Pediatric Cardiology

, Volume 35, Issue 2, pp 239–252

How Not to Tell Parents About Their Child’s New Diagnosis of Congenital Heart Disease: An Internet Survey of 841 Parents

  • Debra Hilton-Kamm
  • Mark Sklansky
  • Ruey-Kang Chang
Original Article

DOI: 10.1007/s00246-013-0765-6

Cite this article as:
Hilton-Kamm, D., Sklansky, M. & Chang, RK. Pediatr Cardiol (2014) 35: 239. doi:10.1007/s00246-013-0765-6

Abstract

An online survey for parents of children with congenital heart disease (CHD) was developed to study the perceptions and experiences of parents when receiving the diagnosis. The survey was distributed to online support groups. A total of 841 responses from parents of children with CHD in the United States were received over a 4-week period in 2010. The authors hypothesized that the counseling and demeanor of the pediatric cardiologist (PC) may be important factors in determining whether parents of children with CHD seek second opinions, and that the terminology used in counseling may be variably interpreted. Of the 841 respondents, 349 (41 %) received the diagnosis prenatally. A minority of the respondents received: support group information (14 %), Internet resources (21 %), success rates at other hospitals (16 %), or maximum ages of survivors (29 %). Among 26 % of the parents who reported seeking a second opinion from another PC, the majority (71 %) chose the second PC for long-term follow-up care. Those receiving a prenatal diagnosis were more likely to seek a second opinion than those receiving the diagnosis postnatally (32 vs 22 %; p < 0.01). Parents’ perception of the PC’s compassion and empathy was inversely related to the likelihood of seeking a second opinion. Parents were more likely to seek a second opinion when they were not optimistic about their child’s life expectancy, felt pressured by the PC to terminate the pregnancy, were told that their child’s death was “somewhat” or “very” likely, or were told the child’s CHD was “rare” (all p < 0.01). Two thirds (66 %) of the respondents were told that their child’s condition was “rare.” The majority of these (77 %) reported that the term was used by the PC. “Rare” was interpreted as “occurring in less than a million births” by 25 %, and as “few or no other people alive with this defect” by 27 %. Parental interpretation of “rare” was unrelated to their levels of education. As reported by the respondents, 13 % felt pressured to terminate the pregnancy by the PC. Those with hypoplastic left heart syndrome were more likely to report feeling pressure to terminate the pregnancy by the PC (21 vs 9 %; p < 0.001) or the perinatologist (23 vs 14 %; p = 0.026). The approach to counseling and the demeanor of the PC have important implications for parents’ perceptions of their child’s chance of survival. The information given at diagnosis, the manner in which it is presented, and the parents’ understanding and interpretation of that information are critical factors in shaping parents’ perceptions and management decisions.

Keywords

Congenital heart disease Counseling Hypoplastic left heart syndrome Internet survey Parent perceptions Psychosocial needs Support groups 

Congenital heart disease (CHD) occurs in ~8 of 1,000 births in the United States, with approximately one-third of those cases requiring invasive treatment during the first year of life [22]. Parents confronted with the diagnosis of their child’s complex CHD must make critical decisions based on information given at the time of diagnosis, often within very short time frames. The decisions may include choosing where to have the treatment, selecting a treatment option, and determining whether or not to continue a pregnancy if the diagnosis is received prenatally. All these decisions hinge on the information parents are given at diagnosis as well as on their interpretation, understanding, and retention of that information.

Few studies have evaluated how information is provided to parents at the time of CHD diagnosis and how it is interpreted. Kon et al. [12] found great variability in information provided to parents of children with a diagnosis of hypoplastic left heart syndrome (HLHS) regarding treatment options. Arya et al. [2] recently found that parents of children with CHD prefer to receive more information than cardiologists provide during the prenatal and neonatal periods.

Advances in prenatal screening have led to an increased rate of CHD diagnosed in the fetal stage, allowing parents more time to research the condition and arrange for the delivery at an appropriate facility [3, 11, 14, 15, 25, 27]. However, the additional stress of considering termination of pregnancy may be difficult for some parents [21, 23, 24]. Some factors influencing the decision to terminate have been identified [2, 6], with findings showing significant differences in the importance of this decision between parents and physicians [2]. However, little research has examined the potential impact of prenatal counseling on parental decision making.

We developed an online survey to study parents’ perceptions and experiences of physician counseling at the time of their child’s CHD diagnosis. We hypothesized that the information provided and the manner in which it is delivered may have an impact on parents’ perceptions of their child’s survival and may subsequently influence decision making. We further hypothesized that the counseling and demeanor of the pediatric cardiologist (PC) may be important factors in determining whether parents of children with CHD seek second opinions and that the terminology used in counseling may be variably interpreted.

Methods

The survey was distributed to online support groups for parents of children with CHD through Zoomerang (now SurveyMonkey.com). This anonymous, 82-question survey included quantitative and qualitative questions regarding parents’ experiences at the time of CHD diagnosis. Because no personal identifying information was collected in the survey, this study was considered exempt from our Institutional Review Board. Selected survey questions are shown in “Appendix 1”.

Parents or guardians of children with CHD who lived in the United States at the time of diagnosis were eligible to participate in the survey. A total of 1,001 responses were received over a 4-week period in 2010. Responses were excluded if they failed to meet the eligibility criteria (n = 31) or if the survey was incomplete (n = 129). The remaining 841 responses represented the study population and were analyzed.

Because HLHS represented the largest CHD diagnosis group and often carries a worse prognosis, we compared HLHS and non-HLHS groups in many of the responses to the survey. Categorical variables and proportions were compared using the chi-square test. A p value lower than 0.05 was considered statistically significant.

Results

Respondent Characteristics

Of the 841 respondents, 95 % were mothers and 91 % were married at the time of the CHD diagnosis. The majority of the respondents (65 %) were 26–35 years of age at the time of the diagnosis. This cohort was well-educated, with 43 % holding a college degree and 20 % holding an advanced degree. The respondents primarily had private insurance and were from all regions of the United States.

At the time of the survey, the subjects with CHD ranged in age from younger than 1 year to older than 30 years, with the majority of the children 6 years of age or younger (63 %). Seven parents were expecting a child with CHD, and 73 respondents (9 %) reported that their child was deceased. Of those deceased, one was due to termination of pregnancy, and 48 (66 %) had a diagnosis of HLHS.

Table 1 describes the characteristics of the respondents. The largest group of respondents (25 %) reported their child’s diagnosis as HLHS. The next most commonly reported diagnoses were tetralogy of Fallot (12 %), transposition of the great arteries (9 %), and ventricular septal defect (5 %). Table 2 lists the diagnoses represented in our survey.
Table 1

Respondent characteristics

 

n

%

Relation to child

 Mother

795

95

 Father

42

5

 Other (stepparent, guardian)

4

<1

Marital status

 Single

77

9

 Married

759

91

Education level

 Some high school

16

2

 High school diploma

80

10

 Some college

214

26

 College degree

359

43

 Advanced degree

165

20

Insurance

 PPO

440

53

 HMO

192

23

 Medicaid

96

12

 Other

100

12

Region

 Northeast

120

14

 South

242

29

 West

265

32

 Midwest

206

24

Child’s age at survey

 Not yet born

7

<1

 <1 year

67

8

 1 to 3 years

284

34

 4 to 6 years

173

21

 7 to 10 years

112

13

 11 to 14 years

66

8

 15 to 20 years

41

5

 >20 years

18

2

 Deceased

73

9

PPO preferred provider organization, HMO health maintenance organization

Table 2

Most commonly reported diagnoses

Child’s diagnosis

n

%

HLHS

211

25

Tetralogy of Fallot

102

12

TGA

76

9

Other

43

5

VSD

41

5

CoA

37

4

HRHS

37

4

Pulmonary atresia

33

4

Tricuspid atresia

33

4

A-V canal defect

24

3

ASD

23

3

Truncus arteriosus

23

3

AVR or stenosis

20

2

DORV

18

2

DILV

15

2

Shone’s complex

15

2

Single ventricle

15

2

TAPVR

14

2

Less than 1 % reported for each of the following: pulmonary stenosis, DiGeorge syndrome, cardiomyopathy, Ebstein’s anomaly, interrupted aortic arch, mitral valve regurgitation, patent ductus arteriosus

HLHS hypoplastic left heart syndrome, TGA transposition of the great arteries, VSD ventricular septal defect, CoA coarctation of the aorta, HRHS hypoplastic right heart syndrome, A-V atrioventricular, ASD atrial septal defect, AVR aortic valve regurgitation, DORV double-outlet right ventricle, DILV double-inlet left ventricle, TAPVR total anomalous pulmonary vein return

More than 70 % of the respondents reported receiving the diagnosis within 6 years before the survey, and 51 % received the diagnosis within 3 years. The majority (92 %) of the children had undergone surgery at the time of the survey, with no difference found between those with HLHS and those with other diagnoses. The diagnosis was received prenatally for 65 % (138/211) of those with HLHS and 33 % (211/630) of those with other diagnoses.

Information and Support

The respondents received the following information from the first PC they consulted: treatment options (75 %), written information on the diagnosis (63 %), information on the ages of survivors (29 %), Internet resources/Web sites (21 %), success rates at different hospitals (16 %), and support group information (14 %). Parents of children with HLHS were more likely than their non-HLHS counterparts to first learn of support groups from an Internet search on their own (111/209 [53 %] vs 276/627 [44 %]; p = 0.02). Others first learned of support groups through hospital social workers/case managers (17 %), friends or family (10 %), a cardiologist (10 %), or a nurse (7 %). No difference was found between parents of those with HLHS and other diagnoses.

The open-ended question, “What else would have been helpful at diagnosis?” was asked, to which 408 (49 %) of the 841 parents responded. Almost half of the respondents (201 of 408) reported that more information at the time of diagnosis would have been helpful. According to the responses, 30 % would have liked more information on support groups or survivors with their child’s defects. Table 3 provides the number of responses by category. Selected quotes by theme are shown in “Appendix 2”.
Table 3

Open-ended question: what else would have been helpful when the diagnosis was received?

 

n

%

Information

 Content

  Information at diagnosis

32

8

  More information in general

28

7

  Long-term issues (QOL, DD)

24

6

  Resources (financial/insurance)

19

5

  Complications from surgery

12

3

  Treatment options

6

1

  Preparation for surgery

5

1

  Causes/genetics

3

1

 Statistics

  Statistics and survival rates

25

6

  Other hospitals’ statistics

16

4

 Delivery of information

  Written information/diagrams

20

5

  Simple terms

6

1

  Less information/overload

3

1

  Internet sites

2

0

 

201

49

Support

 Learning of survivors/support groups

102

25

 More hospital support (counseling)

22

5

 

124

30

Physician

 Compassion/empathy, reassurance

30

7

 More time with physician/follow-up appointment

16

4

 Positive/optimistic information

12

3

 Consistent information between physicians

12

3

 

70

17

Other

 Don’t know

40

10

 Miscellaneous

27

7

 Examples of good experiences

23

6

Responses are categorized by theme. Of the 841 respondents, 408 (49 %) responded to the question. Some respondents mentioned multiple categories, so the total exceeds 100 %

QOL quality of life, DD developmental delay

The two most commonly cited stress factors were “uncertainty of my child’s future” (87 %) and “not knowing about survivors with this defect” (52 %). The following also were rated as “very stressful” by respondents: financial concerns (41 %), conflicting medical opinions (28 %), confusion about insurance coverage (23 %), choosing a physician or surgeon (22 %), and lack of compassion and empathy from physicians (15 %). No difference was found between parents of children with HLHS and those with other diagnoses.

The Term “Rare”

Two thirds of respondents (66 %) were told that their child’s condition was “rare,” with 77 % reporting that the term was used by the PC. Those receiving the diagnosis of HLHS were more likely to be told the condition was “rare” and also more likely to be told that the condition was rare by the obstetrician or the perinatologist. Comparison of results between parents of children with HLHS and non-HLHS diagnoses is shown in Table 4.
Table 4

Results for parents of children with hypoplastic left heart syndrome (HLHS) versus those with a non-HLHS diagnosis

 

HLHS (%)

Non-HLHS (%)

p Value

Rare

 Told the condition was “rare”

88

58

<0.01

 Told the condition was “rare” by

  The pediatric cardiologist

74

80

NS

  The obstetrician

22

9

<0.01

  The perinatologist

24

9

<0.01

 Interpreted “rare” to mean

  Few or no other people alive with this defect

30

30

NS

  Occurs in fewer than one in a million births

27

25

NS

  Little or no chance of survival

23

14

0.01

Second opinion

 Sought second opinion

27

26

NS

 Chose different PC for follow-up

68

73

NS

Optimism/prognosis

 Was “very optimistic” about the child’s life expectancy after meeting with PC

15

38

<0.01

 Told death was “very likely” by PC

20

8

<0.01

Termination of pregnancy

 Felt pressured to terminate by the PC

21

9

<0.01

 Felt pressured to terminate by the perinatologist

23

14

0.03

 Had termination mentioned after they declined

35

21

<0.01

 Optimistic about child’s life expectancy after termination was mentioned again

67

94

<0.01

 Sought second opinion if felt pressure to terminate

59

28

<0.01

NS not significant, PC pediatric cardiologist

“Rare” was interpreted as “few or no other people alive with this defect” by 27 % of respondents, and as “occurring in less than a million births” by 25 %, with no difference found for education level or for HLHS cases. Those receiving the diagnosis of HLHS were more likely to interpret “rare” to mean “there was little or no chance of survival.” The respondents receiving non-HLHS diagnoses were less likely to report being “very optimistic” about their child’s life expectancy when told the condition was rare (100 of 366 [27 %] vs 135 of 259 [52 %]; p < 0.0001).

Second Opinions

According to their reports, 26 % of the parents (221 of 841) sought a second opinion from a second PC. Of these parents, 72 % (158 of 221) chose a different PC for long-term follow-up care. The main reasons cited for seeking a second opinion (the respondents checked all applicable reasons, so the total exceeds 100 %) were as follows:
  • To find someone who had more experience with our child’s diagnosis (n = 108, 49 %)

  • To see if other treatment options were available (n = 102, 46 %)

  • To find someone with more compassion and empathy (n = 76, 36 %)

  • To find someone who was more positive about my child’s future (n = 69, 31 %).

No difference was found between parents of children with HLHS and those with other diagnoses, or between those receiving the diagnosis prenatally and those receiving the diagnosis after birth. Parents’ perception of the PC’s compassion and empathy was inversely related to the likelihood of seeking a second opinion (Fig. 1).
Fig. 1

Relation between parents’ rating of pediatric cardiologists’ compassion/empathy and seeking a second opinion

The parents whose children had HLHS were more likely to be told by the first PC they consulted that the child’s death was “very likely” than their non-HLHS counterparts and were less likely to report being “very optimistic” regarding their child’s life expectancy.

The respondents who were “not optimistic” about their child’s life expectancy were more likely to seek a second opinion (59 of 138 [43 %] vs 148 of 676 [22 %]; p < 0.0001). Parents receiving a non-HLHS diagnosis were more likely to seek a second opinion if they were told the child’s death was “somewhat” or “very” likely (57 of 173 [33 %] vs 91 of 406 [22 %]; p = 0.011) or if they were told the child’s condition was “rare” (110 of 369 [30 %] vs 55 of 261 [21 %]; p = 0.012).

Pressure to Terminate

Of the 841 respondents, 349 (41 %) received the diagnosis prenatally: 65 % of parents of children with HLHS (138 of 211) and 33 % of parents of children with other diagnoses (211 of 630). Of the 349 parents who received prenatal diagnoses, 47 (13 %) reported feeling “somewhat” or “very” pressured by the PC to terminate the pregnancy. No difference was found for maternal age, education level, insurance type, or the presence of other major congenital abnormalities.

More parents reported feeling “very pressured” to terminate the pregnancy by the perinatologist than by the PC (7 vs 3 %; p = 0.02). More parents felt “somewhat” or “very” pressured to terminate by the PC when termination was mentioned again after they declined (26 vs 18 %; p < 0.01) or when they were told the condition was rare (16 vs 7 %; p = 0.03).

Those who felt pressured by the PC to terminate the pregnancy were less likely to report being optimistic about their child’s life expectancy (22 of 47 [47 %] vs 240 of 287 [84 %]; p < 0.0001) and more likely to rate the PC’s compassion and empathy as “poor” or “fair” (30 of 47 [64 %] vs 39 of 284 [14 %]; p < 0.0001. No difference was found between HLHS and non-HLHS diagnoses.

Those receiving a diagnosis of HLHS were more likely to feel pressure by the PC or perinatologist to terminate the pregnancy, to have termination mentioned again after they declined, and to seek a second opinion if they felt pressured to terminate the pregnancy by the PC. Parents of children with HLHS were less likely to report being optimistic about their child’s life expectancy when termination of the pregnancy was mentioned again.

Discussion

The information received at a CHD diagnosis and the manner in which it is given may shape parents’ perceptions of their child’s chance for survival and might influence decision making. Due to the lifelong consequences of these decisions, obtaining clear, accurate information is of great importance to parents.

Parents in the United Kingdom have access to procedure volume and mortality rates of CHD surgical centers through an online database, ensuring that all parents have access to the same data [28]. In the United States, however, physicians remain the primary source of information for parents due to the lack of a public reporting structure for outcomes of treatment for CHD. This survey sought to gain insight into what information is presented to families at the diagnosis of CHD.

Several studies investigating HLHS have found great variation in information presented by cardiologists regarding treatment options and estimates of survival. Prsa et al. [19] found that physicians did not relate all treatment options to parents receiving the diagnosis of their child’s HLHS. Kon et al. [12] found that recommendations for treatment were associated with the procedure most commonly performed at the physician’s affiliated hospital and not with the physician’s belief in the best outcome. The majority of the respondents in our survey received information on the diagnosis and treatment options, but the scope and accuracy of the information provided is unknown.

In our study, the parents of children with a diagnosis of HLHS were more likely to be told the child’s death was very likely and less likely to be optimistic than those who received a non-HLHS diagnoses. The survival estimates for HLHS vary considerably. Some predict that 70 % of newborns currently born with HLHS may reach adulthood [7]. However, among physicians at the largest 14 cardiac centers in the United States, the estimates of 1-year survival varied from 30 to 88 % for three-stage surgeries, and from 5 to 90 % for heart transplantation [12]. These divergent estimates of survival may be due in part to the considerable variation in surgical outcomes among hospitals [4, 5, 9, 17]. Some parents, therefore, are given a more negative prognosis than others regarding the diagnosis of HLHS, which may have an impact on their perceptions and decision making [8].

The majority of the respondents noted that more information at diagnosis would have been helpful. This is consistent with the study by Arya et al. [2], which found that parents of children with CHD ranked educational topics as more important than did cardiologists, illustrating that parents prefer more information than cardiologists provide.

Only a minority of the respondents in our survey obtained information on Internet resources from the PC. According to the findings of Ikemba et al. [10] in 2002, more than half of the families of children with CHD that had Internet access sought diagnosis-specific information online. The majority found the information obtained via the Internet to be helpful. Currently, with the likelihood of increased Internet use by parents, an even greater need exists for physicians to give pre-approved, pre-screened online resources.

“Uncertainty” and “not knowing of survivors” were the leading causes of stress reported by parents, but few were told about the ages of survivors or referred to support groups. Meeting other families may help to reduce feelings of isolation and give parents a practical view of raising a child with CHD. These “living examples” can provide hope to parents.

Physicians need to be aware of how information is interpreted by parents. The physician’s use of the term “rare” to describe the CHD led many parents to grossly underestimate the true incidence of CHD and its survival rate. This, in conjunction with the lack of referrals to support groups, may create the impression that CHD has very few survivors, decreasing parents’ optimism. Providing context for parents by quantifying the true incidence of the CHD, relating how long treatments have been available, citing the ages of survivors, and referring parents to support networks may reduce parents’ feelings of isolation and increase their optimism for their child’s future. Even with a serious diagnosis, parents want to be allowed hope [18].

The manner in which the information is presented to parents is also important. Those who perceived the PC as lacking in compassion and empathy and those without optimism about their child’s life expectancy were more apt to find another PC. It is possible that the parents in our survey were not seeking a true “second medical opinion” regarding diagnosis or treatment options but rather were already dissatisfied and seeking a new cardiologist. Empathy exhibited by physicians has been identified as an important factor in parental satisfaction [1, 13, 18]. Physicians can communicate empathy by focusing on parents’ concerns and using active listening to ensure that parents are heard and understood [26].

A recent study found that during prenatal counseling, discussion of the option to terminate a pregnancy was considered to be far more important by cardiologists than by parents. The study also found that 54 % of parents but only 2 % of cardiologists opposed pregnancy termination for religious or moral reasons [2]. This difference may reflect physicians’ beliefs that it is their duty to inform parents of pregnancy termination as opposed to the belief of some parents that termination is not an option for them. Some parents may view the mention of terminating a pregnancy as a recommendation by the physician and may be offended if they perceive a bias toward termination [21].

In our study, those who felt pressure to terminate their pregnancy were less likely to be optimistic about their child’s life expectancy, possibly due to a perception that physicians would offer pregnancy termination only if the child’s chances of surviving were minimal. Those who felt pressured to terminate their pregnancy also rated the PC lower in compassion and empathy.

Physicians and parents may have differing perspectives on what criteria are most important in deciding to terminate a pregnancy. Arya et al. [2] found that parents and physicians both rated survival high in importance when determining whether or not to continue the pregnancy. However, physicians emphasized the importance of the child’s survival into adulthood, whereas parents also rated survival into early childhood as an important factor in the decision making. This is consistent with Rakow’s [20] finding that physicians place more importance on the value of future years than on short- or intermediate-term survival.

Arya et al. [2] also found that physicians rated the potential for neurodevelopmental delay and the severity of the CHD higher in importance than parents when considering pregnancy termination [2]. In their study, cardiologists and parents both rated quality of life (QOL) as the most important factor in deciding whether to terminate the pregnancy. However, Marino et al. [16] found that parents and physicians define QOL differently. Physicians’ definitions of adolescent patients’ QOL included more negative descriptors often associated with hospital stays and medical procedures. The adolescents and their parents, however, viewed QOL in a broader context and included positive descriptors of having a CHD. To improve communication at prenatal diagnosis, counselors should distinguish between short-, intermediate-, and long-term survival and should specifically define QOL.

Study Limitations

Due to possible overlapping memberships of online groups and the distribution of the survey to parents who were not members of the support groups via social media and email, the total number of survey recipients was unknown.

The survey results may have been subject to recall bias because many parents had received the diagnosis several years before the survey. We did not independently verify what information actually was given to parents by physicians. Selection bias also was a possibility because those who responded to the survey may have been parents with strong opinions about how they were given the diagnosis.

The survey included only parents with access to the Internet, which represents 80 % of U.S. households. Therefore, the results may not be generalizable to the entire population.

Parents who chose to terminate pregnancy after a prenatal diagnosis might have been underrepresented in our survey. Parents who chose not to terminate may have had different perceptions of pressure to terminate and may have sought second opinions for reasons different from those of parents who terminated the pregnancy. Multiple responses by survey recipients were possible, although this was mitigated by the limitation of allowing only one survey per computer. Because the information gathered in this study was novel, no standardized assessment tool was available that would have captured these data.

Conclusions

Parents faced with their child’s CHD diagnosis often have little time to make decisions. It is critical, therefore, that parents receive and understand information upon which to make informed choices regarding treatment options, where to have treatment, and whether or not to continue a pregnancy in the case of a prenatal diagnosis.

To be given context, parents should receive information on success rates at different hospitals, Internet resources, and referrals to support networks. Physicians should avoid ambiguity and choose words carefully. The term “rare” should be clarified or eschewed. Physicians also need to be cognizant of how their demeanor and the terminology they use may be interpreted by parents.

More research is needed to identify the content and scope of information given to parents at the diagnosis of CHD as well as the type of information desired by parents. Effective methods of providing information to parents that promote optimal understanding and retention while avoiding misinterpretations need to be investigated further. Understanding how parents interpret information and how they define compassion and empathy will also help to improve physician-parent communication at this critical time.

The large response to our survey within a short period suggests that many parents are willing to share their opinions. Although this was an anonymous survey, 665 (79 %) of the 841 respondents voluntarily provided an email address because they were interested in receiving notices of any publication of the data. This illustrates their eagerness to share their experiences with physicians as well as their interest in seeing how this information is used. The Internet provides a valuable opportunity to elicit feedback from parents across multiple institutions, which can be used to improve physician-parent communication.

Acknowledgments

The authors thank Susan Sabanos for help with the survey design; Karin Yospe, cofounder of California Heart Connection, for distribution of the survey; and the many online support groups that distributed the survey to their members and provide much-needed support to families.

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Debra Hilton-Kamm
    • 1
  • Mark Sklansky
    • 2
  • Ruey-Kang Chang
    • 3
  1. 1.California Heart ConnectionIrvineUSA
  2. 2.David Geffen School of Medicine at UCLALos AngelesUSA
  3. 3.Harbor-UCLA Medical CenterTorranceUSA

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