the Thoracic

A resource guide for diseases treated by thoracic procedures: Program :: Wall Deformities :: Malignant Thoracic Diseases :: Benign Thoracic Diseases :: Other Related Programs and Diseases A note about this booklet

This booklet was assembled as an informational resource for pediatricians, family practice , nurse practitioners, and other providers seeking a greater understanding of the breadth of thoracic performed by the Department of at Nationwide Children’s .

In general there are four broad categories of thoracic diseases treated by thoracic procedures: 1. Chest Wall Deformities 2. Malignant Thoracic Diseases 3. Benign Thoracic Diseases 4. Other Related Programs and Disorders

In this booklet, we would like to describe each one of these categories in more detail.

For more information, please visit us at NationwideChildrens.org/Thoracic-Surgery

Arranging a Consult To arrange a referral with the Department of Cardiothoracic Surgery: phone: (614) 722-3101 fax: (614) 722-3111 online: NationwideChildrens.org/PhysicianResources

For urgent consults, call the Direct Connect Line: phone: (614) 355-0221 toll free: 1(877) 355-0221 fax: (614) 722-2140 About the

Alistair Phillips, MD Dr. Phillips is an attending cardiothoracic at The Center at Nationwide Children’s Hospital and an Assistant Professor of Surgery at The Ohio State University College of . He is board certified in both surgery and thoracic surgery. Dr. Phillips received his undergraduate degree in from The Johns Hopkins University and his from The College of Physicians & Surgeons of . He completed his in surgery and cardiothoracic surgery at Cornell Medical Center, and a in thoracic surgery at Memorial Sloan-Kettering Center and a fellowship in pediatric at Columbia-New York Presbyterian Medical Center.

Clinical areas of focus are congenital thoracic disorders, congenital heart disease in children and adults, heart and transplantation, , and research to improve cardiothoracic outcomes. Additionally, he is actively involved in developing new techniques and equipment for use in the hybrid approach to pediatric cardiothoracic diseases.

Mark Galantowicz, MD Dr. Galantowicz is co-director of The Heart Center at Nationwide Children’s Hospital, Chief of Cardiothoracic Surgery and an Associate Professor of Surgery at The Ohio State University College of Medicine. Dr. Galantowicz received his medical degree from Cornell University and completed his surgical, cardiothoracic and pediatric cardiothoracic surgery fellowships at Columbia-New York Presbyterian Medical Center.

Clinical areas of focus are neonatal surgery, hypoplastic left heart syndrome (HLHS), and heart and . Dr. Galantowicz is actively involved in developing new strategies for treatment and is one of the pioneers to the hybrid approach to hypoplastic left heart syndrome. common approaches to thoracic surgery

Thoracic surgical approaches utilized at Nationwide Children’s Hospital typically fall into one of two categories — minimally invasive via use of video-assisted thorascopy, or by way of open approach via a surgical incision. The approach used depends on presenting diagnosis and is discussed later in detail.

At Nationwide Children’s Hospital there is an innovative spirit and desire to improve the care of patients with congenital disorders. We have instituted a new 3-D system from Viking Corporation that will allow us to expand minimally invasive techniques to many other patients.

Expanding the role of minimally invasive procedures for children using a 3D visual system, combining the benefits of robotic surgery with the benefit of the surgeon being at the surgical field.

2 thoracic and postoperative

Cardiothoracic anesthesia at Nationwide Children’s Hospital is performed by members of the Department of . We have a dedicated anesthesia team for our cardiothoracic patients, which includes board-certified anesthesiologists who have completed a fellowship in pediatric anesthesia, and have received extensive training in cardiothoracic anesthesia. Most are also board certified in , and several are board certified in pediatrics, anesthesia and pediatric intensive care. Additionally, Certified Registered Nurse Anesthetists and Anesthesia Fellows provide care under direct supervision of the attending anesthesiologist.

Cardiothoracic anesthesia requires special techniques and equipment to allow surgical access to one side of the chest, while maintaining ventilation and oxygenation with only one lung. Special double-lumen endotracheal tubes can be placed in older children allowing easy isolation of an individual lung. For smaller children, special devices can be placed, with the aid of fiberoptic scopes, in the main bronchus to facilitate surgical access. In both cases, patients are followed closely to assure a stable clinical course throughout the case.

After thoracic surgery, patients will typically be admitted to the Cardiothoracic Intensive Care Unit (CTICU) for monitoring – mainly from a pain-control perspective. Patients are followed by members of the Division of Anesthesiology’s Pain Service. Typical pain-control methods utilized for thoracic surgery are epidural infusions, patient controlled analgesia pumps, or nurse controlled analgesia pumps with transition to oral pain medications after removal.

3 Classifications of Diagnoses for Potential Surgical Intervention

Chest Wall Deformities

1A Pectus carinatum (unusual prominence of the ) B Pectus excavatum (depression of the sternum)

Surgical Approach to Pectus Repair

Pectus defects are repaired via the modified Ravitch procedure. This involves a midline lower sternal incision and usually the removal of the lower four costal cartilages leaving the perichondrium foreshortening costal cartilage. The sternum is then elevated and stabilized with wires.

The is an alternative approach to pectus excavatum repair. It requires placement of a custom fitted titanium bar inserted laterally and positioned behind the sternum to push the sternum outward. This specific procedure is not utilized by thoracic surgery but is performed by the pediatric surgeon(s) in the Department at Nationwide Children’s Hospital. This approach is common for females who would prefer not to have a midline anterior chest incision. It is important to note the bar must be removed two to three years after insertion and the patient will likely have restrictions from contact sports.

In the case of a pectus deformity, it is important to note most insurance companies do not cover this repair as it is felt to be a cosmetic issue. However, insurance companies do consider the Haller index and any associated symptoms, such as decreased pulmonary function, when considering approval for this type of surgery.

Typical length of stay in the hospital following a pectus repair is approximately four days. The patient typically will miss two to three days of school/work and will have activity restrictions for approximately three months. Most patients who undergo pectus repair are teenagers or adults. Repair for those under age 10 is uncommon as these defects can worsen with growth spurts (or during puberty).

4 C Jeune’s syndrome While a rare disease, Jeune’s syndrome is an autosomal recessive disorder characterized by a small with short, horizontally oriented ribs which results in a very stiff chest wall. This leads to inadequate pulmonary volumes which subsequently leads to respiratory insufficiency and death by asphyxiation. Additionally, there can be associated parenchymal lung changes such as patchy atelectasis and bronchial crowding. Renal and hepatic disorders can be associated with this syndrome. Most patients appear to be unaffected mentally by the disorder with most patients being quite bright. The degree of impairment can range from mild to severe.

To meet the needs of this growing thoracic dystrophy population, Nationwide Children’s now offers a multidisciplinary Thoracic Dystrophy . Led by Melissa Holtzlander, MD, and Alistair Phillips, MD, the clinic serves both current thoracic dystrophy patients and new referrals. In addition to Pulmonary Medicine and Cardiothoracic Surgery physicians, patients will also have the opportunity to see physicians from Clinical Genetics and . Nutritionists and social workers are available to assist and manage the many complex needs of patients with thoracic dystrophies. If needed, diagnostic testing will be scheduled for the day of the clinic.

The palliation for Jeune’s syndrome was pioneered by J. Terrance Davis, MD, a cardiothoracic surgeon at Nationwide Children’s Hospital. Although Dr. Davis is now clinically retired, the lateral thoracic expansion procedure is still performed at Nationwide Children’s Hospital.

Evaluation for Jeune’s syndrome is performed by a multidisciplinary team consisting of pulmonologists, radiologists, cardiologists, otolaryngologists and thoracic surgeons, and takes approximately two to three days to complete.

5 Candidates for surgery typically are at least six to nine months of age, are mechanically ventilated and unable to undergo further vent wean, do not have tracheomalacia, and have severe narrowing of the . Only one side of the thorax is expanded at a time. Patients typically return in two to six months to have the opposite side expanded.

Repair of Thoracic Dystrophy – Combining two ribs increases the diameter of the chest cavity and significantly increases the volume. Ribs are held together by titanium plates.

For specific details about the surgical repair, the following reference is provided: Staged Surgical Approach to Thoracic Expansion in Jeune Syndrome and other Asphyxiating Thoracic Dysprotphies. In: Reoperative , Caniano DA and Teich S, eds. The Humana Press, Ottawa, NJ in press. J. Terrance Davis, MD, Alistair B.M. Phillips, MD, Frederick R. Long, MD and Robert G. Castile, MD.

6 Primary or Secondary Malignant Pulmonary Disease and Malignancies of the Thoracic Cavity

The thoracic program collaborates extensively with the Division of / and physicians Mark Ranalli, MD, Nicholas D.2 Yeager, MD, and Thomas G. Gross, MD, PhD, for pre- and post-surgical consultation, treatment, and follow up in cases involving benign and malignant disease and associated metastasis.

A Primary Tumors :: Neuroblastoma :: Teratomas :: Pleuropulmonary blastoma :: Lymphoma :: Inflammatory myofibroma :: Papillomas :: Mediastinal tumors :: Histiocytoma :: Wilm’s tumor :: Leiomyoma :: Ewing’s sarcoma :: Chrondroma

Depending upon primary tumor location and size, resection is occasionally performed on , as in this case of a Wilm’s tumor growing into the inferior vena cava and into the heart.

7 B Lung Nodules :: Metastatic nodules – such as those of osteogenic tumors :: Others – indeterminate lung nodules requiring excision to facilitate diagnosis

Surgical options for intervention of malignant, benign, infectious, congenital, and idiopathic conditions include:

Video assisted thorascopy (VAT’s), open , or sternotomy. The method utilized depends upon size, location, depth, and accessibility to the area of interest. Length of stay for resection of malignant disease varies pending input from the hematology/oncology team. However, typical length of stay for a VAT’s procedure is two to three days, and three to six days for the surgical portion of an open procedure. It should be noted that additional inpatient time may be needed for treatment, such as chemotherapy or antibiotic .

Resections may include:

:: of the lung

:: Segmentectomy of the lung Neuroblastoma resected from the posterior :: of the lung . The tumor :: of the lung, including is well encapsulated, intracardiac and extrapleural pneumenectomy and was resected off depending on tumor location and type the spinal fascia with :: Thymectomy division of nerve roots :: Chest wall resection and reconstruction T4, T5, T6 and T7.

:: Pericardial resection and reconstruction

:: Diaphragmatic resection and reconstruction

:: Great vessel resection and reconstruction

:: Rib resection

8 Benign thoracic diseases

a spontaneous 3 For the first episode, most will resolve with conservative drainage with a chest tube. For recurrent episodes and patients with blebs (air pockets within the lung usually at the apex of the lung), surgical resection is recommended. General approach is via video assisted thorascopy (VAT’s) with two incisions each approximately 1 centimeter (one camera port and one working port). A is performed with doxycyline which is injected into the pleural space to promote adhesions between the pleura and the lung; along with an apical pleurectomy where the lining of the chest wall is removed to improve adhesion between the lung and the chest wall. b congenital pulmonary deformities Congenital pulmonary deformities included in this category are the diagnosis of: congenital lobar emphysema, congenital pulmonary cysts, bronchogenic cysts, and pulmonary sequestration. Surgical approach depends upon the actual malformation, size and location. CT scans and pulmonary function tests are beneficial in determining timing of surgical intervention. Typically, these defects require an open approach, however, with the use of the Viking 3Di Vision Systems more surgeries can be done minimally invasive.

Spontaneous pneumothorax is usually caused by apical blebs. Using the 3D Viking system with two incisions, the apical blebs are resected. Less than 1 percent of the lung is removed during the procedure. The apical bleb is completely removed and sent for evaluation. 9 C Cystic fibrosis Spontaneous Pneumothorax In this group of patients, conservative treatment with a chest tube is the preferred management strat- egy as scarring from a blebectomy and pleurodesis may be a contraindication to transplant in some centers. However, at Nationwide Children’s Hospital, a patient who has undergone a pleurodesis can The right middle lobe with still be a candidate for lung transplant. Indications for surgical intervention in cystic fibrosis patients severe bronchiectasis in a include recurrent episodes of spontaneous pneumothorax or continuous air leak. patient with cystic fibrosis requiring right middle Bronchiectasis lobectomy. A CT scan of the chest evaluation is performed to determine the amount of lung affected. If surgical intervention is warranted, this can be performed via a VAT’s approach. However, for a large affected area, a segmentectomy is usually needed which requires an open approach.

D mature and immature teratomas A mature teratoma resected Diagnosis is usually made from visualization of a mass via a sternotomy. The tumor on an X-ray. While most are benign, a local recurrence had components from all three can occur if margins are positive. embryononic cell lines.

e lung biopsies Lung biopsies are occasionally performed to obtain quality tissue samples when a definitive diagnosis is inconclusive or when other testing modalities have failed to produce an adequate pathological specimen. Lung biopsies are performed using a minimally invasive approach. Indications for open lung biopsy include persistent interstitial lung disease (without definitive diagnosis), mediastinal lymph- adenopathy, presence of pulmonary nodules, and to determine rejection classification in lung transplantation.

10 f vascular rings Vascular rings are typically formed by a double aortic arch or by an aberrant subclavian artery. Symptoms may include difficulty swallowing, stridor, or recurrent lung . These abnormalities are often noted as indentations on the trachea or if an upper gastrointestinal study has been performed. Evaluation by either CT scan or MRI with contrast can confirm Vascular rings are generally approached via left thoracotomy. Most the abnormality. Surgical repair is usually via a left thoracotomy frequently, there is an atretic left aortic arch but there can be right with division of an atretic left arch and ligementous arteriosus, and left arches. The small arch is divided and oversewn, which which is the most common approach. opens up the ring, giving room to the esophagus and trachea.

g congenital pulmonary deformities/mediastinal lymph node dissection Lung biopsies and medistinal lymph node dissections are performed to obtain quality tissue samples when a definitive diagnosis is inconclusive or when other testing modalities have failed to produce an adequate pathological specimen. Lung biopsies and mediastinal lymph node dissection are generally performed using the Viking 3Di Vision System, which provides excellent clarity. Indications for lung biopsy include persistent interstitial lung disease (without definitive diagnosis), mediastinal lymphadenopathy, presence of pulmonary nodules, and to determine rejection classification in lung transplantation. These procedures can be very helpful in diagnosing causes of like histoplasmosis, which is pandemic in the Ohio River Valley.

Congenital lobar emphysema caused by bronchial narrowing leads to hyperinflation of the diseased segment, which can lead to compression of the normal lung. These patients can have respiratory distress. CXR will show hyperinflation with associated atelectasis of the other parts of the lung. Usually, a lobectomy is needed but segmentectomy can be performed. In the picture, there is demarcation between the normal lung at the top and the diseased lung at the bottom.

11 H Thoracic outlet syndrome typically results from the compression of nerves and blood supply of the thoracic outlet, usually caused by muscle hypertrophy, but can be positional as well. Surgery may be indicated if improvement by conventional therapy has failed. The surgical procedure typically requires the division of muscle and resection of a portion of the first rib.

i pneumatocele/pulmonary cysts Cystic or cavitary lesions are air or fluid filled collections that can be congenital or associated with a pulmonary disease such as cystic fibrosis, broncopulmonary dysplasia, or the result of an infectious pulmonary process such as pneumonia. Neoplasms can also be a source for consideration.

Pulmonary cyst adjacent to the right upper lobe causing compression of the right upper lobe bronchus. Patient with bronchopulmonary dysplasia and severe right upper lobe lung disease. Patient underwent right-upper lobectomy with resection of cyst.

J Diaphragmatic plication Diaphragmatic paralysis or injury can be caused by interruption of the phrenic nerve due to surgical complication, disease process such as neuromuscular junction disorder, immunologic process, myopathy, or neoplasm. Plication or pleating of the diaphragm allows for decompression of the affected hemithorax.

12 K Thoracic duct ligation Thoracic duct ligation is occasionally needed after cardiothoracic surgery due to injury to the thoracic duct. However, in cases unrelated to cardiothoracic surgery, congenital malformations and malignancy are common causes to the associated chylothorax. Thoracic duct ligation may be indicated to relieve persistent chylothorax or recurrent pleural effusion.

Thoracic duct leaking from the left subclavian. The leak was identified by giving half-half (heavy cream) and was repaired by simple ligation with a 5-0 polypropylene.

l pericardial diseases Pericardial diseases can be infectious, malignant or idiopathic. Most pericardial problems can be approached using a minimally invasive approach via the Viking 3D system.

Pericardial window for chylous pericardial effusion, per- formed by left video assisted thorascopy using the Viking 3D system. The is open just above the phrenic nerve seen in the picture. The pericardium is opened widely and a large portion is sent for pathology evaluation.

13 oTher related programs

4A Transplantation The Department of Cardiothoracic Surgery performs , lung transplantation, and combined heart-lung transplantation. Nationwide Children’s Hospital received accreditation from the United Network of Organ Sharing (UNOS) in 2005.

This multidisciplinary transplantation team consists of pulmonologists, cardiothoracic surgeons, transplant nurse coordinators, anesthesiologists, cardiologists, social workers, respiratory therapists, physical therapists, psychologists, dieticians, and financial coordinators. Other disciplines are available on a consult basis.

Care of lung and heart-lung transplant patients is directed by Todd Astor, MD, Section of Pulmonary Medicine, Medical Director of Lung and Heart-Lung Transplant program, and Tim Hoffman, MD, Section of , Medical Director of Heart Transplant and Heart Failure program, and the . This includes pre-listing testing as well as post-transplant follow up and surveillance testing.

b cardiothoracic Intensive Care Unit Depending upon the diagnosis and nature of the operation, the majority of patients will recover in one to two days in the cardiothoracic intensive care unit (CTICU). Our intensive care team consists of intensivists, anesthesiologists, cardiologists, pharmacists, and acute care certified nurse practitioners who collaborate for optimum patient care.

14 c post-ICU recovery Depending upon the patient’s diagnosis, post-operative recovery outside of the ICU can be on a cardiothoracic floor, hematology/ oncology floor, or on the pulmonary floor with associated collaboration among service lines. In complex situations, social work and other services, such as nutrition, are consulted to assist in meeting the patient’s needs in anticipation of their discharge goal.

D Cardiothoracic Surgery Nurse Clinicians The cardiothoracic surgery nurse clinicians assist with coordination of care throughout the hospitalization from preadmission testing to post-discharge. This includes patient teaching, assisting with family needs, incision evaluation, home care instruction, and telephone follow up after discharge as well as answering any questions the primary or referring physician may have about the patient’s status during their hospitalization.

15 case review

McKenna was a previously healthy 4-year-old who presented to her primary care physician with a fever of 102 degrees, shallow breathing, loss of appetite, and swollen lymph nodes.

List of differential diagnosis :: Viral illness :: Pneumonia :: Pleuropulmonary blastoma McKenna at age 5 in McKenna at age 7 in 2009 :: Influenza February 2007 :: Pleural effusion

The primary physician prescribed an antibiotic which improved McKenna’s condition for two to three weeks. However, McKenna re-presented to her primary physician with complaints of stomach pain, left shoulder pain, vomiting, diarrhea, sore throat, earache, persistent and non-productive cough, and fever of 101 degrees. She was referred to the emergency department for evaluation based upon her exam.

On arrival to the emergency department, McKenna had significantly increased respiratory effort as she could only breathe while laying on her left side. Adequate breath sounds were noted on the right, with absent breath sounds on the left. A chest X-ray was obtained.

Figure (1): Admission CXR, showing large tumor involving the entire left hemithorax and heart shift into the right chest. Note the trachea, arrow, deviated to the right.

16 McKenna underwent a CT scan, two biopsies by interventional , and a PET scan, (figure 2), which confirmed the large tumor in the left chest was compressing all of her mediastinal organs.

Figure (2): Initial PET scan showing extensive uptake within the tumor.

The last biopsy on July 12 confirmed left pleural pulmonary blastoma. Due to the large size of the tumor, the recommen- dation was to treat initially with chemotherapy to shrink the tumor so resection could be safely undertaken.

McKenna was followed with frequent CXRs, (figure 3), CT scans (figure 4) and PET scans, (figure 5) during the chemotherapy treatment.

a. July b. August Figure (3): Regression of tumor on CXR from response 2006 2006 to chemotherapy. (a) July 2006, (b) August 2006, (c) January 2007, (d) Post-operative, February 9, 2007 chest tube in left pleural space

Figure (4): Regression of tumor seen on CT scan c. c. (a) July 2006, (b) August 2006, (c) February 2007

Figure (5): PET scan January 2007, showing no uptake in the tumor bed. February February 2007 2007 Figure (3) Figure (4) Figure (5)

17 After five cycles of chemotherapy, Dr. Phillips performed a left extrapleural pneumonectomy on now 5-year-old McKenna. The goal was to remove the entire tumor with the entire left lung and parietal pleura, called an extrapleural pneumonectomy. The tumor is encased in the pleura and needs to be resected in certain tumors, like this one, to ensure negative margins. During the surgery the tumor was noted to be invading the diaphragm and pericardium, (figure 6), which were both resected en-bloc with the tumor. Both were then reconstructed with GORE-TEX® patches, (figure 7). During surgery and post-operatively there were no complications or difficulties.

Figure (6): Diaphragm and pericardium resected.

a. b.

Figure (7): (a) Reconstruction of the pericardium with GORE-TEX® patch and (b) Completed patches of the diaphragm and pericardium.

The pathology revealed that the entire tumor was removed and all margins were negative except one microscopic area which showed tumor going into the margin. She received post-operative chemotherapy which has now been completed. She will need to be followed for the rest of her life, but she has done remarkably well throughout the entire 10 months of her treatment.

Patient Outcome McKenna’s surgeries and treatments are proving successful and she has resumed a normal life for a 7-year-old girl, playing with her friends and going to school. She will continue follow-up therapy for the rest of her life. Her prognosis is excellent.

Case study adapted from article published in Pediatric Directions.

18 Team members

Brent H. Adler, MD Jeune’s team

Brent H. Adler, MD, is Section Chief of Musculoskeletal Radiology in the Department of Radiology at Nationwide Children’s Hospital and a Clinical Assistant Professor of Radiology and Pediatrics at The Ohio State University College of Medicine. He is also an Adjunct Assistant Professor in the Department of Radiology at the University of Toledo Medical Center. He is a member of the Editorial Board of Pediatric Radiology.

Todd L. Astor, MD Lung and Heart-Lung Transplantation

Todd L. Astor, MD, is Medical Director of the Lung and Heart-Lung Transplant Program. He is an Assistant Profes- sor of Clinical Pediatrics as well as an Assistant Professor of at The Ohio State University College of Medicine. Dr. Astor received his medical degree from George Washington University School of Medicine. He completed residency in Internal Medicine at Loyola University Medical Center, and his pulmonary/critical care medicine and lung/heart-lung transplantation at the University of Colorado. Dr. Astor is board certified in internal medicine, pulmonary medicine, and critical care medicine. Additionally, he is certified by UNOS as a lung and heart-lung transplant pulmonologist. His research interests are directed at the mechanisms of rejection and the role respiratory viruses may have in triggering rejection.

19 Melissa Cannon, RN, BSN cardiothoracic surgery

Melissa Cannon, RN, BSN, is a Cardiothoracic Surgery Nurse Clinician at Nationwide Children’s Hospital. She earned her Associate Degree of Science in both and radiology from Central Ohio Technical College and her Bachelor of Sci- ence in nursing from Mount Carmel College of Nursing. Melissa is currently working on her pediatric nurse practitioner Master’s degree from Wright State University.

Robert G. Castile, MD, MS Jeune’s team

Robert G. Castile, MD, MS, is a member of the Center for Perinatal Research at The Research Institute at Nationwide Children’s Hospital and the Section of Pulmonary Medicine at Nationwide Children’s Hospital and a Professor of Pediatrics at The Ohio State University College of Medicine. His undergraduate and medical training was completed at the University of Maryland. Residency training in pediatrics was completed at the in Rochester, Minnesota. His fellowship training was completed at Children’s Hospital in , where he practiced pediatric for 14 years prior to moving to Columbus, Ohio. He also holds a master’s degree in pediatrics from the . He has been engaged in research and clinical practice in the area of lung disorders of infants and children for more than 30 years. His research interests include infant pulmonary function testing, CT lung imaging, lung growth, bronchopulmonary dysplasia, cystic fibrosis, asthma, Jeune’s syndrome and interstitial lung diseases. He is a frequent speaker at national and international medical meetings and has more than 70 peer reviewed publications.

Clifford Cua, MD Jeune’s team

Clifford Cua, MD, is a Clinical Cardiologist and Cardiac Intensivist at The Heart Center at Nationwide Children’s Hospital and an Assistant Professor of Clinical Pediatrics at The Ohio State University College of Medicine. His clinical interests include the perioperative care of neonates and infants with congenital heart disease and the management of patients requiring critical care due to cardiac disease. He is active in research pertaining to cardiothoracic disease. 20 Jill A. Fitch, MD CtICU team

Jill A. Fitch, MD, is an attending physician in the Pediatric Intensive Care Unit and Cardiothoracic Intensive Care Unit, Director of the Pediatric Critical Care Fellowship Program and Director of the Pediatric Analgesia and Sedation Service (PASS) at Nationwide Children’s Hospital, and a Clinical Associate Professor of Pediatrics at The Ohio State University College of Medicine. She is also an Associate Attending at The Ohio State University James Cancer Hospital and Solove Research Institute. Dr. Fitch completed at Northeastern Ohio Universities College of Medi- cine in Rootstown, Ohio, followed by a fellowship in pediatric critical care medicine and a residency in combined internal medicine and pediatrics, both at the Cleveland Clinic Foundation. She is a Fellow of the American Academy of Pediatrics, Association of Pediatric Program Directors and President of the Central Ohio Pediatric Society.

Thomas G. Gross, MD, PhD Hematology/Oncology

Thomas G. Gross, MD, PhD, is the Chief of the Section of Hematology/Oncology/Blood and Marrow Transplant (BMT) at Nationwide Children’s Hospital, a member of the Center for Childhood Cancer at Nationwide Children’s Research Institute and an Associate Professor of Pediatrics at The Ohio State University College of Medicine. He serves on the Institutional Review Board and Clinical Research Scientific Council and is a member of the Pediatric Oncology and Viral Oncogenesis Program at the NCI-designated Comprehensive Cancer Center at The Ohio State University. His clinical interests are BMT and the treatment of in immunocompromised patients, such as post-transplant lymphoproliferative disease (PTLD). His research interests are focused on transplant and tumor . He is the Principal Investigator for the PTLD clinical trial in the Children’s Oncology Group (COG), and is the Chair of the Non-Hodgkin’s Lymphoma (NHL) Disease Committee in COG. Dr. Gross is co-investigator on several NIH-funded clinical studies in transplantation and NHL. He serves on the Pediatric Cancer Editorial Board for the Physician Data Query at the National Cancer Institute, on the Board of Trustees of the National Childhood Cancer Foundation and the Board of Directors of the Israel Penn International Transplant Tumor Registry. He is a member of several committees for the Pediatric Blood and Marrow Transplant Consortium, Center for International Blood and Marrow Transplant Research, International Pediatric Transplantation Association, American Society of Transplantation, as well as scientific advisory committees for several pharmaceutical companies. 21 Melissa Holtzlander, MD Jeune’s team

Melissa Holtzlander, MD, is a member of the Division of Pediatric Pulmonology at Nationwide Children’s Hospital and an Assistant Professor of Clinical Pediatrics at The Ohio State University College of Medicine. Her clinical interests include the evaluation and management of infants, children and adolescents with respiratory illnesses including managing patients of all ages with cystic fibrosis (CF). Her research interests include the study of corneal changes in patients with cystic fibrosis. She is involved in teaching medical professionals at multiple levels about pulmonary diseases.

D. Richard Kang, MD, FACS, FAAP Jeune’s team

D. Richard Kang, MD, FACS, FAAP, was appointed Chief, Department of Otolaryngology at Nationwide Children’s Hospital in December 2003 and also serves as Clinical Associate Professor of Otolaryngology at The Ohio State University College of Medicine. He came to Nationwide Children’s Hospital from San Diego where he spent a 20-year career in Navy medicine. He completed pediatric otolaryngology fellowships at both St. Louis Children’s Hospital and San Diego Children’s Hospital. Dr. Kang was the Chairman and Program Director for two Otolaryngology-Head and Neck Surgery departments at Naval Medical Centers in Oakland and San Diego. He was also the Otolaryngology Specialty Advisor to the Navy Surgeon General. He joined San Diego Children’s Hospital where he was director of the Hearing Center and, while there, developed a large Cochlear Implant Center – one of only four recognized pediatric cochlear implant centers in California. His clinical interest is in all aspects of pediatric otolaryngology and, in particular, pediatric otology.

22 Christopher T. Lancaster, MD Anesthesia

Christopher T. Lancaster, MD, is an attending physician in Pediatric Cardiac Intensive Care and Critical Care Medicine and an attending Pediatric Anesthesiologist at Nationwide Children’s Hospital. He received his medical degree from New York Medical College. He then completed his pediatric residency training at UC San Francisco, Fresno program, and his anesthesia residency at The Johns Hopkins Hospital. Additionally, he completed fellow- ships in both pediatric anesthesia and pediatric critical care at Johns Hopkins. He is board certified in pediatrics and anesthesiology, and board eligible in pediatric critical care.

Anthony Lee, MD CtICU team

Anthony Lee, MD, is an attending physician in the Cardiothoracic Intensive Care Unit and the Pediatric Intensive Care Unit at Nationwide Children’s Hospital. He is also a Clinical Assistant Professor of Pediatrics at The Ohio State University. Dr. Lee is board certified in internal medicine and pediatrics and is board eligible in pediatric critical care medicine. He completed his Critical Care Fellowship at Children’s National Medical Center. His clinical interests include medical informatics and quality improvement techniques utilizing information technology.

Eric Lloyd, MD CtICU team

Eric Lloyd, MD, is an attending physician in the Pediatric Intensive Care Unit at Nationwide Children’s Hospital and an Assistant Professor of Clinical Pediatrics at The Ohio State University College of Medicine. Dr. Lloyd received his medical degree from Northeastern Ohio Universities College of Medicine and completed a categorical residency in pediatrics at Lutheran General Children’s Hospital. Dr. Lloyd completed a pediatric critical care fellowship at McGaw Medical Center of Program, Children’s Memorial Hospital in Chicago, Illinois. Dr. Lloyd is board certified in pediatrics. His clinical interests include postoperative cardiac care.

23 Frederick R. Long, MD Jeune’s team

Frederick R. Long, MD, is Section Chief, Body MRI and CT in the Radiology Department at Nationwide Children’s Hospital and a Clinical Associate Professor of Radiology and Pediatrics at The Ohio State University College of Medicine. He is also Clinical Assistant Professor at the Medical University of Ohio at the University of Toledo Medical Center. He is a member of the Children’s Radiological Institute, Inc., and biomedical engineering graduate faculty at The Ohio State University. His clinical specialization is body imaging with a focus on cardiopulmonary disease and tumors in children. His clinical research interests include high resolution, quantitative and imaging of the infant heart and lung as well as the development of advanced CT and MRI techniques for body imaging. Funded research involves development and application of controlled ventilation CT in children with cystic fibrosis. He is also a funded research consultant working on high-resolution infant lung imaging.

Christopher T. McKee, DO Anesthesia/CTICU Team

Christopher T. McKee, DO, is an Attending Anesthesiologist and Intensivist at The Heart Center at Nationwide Children’s Hospital. Dr. McKee attended the New York College of Osteopathic Medicine. He completed a residency in general pediatrics at the State University of New York Upstate Medical University in Syracuse, New York. Dr. McKee concluded his training at The Johns Hopkins Hospital in Baltimore, Maryland, where he completed a residency in anesthesiology and fellowship training in pediatric critical care medicine and pediatric anesthesiology. He is a Diplomate of the American Board of Pediatrics-General Pediatrics. Dr. McKee is a board-eligible anesthesiologist and pediatric intensivist.

24 Aymen N. Naguib, MD Anesthesia

Aymen N. Naguib, MD, is Director of Anesthesiology at The Heart Center at Nationwide Children’s Hospital and a Clinical Assistant Professor at The Ohio State University College of Medicine. Dr. Naguib received a medical degree from Cairo University School of Medicine, Cairo, Egypt, followed by residency in surgery at the College of Physicians and Surgeons of Columbia University at Harlem Hospital, and a residency in anesthesiology at Illinois Masonic Medical Center. He did his fellowship training at Children’s Memorial Hospital, Northwestern University, Chicago, Illinois, in pediatric anesthesiology. He is certified by the American Board of Anesthesiology.

Greg D. Pearson, MD Jeune’s/Thoracic Surgery Team

Greg D. Pearson, MD, is a member of the Cleft Palate/Craniofacial Team, staffs the Vascular Malformations Clinic at Nationwide Children’s Hospital and is an Assistant Professor of Clinical Plastic Surgery at The Ohio State University College of Medicine. Dr. Pearson sees patients in the Plastic Surgery Clinic located in the Outpatient Care Center at Nationwide Children’s. Along with members of the Section of , he performs reconstruction of complex craniofacial anomalies at Nationwide Children’s Hospital.

25 Christina Phelps, MD CTICU Team

Christina Phelps, MD, is a Pediatric Cardiologist and Cardiac Intensivist at The Heart Center at Nationwide Children’s Hospital and a Clinical Assistant Professor of Pediatrics at The Ohio State University College of Medi- cine. Dr. Phelps received her medical degree from SUNY Upstate Medical University. After completing her pediatric residency at Virginia Commonwealth University, she completed her fellowship training in pediatric cardiology and a fourth year of cardiac critical care at The Children’s Hospital in Denver. She is board certified in pediatrics and pediatric cardiology.

Mark A. Ranalli, MD Hematology/Oncology

Mark A. Ranalli, MD, is an attending physician in the Division of Hematology/Oncology/BMT at Nationwide Children’s Hospital and an Associate Professor of Pediatrics at The Ohio State University College of Medicine. Dr. Ranalli serves as Medical Director of the Comprehensive Hemoglobinopathy Center, medical consultant to the Thoracic Tumor Program, and oversees the Embryonal Tumor Program. His clinical and academic interests include: cardiopulmonary and cerebrovascular complications in sickle cell ; the treatment of neuroblastoma, primary renal tumors, and germ cell malignancies; and the use of novel for refractory malignancies. Dr. Ranalli is a member of The Ohio State University Comprehensive Cancer Center Institutional Review Board. He serves as the institutional principle investigator for national clinical trials investigating the natural history of iron overload and the management of silent cerebral infarcts in children and young adults with sickle cell anemia.

26 Lawrence I. Schwartz, MD Anesthesia and CtICU team

Lawrence I. Schwartz, MD, is an attending anesthesiologist and Director of the Cardiac Intensive Care Unit at The Heart Center at Nationwide Children’s Hospital and a Clinical Assistant Professor of Anesthesiology at The Ohio State University College of Medicine. Dr. Schwartz was trained at the and Johns Hopkins University, Department of Anesthesiology. He completed a fellowship in pediatric anesthesiology and pediatric critical care at Johns Hopkins Hospital, Baltimore, Maryland. He is board certified in anesthesiology, pediatrics and pediatric critical care. Dr. Schwartz is a Diplomate with the American Board of Pediatrics, American Board of Anesthesiologists, and American Board of Pediatrics, Sub-board of Pediatric Critical Care Medicine.

Randall M. Schwartz, MD CtICU team

Randall M. Schwartz, MD, is an attending physician in Pediatric Cardiac Intensive Care and Critical Care Medicine at Nationwide Children’s Hospital and an Assistant Professor of Clinical Pediatrics at The Ohio State University College of Medicine. He is also an attending physician in the Division of Pediatric Critical Care Medicine. He received his medical degree from Jefferson Medical College. He completed his residency in pediatrics at Cincinnati Children’s Hospital Medical Center and his fellowship in pediatric critical care medicine at Children’s Medical Center of Dallas. Dr. Schwartz is board eligible in pediatric critical care medicine. He is currently pursuing specialized training in pediatric , cardiac electrophysiology and congenital heart disease in general. Research interests include pediatric as well as inflammation associated with cardiopulmonary bypass. Dr. Schwartz is active clinically and academically in The Heart Center/Section of Cardiology and the Section of Pediatric Critical Care Medicine. He is one of six dedicated pediatric cardiac intensivists who care for the more than 400 patients per year undergoing open-heart surgery at Nationwide Children’s Hospital.

27 Peter Winch, MD Anesthesia Team

Peter Winch, MD, is a Pediatric Cardiac and Transplant Anesthesiologist at Nationwide Children’s Hospital and a Clinical Assistant Professor of Pediatric Anesthesiology at The Ohio State University College of Medicine. Dr. Winch received his medical degree from the University of Cincinnati College of Medicine and his business degree from the University of Pitts- burgh Mercy Children’s Hospital and the . He is board certified in anesthesiology and pediatrics.

Andrew Yates, MD CTICU Team

Andrew Yates, MD, is a Pediatric Cardiologist at The Heart Center at Nationwide Children’s Hospital and an Assistant Professor of Clinical Pediatrics in the Divisions of Cardiology and Critical Care Medicine. Dr. Yates received his medical degree from The Ohio State University. After completing his residency at Nationwide Children’s Hospital, he completed his fellowship training at Nationwide Children’s Hospital in both pediatric cardiology and pediatric critical care medicine. He is board certified in pediatrics and pediatric cardiology.

Nicholas Yeager, MD Hematology/Oncology

Nicholas Yeager, MD, is an assistant hematologist/oncologist at Nationwide Children’s Hospital and a Clinical Assistant Professor of Pediatrics at The Ohio State University College of Medicine. His clinical interests include bone tumors, soft tissue sarcomas and malignancy in adolescents. He is Co-director of the Ortho-Oncology Program working collaboratively with Joel Mayerson, MD.

28 nationwide children’s hospital

Ranked in U.S.News & World Report’s 2009 list of America’s Best Pediatric , Nationwide Children’s Hospital is a collaborative environment that fosters forward thinking and innovation, which leads to outstanding patient care across all departments and specialties, including advancements that have transformed how patients are cared for here and around the world.

As one of the nation’s largest not-for-profit freestanding pediatric health care networks, Nationwide Children’s Hospital provides wellness, preventive, diagnostic, treatment and rehabilitative care for infants, children, adolescents and adult patients with congenital disease. A medical staff of nearly 900 and a hospital staff of 6,000 provide state-of-the-art pediatric care for more than 800,000 patient visits annually. As home to the Department of Pediatrics of The Ohio State University College of Medicine, Nationwide Children’s Hospital physicians train the next generation of pediatricians and pediatric specialists. The Research Institute at Nationwide Children’s Hospital is one of the top 10 National Institutes of Health-funded freestanding pediatric research facilities. Nationwide Children’s remains true to the original mission since its founding in 1892 of providing care regardless of a family’s ability to pay.

29 700 Children’s Drive Columbus, Ohio 43205 NationwideChildrens.org

CH684.03.10.10,000