Efficacy of intraoperative cine-portogram for complicated portal vein reconstruction in pediatric living donor liver transplantation.

Sufficient PV flow is necessary to achieve successful PV reconstruction in pediatric LDLT. IOCP can be used to assess the severity of PV stenosis and to identify potential portosystemic collateral pathways. The present study reviewed the utility of IOCP and the outcomes of patients who underwent assessment with an IOCP. Consecutive primary LDLTs were performed in 488 pediatric recipients between November 2005 and October 2019. IOCP was used in patients who were unable to achieve sufficient PV flow after the ligation of collaterals. In total, 11 patients underwent IOCP to assess potential portosystemic collateral pathways. The median age and body weight was 8 months (IQR, 6-11 months) and 6.6 kg (IQR, 5.7-8.9 kg), respectively. The reasons for using the IOCP were recurrent PV thrombus in seven patients and insufficient PV flow in four patients. IOCP revealed remaining collaterals in six patients and residual hypoplastic PV in eight patients. Two patients required additional interruption of the potential collaterals under IOCP, which were unable to be recognized as a dominant portosystemic collateral pathway on preoperative imaging. All eight patients with residual hypoplastic PV required vein graft interposition for the complete removal of the hypoplastic PV. All the patients are currently doing well with a median follow-up period of 4.9 years (IQR, 2.2-5.6 years). IOCP can be an effective tool for precisely detecting occult portosystemic collateral pathways and for assessing the patency of the PV anastomosis in pediatric LDLT.

Significance of nailfold videocapillaroscopy in patients with idiopathic inflammatory myopathies.

Objective: The aim of this study was to investigate the clinical and immunological significance of nailfold videocapillaroscopy (NVC) abnormalities in patients with idiopathic inflammatory myopathies (IIMs). Methods: Seventy consecutive Japanese patients with untreated IIMs, enrolled between April 2014 and August 2017, were prospectively studied. Clinical features, NVC findings, autoantibody profile by immunoprecipitation and ELISA, and histopathological findings of skin biopsies of DM rash were assessed at baseline and after 1-year of immunosuppressive therapy. Results: NVC abnormalities were found in 55.7% (39/70) of IIM patients, with significantly higher prevalence in DM (65.4%) compared with PM (27.8%) (P = 0.01). In subsets of patients classified by autoantibody specificities, the prevalence of NVC abnormalities was significantly higher in patients with anti-MDA5 (87.5%) and anti-transcriptional intermediary factor 1γ (88.9%) vs anti-aminoacyl-tRNA synthetase (26.9%, P < 0.001). Perivascular lymphocytic infiltration in the upper dermis of skin rash biopsy of DM was more severe in patients with NVC abnormalities (P < 0.05). Unexpectedly, NVC abnormalities disappeared in 75% of IIM patients after 1-year of immunosuppressive therapy in contrast to stable NVC changes seen in scleroderma patients. Conclusion: Nailfold microvascular abnormalities were common in DM patients, associated with anti-MDA5 and transcriptional intermediary factor 1γ antibodies, and perivascular inflammation in skin histology. NVC abnormalities in IIMs may become clinically useful markers for defining subsets of DM and understanding the pathogenesis of the clinical features seen in these patients.

Dynamic quantitative nonenhanced magnetic resonance angiography of the abdominal aorta and lower extremities using cine fast interrupted steady-state in combination with arterial spin labeling: a feasibility study.

BACKGROUND: Cine fast interrupted steady-state in combination with arterial spin labeling is a recently described nonenhanced magnetic resonance angiography (MRA) technique that relies on bolus tracking for time-resolved digital subtraction angiography-like displays of blood flow patterns. We evaluated the feasibility of applying this technique to display in-plane flow patterns in two regions: the abdominal aorta and lower extremity peripheral arteries. METHODS: We performed an institutional review board-approved study in healthy subjects and patients. In 7 healthy subjects, in-plane flow was imaged at 4 stations ranging from the lower legs to the aorto-iliac bifurcation (junction of the distal thigh and upper calf, mid-thigh, junction of the upper thigh and pelvis, upper pelvis). In 5 healthy subjects and 6 patients without abdominal aortopathy, images were acquired through the suprarenal abdominal aorta. Ten patients with known peripheral arterial disease and two patients with stable disease of the abdominal aorta were also evaluated. Peak velocity was compared at each of the 4 stations for cine fast interrupted steady-state in combination with arterial spin labeling and two-dimensional cine phase contrast in patients with normal vessels. RESULTS: In-plane flow patterns were well visualized in all peripheral arterial stations and in the abdominal aorta, providing a high quality display of hemodynamic patterns along extensive lengths of the vessels. There was very strong positive correlation (r = 0.952, P < 0.05) and excellent agreement (intraclass correlation coefficient, 0.935; 95% confidence interval, 0.812-0.972) between peak flow velocities measured by cine fast interrupted steady-state in combination with arterial spin labeling and two-dimensional cine phase contrast. In 10 patients with peripheral artery disease and 2 patients with aortic pathology, cine fast interrupted steady-state in combination with arterial spin labeling provided a visual demonstration of abnormal hemodynamics. CONCLUSION: This feasibility study suggests that cine fast interrupted steady-state in combination with arterial spin labeling provides an efficient, high quality and physiologically accurate display of in-plane flow patterns over extensive lengths of the lower extremity peripheral arteries, which can be difficult to achieve using other MRA techniques.

Variability in radiation dose and image quality: A comparison across fluoroscopy-system vendors, generations of equipment and institutions.

OBJECTIVES: To evaluate differences in radiation dose and image quality across institutions, fluoroscope vendors and generations of fluoroscopes for pediatric cardiac catheterization. BACKGROUND: Increased recognition of the potentially harmful effects of ionizing radiation has spurred technological advances in fluoroscopes, as well as increased focus on optimizing fluoroscope performance. There is currently little understanding of variability in the dose-image quality relationship across institutions, fluoroscope vendor and/or generation of equipment. METHODS: We evaluated latest generation fluoroscopes from Phillips, Siemens, GE, and Toshiba, and an older generation Phillips fluoroscope (release date 2003) at three different institutions. Radiation dose was measured using an anthropomorphic dose-assessment phantom with effective dose in mSv estimated from Monte Carlo simulations. Image quality phantom images were scored on a 12-point scale by three blinded reviewers. RESULTS: Fluoroscope effective doses ranged from 0.04 to 0.14 mSv/1,000 pulses for fluoroscopy with associated composite image quality scores ranging from 8.0 ± 0.6 to 10.4 ± 1.3. For cineangiography, effective doses ranged from 0.17 to 0.57 mSv/1,000 frames with image quality scores ranging from 10.1 ± 0.3 to 11.1 ± 0.3. There was modest correlation between effective dose and image quality (r = 0.67, P = 0.006). The older generation fluoroscope delivered consistently higher doses than the newer generation systems (2.3- to 3.5-fold higher for fluoroscopy; 1.1- to 3.4-fold higher for cineangiography) without appreciable differences in image quality. CONCLUSION: Technological advances have markedly improved fluoroscope performance. Comparing latest generation systems across vendors and institutions, we found variability in the dose-IQ relationship and speculate that this reflects both equipment and institutional optimization practices.

An algorithm for the differentiation of the infarct territory in difficult to discern electrocardiograms.

BACKGROUND: In a minority of the patients presenting with ST-segment elevation (STE) myocardial infarction (MI), electrocardiogram (ECG) may show a balanced STE in both anterior and inferior lead groups and may cause diagnostic confusion about involved myocardial territory. In this study, we sought ECG clues which may facilitate discriminating (1) MI location and then (2) culprit artery in patients with difficult-to-discern ECGs. MATERIAL AND METHODS: Consecutive patients with the diagnosis of STEMI were scanned and patients with ECGs displaying both anterior and inferior STE were enrolled. ECGs with obvious ST elevation in either lead group and reciprocal ST-segment depression were excluded. Predictive power of several ECG variables has been analyzed and an algorithm has been constructed. RESULTS: A total of 959 STEMI cases were scanned, the final study population was consisted of 114 patients. Our algorithm for locating MI territory had a sensitivity, specificity, positive and negative predictive value of 72.1%, 92.5%, 91.7% and 74.2% for inferior versus anterior location, respectively (P < 0.001, φ = 0.652). As anterior MI was strictly reserved for left anterior descending (LAD) artery occlusion, these diagnostic values were also valid for discriminating circumflex artery [Cx]/right coronary artery [RCA] versus LAD as the culprit artery. In patients classified as having inferior MI, an STE in lead III greater than STE in lead II favored RCA over Cx as the culprit artery with a sensitivity, specificity, positive and negative predictive value of 97%, 46.6%, 80% and 87.5%, respectively (P < 0.001; φ = 0.544). CONCLUSION: Our algorithm can be used in difficult-to-discern ECGs for defining involved myocardial territory and culprit artery.

Angiographic severity does not correlate with fractional flow reserve in heavily calcified coronary arteries.

OBJECTIVES: To determine the relationship between severity of stenosis and hemodynamic significance in calcified coronary arteries. BACKGROUND: Severity of stenosis is widely used to determine the need for revascularization but the effect of lesion calcification on hemodynamic significance is not well understood. METHODS: Two hundred consecutive patients undergoing fractional flow reserve (FFR) testing of an intermediate coronary lesion with a pressure wire and intravenous infusion of adenosine were studied. Coronary calcium was quantified based upon radiopacities at the site of the stenosis on cineangiography using the method of Mintz et al. (0 = none or mild calcium, 1 = moderate calcium, 2 = severe calcium). RESULTS: Mean age was 61 ± 11 years, 66% were males, 87.5% had hypertension, 44.5% had diabetes, and 20.5% were current smokers. The mean coronary stenosis by quantitative coronary angiography was 60 ± 12% and the mean FFR was 0.83 ± 0.08. There were 109, 45, and 46 patients classified as Calcium Score of 0, 1, or 2, respectively. Compared to those with no/mild or moderate calcification, patients with severe coronary calcium were older and more likely to have chronic kidney disease and pulmonary disease. The correlation between angiographic severity and FFR decreased as lesion calcification increased [calcium score = 0 (R2 = 0.25, P < 0.005); calcium score = 1 (R2 = 0.11, P < 0.005); calcium score = 2 (R2 = 0.02, P = 0.35)]. CONCLUSIONS: In patients with heavily calcified coronary lesions, there was no association between angiographic stenosis and hemodynamic significance and FFR is needed to determine hemodynamic significance of intermediate lesions. © 2016 Wiley Periodicals, Inc.

Acute invasive hemodynamic effects of percutaneous mitral paravalvular leak closure.

OBJECTIVES: The aim of this study was to demonstrate the physiologic effects of percutaneous mitral paravalvular leak (PVL) closure through pre- and post-closure left and right heart catheterization. BACKGROUND: Mitral PVL represents a significant source of morbidity and mortality following mitral valve repair and replacement. Although percutaneous PVL closure is an effective treatment with improvements in symptoms and mortality, data regarding the acute hemodynamic effects of such closure are lacking. METHODS: Consecutive patients with clinically significant heart failure and/or hemolysis attributed to mitral PVL underwent percutaneous mitral PVL closure with pre- and post-procedural right and left heart catheterization. Hemodynamic measurements of cardiovascular function obtained in this manner were compared and stratified according to pre- and post-procedural echocardiographic severity of PVL. RESULTS: Twenty-four patients (age 68 ± 9.4 years, 75% male) underwent percutaneous mitral PVL closure. Significant improvements were found in left atrial pressure (LAP) (mean LAP lowered from 21 ± 4 to 19 ± 3 mm Hg, P = 0.005), pulmonary artery pressure (PAP) (mean PAP lowered from 36 ± 11 to 33 ± 9, P = 0.04), and cardiac index (increased from 2.8 ± 0.8 to 3.0 ± 0.7 L/min/m2 , P = 0.01). Left atrial v-wave reduction of 20% was associated with ≤ mild residual PVL by transesophageal echocardiography (P = 0.09). CONCLUSIONS: Percutaneous mitral PVL closure is associated with significant reductions in LAP and PAP and an increase in cardiac index. These hemodynamic effects underlie the clinical benefits of PVL closure and may be a useful tool for intraprocedural guidance. © 2017 Wiley Periodicals, Inc.

[Trigeminy of ventricular bigeminy caused by reentrant mechanism: reentry of reentry]. / Trigeminia de la bigeminia ventricular por mecanismo reentrante: reentrada de la reentrada.

The process that follows an acute myocardial infarction generates an appropriate substrate for the formation of reentry circuits, considered to be the most frequent mechanism of ventricular extrasystoles and tachyarrhythmias. We present the case of a patient with an acute myocardial infarction unusually concurring with ventricular trigeminy coupled to ventricular bigeminated extrasystoles giving rise to a trigeminy sequence over the bigeminy, which indicates the existence of two reentry circuits (reentry of reentry) that trigger ventricular flutter.

Evaluation of a new very low dose imaging protocol: feasibility and impact on X-ray dose levels in electrophysiology procedures.

AIMS: This study presents and evaluates the impact of a new lowest-dose fluoroscopy protocol (Siemens AG), especially designed for electrophysiology (EP) procedures, on X-ray dose levels. METHODS AND RESULTS: From October 2014 to March 2015, 140 patients underwent an EP study on an Artis zee angiography system. The standard low-dose protocol was operated at 23 nGy (fluoroscopy) and at 120 nGy (cine-loop), the new lowest-dose protocol was operated at 8 nGy (fluoroscopy) and at 36 nGy (cine-loop). Procedural data, X-ray times, and doses were analysed in 100 complex left atrial and in 40 standard EP procedures. The resulting dose-area products were 877.9 ± 624.7 µGym² (n = 50 complex procedures, standard low dose), 199 ± 159.6 µGym² (n = 50 complex procedures, lowest dose), 387.7 ± 36.0 µGym² (n = 20 standard procedures, standard low dose), and 90.7 ± 62.3 µGym² (n = 20 standard procedures, lowest dose), P < 0.01. In the low-dose and lowest-dose groups, procedure times were 132.6 ± 35.7 vs. 126.7 ± 34.7 min (P = 0.40, complex procedures) and 72.3 ± 20.9 vs. 85.2 ± 44.1 min (P = 0.24, standard procedures), radiofrequency (RF) times were 53.8 ± 26.1 vs. 50.4 ± 29.4 min (P = 0.54, complex procedures) and 10.1 ± 9.9 vs. 12.2 ± 14.7 min (P = 0.60, standard procedures). One complication occurred in the standard low-dose and lowest-dose groups (P = 1.0). CONCLUSION: The new lowest-dose imaging protocol reduces X-ray dose levels by 77% compared with the currently available standard low-dose protocol. From an operator standpoint, lowest X-ray dose levels create a different, reduced image quality. The new image quality did not significantly affect procedure or RF times and did not result in higher complication rates. Regarding radiological protection, operating at lowest-dose settings should become standard in EP procedures.

Patient radiation dose reduction using an X-ray imaging noise reduction technology for cardiac angiography and intervention.

Coronary angiography and intervention can expose patients to high radiation dose. This retrospective study quantifies the patient dose reduction due to the introduction of a novel X-ray imaging noise reduction technology using advanced real-time image noise reduction algorithms and optimized acquisition chain for fluoroscopy and exposure in interventional cardiology. Patient, procedure and radiation dose data were retrospectively collected in the period August 2012-August 2013 for 883 patients treated with the image noise reduction technology (referred as "new system"). The same data were collected for 1083 patients in the period April 2011-July 2012 with a system using state-of-the-art image processing and reference acquisition chain (referred as "reference system"). Procedures were divided into diagnostic (CAG) and intervention (PCI). Acquisition parameters such as fluoroscopy time, volume of contrast medium, number of exposure images and number of stored fluoroscopy images were collected to classify procedure complexity. The procedural dose reduction was investigated separately for three main cardiologists. The new system provides significant dose reduction compared to the reference system. Median DAP values decreased for all procedures (p < 0.0001) from 172.7 to 59.4 Gy cm(2), for CAG from 155.1 to 52.0 Gy cm(2) and for PCI from 229.0 to 85.8 Gy cm(2) with reduction quantified at 66, 66 and 63 %, respectively. Based on median values, the dose reduction for all procedures was 68, 60 and 67 % for cardiologists 1, 2 and 3, respectively. The X-ray imaging technology combining advanced real-time image noise reduction algorithms and anatomy-specific optimized fluoroscopy and cine acquisition chain provides 66 % patient dose reduction in interventional cardiology.

Palmar arch anatomy: Ajmer Working Group classification.

INTRODUCTION: Forearm arteries are frequently used as workhorse site for cardiac catheterization, bypass grafting and haemodialysis access. There is paucity of data on palmar circulation in live human being and only cadaveric data are available till date. We, therefore, made an attempt to look at the various patterns of sufficient or insufficient palmar arch circulation and various anomalies of forearm arteries, to discuss their clinical implications. METHODS AND RESULTS: We obtained the forearm and hand arteriograms of patients (n = 302) through radial (n = 200) and ulnar routes (n = 102). Modified Allen's test was normal in all of our patients. On the basis of predetermined parameters angiograms were analysed and findings were divided into three groups. These three groups were further classified as type A, type B, type C superficial palmar arch. CONCLUSION: We concluded that type A superficial palmar arch is most suitable for providing adequate collateral circulation in case of harvesting of forearm vessel, whereas type C superficial palmar arch appears to be highly susceptible for digital ischemia in case of radial or ulnar artery occlusion. Modified Allen's test alone is not justifiable for documenting good collateral circulation and it should be supplemented by other tests to document good collateral circulation before proceeding to any radical procedure.

A cross-sectional study of the radiation dose and image quality of X-ray equipment used in IVR.

There are case reports of injuries caused by the radiation from interventional radiology (IVR) X-ray systems. Therefore, the management of radiation doses in IVR is important. However, no detailed report has evaluated image quality for a large number of IVR X-ray systems. As a result, it is unclear whether the image quality of the X-ray equipment currently used in IVR procedures is optimal. We compared the entrance surface doses and image quality of multiple IVR X-ray systems. This study was conducted in 2014 at 13 medical facilities using 18 IVR X-ray systems. We evaluated image quality and simultaneously measured the radiation dose. Entrance surface doses for fluoroscopy (duration, 1 min) and cineradiography (duration, 10 s) are measured using a 20-cm-thick acrylic plate and skin dose monitor. The image quality (such as spatial resolution and low-contrast detectability) of both fluoroscopy and cineradiography was evaluated using a QC phantom. For fluoroscopy, the average entrance surface dose using the 20-cm-thick acrylic plate was 13.9 (range 2.1-28.2) mGy/min. For cineradiography, the average entrance surface dose was 24.6 (range 5.1-49.3) mGy/10 s. We found positive correlations between radiation doses and image quality scores, in general, especially for fluoroscopy. The differences in surface dose among the 18 IVR X-ray systems were high (max/min, 9.7-fold for cineradiography; 13.4-fold for fluoroscopy). The differences in image quality scores (spatial resolution, low-contrast detectability, and dynamic range) were also very large. In general, there tended to be a correlation between radiation dose and image quality. Periodical measurements of the radiation dose and image quality of the X-ray equipment used for cineradiography and fluoroscopy in IVR are necessary. The need to minimize patient exposure requires that the dose be reduced to the minimum level that will generate an image with an acceptable degree of noise.

Alterations in lipid transfers to HDL associated with the presence of coronary artery disease in patients with type 2 diabetes mellitus.

BACKGROUND: We previously showed that unesterified-cholesterol transfer to high-density lipoprotein (HDL), a crucial step in cholesterol esterification and role in reverse cholesterol transport, was diminished in non-diabetic patients with coronary artery disease (CAD). The aim was to investigate whether, in patients with type 2 diabetes mellitus (T2DM), the occurrence of CAD was also associated with alterations in lipid transfers and other parameters of plasma lipid metabolism. METHODS: Seventy-nine T2DM with CAD and 76 T2DM without CAD, confirmed by cineangiography, paired for sex, age (40-80 years), BMI and without statin use, were studied. In vitro transfer of four lipids to HDL was performed by incubating plasma of each patient with a donor emulsion containing radioactive lipids during 1 h at 37 °C. Lipids transferred to HDL were measured after chemical precipitation of non-HDL fractions and the emulsion. Results are expressed as % of total radioactivity of each lipid in HDL. RESULTS: In T2DM + CAD, LDL-cholesterol and apo B were higher than in T2DM. T2DM + CAD also showed diminished transfer to HDL of unesterified cholesterol (T2DM + CAD = 7.6 ± 1.2; T2DM = 8.2 ± 1.5%, p < 0.01) and of cholesteryl-esters (4.0 ± 0.6 vs 4.3 ± 0.7, p < 0.01). Unesterified cholesterol in the non-HDL serum fraction was higher in T2DM + CAD (0.93 ± 0.20 vs 0.85 ± 0.15, p = 0.02) and CETP concentration was diminished (2.1 ± 1.0 vs 2.5 ± 1.1, p = 0.02). Lecithin-cholesterol acyltransferase activity, HDL size and lipid composition were equal. CONCLUSION: Reduction in T2DM + CAD of cholesterol transfer to HDL may impair cholesterol esterification and reverse cholesterol transport and altogether with simultaneous increased plasma unesterified cholesterol may facilitate CAD development in T2DM.

Comparison of radiation dose between different fluoroscopy systems in the modern catheterization laboratory: Results from bench testing using an anthropomorphic phantom.

BACKGROUND: Variations in radiation dose between various X-ray systems have received limited study. OBJECTIVE: We examined the impact of X-ray system type on patient radiation dose during cardiac catheterization. METHODS: An anthropomorphic phantom was used in a series of standardized experiments that involved 15 sec of continuous cineangiography in 7 projections. Three to seven experiments were performed in four commonly used X-ray systems: Innova IGS (GE Healthcare), Integris Allura FD20 (Philips), Allura Clarity (Philips), and Artis one (Siemens). Phantom radiation dose was measured with a dedicated X-ray dosimetry system (Gafchromic radiology film and Film QA XR software, Ashland) that was precalibrated at 0, 1, 2, 3, and 4 Gray, and with the X-ray system built-in functions. RESULTS: Radiation dose was lowest with the Allura Clarity system [average film dose 4.2±0.1 cGray, peak film dose 18.3±1.6 cGray, Air Kerma (AK) dose 0.310±0.002 Gray, Dose Area Product (DAP) dose 23.72±0.84 Gray*cm2], intermediate with the Integris Allura FD20 (average film dose 4.4±1.1 cGray, peak film dose 29.4±15.5 cGray, AK 0.482±0.189 Gray, DAP 45.18±21.90 Gray*cm2), and highest with the Artis one system (average film dose 7.4±0.8 cGray, peak film dose 66.9±0.09 cGray, AK 0.746±0.085 Gray, DAP 75.93±9.11 Gray*cm2) and the Innova IGS system (average film dose 7.2±1.0 cGray, peak film dose 49.3±28.9 cGray, AK 0.874±0.340 Gray, DAP 92.28±14.73 Gray*cm2; P=0.011 for average film dose, P=0.019 for maximum film dose, P=0.033 for AK, and P=0.008 for DAP). CONCLUSIONS: The X-ray system type has significant impact on patient radiation dose during cardiac catheterization.

Novel X-ray imaging technology enables significant patient dose reduction in interventional cardiology while maintaining diagnostic image quality.

OBJECTIVES: The purpose of this study was to quantify the reduction in patient radiation dose during coronary angiography (CA) by a new X-ray technology, and to assess its impact on diagnostic image quality. BACKGROUND: Recently, a novel X-ray imaging technology has become available for interventional cardiology, using advanced image processing and an optimized acquisition chain for radiation dose reduction. METHODS: 70 adult patients were randomly assigned to a reference X-ray system or the novel X-ray system. Patient demographics were registered and exposure parameters were recorded for each radiation event. Clinical image quality was assessed for both patient groups. RESULTS: With the same angiographic technique and a comparable patient population, the new imaging technology was associated with a 75% reduction in total kerma-area product (KAP) value (decrease from 47 Gycm2 to 12 Gycm2, P<0.001). Clinical image quality showed an equivalent detail and contrast for both imaging systems. On the other hand, the subjective appreciation of noise was more apparent in images of the new image processing system, acquired at lower doses, compared to the reference system. However, the higher noise content did not affect the overall image quality score, which was adequate for diagnosis in both systems. CONCLUSIONS: For the first time, we present a new X-ray imaging technology, combining advanced noise reduction algorithms and an optimized acquisition chain, which reduces patient radiation dose in CA drastically (75%), while maintaining diagnostic image quality. Use of this technology may further improve the radiation safety of cardiac angiography and interventions.

Comparison of acute elastic recoil between the SAPIEN-XT and SAPIEN valves in transfemoral-transcatheter aortic valve replacement.

BACKGROUND: The SAPIEN-XT is a newer generation balloon-expandable valve created of cobalt chromium frame, as opposed to the stainless steel frame used in the older generation SAPIEN valve. We sought to determine if there was difference in acute recoil between the two valves. METHODS: All patients who underwent transfemoral-transcatheter aortic valve replacement using the SAPIEN-XT valve at the Cleveland Clinic were included. Recoil was measured using biplane cine-angiographic image analysis of valve deployment. Acute recoil was defined as [(valve diameter at maximal balloon inflation) - (valve diameter after deflation)]/valve diameter at maximal balloon inflation (reported as percentage). Patients undergoing SAPIEN valve implantation were used as the comparison group. RESULTS: Among the 23 mm valves, the mean (standard deviation-SD) acute recoil was 2.77% (1.14) for the SAPIEN valve as compared to 3.75% (1.52) for the SAPIEN XT valve (P = 0.04). Among the 26 mm valves, the mean (SD) acute recoil was 2.85% (1.4) for the SAPIEN valve as compared to 4.32% (1.63) for the SAPIEN XT valve (P = 0.01). Multivariable linear regression analysis demonstrated significantly greater adjusted recoil in the SAPIEN XT valves as compared to the SAPIEN valves by 1.43% [(95% CI: 0.69-2.17), P < 0.001]. However, the residual peak gradient was less for SAPIEN XT compared to SAPIEN valves [18.86 mm Hg versus 23.53 mm Hg (P = 0.01)]. Additionally, no difference in paravalvular leak was noted between the two valve types (P = 0.78). CONCLUSIONS: The SAPIEN XT valves had significantly greater acute recoil after deployment compared to the SAPIEN valves. Implications of this difference in acute recoil on valve performance need to be investigated in future studies.

Perventricular closure of pulmonary stump in a 16-kg child.

Blind pouch formation of the pulmonary artery (PA) in patients having undergone a Fontan operation can present a serious risk for thromboembolic events. Either primary or secondary closure of this stump is necessary to reduce this risk. Unfortunately, secondary closure is oftentimes difficult due to the size and anatomy of the presenting patient. We describe the insertion of a muscular ventricular septal defect (VSD) device via a perventricular approach for successful closure of a pulmonary stump in a 3-year old, 16-kg child. To our knowledge, this is the first report of a perventricular approach for successful closure of a PA stump.

Percutaneous closure of an iatrogenic fistula from the left ventricle to the coronary sinus.

A patient with a history of rheumatic mitral valve disease and valve replacement in childhood presented with severe, persistent dyspnea. During an electrophyisiologic procedure, she was discovered to have a fistula from the left ventricle to the coronary sinus. She had severe pulmonary hypertension and elevated filling pressures, with a significant left-to-right shunt. Percutaneous closure of the fistula was performed using two vascular plugs. Subsequently the patient's hemodynamics improved and her symptoms subsided. Here, we describe the case and review the literature.

An unusual case of infective endocarditis involving a right coronary artery to superior vena cava fistula.

Coronary artery fistulas (CAFs) are rare and mostly congenital anomalous connections between a coronary artery and a cardiac chamber or great vessel. Most CAFs are small, asymptomatic, and found incidentally during cardiac imaging. However, they can lead to serious complications including myocardial infarction, congestive heart failure, arrhythmias, or fistula rupture. CAFs have been associated with infective endocarditis, but to our knowledge, this complication has never been reported involving an isolated CAF to an otherwise anatomically normal great vessel. We report the first case of this complication in a 49-year-old man with a presumed streptococcus vegetation found within an isolated large, tortuous CAF connecting the right coronary artery to the superior vena cava. After completing antibiotic treatment, transcatheter closure of the CAF was performed. Since then, the patient has remained symptom-free. This case demonstrates that CAF closure is feasible following CAF-associated endocarditis, and that closure may represent a viable strategy for reducing risk of recurrent infection.

The lateral plane delivers higher dose than the frontal plane in biplane cardiac catheterization systems.

The objective of the study is to compare radiation dose between the frontal and lateral planes in a biplane cardiac catheterization laboratory. Tube angulation progressively increases patient and operator radiation dose in single-plane cardiac catheterization laboratories. This retrospective study captured biplane radiation dose in a pediatric cardiac catheterization laboratory between April 2010 and January 2014. Raw and time-indexed fluoroscopic, cineangiographic and total (fluoroscopic + cineangiographic) air kerma (AK, mGy) and kerma area product (PKA, µGym(2)/Kg) for each plane were compared. Data for 716 patients were analyzed: 408 (56.98 %) were male, the median age was 4.86 years, and the median weight was 17.35 kg. Although median beam-on time (minutes) was 4.2 times greater in the frontal plane, there was no difference in raw median total PKA between the two planes. However, when indexed to beam-on time, the lateral plane had a higher median-indexed fluoroscopic (0.75 vs. 1.70), cineangiographic (16.03 vs. 24.92), and total (1.43 vs. 5.15) PKA (p < 0.0001). The median time-indexed total PKA in the lateral plane is 3.6 times the frontal plane. This is the first report showing that the lateral plane delivers a higher dose than the frontal plane per unit time. Operators should consciously reduce the lateral plane beam-on time and incorporate this practice in radiation reduction protocols.