Analysis and predictability of technologists' perception of MR exam complexity.

INTRODUCTION: As MRI becomes a routine clinical diagnostic method, its complexity of techniques, protocols and scanning is growing. On the other hand, aggravated by the ubiquitous shortage of workforce, technologists' stress level and burnout rates are increasing. In this context, our study aims to shed light on technologists' perceived complexity of MR exams, by analyzing a multidimensional dataset composed of workflow, patient, and operational details, and further predicting perceived exam complexity. METHODS: In this IRB-approved study, data about imaging workflow, exam context, and patient characteristics were collected over one year from MR modality logfiles and from technologist questionnaires, including the perceived exam complexity. The association of individual factors with complexity was analyzed via Fisher's exact tests and Cramér's V values. Predictability of exam complexity was further evaluated via ROC analysis of three different multivariate classifiers. RESULTS: Retakes, delays, and extended exam duration are associated with perceived complexity (V ≥ 0.2). From the set of possible predictors, patient mobility and communication ability have the most influence on perceived complexity (V > 0.2), followed by special equipment needs (pulse oximetry, intubation, or ECG), protocol details and other patient characteristics. Feasibility of predicting the perceived exam complexity from a multivariate set of exam and patient details known at the time of scheduling has been demonstrated (AUC = 0.73), and suitable classification algorithms have been identified. CONCLUSION: Perceived exam complexity is associated with various factors. Our results suggest that it can be predicted sufficiently well to support early operational decision making. Some factors, however, may not be readily available in hospital IT systems and must be obtained before scheduling. IMPLICATIONS FOR PRACTICE: Results and observations of this study could be utilized to assist operational scheduling in the radiology department and reduce MR technologists' stress levels.

Balloon valvuloplasty in the treatment of congenital aortic valve stenosis--a retrospective multicenter survey of more than 1000 patients.

BACKGROUND: The value of balloon valvuloplasty of the aortic valve in childhood is still under debate. OBJECTIVE: To evaluate the results of the procedure in a retrospective multicenter survey of a large cohort over a long time interval. METHODS: Retrospective analysis of 1004 patients with balloon valvuloplasty of the aortic valve performed between 9/1985 and 10/2006 at 20 centers in Germany, Austria and Switzerland. Amongst others, the following parameters were evaluated before and after the procedure as well as at the end of follow-up or before surgery: clinical status, left ventricular function, transaortic pressure gradient, degree of aortic regurgitation, freedom from re-intervention or surgery. PATIENTS: Patients from 1 day to 18 years of age with aortic valve stenosis were divided into four groups: 334 newborns (1-28 days); 249 infants (29-365 days); 211 children (1-10 years), and 210 adolescents (10-18 years). RESULTS: Median follow-up was 32 months (0 days to 17.5 years). After dilatation the pressure gradient decreased from 65 (± 24)mm Hg to 26 (± 16)mm Hg and remained stable during follow-up. The newborns were the most affected patients. Approximately 60% of them had clinical symptoms and impaired left ventricular function before intervention. Complication rate was 15% in newborns, 11% in infants and 6% in older children. Independently of age, 50% of all patients were free from surgery 10 years after intervention. CONCLUSIONS: In this retrospective multicenter study, balloon valvuloplasty of the aortic valve has effectively postponed the need for surgery in infants, children and adolescents up to 18 years of age.

Integration of intraoperative 3D-ultrasound in a commercial navigation system.

STUDY AIMS: The purpose of this study was the integration of three-dimensional ultrasound data into a neuronavigation system, in order to allow a guided intraoperative resection control during neurosurgical interventions. MATERIAL AND METHODS: A system for iterative neuronavigation based on 3D-ultrasound (US) has been developed. The main components of the system are the ultrasound device Voluson 730 (GE Healthcare) with a 5 - 9 MHz probe, the navigation system VectorVision2 (BrainLAB AG) and a standard PC with Windows XP. The ultrasound data are transferred via DICOM from the ultrasound device to an external computer, where they are processed with a C++ program for representation in the neuronavigation coordinate system. The data transfer between the navigation system and the external computer is performed via the VVLink interface from BrainLAB. The feasibility test of the system was performed with an ultrasound phantom RMI 403GS (Gammex-RMI GmbH). RESULTS: The error of homologous points mapping from US datasets to a CT dataset in the neuronavigation system was determined to be 1.9 +/- 0.97 mm. The maximum time required to technically integrate the ultrasound data into the navigation system was 1.5 min. CONCLUSIONS: The developed system allows 3D-ultrasound based navigation to be carried out with a commercially available navigation system. The functionality of this system has been proven by technical tests. Recording and integration of the ultrasound data can be repeated at any time during surgery and can be used to update anatomical data and consequently for resection control. Another application is the intraoperative adaptation of preoperative datasets (MRI or CT) in order to compensate for "brain shift" during neurosurgical operations.

First experience with an oral combination therapy using bosentan and sildenafil for pulmonary arterial hypertension.

BACKGROUND: New oral substances such as beraprost, bosentan and sildenafil have proven effective in different forms of pulmonary arterial hypertension (PAH), both alone and in combination with standard treatment such as intravenous and inhaled prostacyclins. However, there are few reports so far on the effect of a combination of exclusively oral substances. In this paper, we present our initial findings of treatment using a combination of these oral substances in a heterogeneous group of patients with different forms of PAH. MATERIALS AND METHODS: Eleven patients with a median age of 12.9 years (5.5-54.7 years) with both idiopathic PAH and forms associated with congenital cardiac defects (PAH-CHD) with a mean pulmonary arterial pressure > 25 mmHg were enrolled in an observational, open-label, prospective, single-centre study. Either combination treatment with bosentan and sildenafil was started initially, or an existing bosentan treatment was complemented with sildenafil given as an add-on therapy. Mean doses given were 2.3 +/- 0.6 mg kg(-1) for bosentan and 2.1 +/- 0.9 mg kg(-1) for sildenafil. Clinical status, exercise capacity, and haemodynamics were assessed at baseline and at the end of the observation period after a mean follow-up time of 1.1 years (0.5-2.5 years). RESULTS: No major side effects regarding liver function and blood pressure regulation were noted. One patient died of sudden death elsewhere. Most patients were in New York Heart Association (NYHA) functional class III. Clinical improvement was about one NYHA class (mean 2.8 +/- 0.4-1.6 +/- 0.8, P = 0.001), which was associated with an increase of transcutaneous oxygen saturation (89.9 +/- 9.9-92.3 +/- 7.1%; P = 0.037), maximum oxygen uptake (18.1 +/- 6.8-22.8 +/- 10.4 mL kg(-1) x min; P = 0.043), and 6-minute walking distance (351 +/- 58-451 +/- 119 m; P = 0.039). Mean pulmonary arterial pressure measured invasively decreased (62 +/- 12-46 +/- 18 mmHg; P = 0.041). CONCLUSIONS: In our patient group, a combination of oral bosentan and sildenafil proved to be safe and effective. Clearly, randomized, double-blind, placebo-controlled studies are warranted to define the role and type of combination therapies in PAH.

Initial experience using the NuMED Cheatham Platinum (CP) stent for interventional treatment of coarctation of the aorta in children and adolescents.

We report the immediate results in a group of selected patients with native or recurrent coarctation of the aorta who underwent endovascular stent implantation using the newly designed Cheatham-Platinum (CP)-stent. The balloon-expandable stents were implanted in 6 patients (mean age 12.7 years) with coarctation of the aorta (5 native, 1 recurrent). The maximal systolic peak pressure gradient was decreased from 49 to 3 mmHg (p <0.001). There was a 350% increase in the mean diameter at the original coarctation site (3.8 to 13.8 mm, p <0.01). Although the maximal diameter varied from 8 to 18 mm, there was only a minor reduction in the length of the CP-stents used (max. 11%). The dilatation was successful in all patients and there were no complications during balloon dilatation or stent implantation. All patients were hypertensive prior to stent implantation, with three of them requiring antihypertensive drug therapy. In 2 patients only a moderate dilatation diameter was chosen initially due to the extremely small coarctation site (1 mm) and repeat dilatation after 12 months was performed in order to obtain a maximal aortic diameter. At a mean of 18 months of follow-up, 5 of 6 patients are normotensive. There is no recurrence of coarctation, aortic dissection or aneurysm formation and no stent displacement. These findings suggest that the implantation of CP-stents for coarctation of the aortamay cover a wide spectrum of aortic diameters and consequently hereby offer an effective alternative approach to surgery or ballon dilatation alone even in infancy and childhood. The potential for redilatation of CP-stents in a wide range of diameters without significant shortening adds to the benefit of this device in growing children.

Objective evaluation of three-dimensional image registration algorithms--tools for optimization and evaluation.

OBJECTIVE: The registration of medical volume data sets plays an important role when different images or modalities are used during computer-assisted surgical procedures. Nevertheless, it is often questionable how robust and accurate the underlying algorithms really are. Therefore, the goal is to foster the establishment of methods for an objective evaluation. METHOD: To reliably calculate the accuracy of registration algorithms, a reference transformation must be known. Due to the unknown perfect registration for real clinical data, the simulation of realistic data and successive affine transformations are employed. The simulation is based on models of the respective imaging modality where the dominant physical effects are taken into account. This gives the user full control over all simulation and transformation parameters. Finally, suitable quality measures are applied which allow a systematic evaluation of image registration accuracy by comparing the known theoretical result and the transformation calculated by the algorithm under investigation. RESULTS: During the development of a new registration algorithm, the presented method proved to be a very valuable tool for optimization and evaluation of registration accuracy, since it allows objective numerical comparison of the calculated results. CONCLUSIONS: The presented method can be used during the development of algorithms for optimization and for quantitative comparison of different registration schemes. The respective software tool can automatically generate and transform simulated but realistic data. Employing suitable numerical quality measures, an objective evaluation of registration results can be easily obtained. Still, the validity of the relatively simple models has to be verified to draw reliable conclusions with respect to real data.

[Isolated myocardial noncompaction in childhood-case report and review of the literature]. / Isolated myocardial noncompaction als seltene Ursache einer Synkope im KindesalterFallbericht mit Literaturübersicht.

The diagnostic work-up for the first syncopal episode of a 14-year-old female adolescent revealed the morphology of an isolated myocardial non-compaction on echography. Angiography and biopsy of the left ventricle confirmed the diagnosis. Despite a reduced shortening fraction (FS 21%) and frequent premature atrial beats, there were no further cardiac or extracardiac symptoms. After establishment of therapy with beta-blockade, digitalis, angiotensin converting enzyme inhibition and acetylsalic acid, the follow-up over 24 months was good; the implantation of an automatic implantable cardioverter-defibrillator is planned.

[Difficulties in diagnosing Marfan's syndrome in childhood and adolescence]. / Diagnostische Schwierigkeiten bei Patienten mit Marfan-Syndrom im Kindes- und Jugendalter.

BACKGROUND: The diagnosis of Marfan's syndrome in childhood and adolescence is made by the criteria of the Gent nosology, which evaluates genetic data, family history and a spectrum of clinical criteria. Due to the age dependent manifestations of the clinical symptoms, combined with the extreme heterogeneity of Marfan's syndrome diagnosis in early childhood remains sometimes difficult. PATIENTS: Prospectively, we analyzed the clinical symptoms of all patients where Marfan's syndrome was suspected. We evaluated those patients between January 1997 and April 2002 by an interdisciplinary approach. METHODS: We compared the clinical datas of the patients by using the Gent nosology and the Berlin nosolgy. RESULTS: 34 patients underwent full follow-up. The median age was 10,32 years with a range of 0,01 to 37,31 years, 19 patients were male, 15 patients were female. In eight patients Marfan's syndrome could be rouled out, 9 of 26 patients (34,6 %) fullified the criteria of the Gent nosology, in 17 of 26 patients (65,4 %) Marfan's syndrome remained just suspected, but was not fullified by the criteria of the Gent nosology. Concerning the Berlin nosology 14 of 26 patients (53,8 %) fullified the criteria, 12 of 26 patients (46,2 %) failed. Due to the criteria of the Gent nosology 14 patients (53,8 %) fullified the criteria of skeletal involvement, 21 patients (80,8 %) fullified cardiovascular major manifestation, 6 patients (23,1 %) had an ophthalmic major manifestation, and 9 patients (34,6 %) had an affected first degree relative or were genetically determined. CONCLUSIONS: On the basis of the data of our patients the diagnosis of Marfan's syndrome in childhood and adolescence can be made more sensitive by the criteria of the Berlin nosology compared to the Gent nosology. This seems to be caused by the age dependent manifestations of the symptoms. Until diagnostic algorhythms of Marfan's syndrome in childhood remain suboptimal, continuous clinical follow-up for all cases even those only in the case of suspected Marfan's syndrome are necessary to exclude complicated course and to improve outcome.

Knowledge, compliance and practice of antibiotic endocarditis prophylaxis of patients with congenital heart disease.

The aim of this study was to determine the knowledge, compliance, and practice of antibiotic endocarditis prophylaxis (AEP) for patients with congenital heart disease (CHD) during various diagnostic or therapeutic procedures. Patients (296) and their parents were interrogated during a visit with an 18-question survey pertaining to the practice of AEP. Most patients (91.6%) had acyanotic congenital heart disease, usually preoperative (45.3%), or had high risk of infective endocarditis due to previous endocarditis (2.0%), cyanosis (8.4%), or prosthetic valves (5.4%). Potential sources for failure of AEP were (1) no existence of a wallet card (6.8%), no communication between patient and doctor concerning the potential risk of endocarditis during a visit (13.2%), or no sufficient anamnestic inquiry by the physician before procedures were performed (43.2%). The patients underestimated (4.4%) or had no knowledge of the individual risks of endocarditis (37.5%) or underestimated indication for AEP (11.1%). AEP was often not performed at all (60.5%). Bad dental status with no previous dental therapy (35.5%) and a high rate of caries (17.2%) or gingivitis (7.4%) even in young children was frequent. AEP for patients with CHD has not been sufficiently used because of the patient's, and the physician's failure to take the necessary steps, the cardiac diagnosis, or the dental health status. Alternative strategies in prophylaxis for AEP are discussed here.

[Comparison of the accuracy of 3-dimensional fusion algorithms]. / Vergleich der Genauigkeit Dreidimensionaler Fusions-Algorithmen.

Recently many algorithms for matching three-dimensional medical data have been developed. Inter- and intramodal fusion of data adds valuable information for planning, controlling and evaluating therapies. This work presents a procedure to evaluate the accuracy of fusion algorithms by numerical means. In contrast to the usual way of visual inspection the developed software tools allow automatic numerical--and thus objective--evaluation of different algorithms using simulated realistic volume data. It is therefore possible to conduct reproducible comparisons of different matching methods. These tools also proved to be very valuable during the development and optimisation of an algorithm employing normalised mutual information.

[Pulmonary plasma catecholamine levels and pulmonary hypertension in congenital heart disease]. / Pulmonale Plasmakatecholaminspiegel bei Patienten mit angeborenen Herzfehlern und erhöhtem pulmonalarteriellen Fluss.

Plasma catecholamines may play a role in the pathogenesis of pulmonary hypertension in congenital heart disease with increased pulmonary blood flow. At cardiac catheterization, blood samples were obtained before and after passage of the lung in patients with congenital heart disease with normal pulmonary blood flow (n=39), elevated pulmonary blood flow with normal pulmonary pressure and normal pulmonary vascular resistance (PVR) in patients with atrial septal defect (ASD) (n=57) or ventricular septal defect (VSD) (n=12), and increased pulmonary blood flow, pressure and vascular resistance in patients with ASD, VSD or both (n=22), or in patients with primary pulmonary hypertension (n=4). Plasma catecholamines were determined by reversed phase high performance liquid chromatography and electrochemical detection (HPLC-ECD). In patients with elevated PVR elevated norepinephrine levels (NE) were observed. In contrast, epinephrine levels (E) were not associated with the development of pulmonary hypertension. Patients with primary pulmonary hypertension had the highest levels of NE while patients with associated Down's syndrome had significantly lower epinephrine levels. Pulmonary plasma norepinephrine levels are increased in patients with elevated pulmonary vascular resistance. Whether this phenomena is the cause or sequalae of pulmonary hypertension needs further examination. In the future, plasma catecholamines may serve as a diagnostic feature or may result in further therapeutic options.

Aortic aneurysm rupture in infantile Marfan's syndrome.

A 3-year-old boy with early rupture of an aortic aneurysm due to infantile Marfan's syndrome is presented. In an emergency operation we prepared a composite graft using a 17-mm St. Jude prosthesis with an 18-mm vascular conduit. The postoperative period was complicated by pneumothoraces, transient bilateral phrenic nerve paralysis, cerebral convulsion, and supraventricular tachycardia. Four months postop the composite graft was replaced with an aortic homograft due to severe stenosis. His condition after 12 months is excellent.

[Is transcatheter occlusion of a persistent foramen ovale a possibility for the avoidance of a paradoxical embolism?]. / Transkatheterverschluss des persistierenden Foramen ovale als Möglichkeit zur Vermeidung paradoxer Embolien?

BACKGROUND AND OBJECTIVE: Cerebral embolism may have different causes with sometimes serious consequences. If no specific reason can be found, paradoxical embolization through a persistent foramen ovale (PFO) is increasingly as a cause of the cerebral ischaemia. This study was undertaken to ascertain whether in patients with cerebral embolism occlusion of a PFO with a transcatheter technique can prevent further cerebral emboli. PATIENTS AND METHODS: Indications for transcatheter occlusion were based on neurological signs (ischaemic stroke), cardiovascular diagnosis, and coagulation tests. Between August 1991 and July 1996, transcatheter occlusion of a PFO was performed in 28 fully anticoagulated patients (median age 37.8 [15.4-65.4] years). The mean PFO diameter was 9.5 mm (3-17), mean duration of fluoroscopy 18.3 (8.7-43.1) min. The Rashkind device was implanted in three patients, the Sideris buttoned device in 25. During the follow-up period (2-64 months; mean 13 months) renewed neurological symptoms occurred in only one patient. Transoesophageal echocardiography excluded thrombi on the implanted device or in the left atrium, and a residual PFO. The cause of the one neurological episode is therefore not clear. All other patients have remained free of symptoms and recurrence without anticoagulation after placement of the device. CONCLUSIONS: Transcatheter occlusion of a PFO is a relatively simple and safe procedure. Our results suggest that it can at least lower the incidence of further cerebral embolizations. The clinical value of the method in comparison with anticoagulation requires further study.

Circulatory support with paracorporeal pneumatic ventricular assist device (VAD) in infants and children.

OBJECTIVE: The feasibility and efficacy of the pneumatic 'Berlin Heart' ventricular assist device (VAD) were evaluated in 14 pediatric patients with profound cardiogenic shock refractory to conventional therapy. METHODS: There were two patient groups. Eleven patients, aged 2 weeks 15 years and weighing 3.2-52 kg received a left ventricular assist device or a biventricular assist device as a bridge to cardiac transplantation (bridge group). Nine of them had liver, kidney, or lung dysfunction before device implantation. Three patients were supported with a biventricular assist device for myocardial recovery (recovery group): a 6-month-old girl for postcardiotomy shock, a 10-month-old girl for allograft failure after cardiac transplantation, and a 4-year-old boy with acute myocarditis. RESULTS: In the bridge group, eight patients were transplanted after a bridge duration of 6-98 days (mean, 32 days) with five long-term survivors. Organ functions were normalized during bridging in all of the transplant recipients. In the recovery group, the first patient was removed from support after 2 days because of irreversible brain damage. The second patient was weaned from biventricular support after 8 days, but suffered from recurrent allograft failure. The third patient received biventricular support for 21 days followed by extracorporeal membrane oxygenation and was subsequently discharged from the hospital. CONCLUSIONS: The 'Berlin Heart' VAD can keep selected infants and children with life-threatening heart failure for weeks or months.

[Aerosolized prostacyclin for preoperative evaluation and post-cardiosurgical treatment of patients with pulmonary hypertension]. / Aerosolisiertes Prostazyklin zur präoperativen Evaluation und postkardiochirurgischen Behandlung von Patienten mit pulmonaler Hypertension.

BACKGROUND: Inhaled nitric oxide (NO) has been shown to selectively lower pulmonary vascular resistance and is applied in patients with pulmonary hypertension (PHT). However, application and monitoring is complex and not always successful ("non-responders"). We evaluated the effect of aerolized prostacyclin (aePGI2) as a therapeutic alternate to NO. PATIENTS AND METHODS: aePGI2 and NO were applied to patients with different causes of pulmonary hypertension (Group 1a: preoperative patients with intracardiac shunting defects and Eisenmenger's disease, n = 30; Group 1b: patients with primary or postoperative PHT, n = 13; Group 2: PHT immediately following surgery for congenital heart disease, n = 6). RESULTS: Pulmonary vascular resistance could be lowered significantly (Group 1a: from 91% of systemic vascular resistance to 58% with NO and 53% with aePGI2; Group 1b: from 20.2 Wood Units*m2 to 13.4 and 11.3; Group 2: from 24.9 Wood Units*m2 to 9.5 and 10.5); cardiac index increased (Group 1b: from 2.96 to 3.55 and 3.96 l/min*m2, Group 2: from 1.57 to 1.89 and 2.00 l/min*m2). CONCLUSIONS: The short-term application of aePGI2 shows a selective pulmonary vasodilation similar to NO. Given adequate monitoring, aePGI2 appears to be useful for the acute treatment of PHT.

Surgical emergency embolectomy for the treatment of fulminant pulmonary embolism in a preterm infant.

A massive pulmonary embolism, demonstrated by echocardiography developed in a 3-week-old preterm infant. An etiologic explanation could not be obtained from either history or clinical and laboratory findings. Pulmonary embolectomy was performed as an emergency procedure because of severe hemodynamic impairment despite intensive medical therapy. In children who have massive pulmonary embolism who remain in a compromised hemodynamic state despite intensive medical therapy, pulmonary embolectomy may be considered the alternative emergency treatment.

[Adults with congenital heart defects--clinical spectrum and surgical management]. / Erwachsene mit angeborenen Herzfehlern--klinisches Spektrum und operative Behandlung.

Two hundred adults who underwent surgery for congenital heart disease at our institution within a four year period were the basis for this report. Clinical data was obtained, i.e. demographic details, past medical history, physical findings, EKGs, echocardiograms, catheterization and angiography material as well as the New York Heart Association (NYHA) class. Intraoperative findings, perioperative management, complications and morbidity and mortality were assessed. After discharge the patients were followed on an outpatient basis. Again the clinical findings, laboratory results and NYHA class were recorded. Age ranged from 16 to 75 years (mean = 38). There were 114 females and 86 males. 178 patients had primary surgical correction, 18 were reoperated after prior correction and 4 underwent palliation. Eighty-three percent of the patients were symptomatic preoperatively. Seventeen percent were diagnosed per chance, for example by a preemployment physical examination, without a prior history of heart disease. The patients were grouped according to related diagnoses (Table 1). Among the 130 patients with left to right shunts, 112 had an atrial septal defect, 7 a ventricular septal defect, 5 a persistent ductus arteriosus, and 6 partial anomalous pulmonary venous return. Atrial flutter or fibrillation occurred in approximately 10% of all patients with atrial septal defects. It was terminated either by rapid overdrive pacing or DC cardioversion. Postoperatively the patients with pulmonary hypertension were monitored invasively with arterial lines and thermodilution catheters. Therapy consisted of alkalization, hyperventilation and sedation. There was only one postoperative death in this patient group due to marked pulmonary hypertension (1/130 = 0.8%). Nineteen adults had obstruction to right or left ventricular outflow. Surgery included valvotomy, infundibulectomy and valve replacement by homograft or mechanical valve. One patient with multiple previous surgeries expired due to bleeding (3%). Thirteen patients had coarctation. All of them were hypertensive, some on medication. Surgery consisted of aortic patchplasty or interposition of a graft. There was no mortality. Perioperative antihypertensive therapy was necessary in most patients and consisted of nifedipin, nitroprussid or propanolol intravenously. Upon follow up 11 patients became normotensive, 8 of these without the need for medication. Fifteen cyanotic patients underwent 11 corrective and 4 shunt procedures (3 with tricuspid atresia, 10 with Tetralogy of Fallot and 2 with complex cyanotic heart disease. Three died due to low cardiac output or dysrhythmias (20%). The survivors improved their clinical status markedly. Seven adults with Ebstein's disease had valve reconstruction and/or ASD closure. Five had recurrent supraventricular tachycardia, 2 paradoxical emboli with neurological symptoms and 4 out of 7 had decreased exercise tolerance. One patient died postoperatively because of dysrhythmias (14%). Sixteen patients had a variety of defects, i.e. status post Rastelli operation and conduit obstruction, status post Tetralogy of Fallot with pulmonary valvar disease, corrected transposition with left AV valve insufficiency, congenital mitral valve disease and double aortic arch, no deaths. The overall operative mortality was 6/200 = 3%. the late mortality was 4/200 = 2%. The morbidity included 7 reoperations due to bleeding. Five patients needed short-term hemodialysis. One patient developed hemiplegia and two patients had permanent decrease of their left ventricular function. The mean length of follow up was 21 months. The clinical status improved from a NYHA class mean of 2.1 +/- 0.9 to 1.2 +/- 0.45 (p < 0.001). In Germany significant numbers of adults with operated and unoperated congenital heart disease do exist. Detection of these patients can be difficult due to inconspicuous murmurs or stable clinical status.

Mechanical circulatory support for post cardiotomy cardiogenic shock in infants.

Eleven infants weighing 2.3 to 7.8 kg underwent mechanical circulatory support for post cardiotomy cardiogenic shock. Initiated pre-operatively in two patients, extracorporeal membrane oxygenation was used in a total of eight patients aged 6 days to 3 months in association with repair of cyanotic congenital heart disease with increased pulmonary blood flow or with a right sided obstructive lesion. Ventricular assist devices were used in three other patients: a centrifugal left ventricular assist device in Patient 1 (10 months, 5.7 kg) after repair of the anomalous left coronary artery, and a pneumatic biventricular assist device (stroke volume 12 ml) in Patient 2 (6 months, 7.0 kg) for cardiac arrest after closure of ventricular septal defect and in Patient 3 (10 months, 7.8 kg) for post transplant graft failure. Duration of extracorporeal membrane oxygenation duration ranged from 26 to 192 hr (mean, 88 hr). Three patients were weaned from extracorporeal membrane oxygenation and two survived. Two others were separated from extracorporeal membrane oxygenation because of bleeding, but both subsequently died. Patient 1 was weaned from the left ventricular assist device after 192 hr and discharged from the hospital. Support was discontinued after 45 hr in Patient 2 who exhibited irreversible brain damage. Patient 3 was weaned from a biventricular assist device after 174 hr, but suffered recurrent graft failure. Our results show that an appropriate circulatory support system should be selected according to the cardiac anatomy in infants.