Intra-bin correction and inter-bin compensation of respiratory motion in free-running five-dimensional whole-heart magnetic resonance imaging.

BACKGROUND: Free-running cardiac and respiratory motion-resolved whole-heart five-dimensional (5D) cardiovascular magnetic resonance (CMR) can reduce scan planning and provide a means of evaluating respiratory-driven changes in clinical parameters of interest. However, respiratory-resolved imaging can be limited by user-defined parameters which create trade-offs between residual artifact and motion blur. In this work, we develop and validate strategies for both correction of intra-bin and compensation of inter-bin respiratory motion to improve the quality of 5D CMR. METHODS: Each component of the reconstruction framework was systematically validated and compared to the previously established 5D approach using simulated free-running data (N = 50) and a cohort of 32 patients with congenital heart disease. The impact of intra-bin respiratory motion correction was evaluated in terms of image sharpness while inter-bin respiratory motion compensation was evaluated in terms of reconstruction error, compression of respiratory motion, and image sharpness. The full reconstruction framework (intra-acquisition correction and inter-acquisition compensation of respiratory motion [IIMC] 5D) was evaluated in terms of image sharpness and scoring of image quality by expert reviewers. RESULTS: Intra-bin motion correction provides significantly (p < 0.001) sharper images for both simulated and patient data. Inter-bin motion compensation results in significant (p < 0.001) lower reconstruction error, lower motion compression, and higher sharpness in both simulated (10/11) and patient (9/11) data. The combined framework resulted in significantly (p < 0.001) sharper IIMC 5D reconstructions (End-expiration (End-Exp): 0.45 ± 0.09, End-inspiration (End-Ins): 0.46 ± 0.10) relative to the previously established 5D implementation (End-Exp: 0.43 ± 0.08, End-Ins: 0.39 ± 0.09). Similarly, image scoring by three expert reviewers was significantly (p < 0.001) higher using IIMC 5D (End-Exp: 3.39 ± 0.44, End-Ins: 3.32 ± 0.45) relative to 5D images (End-Exp: 3.02 ± 0.54, End-Ins: 2.45 ± 0.52). CONCLUSION: The proposed IIMC reconstruction significantly improves the quality of 5D whole-heart MRI. This may be exploited for higher resolution or abbreviated scanning. Further investigation of the diagnostic impact of this framework and comparison to gold standards is needed to understand its full clinical utility, including exploration of respiratory-driven changes in physiological measurements of interest.

Combined free-running four-dimensional anatomical and flow magnetic resonance imaging with native contrast using Synchronization of Neighboring Acquisitions by Physiological Signals.

BACKGROUND: Four-dimensional (4D) flow magnetic resonance imaging (MRI) often relies on the injection of gadolinium- or iron-oxide-based contrast agents to improve vessel delineation. In this work, a novel technique is developed to acquire and reconstruct 4D flow data with excellent dynamic visualization of blood vessels but without the need for contrast injection. Synchronization of Neighboring Acquisitions by Physiological Signals (SyNAPS) uses pilot tone (PT) navigation to retrospectively synchronize the reconstruction of two free-running three-dimensional radial acquisitions, to create co-registered anatomy and flow images. METHODS: Thirteen volunteers and two Marfan syndrome patients were scanned without contrast agent using one free-running fast interrupted steady-state (FISS) sequence and one free-running phase-contrast MRI (PC-MRI) sequence. PT signals spanning the two sequences were recorded for retrospective respiratory motion correction and cardiac binning. The magnitude and phase images reconstructed, respectively, from FISS and PC-MRI, were synchronized to create SyNAPS 4D flow datasets. Conventional two-dimensional (2D) flow data were acquired for reference in ascending (AAo) and descending aorta (DAo). The blood-to-myocardium contrast ratio, dynamic vessel area, net volume, and peak flow were used to compare SyNAPS 4D flow with Native 4D flow (without FISS information) and 2D flow. A score of 0-4 was given to each dataset by two blinded experts regarding the feasibility of performing vessel delineation. RESULTS: Blood-to-myocardium contrast ratio for SyNAPS 4D flow magnitude images (1.5 ± 0.3) was significantly higher than for Native 4D flow (0.7 ± 0.1, p < 0.01) and was comparable to 2D flow (2.3 ± 0.9, p = 0.02). Image quality scores of SyNAPS 4D flow from the experts (M.P.: 1.9 ± 0.3, E.T.: 2.5 ± 0.5) were overall significantly higher than the scores from Native 4D flow (M.P.: 1.6 ± 0.6, p = 0.03, E.T.: 0.8 ± 0.4, p < 0.01) but still significantly lower than the scores from the reference 2D flow datasets (M.P.: 2.8 ± 0.4, p < 0.01, E.T.: 3.5 ± 0.7, p < 0.01). The Pearson correlation coefficient between the dynamic vessel area measured on SyNAPS 4D flow and that from 2D flow was 0.69 ± 0.24 for the AAo and 0.83 ± 0.10 for the DAo, whereas the Pearson correlation between Native 4D flow and 2D flow measurements was 0.12 ± 0.48 for the AAo and 0.08 ± 0.39 for the DAo. Linear correlations between SyNAPS 4D flow and 2D flow measurements of net volume (r2 = 0.83) and peak flow (r2 = 0.87) were larger than the correlations between Native 4D flow and 2D flow measurements of net volume (r2 = 0.79) and peak flow (r2 = 0.76). CONCLUSION: The feasibility and utility of SyNAPS were demonstrated for joint whole-heart anatomical and flow MRI without requiring electrocardiography gating, respiratory navigators, or contrast agents. Using SyNAPS, a high-contrast anatomical imaging sequence can be used to improve 4D flow measurements that often suffer from poor delineation of vessel boundaries in the absence of contrast agents.

Focused navigation for respiratory-motion-corrected free-running radial 4D flow MRI.

PURPOSE: To validate a respiratory motion correction method called focused navigation (fNAV) for free-running radial whole-heart 4D flow MRI. METHODS: Using fNAV, respiratory signals derived from radial readouts are converted into three orthogonal displacements, which are then used to correct respiratory motion in 4D flow datasets. Hundred 4D flow acquisitions were simulated with non-rigid respiratory motion and used for validation. The difference between generated and fNAV displacement coefficients was calculated. Vessel area and flow measurements from 4D flow reconstructions with (fNAV) and without (uncorrected) motion correction were compared to the motion-free ground-truth. In 25 patients, the same measurements were compared between fNAV 4D flow, 2D flow, navigator-gated Cartesian 4D flow, and uncorrected 4D flow datasets. RESULTS: For simulated data, the average difference between generated and fNAV displacement coefficients was 0.04 ± $$ \pm $$ 0.32 mm and 0.31 ± $$ \pm $$ 0.35 mm in the x and y directions, respectively. In the z direction, this difference was region-dependent (0.02 ± $$ \pm $$ 0.51 mm up to 5.85 ± $$ \pm $$ 3.41 mm). For all measurements (vessel area, net volume, and peak flow), the average difference from ground truth was higher for uncorrected 4D flow datasets (0.32 ± $$ \pm $$ 0.11 cm2 , 11.1 ± $$ \pm $$ 3.5 mL, and 22.3 ± $$ \pm $$ 6.0 mL/s) than for fNAV 4D flow datasets (0.10 ± $$ \pm $$ 0.03 cm2 , 2.6 ± $$ \pm $$ 0.7 mL, and 5.1 ± 0 $$ \pm 0 $$ .9 mL/s, p < 0.05). In vivo, average vessel area measurements were 4.92 ± $$ \pm $$ 2.95 cm2 , 5.06 ± $$ \pm $$ 2.64 cm2 , 4.87 ± $$ \pm $$ 2.57 cm2 , 4.87 ± $$ \pm $$ 2.69 cm2 , for 2D flow and fNAV, navigator-gated and uncorrected 4D flow datasets, respectively. In the ascending aorta, all 4D flow datasets except for the fNAV reconstruction had significantly different vessel area measurements from 2D flow. Overall, 2D flow datasets demonstrated the strongest correlation to fNAV 4D flow for both net volume (r2  = 0.92) and peak flow (r2  = 0.94), followed by navigator-gated 4D flow (r2  = 0.83 and r2  = 0.86, respectively), and uncorrected 4D flow (r2  = 0.69 and r2  = 0.86, respectively). CONCLUSION: fNAV corrected respiratory motion in vitro and in vivo, resulting in fNAV 4D flow measurements that are comparable to those derived from 2D flow and navigator-gated Cartesian 4D flow datasets, with improvements over those from uncorrected 4D flow.

Pilot tone navigation for respiratory and cardiac motion-resolved free-running 5D flow MRI.

PURPOSE: In this work, we integrated the pilot tone (PT) navigation system into a reconstruction framework for respiratory and cardiac motion-resolved 5D flow. We tested the hypotheses that PT would provide equivalent respiratory curves, cardiac triggers, and corresponding flow measurements to a previously established self-gating (SG) technique while being independent from changes to the acquisition parameters. METHODS: Fifteen volunteers and 9 patients were scanned with a free-running 5D flow sequence, with PT integrated. Respiratory curves and cardiac triggers from PT and SG were compared across all subjects. Flow measurements from 5D flow reconstructions using both PT and SG were compared to each other and to a reference electrocardiogram-gated and respiratory triggered 4D flow acquisition. Radial trajectories with variable readouts per interleave were also tested in 1 subject to compare cardiac trigger quality between PT and SG. RESULTS: The correlation between PT and SG respiratory curves were 0.95 ± 0.06 for volunteers and 0.95 ± 0.04 for patients. Heartbeat duration measurements in volunteers and patients showed a bias to electrocardiogram measurements of, respectively, 0.16 ± 64.94 ms and 0.01 ± 39.29 ms for PT versus electrocardiogram and of 0.24 ± 63.68 ms and 0.09 ± 32.79 ms for SG versus electrocardiogram. No significant differences were reported for the flow measurements between 5D flow PT and from 5D flow SG. A decrease in the cardiac triggering quality of SG was observed for increasing readouts per interleave, whereas PT quality remained constant. CONCLUSION: PT has been successfully integrated in 5D flow MRI and has shown equivalent results to the previously described 5D flow SG technique, while being completely acquisition-independent.

Coronary artery to pulmonary artery collateral as the principal source of pulmonary blood supply in pulmonary atresia and ventricular septal defect with absent left pulmonary artery.

Pulmonary atresia and ventricular septal defect is associated with variable sources of pulmonary blood supply. We present a case of a coronary artery to pulmonary artery collateral as the principal source of pulmonary blood supply.

Splanchnic, Thoracoabdominal, and Cerebral Blood Flow Volumes in Healthy Children and Young Adults in Fasting and Postprandial States: Determining Reference Ranges by Using Phase-Contrast MR Imaging.

Purpose To estimate reference ranges for blood flow volume (BFV) in major splanchnic, thoracoabdominal, and neck vessels by using phase-contrast magnetic resonance (MR) imaging in children and young adults in fasting and postprandial states. Materials and Methods In this institutional research ethics board-approved prospective study, healthy volunteers underwent phase-contrast MR imaging in a fasting state and again after a standardized meal. BFV values were reported as medians and ranges, and postmeal to premeal BFV ratios were calculated. BFVs in volunteers divided into two groups according to age (≤18 years old and >18 years old) were compared by using the Mann-Whitney test adjusted for multiple comparisons. Linear regression for internal validation of BFV and Pearson correlation and Bland-Altman analysis for interobserver agreement were used. Results Reference ranges for BFVs were estimated in 39 volunteers (23 male and 16 female; mean age, 21.2 years ± 8.5; range, 9-40 years) and were indexed according to body surface area, with internal validation (R2 = 0.84-0.92) and excellent interobserver agreement (R2 = 0.9928). There was an almost 30% increase in total abdominal BFV (P < .0001) in response to a meal, which was the result of a threefold increase in superior mesenteric artery BFV (P < .0001). BFV after the meal remained unaffected in the celiac artery and cerebral circulation. Significantly higher normalized BFVs in the cerebral circulation were measured in children with both preprandial (P = .039) and postprandial (P = .008) status than those in adults. Conclusion Reference ranges for BFVs and changes in BFVs in response to a meal in major splanchnic, thoracoabdominal, and neck vessels were estimated by using phase-contrast MR imaging in healthy volunteers to allow hemodynamic assessment of children and young adults with various diseases. © RSNA, 2017 Online supplemental material is available for this article.

Loss-of-function mutations in the X-linked biglycan gene cause a severe syndromic form of thoracic aortic aneurysms and dissections.

PURPOSE: Thoracic aortic aneurysm and dissection (TAAD) is typically inherited in an autosomal dominant manner, but rare X-linked families have been described. So far, the only known X-linked gene is FLNA, which is associated with the periventricular nodular heterotopia type of Ehlers-Danlos syndrome. However, mutations in this gene explain only a small number of X-linked TAAD families. METHODS: We performed targeted resequencing of 368 candidate genes in a cohort of 11 molecularly unexplained Marfan probands. Subsequently, Sanger sequencing of BGN in 360 male and 155 female molecularly unexplained TAAD probands was performed. RESULTS: We found five individuals with loss-of-function mutations in BGN encoding the small leucine-rich proteoglycan biglycan. The clinical phenotype is characterized by early-onset aortic aneurysm and dissection. Other recurrent findings include hypertelorism, pectus deformity, joint hypermobility, contractures, and mild skeletal dysplasia. Fluorescent staining revealed an increase in TGF-ß signaling, evidenced by an increase in nuclear pSMAD2 in the aortic wall. Our results are in line with those of prior reports demonstrating that Bgn-deficient male BALB/cA mice die from aortic rupture. CONCLUSION: In conclusion, BGN gene defects in humans cause an X-linked syndromic form of severe TAAD that is associated with preservation of elastic fibers and increased TGF-ß signaling.Genet Med 19 4, 386-395.

Impact of bileaflet mitral valve prolapse on quantification of mitral regurgitation with cardiac magnetic resonance: a single-center study.

BACKGROUND: To quantify mitral regurgitation (MR) with CMR, the regurgitant volume can be calculated as the difference between the left ventricular (LV) stroke volume (SV) measured with the Simpson's method and the reference SV, i.e. the right ventricular SV (RVSV) in patients without tricuspid regurgitation. However, for patients with prominent mitral valve prolapse (MVP), the Simpson's method may underestimate the LV end-systolic volume (LVESV) as it only considers the volume located between the apex and the mitral annulus, and neglects the ventricular volume that is displaced into the left atrium but contained within the prolapsed mitral leaflets at end systole. This may lead to an underestimation of LVESV, and resulting an over-estimation of LVSV, and an over-estimation of mitral regurgitation. The aim of the present study was to assess the impact of prominent MVP on MR quantification by CMR. METHODS: In patients with MVP (and no more than trace tricuspid regurgitation) MR was quantified by calculating the regurgitant volume as the difference between LVSV and RVSV. LVSVuncorr was calculated conventionally as LV end-diastolic (LVEDV) minus LVESV. A corrected LVESVcorr was calculated as the LVESV plus the prolapsed volume, i.e. the volume between the mitral annulus and the prolapsing mitral leaflets. The 2 methods were compared with respect to the MR grading. MR grades were defined as absent or trace, mild (5-29% regurgitant fraction (RF)), moderate (30-49% RF), or severe (≥50% RF). RESULTS: In 35 patients (44.0 ± 23.0y, 14 males, 20 patients with MR) the prolapsed volume was 16.5 ± 8.7 ml. The 2 methods were concordant in only 12 (34%) patients, as the uncorrected method indicated a 1-grade higher MR severity in 23 (66%) patients. For the uncorrected/corrected method, the distribution of the MR grades as absent-trace (0 vs 11, respectively), mild (20 vs 18, respectively), moderate (11 vs 5, respectively), and severe (4 vs 1, respectively) was significantly different (p < 0.001). In the subgroup without MR, LVSVcorr was not significantly different from RVSV (difference: 2.5 ± 4.7 ml, p = 0.11 vs 0) while a systematic overestimation was observed with LVSVuncorr (difference: 16.9 ± 9.1 ml, p = 0.0007 vs 0). Also, RVSV was highly correlated with aortic forward flow (n = 24, R 2 = 0.97, p < 0.001). CONCLUSION: For patients with severe bileaflet prolapse, the correction of the LVSV for the prolapse volume is suggested as it modified the assessment of MR severity by one grade in a large portion of patients.

Bias related to body mass index in pediatric echocardiographic Z scores.

In pediatric echocardiography, cardiac dimensions are often normalized for weight, height, or body surface area (BSA). The combined influence of height and weight on cardiac size is complex and likely varies with age. We hypothesized that increasing weight for height, as represented by body mass index (BMI) adjusted for age, is poorly accounted for in Z scores normalized for weight, height, or BSA. We aimed to evaluate whether a bias related to BMI was introduced when proximal aorta diameter Z scores are derived from bivariate models (only one normalizing variable), and whether such a bias was reduced when multivariable models are used. We analyzed 1,422 echocardiograms read as normal in children ≤18 years. We computed Z scores of the proximal aorta using allometric, polynomial, and multivariable models with four body size variables. We then assessed the level of residual association of Z scores and BMI adjusted for age and sex. In children ≥6 years, we found a significant residual linear association with BMI-for-age and Z scores for most regression models. Only a multivariable model including weight and height as independent predictors produced a Z score free of linear association with BMI. We concluded that a bias related to BMI was present in Z scores of proximal aorta diameter when normalization was done using bivariate models, regardless of the regression model or the normalizing variable. The use of multivariable models with weight and height as independent predictors should be explored to reduce this potential pitfall when pediatric echocardiography reference values are evaluated.

Similarity-driven motion-resolved reconstruction for ferumoxytol-enhanced whole-heart MRI in congenital heart disease.

A similarity-driven multi-dimensional binning algorithm (SIMBA) reconstruction of free-running cardiac magnetic resonance imaging data was previously proposed. While very efficient and fast, the original SIMBA focused only on the reconstruction of a single motion-consistent cluster, discarding the remaining data acquired. However, the redundant data clustered by similarity may be exploited to further improve image quality. In this work, we propose a novel compressed sensing (CS) reconstruction that performs an effective regularization over the clustering dimension, thanks to the integration of inter-cluster motion compensation (XD-MC-SIMBA). This reconstruction was applied to free-running ferumoxytol-enhanced datasets from 24 patients with congenital heart disease, and compared to the original SIMBA, the same XD-MC-SIMBA reconstruction but without motion compensation (XD-SIMBA), and a 5D motion-resolved CS reconstruction using the free-running framework (FRF). The resulting images were compared in terms of lung-liver and blood-myocardium sharpness, blood-myocardium contrast ratio, and visible length and sharpness of the coronary arteries. Moreover, an automated image quality score (IQS) was assigned using a pretrained deep neural network. The lung-liver sharpness and blood-myocardium sharpness were significantly higher in XD-MC-SIMBA and FRF. Consistent with these findings, the IQS analysis revealed that image quality for XD-MC-SIMBA was improved in 18 of 24 cases, compared to SIMBA. We successfully tested the hypothesis that multiple motion-consistent SIMBA clusters can be exploited to improve the quality of ferumoxytol-enhanced cardiac MRI when inter-cluster motion-compensation is integrated as part of a CS reconstruction.

Choices doctors would make if their infant had hypoplastic left heart syndrome: comparison of survey data from 1999 and 2007.

Data suggest that despite improved surgical outcomes for infants with hypoplastic left heart syndrome (HLHS), the past two decades have seen little change in parents' decisions whether to choose surgery or palliative treatment without life-prolonging intervention. Data also suggest that doctors' predictions of the choices they would make if their own infant were diagnosed with HLHS do not correlate with their predictions of surgical outcomes. Although previous studies have compared rates of surgery and palliative treatment without life-prolonging intervention over time, no studies have assessed changes in doctors' attitudes. The current study used descriptive and quantitative statistics to compare responses from American pediatric cardiologists and congenital cardiac surgeons from studies conducted in 1999 and 2007. These doctors were asked what choice they believe they would make for their own affected infant. Comparison of responses from 1999 and 2007 showed no difference in the responses of cardiologists: 1999 (44 % surgery, 17 % palliative treatment, 40 % uncertain) versus 2007 (45 % surgery, 20 % palliative treatment, 35 % uncertain). Among surgeons, there was a non-statistically significant trend away from choosing surgery: 1999 (77 % surgery, 5 % palliative treatment, 18 % uncertain) versus 2007 (56 % surgery, 8 % palliative treatment, 36 % uncertain). In conclusion, these analyses suggest that despite improving surgical outcomes, doctors are no more likely to predict that they would choose surgery for their own hypothetical infant with HLHS. Further research is needed to determine what factors influence choice making in the care of infants with HLHS.

Three-dimensional printing and virtual reconstruction in surgical planning of double-outlet right ventricle repair.

Objectives: For more than a decade, 3-dimensional (3D) printing has been identified as an innovative tool for the surgical planning of double-outlet right ventricle (DORV). Nevertheless, lack of evidence concerning its benefits encourages us to identify valuable criteria for future prospective trials. Methods: We conducted a retrospective study involving 10 patients with DORV operated between 2015 and 2019 in our center. During a preoperative multidisciplinary heart team meeting, we harvested surgical decisions following a 3-increment step process: (1) multimodal imaging; (2) 3D virtual valvular reconstruction (3DVVR); and (3) 3D-printed heart model (3DPHM). The primary outcome was the proportion of predicted surgical strategy following each of the 3 steps, compared with the institutional retrospective surgical strategy. The secondary outcome was the change of surgical strategy through 3D modalities compared with multimodal imaging. The incremental benefit of the 3DVVR and 3DPHM over multimodal imaging was then assessed. Results: The operative strategy was predicted in 5 cases after multimodal imaging, in 9 cases after 3DVVR, and the 10 cases after 3DPHM. Compared with multimodal imaging, 3DVVR modified the strategy for 4 cases. One case was correctly predicted only after 3DPHM inspection. Conclusions: 3DVVR and 3DPHM improved multimodal imaging in the surgical planning of patients with DORV. 3DVVR allowed a better appreciation of the relationships between great vessels, valves, and ventricular septal defects. 3DPHM offers a realistic preoperative view at patient scale and enhances the evaluation of outflow tract obstruction. Our retrospective study demonstrates benefits of preoperative 3D modalities and supports future prospective trials to assess their impact on postoperative outcomes.

Epidemiology of Kawasaki Disease in children in Switzerland: a national prospective cohort study.

AIM OF THE STUDY: Kawasaki disease is a febrile illness which can lead to significant coronary artery lesions. Its incidence varies among countries and is highest in Japan (330.2 children under 5 years old/100,000 per year). Since the epidemiology of Kawasaki disease in Switzerland is unknown, we conducted a national prospective data collection between 2013 and 2017 to describe its incidence, diagnosis, and treatment. METHODS: We collected demographic and clinical data of the children under 17 years old hospitalised with Kawasaki disease in Switzerland between March 2013 and February 2017 using anonymous data collection forms with the help of the Swiss Paediatric Surveillance Unit (SPSU). We defined Kawasaki disease per the 2004 American Heart Association criteria: patients with ≥5 days of fever and ≥4 of the 5 main clinical features were included as complete Kawasaki disease and patients with ≥5 days of fever and <4 of the 5 main clinical features were included as incomplete Kawasaki disease. The incidence was calculated with the data of the Federal Statistical Office of Switzerland, considering permanent residents of the country. The different groups were compared by the unpaired student t-test for continuous variables and Pearson's chi squared test for categorical variables, respectively. RESULTS: We included 175 patients: 60% were boys, with a mean age of 38.2 months. The incidence of Kawasaki disease was 3.1/100,000 [95% CI 2.6-3.7] per year in children under 17 years of age and 8.4/100,000 [95% CI 6.7-10.2] per year in children under 5 years of age. The most frequent clinical signs were a rash (85.4%) and changes of the lips and oral/pharyngeal mucosa (83.4%). The diagnosis of Kawasaki disease was made at a mean of 7.3 days after the first symptom. Echocardiography was abnormal in 52.3%. The treatment with intravenous immunoglobulins (IVIG) and acetylsalicylic acid was administered in accordance with international guidelines. Subgroup analysis showed that children older than 5 years old had significantly more complete Kawasaki disease than the younger ones (78.8% vs 57.4%, p = 0.021). Children with "extreme ages" (<1 year old and >8 years old) were diagnosed later (8.6 (±0.9) vs 7.0 (±0.3) days, p = 0.0129), had longer duration of fever (9.8 (±0.9) vs 8.1 (±0.3) days, p = 0.013) and had more echocardiographic abnormalities (n = 26 (70.3%) vs n = 65 (47.5%), p = 0.014) at diagnosis. One child died during the acute phase of the illness. CONCLUSIONS: The incidence of Kawasaki disease in Switzerland is in the lower range of other European countries.

Transcatheter closure of a patent ductus arteriosus in a preterm infant with an Amplatzer Vascular Plug IV device.

Rapid advances in paediatric interventional cardiology allow transcatheter closure of patent ductus arteriosus (PDA) in increasingly smaller patients. We describe a successful transcatheter closure of a large tubular PDA in a symptomatic preterm infant of 2,210 g using an Amplatzer Vascular Plug IV device.

Contemporary early results of late repair of tetralogy of Fallot in children: a single-centre case series.

AIMS: To describe the early results of complete repair of tetralogy of Fallot (TOF) in children older than one year of age. METHODS: We identified all patients older than one year of age who underwent TOF repair between 2007 and 2017. Data collected included type of surgical repair, survival at 30 days after surgery, reintervention within 30 days of surgery, length of stay in the intensive care unit (ICU), length of stay in hospital, and degree of residual right ventricular outflow tract (RVOT) stenosis and pulmonary insufficiency 30 days after surgery. RESULTS: 125 children (median age 4.4 years, interquartile range [IQR] 3–5.7) underwent complete repair of TOF, with pulmonary valve preservation in 66%, a transannular patch in 19%, and a valved right ventricular-to-pulmonary artery conduit in 15%. All patients survived. There were twelve (9.6%) reinterventions. Median ICU length of stay was 7 days and median hospital length of stay was 12 days. Significant residual RVOT stenosis was present in 7.2% and significant pulmonary insufficiency in 19.2%. Patients with a transannular patch had a significantly higher proportion of significant residual RVOT stenosis and significant pulmonary insufficiency compared with the other types of surgical repair. CONCLUSIONS: Compared with the existing literature on complete late repair of TOF in children, this study showed good early results with no mortality, similar rates of reintervention and valve-preserving surgery, higher ICU and hospital length of stay, higher incidence of significant residual RVOT stenosis, and lower incidence of significant pulmonary insufficiency. Repair with a transannular patch was a risk factor for significant residual RVOT stenosis and significant pulmonary insufficiency.

Immediate results of percutaneous management of coarctation of the aorta: A 7-year single-centre experience.

BACKGROUND: Coarctation of the aorta (CoA) is often treated percutaneously. The aim of this study was to describe the immediate results of percutaneous management of native aortic coarctation (NaCoA) and recoarctation of the aorta (ReCoA) at our institution. METHODS: We identified all patients with NaCoA or ReCoA who underwent percutaneous dilatation by either balloon angioplasty (BAP) or endovascular stent implantation (ESI) between 2011 and 2017. Success was defined as a residual peak-to-peak gradient (PPG) <20 mmHg or a ≥50% reduction in the gradient if the pre-intervention PPG was <20 mmHg. RESULTS: 63 patients (median age 6.8 years, interquartile range [IQR] 0.4-14.2) were identified. Among 11 patients with NaCoA, 7 underwent BAP and 4 had ESI, and among 52 patients with ReCoA, 42 underwent BAP and 10 had ESI. In patients with NaCoA, BAP was successful in 71%, with median PPG decreasing from 32 mmHg (IQR 25-46) to 17 mmHg (IQR 4-23) (p = .02), and ESI was successful in 100%, with median PPG decreasing from 20 mmHg (IQR 14.5-40) to 2 mmHg (IQR 0-6) (p < .01). In patients with ReCoA, BAP was successful in 69%, with median PPG decreasing from 20 mmHg (IQR 16-31.3) to 9 mmHg (IQR 0-14.3) (p < .001), and ESI was successful in 100%, with median PPG decreasing from 18 mmHg (IQR 11.5-22.8) to 0 mmHg (IQR 0-3.5) (p < .01). ESI was more successful than BAP (p = .01). There was only one complication. CONCLUSIONS: Percutaneous management of CoA is safe and effective in both NaCoA and ReCoA. Stent implantation is more effective than BAP.

Therapeutic strategies in children with an isolated unilaterally absent proximal pulmonary artery.

Therapeutic strategies for isolated unilateral absence of a proximal pulmonary artery remain unclear. The natural history of the disease, or thrombosis of primary surgical anastomosis, leads to exclusion of the affected lung with increased risk of intrapulmonary bleeding, impaired quality of life, and shortened life expectancy. We herein describe our two-stage approach in a small series of patients starting with interventional catheterization followed by surgical anastomosis. Other medical interventions, such as anticoagulation and pulmonary vasodilatation, are key factors to successfully restore pulmonary circulation in this rare defect.

Author Correction: Fetal cardiac cine magnetic resonance imaging in utero.

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