting of five patients with interatrial communication, inflation resulted in an increase in right-to-left shunt fraction, arterial desaturation, a major decrease in rSO2 and minor changes in Vmca. Balloon dilatation affected cerebral oxygen delivery, either by a decrease in blood flow velocity or a decrease in arterial oxygen content (8). Although MCA flow was not investigated in our study, a fall in cerebral NIRS values was apparent in all patients. While marked desaturation was present in all five patients with interatrial communication, none of the five patients without such communication had a reduction of over 5% in oxygen saturation. CONCLUSION Near-infrared spectroscopy monitoring may provide an early warning with regard to complications likely to develop in pediatric patients undergoing cardiac catheterization. We believe that routine renal and cranial NIRS monitoring may profit pediatric cases at risk during cardiac catheterization. Limitations of the study Some of our results could not be interpreted due to the very wide distribution of patient and cardiac disease characteristics. We therefore suggest that studies with larger numbers of patients should be conducted. Author contributions: Concept/design: Ibrahim Cansaran Tanidir, Alper Guzeltas, Ender Odemis. Data collection: Ibrahim Cansaran Tanidir, Erkut Ozturk, Murat Saygi. Data analysis/interpretation:

Artif Organs, Vol. 38, No. 10, 2014

Ibrahim Cansaran Tanidir, Neslihan Kiplapinar, Sertac Haydin. Statistics: Erkut Ozturk, Isa Ozyilmaz. Drafting article: Ibrahim Cansaran Tanidir, Erkut Ozturk, Isa Ozyilmaz, Murat Saygi, Neslihan Kiplapinar. Critical revision of article: Sertac Haydin, Alper Guzeltas, Ender Odemis. Approval of article: Ibrahim Cansaran Tanidir, Erkut Ozturk, Isa Ozyilmaz, Murat Saygi, Neslihan Kiplapinar, Sertac Haydin, Alper Guzeltas, Ender Odemis. Acknowledgment: We want to thank Konyalioglu for additional statistical advice.

Rana

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Near infrared spectroscopy monitoring in the pediatric cardiac catheterization laboratory.

Near-infrared spectroscopy (NIRS) is a noninvasive method used to evaluate tissue oxygenation. We evaluated the relationship between cerebral and rena...
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