1. Executive Summary 112 Goals of Imaging 112 Imaging Modalities 112 Echocardiography 113 CMR 113 Cardiovascular CT 113 Nuclear Scintigraphy 113 X-Ray Angiography 113 Multimodality Imaging 113 2. Background 113 3. General Considerations 114 4. Goals of Imaging 114 5. Echocardiography 114 a. Overview of Modality 114 b. Strength and Limitations 115 c. Assessment of Repaired TOF with Echocardiography 115 RVOT 115 PAs 115

Multimodality Imaging Guidelines for Patients with Repaired Tetralogy of Fallot: A Report from the American Society of Echocardiography: Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance and the Society for Pediatric Radiology

Background—A complete understanding of fluid mechanics in Fontan physiology includes knowledge of the caval contributions to right (RPA) and left (LPA) pulmonary arterial blood flow, total systemic venous return, and relative blood flow to each lung. Methods and Results—Ten Fontan patients underwent cine MRI. Three cine scans of the pulmonary arteries were performed: (1) no presaturation pulse, (2) a presaturation pulse labeling inferior vena cava (IVC) blood (signal void), and (3) a presaturation pulse labeling superior vena cava (SVC) blood. The relative signal decrease is proportional to the amount of blood originating from the labeled vena cava. This method was validated in a phantom. Whereas 60±6% of SVC blood flowed into the RPA, 67±12% of IVC blood flowed toward the LPA. Of the blood in the LPA and RPA, 48±14% and 31±17%, respectively, came from the IVC. IVC blood contributed 40±16% to total systemic venous return. The distributions of blood to each lung were nearly equal (RPA/LPA blood=0.94±11). C...

Caval contribution to flow in the branch pulmonary arteries of Fontan patients with a novel application of magnetic resonance presaturation pulse.

The field of pediatric cardiac intensive care continues to evolve, which is in large part the result of collaborative efforts from anesthesia, surgery, cardiology, critical care, and other subspecialties, including neonatology, neurology, and endocrinology. Examples include an increasing number of surgeries in very low birth weight infants; the extension of technology such as cerebral oximetry from the operating room into the intensive care setting; and innovations in mechanical circulatory devices. Industrysponsored studies and initiatives from the National Institutes of Health such as the Pediatric Heart Network have contributed to the evolution of pediatric cardiac intensive care. These collective efforts are demonstrated in the Prophylactic Intravenous Use of Milrinone After Cardiac Operation in Pediatrics (PRIMACORP) study and more recently the single ventricle reconstruction trial and thyroid supplementation study (to be discussed). The increase in complexity of disease, innovations in technology, and evolving therapeutic strategies as well as national quality initiatives, individually and collectively, place a tremendous demand on the team, necessitating a focused, concerted effort by all members to challenge current practices while practicing state-of-the-art care. In this review, we discuss the salient aspects and latest advances in the primary challenge after surgery, which is to maintain adequate cardiopulmonary function and to ensure adequate tissue oxygenation.

Management of the postoperative pediatric cardiac surgical patient.

The objective of this study was to determine the procedural success rate of balloon angioplasty for branch pulmonary artery stenosis in terms of its clinical impact on the subsequent management of these patients. Most previous studies of balloon angioplasty have concentrated on the initial success rate (50–60%), complications (6–10%), recurrence rate (∼15%), and technical issues. A favorable clinical impact was noted in only 35% of patients. Over a 3-year period (March 1990 to March 1993), 32 patients (17 boys, 15 girls) underwent 34 balloon angioplasty procedures. Their mean age at dilation was 7.6 ± 4.3 years (range 1.1–19.0 years). Postoperative tetralogy of Fallot and tetralogy of Fallot with pulmonary atresia were the most frequent cardiac lesions (44%). The procedures were ``technically'' successful in 56% (19 of 34) of balloon dilations on the basis of at least two of the following criteria: an increase of >50% of the predilation diameter; an increase of >20% in the relative flow to the affected lung by radioisotope study; or a decrease in the systolic right ventricular/aortic pressure ratio from 85–100% to <60%. Twelve percent of the patients had transient complications (two deep vein thromboses, one unilateral pulmonary edema, and one pneumothorax). In 17 of 19 (89%) of the patients there was a favorable clinical impact on their subsequent care as based on one of the following criteria: resolution of the stenosis and avoidance of surgical intervention (n= 14); optimization of future surgical procedure (n= 3); reduction in right ventricular pressure to <60% of aortic pressure (n= 13). Five patients who had unsuccessful balloon angioplasty and one with initially successful balloon angioplasty later underwent endovascular stent placement, which also favorably influenced their clinical status. The success rate of balloon angioplasty for branch pulmonary artery stenosis, when measured by strict procedural criteria, is accompanied by a favorable clinical impact in more than 50% of patients. Hence this procedure should be the initial therapeutic modality in this setting despite the relatively high transient complication rate. The use of endovascular stents probably increases the favorable clinical impact.

Midterm Clinical Impact Versus Procedural Success of Balloon Angioplasty for Pulmonary Artery Stenosis

The beneficial vortex and best spatial arrangement in total extracardiac cavopulmonary connection.

Lung perfusion scans in patients with congenital heart defects

Recently published analyses showed that computed tomography (CT) scans in pediatric patients are associated with increased risk of radiation-related cancer. These analyses were based on data collected both from either hospitals and primary care services. Study objectives were to characterize cohorts of pediatric patients in Israel undergoing CT scans in primary care compared to hospitals settings. These cohorts will be further used for evaluating cancer risks. The present study was conducted in Schneider Children Medical Center in Israel (SCMCI), the largest tertiary pediatric hospital in the country. Data were collected directly from the listings of the pediatric radiology department for the period 1985–2005. Results were compared with previously published data on pediatric CT in the primary healthcare service performed between 1999 and 2003 in a large health organization, Maccabi Healthcare Services (MHS). During the study observation periods, 38,351 and 22,223 examinations were documented in 13,726 and 18,075 pediatric patients in SCMCI and MHS, respectively. Compared to pediatric patients in the primary care, patients undergoing CT scans in the hospital were more likely to be younger, to have multiple CT scans, and to be scanned in the trunk. Also, cancer-related indications accounted for nearly 50 % of all CT scans conducted in the hospital compared to only 3 % in primary care settings. The results indicate major differences in the characteristics of children and adolescents scanned in hospitals compared to primary care settings. Some of these characteristics may be associated with cancer risk later in life, and should be taken into account in cancer risk assessments.

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Differences in characteristics of pediatric patients undergoing computed tomography between hospitals and primary care settings: implications for assessing cancer follow-up studies.

Gad Horev

Papers

Lung perfusion scans in patients with congenital heart defects

Differences in characteristics of pediatric patients undergoing computed tomography between hospitals and primary care settings: implications for assessing cancer follow-up studies.