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Eur J Pediatr Surg 2019; 29(01): 014-022
DOI: 10.1055/s-0038-1668144
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Cardiogenic Necrotizing Enterocolitis: A Clinically Distinct Entity from Classical Necrotizing Enterocolitis

Elisa Siano
1   Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
,
Giuseppe Lauriti
2   Department of Pediatric Surgery, Spirito Santo Hospital, Pescara, and G. d'Annunzio University, Chieti-Pescara, Italy
,
Silvia Ceccanti
3   Pediatric Surgery Unit, Sapienza University of Rome, Azienda Policlinico Umberto I, Rome, Italy
,
Augusto Zani
1   Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
4   Department of Surgery, University of Toronto, Toronto, Ontario, Canada
› Author Affiliations
Further Information

Publication History

15 May 2018

26 June 2018

Publication Date:
15 August 2018 (online)

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Abstract

Aim The main purpose of this study was to investigate if necrotizing enterocolitis (NEC) has a different presentation and outcome in patients with congenital heart defect (CHD) (cardiogenic NEC) from those without (classical NEC).

Materials and Methods A systematic review of the literature on the characteristics of infants with NEC and CHD was performed by three independent investigators using a defined strategy (PubMed, Cochrane, Embase, and Web of Science). A meta-analysis was conducted on studies comparing NEC in infants with CHD and non-CHD infants using RevMan 5.3.

Results Systematic review: Of 7,291 abstracts screened, 126 full-text articles were analyzed and 51 studies were included. NEC had an incidence of 5.1% in CHD infants (7,728/151,046, range 0–24%) and 0.8% in non-CHD infants (26,430/3,256,891, range 0.1–8.9%; p < 0.0001). In very low birth weight infants, NEC occurred in 6.3% of CHD patients (6,361/100,454pts) and in 8.9% of non-CHD (23,201/257,794pts; p < 0.0001). In CHD cases, NEC occurred before cardiac surgery in 48% cases and surgery for NEC was required in 31% infants (2,037/6,683). Meta-analysis: In eight comparative studies, the incidence of NEC was higher in CHD infants (6%, 768/13,145) than in infants with no CHD (0.9%, 32,625/3,354,323pts; p < 0.00001, odds ratio [OR] 1.84, 95% confidence interval [CI] 1.7–1.9). The overall mortality was higher in infants with CHD and NEC (38%, 243/640) than in those without CHD (27%, 6651/24810; p < 0.00001, OR 3.4, 95% CI 2.8–4.1).

Conclusion This is the first evidence-based study showing that infants with cardiogenic NEC have different demographics and outcomes than those with classical NEC. The risk of developing NEC and the mortality rate are higher among infants with CHD than in those without. Conversely, the need for intestinal surgery is lower in babies with cardiogenic NEC than in those with classical NEC. Further studies are needed to establish preventative and management interventions that are specific to infants with or at risk of developing cardiogenic NEC.

Keywords

necrotizing enterocolitis - meta-analysis - systematic review - congenital heart defect - neonates

Supplementary Material

 

  • References

  • 1 Guner YS, Friedlich P, Wee CP, Dorey F, Camerini V, Upperman JS. State-based analysis of necrotizing enterocolitis outcomes. J Surg Res 2009; 157 (01) 21-29
    CrossrefPubMedGoogle Scholar
  • 2 Llanos AR, Moss ME, Pinzòn MC, Dye T, Sinkin RA, Kendig JW. Epidemiology of neonatal necrotising enterocolitis: a population-based study. Paediatr Perinat Epidemiol 2002; 16 (04) 342-349
    CrossrefPubMedGoogle Scholar
  • 3 Foglia RP. Necrotizing enterocolitis. Curr Probl Surg 1995; 32 (09) 757-823
    CrossrefPubMedGoogle Scholar
  • 4 Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am 1986; 33 (01) 179-201
    CrossrefPubMedGoogle Scholar
  • 5 Andrews DA, Sawin RS, Ledbetter DJ, Schaller RT, Hatch EI. Necrotizing enterocolitis in term neonates. Am J Surg 1990; 159 (05) 507-509
    CrossrefPubMedGoogle Scholar
  • 6 Ostlie DJ, Spilde TL, St Peter SD. , et al. Necrotizing enterocolitis in full-term infants. J Pediatr Surg 2003; 38 (07) 1039-1042
    CrossrefPubMedGoogle Scholar
  • 7 Polin RA, Pollack PF, Barlow B. , et al. Necrotizing enterocolitis in term infants. J Pediatr 1976; 89 (03) 460-462
    CrossrefPubMedGoogle Scholar
  • 8 Bolisetty S, Lui K, Oei J, Wojtulewicz J. A regional study of underlying congenital diseases in term neonates with necrotizing enterocolitis. Acta Paediatr 2000; 89 (10) 1226-1230
    CrossrefPubMedGoogle Scholar
  • 9 Ahle M, Drott P, Elfvin A, Andersson RE. Maternal, fetal and perinatal factors associated with necrotizing enterocolitis in Sweden. A national case-control study. PLoS One 2018; 13 (03) e0194352
    CrossrefPubMedGoogle Scholar
  • 10 Giannone PJ, Luce WA, Nankervis CA, Hoffman TM, Wold LE. Necrotizing enterocolitis in neonates with congenital heart disease. Life Sci 2008; 82 (7-8): 341-347
    CrossrefPubMedGoogle Scholar
  • 11 Carlo WF, Kimball TR, Michelfelder EC, Border WL. Persistent diastolic flow reversal in abdominal aortic Doppler-flow profiles is associated with an increased risk of necrotizing enterocolitis in term infants with congenital heart disease. Pediatrics 2007; 119 (02) 330-335
    CrossrefPubMedGoogle Scholar
  • 12 McElhinney DB, Hedrick HL, Bush DM. , et al. Necrotizing enterocolitis in neonates with congenital heart disease: risk factors and outcomes. Pediatrics 2000; 106 (05) 1080-1087
    CrossrefPubMedGoogle Scholar
  • 13 Kliegman RM. Models of the pathogenesis of necrotizing enterocolitis. J Pediatr 1990; 117 (1 Pt 2): S2-S5
    CrossrefPubMedGoogle Scholar
  • 14 Moher D, Liberati A, Tetzlaff J, Altman DG. ; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6 (07) e1000097
    CrossrefPubMedGoogle Scholar
  • 15 PROSPERO International Prospective Register of Systematic Reviews. Available at: http://www.crd.york.ac.uk/prospero/about.php?about=about . Accessed April 15, 2018
    PubMed
  • 16 Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration; 2014
    Google Scholar
  • 17 Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 2005; 20 (05) 13
    PubMedGoogle Scholar
  • 18 Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 2003; 73 (09) 712-716
    CrossrefPubMedGoogle Scholar
  • 19 Shea BJ, Grimshaw JM, Wells GA. , et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007; 7: 10
    CrossrefPubMedGoogle Scholar
  • 20 Shapiro AJ, Kavey RE, Dangman BC. , et al. Necrotizing enterocolitis syndrome in symptomatic infants with congenital heart disease. Pediatr Res 1977; 11: 542
    PubMedGoogle Scholar
  • 21 Dickinson DF, Galloway RW, Wilkinson JL, Arnold R. Necrotising enterocolitis after neonatal cardiac catheterisation. Arch Dis Child 1982; 57 (06) 431-433
    CrossrefPubMedGoogle Scholar
  • 22 Leung MP, Chau KT, Hui PW. , et al. Necrotizing enterocolitis in neonates with symptomatic congenital heart disease. J Pediatr 1988; 113 (06) 1044-1046
    CrossrefPubMedGoogle Scholar
  • 23 Bartram U, Grünenfelder J, Van Praagh R. Causes of death after the modified Norwood procedure: a study of 122 postmortem cases. Ann Thorac Surg 1997; 64 (06) 1795-1802
    CrossrefPubMedGoogle Scholar
  • 24 Sweet DG, Craig B, Halliday HL, Mulholland C. Gastro-intestinal complications following neonatal cardiac catheterisation. J Perinat Med 1998; 26 (03) 196-200
    CrossrefPubMedGoogle Scholar
  • 25 Cheng W, Leung MP, Tam PK. Surgical intervention in necrotizing enterocolitis in neonates with symptomatic congenital heart disease. Pediatr Surg Int 1999; 15 (07) 492-495
    CrossrefPubMedGoogle Scholar
  • 26 Dees E, Lin H, Cotton RB, Graham TP, Dodd DA. Outcome of preterm infants with congenital heart disease. J Pediatr 2000; 137 (05) 653-659
    CrossrefPubMedGoogle Scholar
  • 27 Thies WR, Breymann T, Boethig D, Blanz U, Meyer H, Koerfer R. Results of staged reconstruction for hypoplasia of the left heart: an experience of 12 years from one institution. Cardiol Young 2003; 13 (06) 509-518
    CrossrefPubMedGoogle Scholar
  • 28 Jenkins PC, Flanagan MF, Jenkins KJ. , et al. Morbidities in patients with hypoplastic left heart syndrome. Pediatr Cardiol 2004; 25 (01) 3-10
    CrossrefPubMedGoogle Scholar
  • 29 Kelleher DK, Laussen P, Teixeira-Pinto A, Duggan C. Growth and correlates of nutritional status among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure. Nutrition 2006; 22 (03) 237-244
    CrossrefPubMedGoogle Scholar
  • 30 Jeffries HE, Wells WJ, Starnes VA, Wetzel RC, Moromisato DY. Gastrointestinal morbidity after Norwood palliation for hypoplastic left heart syndrome. Ann Thorac Surg 2006; 81 (03) 982-987
    CrossrefPubMedGoogle Scholar
  • 31 Lambert DK, Christensen RD, Henry E. , et al. Necrotizing enterocolitis in term neonates: data from a multihospital health-care system. J Perinatol 2007; 27 (07) 437-443
    CrossrefPubMedGoogle Scholar
  • 32 Braudis NJ, Curley MA, Beaupre K. , et al. Enteral feeding algorithm for infants with hypoplastic left heart syndrome poststage I palliation. Pediatr Crit Care Med 2009; 10 (04) 460-466
    CrossrefPubMedGoogle Scholar
  • 33 Pickard SS, Feinstein JA, Popat RA, Huang L, Dutta S. Short- and long-term outcomes of necrotizing enterocolitis in infants with congenital heart disease. Pediatrics 2009; 123 (05) e901-e906
    CrossrefPubMedGoogle Scholar
  • 34 del Castillo SL, McCulley ME, Khemani RG. , et al. Reducing the incidence of necrotizing enterocolitis in neonates with hypoplastic left heart syndrome with the introduction of an enteral feed protocol. Pediatr Crit Care Med 2010; 11 (03) 373-377
    PubMedGoogle Scholar
  • 35 Mukherjee D, Zhang Y, Chang DC, Vricella LA, Brenner JI, Abdullah F. Outcomes analysis of necrotizing enterocolitis within 11 958 neonates undergoing cardiac surgical procedures. Arch Surg 2010; 145 (04) 389-392
    PubMedGoogle Scholar
  • 36 Natarajan G, Reddy Anne S, Aggarwal S. Enteral feeding of neonates with congenital heart disease. Neonatology 2010; 98 (04) 330-336
    CrossrefPubMedGoogle Scholar
  • 37 Luce WA, Schwartz RM, Beauseau W. , et al. Necrotizing enterocolitis in neonates undergoing the hybrid approach to complex congenital heart disease. Pediatr Crit Care Med 2011; 12 (01) 46-51
    CrossrefPubMedGoogle Scholar
  • 38 Weiss SL, Gossett JG, Kaushal S, Wang D, Backer CL, Wald EL. Comparison of gastrointestinal morbidity after Norwood and hybrid palliation for complex heart defects. Pediatr Cardiol 2011; 32 (04) 391-398
    CrossrefPubMedGoogle Scholar
  • 39 Natarajan G, Anne SR, Aggarwal S. Outcomes of congenital heart disease in late preterm infants: double jeopardy?. Acta Paediatr 2011; 100 (08) 1104-1107
    CrossrefPubMedGoogle Scholar
  • 40 Cheng HH, Almodovar MC, Laussen PC. , et al. Outcomes and risk factors for mortality in premature neonates with critical congenital heart disease. Pediatr Cardiol 2011; 32 (08) 1139-1146
    CrossrefPubMedGoogle Scholar
  • 41 Christensen RD, Lambert DK, Baer VL, Gordon PV. Necrotizing enterocolitis in term infants. Clin Perinatol 2013; 40 (01) 69-78
    CrossrefPubMedGoogle Scholar
  • 42 Iannucci GJ, Oster ME, Mahle WT. Necrotising enterocolitis in infants with congenital heart disease: the role of enteral feeds. Cardiol Young 2013; 23 (04) 553-559
    CrossrefPubMedGoogle Scholar
  • 43 Davies RR, Carver SW, Schmidt R, Keskeny H, Hoch J, Pizarro C. Gastrointestinal complications after stage I Norwood versus hybrid procedures. Ann Thorac Surg 2013; 95 (01) 189-195
    CrossrefPubMedGoogle Scholar
  • 44 Kargl S, Maier R, Gitter R, Pumberger W. Necrotizing enterocolitis after open cardiac surgery for congenital heart defects—a serious threat. Klin Padiatr 2013; 225 (01) 24-28
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Cozzi C, Aldrink J, Nicol K, Nicholson L, Cua C. Intestinal location of necrotizing enterocolitis among infants with congenital heart disease. J Perinatol 2013; 33 (10) 783-785
    CrossrefPubMedGoogle Scholar
  • 46 Dilli D, Aydin B, Zenciroğlu A, Özyazici E, Beken S, Okumuş N. Treatment outcomes of infants with cyanotic congenital heart disease treated with synbiotics. Pediatrics 2013; 132 (04) e932-e938
    CrossrefPubMedGoogle Scholar
  • 47 Cozzi C, Stines J, Luce WA. , et al. Diastolic flow parameters are not sensitive in predicting necrotizing enterocolitis in patients undergoing hybrid procedure. Congenit Heart Dis 2013; 8 (03) 234-239
    CrossrefPubMedGoogle Scholar
  • 48 Miller TA, Minich LL, Lambert LM, Joss-Moore L, Puchalski MD. Abnormal abdominal aorta hemodynamics are associated with necrotizing enterocolitis in infants with hypoplastic left heart syndrome. Pediatr Cardiol 2014; 35 (04) 616-621
    CrossrefPubMedGoogle Scholar
  • 49 Baxi AC, Josephson CD, Iannucci GJ, Mahle WT. Necrotizing enterocolitis in infants with congenital heart disease: the role of red blood cell transfusions. Pediatr Cardiol 2014; 35 (06) 1024-1029
    CrossrefPubMedGoogle Scholar
  • 50 DeWitt AG, Charpie JR, Donohue JE, Yu S, Owens GE. Splanchnic near-infrared spectroscopy and risk of necrotizing enterocolitis after neonatal heart surgery. Pediatr Cardiol 2014; 35 (07) 1286-1294
    CrossrefPubMedGoogle Scholar
  • 51 Bain J, Benjamin Jr DK, Hornik CP, Benjamin DK, Clark R, Smith PB. Risk of necrotizing enterocolitis in very-low-birth-weight infants with isolated atrial and ventricular septal defects. J Perinatol 2014; 34 (04) 319-321
    CrossrefPubMedGoogle Scholar
  • 52 Cozzi CT, Galantowicz M, Cheatham JP. , et al. Ultrasound assessment of mesenteric blood flow in neonates with hypoplastic left heart before and after hybrid palliation. Cardiol Young 2015; 25 (06) 1074-1079
    CrossrefPubMedGoogle Scholar
  • 53 Fisher JG, Bairdain S, Sparks EA. , et al. Serious congenital heart disease and necrotizing enterocolitis in very low birth weight neonates. J Am Coll Surg 2015; 220 (06) 1018-1026
    CrossrefPubMedGoogle Scholar
  • 54 Güney LH, Araz C, Beyazpınar DS, Arda İS, Arslan EE, Hiçsönmez A. Abdominal problems in children with congenital cardiovascular abnormalities. Balkan Med J 2015; 32 (03) 285-290
    CrossrefPubMedGoogle Scholar
  • 55 Motta C, Scott W, Mahony L. , et al. The association of congenital heart disease with necrotizing enterocolitis in preterm infants: a birth cohort study. J Perinatol 2015; 35 (11) 949-953
    CrossrefPubMedGoogle Scholar
  • 56 Alten JA, Rhodes LA, Tabbutt S. , et al. Perioperative feeding management of neonates with CHD: analysis of the Pediatric Cardiac Critical Care Consortium (PC4) registry. Cardiol Young 2015; 25 (08) 1593-1601
    CrossrefPubMedGoogle Scholar
  • 57 Becker KC, Hornik CP, Cotten CM. , et al. Necrotizing enterocolitis in infants with ductal-dependent congenital heart disease. Am J Perinatol 2015; 32 (07) 633-638
    Article in Thieme ConnectPubMedGoogle Scholar
  • 58 Carpenito KR, Prusinski R, Kirchner K. , et al. Results of a feeding protocol in patients undergoing the hybrid procedure. Pediatr Cardiol 2016; 37 (05) 852-859
    CrossrefPubMedGoogle Scholar
  • 59 Ferguson LP, Gandiya T, Kaselas C, Sheth J, Hasan A, Gabra HO. Gastrointestinal complications associated with the surgical treatment of heart disease in children. J Pediatr Surg 2017; 52 (03) 414-419
    CrossrefPubMedGoogle Scholar
  • 60 Scahill CJ, Graham EM, Atz AM, Bradley SM, Kavarana MN, Zyblewski SC. Preoperative feeding neonates with cardiac disease. World J Pediatr Congenit Heart Surg 2017; 8 (01) 62-68
    CrossrefPubMedGoogle Scholar
  • 61 Tadphale SD, Tang X, ElHassan NO, Beam B, Prodhan P. Cavopulmonary anastomosis during same hospitalization as stage 1 Norwood/hybrid palliative surgery. Ann Thorac Surg 2017; 103 (04) 1285-1291
    CrossrefPubMedGoogle Scholar
  • 62 Manuri L, Morelli S, Agati S. , et al. Early hybrid approach and enteral feeding algorithm could reduce the incidence of necrotising enterocolitis in neonates with ductus-dependent systemic circulation. Cardiol Young 2017; 27 (01) 154-160
    CrossrefPubMedGoogle Scholar
  • 63 Steurer MA, Baer RJ, Keller RL. , et al. Gestational age and outcomes in critical congenital heart disease. Pediatrics 2017; 140 (04) e20170999
    CrossrefPubMedGoogle Scholar
  • 64 Velazco CS, Fullerton BS, Hong CR. , et al. Morbidity and mortality among “big” babies who develop necrotizing enterocolitis: a prospective multicenter cohort analysis. J Pediatr Surg 2017; S0022-3468(17)30650-4
    PubMedGoogle Scholar
  • 65 Lau PE, Cruz SM, Ocampo EC. , et al. Necrotizing enterocolitis in patients with congenital heart disease: a single center experience. J Pediatr Surg 2018; 53 (05) 914-917
    CrossrefPubMedGoogle Scholar
  • 66 ElHassan NO, Tang X, Gossett J. , et al. Necrotizing enterocolitis in infants with hypoplastic left heart syndrome following stage 1 palliation or heart transplant. Pediatr Cardiol 2018; 39 (04) 774-785
    CrossrefPubMedGoogle Scholar
  • 67 Schuchardt EL, Kaufman J, Lucas B, Tiernan K, Lujan SO, Barrett C. Suspected necrotising enterocolitis after surgery for CHD: an opportunity to improve practice and outcomes. Cardiol Young 2018; 28 (05) 639-646
    CrossrefPubMedGoogle Scholar
  • 68 Al Tawil K, Sumaily H, Ahmed IA. , et al. Risk factors, characteristics and outcomes of necrotizing enterocolitis in late preterm and term infants. J Neonatal Perinatal Med 2013; 6 (02) 125-130
    PubMedGoogle Scholar
  • 69 Lu Q, Cheng S, Zhou M, Yu J. Risk factors for necrotizing enterocolitis in neonates: a retrospective case-control study. Pediatr Neonatol 2017; 58 (02) 165-170
    CrossrefPubMedGoogle Scholar
  • 70 Zani A, Pierro A. Necrotizing enterocolitis: controversies and challenges. F1000 Res 2015; 4: 4
    CrossrefPubMedGoogle Scholar
  • 71 Ellis CL, Rutledge JC, Underwood MA. Intestinal microbiota and blue baby syndrome: probiotic therapy for term neonates with cyanotic congenital heart disease. Gut Microbes 2010; 1 (06) 359-366
    CrossrefPubMedGoogle Scholar
  • 72 Battersby C, Santhalingam T, Costeloe K, Modi N. Incidence of neonatal necrotising enterocolitis in high-income countries: a systematic review. Arch Dis Child Fetal Neonatal Ed 2018; 103 (02) F182-F189
    CrossrefPubMedGoogle Scholar
  • 73 Thilo EH, Lazarte RA, Hernandez JA. Necrotizing enterocolitis in the first 24 hours of life. Pediatrics 1984; 73 (04) 476-480
    PubMedGoogle Scholar
  • 74 Sharma R, Hudak ML, Tepas III JJ. , et al. Impact of gestational age on the clinical presentation and surgical outcome of necrotizing enterocolitis. J Perinatol 2006; 26 (06) 342-347
    CrossrefPubMedGoogle Scholar
  • 75 Yaseen H, Kamaledin K, Al Umran K, Al Arfaj A, Darwich M, Awary B. Epidemiology and outcome of “early-onset” vs “late-onset” necrotizing enterocolitis. Indian J Pediatr 2002; 69 (06) 481-484
    CrossrefPubMedGoogle Scholar
  • 76 González-Rivera R, Culverhouse RC, Hamvas A, Tarr PI, Warner BB. The age of necrotizing enterocolitis onset: an application of Sartwell's incubation period model. J Perinatol 2011; 31 (08) 519-523
    CrossrefPubMedGoogle Scholar
  • 77 Short SS, Papillon S, Berel D, Ford HR, Frykman PK, Kawaguchi A. Late onset of necrotizing enterocolitis in the full-term infant is associated with increased mortality: results from a two-center analysis. J Pediatr Surg 2014; 49 (06) 950-953
    CrossrefPubMedGoogle Scholar
  • 78 Baos S, Sheehan K, Culliford L. , et al. Normothermic versus hypothermic cardiopulmonary bypass in children undergoing open heart surgery (thermic-2): study protocol for a randomized controlled trial. JMIR Res Protoc 2015; 4 (02) e59
    CrossrefPubMedGoogle Scholar
  • 79 Edmunds LH. Inflammatory immunological response to cardiopulmonary bypass. In: Jonas RA, Elliott M. , eds. Cardiopulmonary Bypass in Neonates, Infants and Young Children. Boston, MA: Butterworth-Heinemann/Oxford; 1994
    Google Scholar
  • 80 Booker PD, Romer H, Franks R. Gut mucosal perfusion in neonates undergoing cardiopulmonary bypass. Br J Anaesth 1996; 77 (05) 597-602
    CrossrefPubMedGoogle Scholar
  • 81 Laussen PC. Neonates with congenital heart disease. Curr Opin Pediatr 2001; 13 (03) 220-226
    CrossrefPubMedGoogle Scholar
  • 82 Malagon I, Onkenhout W, Klok G, van der Poel PF, Bovill JG, Hazekamp MG. Gut permeability in paediatric cardiac surgery. Br J Anaesth 2005; 94 (02) 181-185
    CrossrefPubMedGoogle Scholar
  • 83 Malagon I, Onkenhout W, Klok M, van der Poel PF, Bovill JG, Hazekamp MG. Gut permeability in neonates after a stage 1 Norwood procedure. Pediatr Crit Care Med 2005; 6 (05) 547-549
    CrossrefPubMedGoogle Scholar
  • 84 Hebra A, Brown MF, Hirschl RB. , et al. Mesenteric ischemia in hypoplastic left heart syndrome. J Pediatr Surg 1993; 28 (04) 606-611
    CrossrefPubMedGoogle Scholar