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Background: Coronary angiography is considered the gold standard in evaluating vein graft disease; however, angiography does not allow assessment of hemodynamic consequences of lesions. In this study hemodynamic consequences of significant stenoses in vein grafts were evaluated by Doppler velocity assessment, and results were compared with single photon emission computed tomography (SPECT) perfusion imaging., Methods and Results: Angiography was performed in 58 patients after coronary artery bypass grafting because of recurrent chest pain. During the procedure, Doppler velocity measurements were acquired before and after administration of adenosine. Of 58 patients (with 78 vein grafts), 20 patients (with 24 vein grafts) underwent SPECT perfusion imaging. Grafts were divided into those with nonsignificant percent diameter stenosis (< 50%) (n = 49) and those with significant percent diameter stenosis (> or =50%) (n = 29). When a cutoff value for coronary flow velocity reserve (CFVR) of 1.8 was applied, modest agreement (69%, kappa = 0.25, P < .05) between CFVR and angiography was shown. Agreement between SPECT and angiography was also modest (63%, kappa = 0.28, P = not significant). SPECT and CFVR provided comparable information in 20 of 24 grafts with available SPECT, illustrating good agreement (83%, kappa = 0.61, P = .001)., Conclusions: Significant stenoses in vein grafts require further exploration to assess their hemodynamic significance. The Doppler velocity results agreed better with SPECT perfusion imaging than with percent diameter stenosis in the evaluation of vein graft function.

Aims: Late after total correction, Fallot patients with a long QRS duration are prone to serious arrhythmias and sudden cardiac death. Pulmonary regurgitation is a common cause of right ventricular (RV) failure and QRS lengthening. We studied the effects of pulmonary valve replacement (PVR) on QRS duration and RV volume., Methods and Results: Twenty-six consecutive Fallot patients were evaluated both pre-operatively and 6-12 months post-operatively by cardiac magnetic resonance (CMR). In this study, we present the computer-assisted analysis of the standard 12-lead electrocardiograms closest in time to the CMR studies. For the whole group, QRS duration shortened by 6+/-8 ms, from 151+/-30 to 144+/-29 ms (P=0.002). QRS duration decreased in 18 of 26 patients by 10+/-6 ms, from 152+/-32 to 142+/-31 ms. QRS duration remained constant or increased slightly in eight of 26 patients by 3+/-3 ms, from 148+/-27 to 151+/-25 ms. CMR showed a decrease in RV end-diastolic volume from 305+/-87 to 210+/-62 mL (P=0.000004). QRS duration changes correlated with RV end-diastolic volume changes (r=0.54, P=0.01)., Conclusion: Our study shows that PVR reduces QRS duration. The amount of QRS reduction is related to the success of the operation, as expressed by the reduction in RV end-diastolic volume.

The aim of the study was to evaluate segmental and global right ventricular function at rest and during stress in patients having a systemic morphologically right ventricle. We studied 17 patients after atrial correction for transposition, 13 with congenitally corrected transposition, and 11 age-matched controls using cardiovascular magnetic resonance at rest and during stress with dobutamine given at 15 micrograms per kilogram per minute. Blood was drawn to obtain levels of brain natriuretic peptide. Right ventricular ejection fraction was calculated, and wall-motion and wall-thickening were assessed, in 4 segments of a midventricular slice. The findings for the systemic right ventricle were compared to the left ventricle in controls. Patients with transposition showed a decreased ejection fraction at rest (57 percent versus 69 percent, p equal to 0.005), decreased wall motion of the anterior, lateral and septal wall (p less than 0.01, p less than 0.01, and p less than 0.01) and decreased thickening of the lateral wall (p less than 0.01). Patients with congenitally corrected transposition showed normal ejection fraction, wall thickening, and wall motion at rest. During dobutamine stress, we found no significant differences in wall motion and thickening between the two groups. Ejection fraction, also increased to comparable values during stress, at 67 percent versus 66 percent, p not being significant. In both groups, we observed similarly increased levels of brain natriuretic peptide (p equal to 0.02 and 0.03, respectively). We conclude that only patients with transposition showed segmental wall motion and wall thickening abnormalities at rest. After dobutamine stress, however, segmental and global right ventricular dysfunction was similar in both groups.

Over the past decades, life expectancy in patients with congenital heart disease has increased dramatically. However, serious complications may develop late after total repair in infancy. These complications are usually the result of longstanding pulmonary regurgitation, which leads to dilatation of the right ventricle and an increased risk for severe arrhythmias. Therefore lifelong follow-up in these patients is required. Cardiac magnetic resonance imaging is the current imaging tool of choice because it offers superior imaging quality and enables accurate quantification of functional parameters such as flow volumes and systolic and diastolic performance.

Because patients with hypertension are at increased risk for coronary artery disease, early and noninvasive identification of the disease in patients with hypertension is important. Recently, multislice computed tomography (MSCT) has been demonstrated to allow both noninvasive coronary angiography and assessment of left ventricular function. The purpose of the present study therefore was to demonstrate the feasibility of this approach in patients with hypertension with known or suspected coronary artery disease and to compare the results to invasive coronary angiography and 2-dimensional echocardiography, respectively. MSCT was performed in 31 patients with confirmed hypertension. From the MSCT images, the presence of significant coronary stenoses (>or=50% luminal narrowing) and regional wall motion abnormalities were evaluated and compared with invasive coronary angiography and 2-dimensional echocardiography. In addition, left ventricular ejection fraction was calculated from the MSCT images. A total of 243 (88%) coronary artery segments could be evaluated with MSCT. Sensitivity and specificity for the detection of significant coronary artery stenoses were 93% and 96%. On a per-patient basis, MSCT was accurate in 28 (90%) patients. Mean left ventricular ejection fraction was 46+/-14% (range, 16% to 64%). The agreement for assessing regional wall motion was 91% (kappa statistic, 0.81). In conclusion, simultaneous, noninvasive evaluation of coronary artery stenoses and left ventricular function with MSCT is accurate in patients with hypertension. This noninvasive approach may allow triage of patient treatment in terms of conservative versus invasive management.

Cardiovascular magnetic resonance (CMR) with flow velocity mapping has emerged as a noninvasive method to measure flow in saphenous vein coronary artery bypass grafts. The aim of the current study was to retrospectively test two previously described analysis methods on a large CMR data set and to compare their diagnostic accuracy in detecting diseased vein grafts. In 125 vein grafts of 68 patients, volume flow parameters (volume flow, systolic and diastolic peak flow, diastolic-to-systolic flow ratio at rest and during adenosine stress, and flow reserve) were derived from the velocity maps. Method 1 implemented basal flow < 20 ml/min or flow reserve < 2, yielding a sensitivity and specificity of 70% and 38% in the detection of a diseased graft or recipient vessel. Method 2 used receiver operating characteristic (ROC) curve analysis and implemented all significant volume flow parameters in a logistic regression model, yielding a sensitivity of 74% with a specificity of 68% in the detection of a diseased graft or recipient vessel. Evaluating single and sequential grafts separately, this method yielded a sensitivity and specificity of 79% and 87% for single grafts, and 62% and 94% for sequential grafts in the detection of > or = 50% stenosis in grafts or recipient vessels. Cut-off values were formulated for the respective volume flow parameters, which maximally separate grafts with and without > or = 50% stenosis. Using ROC curve analysis with logistic regression the specificity of the analysis method improved considerably. For the current data set the best results were acquired when single and sequential grafts were separately analyzed.

Background: In patients with an intra-atrial correction for transposition of the great arteries (TGA) an abnormal response to stress testing is common. However, hemodynamic responses may vary substantially when different stress tests are used. We compared the hemodynamic response to dobutamine stress with the response to physical exercise in patients and controls., Methods: Thirty-nine patients and 25 age/sex-matched control subjects underwent either dobutamine stress (15 microg/kg/min) or submaximal physical exercise cardiovascular magnetic resonance. End-systolic and end-diastolic right ventricular volumes (ESV; EDV) were determined. Five representative patients underwent both stress tests. For these patients, wall thickening reserve was calculated as systolic wall thickening during stress minus systolic wall thickening at rest., Results: In controls, dobutamine stress and physical exercise showed similar responses: stroke volume, cardiac output, and ejection fraction increased significantly, whereas ESV decreased significantly and EDV was unchanged. In patients, stroke volume did not increase with either dobutamine or exercise (-8.6% vs. 2.9%). Ejection fraction increased significantly with dobutamine (16%, p < 0.001) but tended to decrease during exercise (-2.1%, P = NS). EDV and ESV decreased during dobutamine but were unchanged during exercise. (-22% vs. 5.0%, P < 0.001; -36% vs. 9.0%, P < 0.01 respectively). Wall thickening reserve was higher with dobutamine than with exercise (0.9 mm vs. -0.6 mm, P = 0.02)., Conclusion: Dobutamine stress and physical exercise cannot be used interchangeably for assessment of systolic and diastolic function in patients with an intra-atrial correction for TGA. This may have consequences for the use of different stress CMR approaches in the clinical setting.

Purpose: To assess the time course of right ventricular (RV) function improvement after pulmonary valve replacement (PVR) in patients 25.2 years +/- 7.0 after repair of tetralogy of Fallot., Materials and Methods: The medical ethics committee approved this study, and informed consent was obtained. Cardiac magnetic resonance (MR) imaging was performed before, 7 months after, and 19 months after PVR in 25 consecutive patients with tetralogy of Fallot with a 1.5-T MR imager. RV function was assessed with gradient-echo sequences in the short-axis plane. Pulmonary flow was assessed with a velocity-encoded phase-contrast sequence. Paired t test was used to evaluate follow-up data. Independent samples t test was used to assess differences based on the presence of recurrent pulmonary regurgitation (PR)., Results: Mean indexed RV end-diastolic volume decreased from 166.9 mL/m(2) +/- 41.3 before PVR to 113.5 mL/m(2)+/- 35.7 (P < .001) at 7-month follow-up and 111.7 mL/m(2)+/- 41.1 (P = .46) at 19-month follow-up. The RV ejection fraction was corrected for PR and improved from 25.0% +/- 7.7 before surgery to 44.1% +/- 11.9 (P < .001) and 45.2% +/- 11.1 (P = .39), at 7- and 19-month follow-up, respectively. Recurrent PR after PVR was found in 11 patients; 14 patients did not have recurrent PR. Total reduction of indexed RV end-diastolic volume at 19 months follow-up was more prominent in patients who did not have recurrent PR than in patients who did have recurrent PR (P < .05). Furthermore, improvement of RV ejection fraction corrected for regurgitation was more marked in patients who did not have recurrent PR than in patients who did have recurrent PR (P < .05)., Conclusion: In patients with tetralogy of Fallot, RV function improves rapidly after PVR and is sustained at 19-month follow-up in most patients; however, recurrence of PR after PVR appears to reduce recovery of RV systolic function., ((c) RSNA, 2004.)

Objective: Early identification of coronary artery disease (CAD) in patients with diabetes is important because these patients are at increased risk for CAD and have worse outcome than nondiabetic patients after CAD is diagnosed. Recently, noninvasive coronary angiography and assessment of left ventricular function has been demonstrated with multislice computed tomography (MSCT). The purpose of the present study was to validate this approach in patients with type 2 diabetes., Research Design and Methods: MSCT was performed in 30 patients with confirmed type 2 diabetes. From the MSCT images, coronary artery stenoses (> or =50% luminal narrowing) and left ventricular function (left ventricular ejection fraction, regional wall motion) were evaluated and compared with results of conventional angiography and two-dimensional echocardiography., Results: Two hundred twenty of 256 coronary artery segments (86%) were interpretable with MSCT. In these segments, sensitivity and specificity for detection of coronary artery stenoses were 95%. Including the uninterpretable segments, sensitivity and specificity were 81 and 82%, respectively. Bland-Altman analysis in the comparison of left ventricular ejection fractions demonstrated a mean difference of -0.48 +/- 3.8% for MSCT and echocardiography, which was not significantly different from 0. Agreement between the two modalities for assessment of regional contractile function was excellent (91%, kappa statistic 0.81)., Conclusions: Accurate noninvasive evaluation of both the coronary arteries and left ventricular function with MSCT is feasible in patients with type 2 diabetes. This noninvasive approach may allow optimal identification of high-risk patients.

Objectives: This study was designed to perform a head-to-head comparison between single-photon emission computed tomography (SPECT) and cardiovascular magnetic resonance (CMR) to evaluate hemodynamic significance of angiographic findings in bypass grafts., Background: The hemodynamic significance of a bypass graft stenosis may not always accurately be determined from the coronary angiogram. A variety of diagnostic tests (invasive or noninvasive) can further characterize the hemodynamic consequence of a lesion., Methods: Fifty-seven arterial and vein grafts in 25 patients were evaluated by angiography, SPECT perfusion imaging, and coronary flow velocity reserve determination by CMR. Based on angiography and SPECT, four different groups could be identified: 1) no significant stenosis (<50%), normal perfusion; 2) significant stenosis (>/=50%), abnormal perfusion; 3) significant stenosis, normal perfusion (no hemodynamic significance); and 4) no significant stenosis, abnormal perfusion (suggesting microvascular disease)., Results: A complete evaluation was obtained in 46 grafts. Single-photon emission computed tomography and CMR provided similar information in 37 of 46 grafts (80%), illustrating good agreement (kappa = 0.61, p < 0.001). Eight grafts perfused a territory with scar tissue. When agreement between SPECT and CMR was restricted to grafts without scar tissue, it improved to 84% (kappa = 0.68). Integration of angiography with SPECT categorized 14 lesions in group 1, 23 in group 2, 6 in group 3, and 3 in group 4. Single-photon emission computed tomography and CMR agreement per group was 86%, 78%, 100%, and 33%, respectively., Conclusions: Head-to-head comparison showed good agreement between SPECT and CMR for functional evaluation of bypass grafts. Cardiovascular magnetic resonance may offer an alternative method to SPECT for functional characterization of angiographic lesions.

Forty-nine patients with previous bypass surgery underwent coronary angiography and cardiovascular magnetic resonance (MR) imaging of single-vein bypass grafts. Volume flow and velocity analyses were performed and compared on MR velocity maps. Bland-Altman analysis showed close agreement between the two types of analysis. Comparison of areas under the receiver operating characteristic curve revealed no significant differences between the analyses for detection of stenoses of 70% or greater. Diagnostic accuracy for volume flow and velocity parameters was 92% and 93%, respectively. Velocity analysis appears to be the preferred method, because it is less time-consuming and has a similar diagnostic accuracy to volume flow analysis.

Intracoronary stent implantation is a frequently performed procedure in the treatment of stenoses in coronary arteries, but in-stent restenosis occurs in approximately 10% to 15% of patients. A noninvasive diagnostic procedure to evaluate in-stent restenosis would therefore be of great benefit. We investigated the feasibility of assessing stent patency with 16-slice computed tomography. Multislice computed tomography (MSCT) was performed in 22 patients with previously implanted stents. For each stent, assessability was determined and related to stent type and diameter. Subsequently, the presence of significant restenosis was determined in the evaluable stents. In addition, peristent lumina (5 mm proximal and distal to the stent) were evaluated. Conventional angiography in combination with quantitative coronary angiography served as the standard of reference. MSCT was performed successfully in all but 1 patient. Of 65 stents, 50 (77%) were determined assessable. Uninterpretable stents tended to have a thicker strut and/or a smaller diameter. In the evaluable stents, 7 of 9 stenoses were detected and the absence of restenosis was correctly identified in all 41 patent stents, resulting in a sensitivity and specificity of 78% and 100%, respectively. Sensitivity and specificity for the detection of peristent stenosis were 75% and 96%, respectively. In conclusion, MSCT may be useful in the assessment of stent patency and may function as a gatekeeper before invasive diagnostic procedures.

Objectives: To investigate whether exercise-induced hypertension in successfully repaired adult post-coarctectomy patients is associated with hypertension on 24-h blood pressure measurement and increased left ventricular mass., Methods: One hundred and forty-four consecutive post-coarctectomy patients (mean age 31.5 years, range 17-74 years; mean age at repair 7.9 years, range 0-45 years) from three tertiary referral centres were studied using ambulatory blood pressure monitoring, treadmill exercise testing and echocardiography., Results: Of the 144 patients, 27 (19%) were known to have sustained hypertension, based on their history, and all were on antihypertensive medication. However, 32 (27%) of the remaining 117 patients showed elevated mean daytime systolic blood pressure readings at 24-h ambulatory blood pressure monitoring (systolic blood pressure > or = 140 mmHg). Of the remaining 85 patients with normal mean daytime systolic blood pressure, 18 patients (21%) had exercise-induced hypertension (maximal exercise systolic blood pressure > 200 mmHg). Mean daytime systolic blood pressure was higher in the exercise-induced hypertensive patients compared to the normotensive patients with normal exercise blood pressure (134 +/- 5 versus 129 +/- 7 mmHg, P = 0.008). By multivariate analysis, both maximal exercise systolic blood pressure (P = 0.007) and resting systolic blood pressure (P < 0.0001) were independently associated with mean daytime systolic blood pressure. Maximal exercise systolic blood pressure had no independent predictive value for left ventricular mass (P = 0.132)., Conclusions: In adult post-coarctectomy patients, maximal exercise systolic blood pressure is independently associated with mean daytime systolic blood pressure at ambulatory blood pressure monitoring. In this study no independent predictive value of maximal exercise systolic blood pressure for left ventricular mass could be demonstrated.

Growth hormone therapy in patients with idiopathic dilated cardiomyopathy and ischemic cardiac failure has revealed varying effects on systolic function, probably related to the response in serum insulin-like growth factor I (IGF-I) levels. As diastolic function has not been studied thoroughly, we studied the effects of 6 months of recombinant human growth hormone (rh GH) treatment on systolic and diastolic function in patients with ischemic cardiac failure, using cardiovascular magnetic resonance (MR) imaging. Nineteen patients with ischemic cardiac failure (left ventricular ejection fraction (LVEF), <40%) were studied in a randomized trial. Nine patients received 6 months treatment with growth hormone (2 IU/day). Systolic and diastolic function were assessed at baseline and after 26 weeks by cardiovascular MR imaging. No differences were found in systolic and diastolic function between rh GH treated patients and controls. No change was observed in left ventricular mass index (LVMI), end-diastolic volume, end-systolic-volume and ejection fraction. The treated patients showed no clinical improvement. Six months of treatment with growth hormone therapy in ischemic cardiac failure has no favorable effects on LVMI, on systolic and diastolic function.

Purpose: To provide functional reference values in single and sequential vein grafts by using magnetic resonance (MR) flow mapping and to examine the effect of percutaneous intervention (PCI) on coronary artery bypass graft function., Materials and Methods: Fast MR flow mapping at baseline and during adenosine-induced stress was performed in 39 nonstenotic single vein grafts and 20 nonstenotic sequential vein grafts, as well as in 15 stenotic vein grafts before and 7.3 weeks +/- 1.5 after successful PCI. We evaluated the following parameters (in terms of mean values +/- SDs): average peak velocity (APV) at baseline, stress APV, and velocity reserve. Parameters in nonstenotic single and sequential vein grafts were compared by means of unpaired two-tailed Student t testing. To evaluate changes in velocities before and after PCI, a paired two-tailed Student t test was used. P <.05 was considered to indicate a statistically significant difference., Results: Reference values in single vein grafts for baseline APV, stress APV, and velocity reserve were 8.6 cm/sec +/- 3.4, 20.2 cm/sec +/- 9.5, and 2.4 +/- 0.8, respectively. In sequential vein grafts, significantly higher values for baseline APV (12.2 cm/sec +/- 5.0) and stress APV (27.2 cm/sec +/- 10.6) but a similar velocity reserve (2.3 +/- 0.7) were found. Significant improvements were observed after PCI in baseline APV (before PCI: 9.2 cm/sec +/- 6.6; after PCI: 12.9 cm/sec +/- 7.9; P =.008) and stress APV (before PCI: 12.9 cm/sec +/- 6.3; after PCI: 27.1 cm/sec +/- 13.9; P <.001). No improvement in velocity reserve was observed., Conclusion: Significantly higher absolute velocity and flow values were observed in sequential versus single vein grafts, underscoring the need for separate functional reference values for different graft types. Graft function showed significant improvement after PCI to the point that it was restored or nearly restored to reference values.

Purpose: Evaluation of different electrocardiographic criteria for left ventricular hypertrophy (ECG-LVH criteria) using left ventricular mass index (LVMI) determined by magnetic resonance imaging (MRI). In addition, the relation between LVMI regression after aortic valve replacement and corresponding ECG changes regarding LVH was studied., Methods: A group of 31 patients with severe aortic valve disease was studied to assess the presence of ECG-LVH and to measure LVMI and LV end-diastolic volume index (LVEDVI); 13 patients were restudied at 9.8 +/- 2.7 months after aortic valve replacement., Results: Three criteria had a sensitivity of 100% (SV1 + RV5 or RV6 > 3.0 mV; SV1 or SV2 + RV5 > or = 3.5 mV; SV1 or SV2 + RV5 or RV6 > 3.5 mV), at the cost of specificity (50%, 44.4% and 44.4%, respectively). The R in I > 1.4 mV had a specificity of 100%, at the cost of both sensitivity and accuracy (13.6% and 54.5%, respectively). The Romhilt-Estes point score system, using > or = 4 points as cut-off value for LVH, provided the overall best accuracy of 79.5%. The number of Romhilt-Estes points also showed the best correlation with LVMI, both before and after aortic valve replacement (r = 0.81 and r = 0.67, respectively)., Conclusions: Substantial differences in sensitivity, specificity, accuracy, and correlation with LVMI were found among several ECG-LVH criteria. No single criterion performed optimally since the highest sensitivity, specificity, accuracy, and correlation with LVMI were found with different criteria. The present study may therefore contribute to a more targeted use of the existing ECG-LVH criteria.

Background: Magnetic resonance imaging (MRI) is a potential noninvasive diagnostic tool to detect coronary artery bypass graft stenosis, but its value in clinical practice remains to be established. We investigated the value of MRI in detecting stenotic grafts, including recipient vessels., Methods and Results: We screened for inclusion 173 consecutive patients who were scheduled for coronary angiography because of recurrent chest pain after coronary artery bypass grafting (CABG). We studied 69 eligible patients with 166 grafts (81 single vein, 44 sequential vein, and 41 arterial grafts). MRI with baseline and stress flow mapping was performed. Both scans were successful in 80% of grafts. Grafts were divided into groups with stenosis > or =50% (n=72) and > or =70% (n=48) in the graft or recipient vessels. Marginal logistic regression was used to predict the probability for the presence of stenosis per graft type using multiple MRI variables. Receiver operator characteristics (ROC) analysis was performed to assess the diagnostic value of MRI. Sensitivity (95% confidence interval)/specificity (95% confidence interval) in detecting single vein grafts with stenosis > or =50% and > or =70% were 94% (86 to 100)/63% (48 to 79) and 96% (87 to 100)/92% (84 to 100), respectively., Conclusions: MRI with flow mapping is useful for identifying grafts and recipient vessels with flow-limiting stenosis. Flow scans could be obtained in 80% of the grafts. This proof-of-concept study suggests that noninvasive MRI detection of stenotic grafts in patients who present with recurrent chest pain after CABG may be useful in selecting those in need of an invasive procedure.

Objectives: The aim of this study was to evaluate the effect of aortic valve replacement (AVR) on left ventricular (LV) function and LV remodeling, comparing patients with aortic valve stenosis to patients with aortic regurgitation., Background: Aortic valve disease is associated with eccentric or concentric LV hypertrophy and changes in LV function. The relationship between LV geometry and LV function and the effect of LV remodeling after AVR on diastolic filling, in patients with aortic valve stenosis compared with aortic regurgitation, are largely unknown.Nineteen patients with aortic valve disease (12 aortic valve stenosis, 7 aortic regurgitation) were studied using magnetic resonance imaging to assess LV geometry and LV function before and 9 +/- 3 months after AVR. Ten age-matched healthy males served as control subjects., Results: Before AVR, the ratio between left ventricular mass index (LVMI) and left ventricular end-diastolic volume index (LVEDVI) was only increased in patients with aortic valve stenosis (1.37 +/- 0.16 g/ml) compared with control subjects (0.93 +/- 0.08 g/ml, p < 0.05). After AVR, LVMI/LVEDVI decreased significantly in aortic valve stenosis (to 1.15 +/- 0.14 g/ml, p < 0.0001), but increased significantly in aortic regurgitation (1.02 +/- 0.20 g/ml to 1.44 +/- 0.27 g/ml, p < 0.0001). Before AVR, diastolic filling was impaired in both aortic valve stenosis and aortic regurgitation. Early after AVR, diastolic filling improved in patients with aortic valve stenosis, whereas patients with aortic regurgitation showed a deterioration in diastolic filling., Conclusions: Early after AVR, patients with aortic valve stenosis show a decrease in both LVMI and LVMI/LVEDVI and an improvement in diastolic filling, whereas in patients with aortic regurgitation, LVMI decreases less rapidly than LVEDVI, causing concentric remodeling of the LV, most likely explaining the observed deterioration of diastolic filling in these patients.

Objective: To evaluate job participation, career-related problems, and actual job problems in adults with complex congenital heart disease (CHD) compared with adults with mild CHD and reference groups., Design: Cross-sectional study., Setting: Patients were randomly selected from the archives of the Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands., Patients and Main Outcome Measures: In total, 76 patients with complex CHD and 80 with mild CHD (age range, 17-32 years) completed a self-reported questionnaire on employment and handicaps, with reference data available (response rate, 70%)., Results: In the study groups, 45 (59%) of 76 patients with complex CHD had a paid job compared with 61 (76%) of 80 patients with mild CHD. Patients older than 25 years with complex CHD had significantly lower job participation (64%) than the general population (83%). Multiple logistic regression showed that type of CHD and level of education were significantly and independently related to job participation (odds ratio, 4.8; 99% confidence interval, 1.2-19.6; and odds ratio, 4.7; 99% confidence interval, 1.3-17.2, respectively). Of the 76 patients with complex CHD, 42 (55%) experienced disease-related career problems, in contrast to only 1 patient with mild CHD. Both CHD groups had more job-related mobility handicaps than did the reference group. However, in the mild CHD group, handicaps could be attributed to additional noncardiac diseases., Conclusions: Patients with complex CHD have reduced job participation compared with patients with mild CHD and the general population. Many receive disability benefits or experience career problems or job handicaps. Career counseling focusing on physical abilities and level of education may help prevent or reduce these job-related problems.

Objective: To discuss the need for continuing cardiac surveillance in adults with hemodynamically insignificant congenital cardiac disease., Methods: In 82 patients with mild congenital cardiac malformations, aged from 17 to 32 years, we investigated the subjective health status, the health-related quality of life, any difficulties encountered in daily life, the regularity of follow-up, current diagnosis, and antibiotic prophylaxis., Results: The subjective health status, and the health-related quality of life, did not differ from those of the general population. Nevertheless, patients experienced unnecessary difficulties with choice of sport, obtaining insurance cover, and education. After clinical re-evaluation, diagnosis and antibiotic regimes had to be changed in 9 patients (11%)., Conclusions: Patients with a mild congenital cardiac malformation consider themselves to be in good health. So as to fine tune the diagnosis, and update the information supplied to the patients, we suggest that at least a cardiological assessment be carried out at the age of 16 to 18 years. In this way, patients might be protected from unnecessary difficulties, such as restrictions for sport or the charging of unjustifiably high rates for insurance.

Background: Pulmonary regurgitation (PR) late after total correction for tetralogy of Fallot may lead to progressive right ventricular (RV) dilatation and an increased incidence of severe arrhythmias and sudden death. Timing of pulmonary valve replacement (PVR) is subject to discussion, because the effect of PVR on RV function in adults is unclear. In this study, MRI was used to assess the effect of PVR on RV function and PR. Clinical improvement was established by means of the NYHA classification., Methods and Results: Twenty-six adult patients were included. Cardiac MRI was performed at a median of 5.1+/-3.4 months before and 7.4+/- 2.4 months after PVR. Mean preoperative PR was 46+/-10% (range, 25% to 64%). After PVR, 20 of 26 patients (77%) showed no residual PR, 5 patients showed mild residual PR, and 1 patient showed moderate PR. RV end-diastolic volume (RV-EDV) decreased from 305+/-87 to 210+/-62 mL (P<0.001), and RV end-systolic volume (RV-ESV) decreased from 181+/-67 to 121+/-58 mL (P<0.001). No significant change was found in RV-EF (42% versus 42%). However, RVEF corrected for regurgitations and shunting increased from 25.2+/-8.0% to 43.3+/-13.7% (P<0.001). Mean validity class improved from 2.0 to 1.3 (P<0.001)., Conclusions: In adult patients with PR and RV dilatation, late after total correction of tetralogy of Fallot, MRI measurements show remarkable hemodynamic improvement of RV function after PVR and improvement of validity. We therefore advocate a less restrictive management concerning PVR in these patients.

Objective: Mortality in type 1 diabetic patients with end-stage renal failure is high and dominated by coronary atherosclerotic events. With regard to prognosis, simultaneous transplantation of pancreas and kidney (SPK) may be superior to kidney transplantation alone (KTA) in type 1 diabetic patients, because normalization of blood glucose levels may reduce progression of coronary atherosclerosis and because it is well known that progression of coronary atherosclerosis is one of the major factors that determines clinical prognosis. However, no data are available on progression of coronary atherosclerosis after SPK., Research Design and Methods: We performed an observational angiographic study comparing progression of coronary atherosclerosis, analyzed with quantitative coronary angiography, in patients with (n = 26) and those without (n = 6) a functioning pancreas graft after SPK, to test the hypothesis that normalization of blood glucose levels by SPK may indeed reduce progression of coronary atherosclerosis in type 1 diabetic patients and thereby improve prognosis., Results: Mean follow-up was 3.9 years. Average glucose control was significantly worse for the patients without a pancreas graft than for patients with a functioning pancreas graft: 11.3 (SD 3.5) vs. 5.9 mmol/l (SD 1.1) (P = 0.03). Mean segment diameter loss (progression of diffuse coronary atherosclerosis) was 0.024 mm/year (SD 0.067) in patients with a functioning pancreas graft, compared with 0.044 mm/year (SD 0.038) in patients in whom the pancreas graft was lost. Minimum obstruction diameter loss (progression of focal coronary atherosclerosis) was 0.037 mm/year (SD 0.086) in patients with a functioning pancreas graft compared with 0.061 mm/year (SD 0.038) in patients in whom the pancreas graft was lost. Regression of atherosclerosis occurred in 38% of patients with a functioning pancreas graft compared with 0% of patients of whom the pancreas graft was lost (P = 0.035)., Conclusions: Our study provides, for the first time, evidence that in patients who have undergone SPK, progression of coronary atherosclerosis in patients with a functioning pancreas graft is reduced compared with patients with pancreas graft failure. Our observation is an important part of the explanation for the observed improved mortality rates reported in type 1 diabetic patients with end-stage renal failure after SPK compared with KTA. In light of these findings described above, SPK must to be carefully considered for all diabetic transplant candidates.

Objectives: To evaluate difficulties in daily life, and satisfaction with level of knowledge about their disease, in patients with congenital cardiac disease in order to improve counselling., Methods: A self-administered questionnaire was completed by 80 patients with mild, and 76 with complex, congenital cardiac disease. They were aged from 17 to 32 years., Results: Even patients with only mild malformations experienced difficulties related to their disease, but being found in only 11%, these were significantly less than those uncovered in 87% of those with complex disease (p < 0.001). Those patients with complex malformations frequently felt restricted in choices because of their disease in areas such as sport (59%), employment (51%), and education (34%). Other difficulties reported were: paying a higher premium for life insurance (29%), having to give up on a sport (28%), and being excluded from a job (18%). Depending on the item, between one-fifth and two-thirds of participants reported gaps in knowledge, most frequently for "causes of congenital cardiac disease", "future consequences", and "family planning". For 53% of those with mild anomalies, and 93% of severely affected patients, the cardiologist is the most important source of information., Conclusions: A minority of adults with mild, and a majority of those with complex congenital cardiac disease report difficulties in daily life. A substantial number of these patients feel that they have an inadequate level of knowledge about their disease. Our results suggest the need for a specific programme of counselling.

Purpose: To assess the responses of pulmonary regurgitation (PR) and biventricular function to submaximal exercise by using a magnetic resonance (MR) imaging exercise protocol with young adult patients who underwent tetralogy of Fallot repair at a young age., Materials and Methods: Fifteen patients with corrected tetralogy of Fallot (mean age, 17.5 years +/- 2.5 [SD]) underwent MR imaging at rest and during exercise for the evaluation of PR and biventricular function. Results were compared with findings from 16 control subjects (mean age, 17.5 years +/- 2.3). Mean age at tetralogy of Fallot repair was 2.1 years +/- 1.6, and mean follow-up time after repair was 15.4 years +/- 2.6. Exercise level at MR imaging was calculated individually and corresponded to 60% of peak oxygen uptake. The parameters of cardiac function obtained at rest and during exercise were compared by using a paired t test. An unpaired t test was used to compare parameters of cardiac function between patients and control subjects., Results: PR decreased during exercise (from 27 mL/m(2) +/- 17 to 23 mL/m(2) +/- 15; P =.012). At rest, right ventricular (RV) ejection fraction was normal (>47%) in 80% of patients. RV response to exercise in the patient group was abnormal compared with response in the control group, as demonstrated by an increase in RV end-diastolic volume index (132 mL/m(2) +/- 36 to 137 mL/m(2) +/- 38; P =.041) and no significant change in end-systolic volume index or ejection fraction. In only one patient, RV ejection fraction increased by more than 5%. Left ventricular response was not different between patients and control subjects., Conclusion: MR imaging is well suited to assess cardiac response to exercise, and findings revealed a decrease in PR and an abnormal RV response to exercise in patients with corrected tetralogy of Fallot.

Background: The application of previous magnetic resonance (MR) angiography techniques has enabled noninvasive differentiation between patent and occluded coronary artery bypass grafts. However, the detection of graft stenosis remains difficult. The purpose of our study was to determine the accuracy of high-resolution navigator-gated 3-dimensional (3-D) MR angiography in detecting vein graft disease. Methods and Results- MR angiography was performed in addition to coronary angiography with quantitative coronary analysis in 56 vein grafts from 38 patients (mean age 66.6+/-9.3 years), who presented with recurrent chest pain after bypass surgery. Eighteen grafts showed a luminal stenosis >/=50%, 11 grafts a stenosis >/=70%, and 6 grafts were occluded. All MR angiograms were evaluated independently by 2 blinded observers, who scored the presence of graft occlusion and graft stenosis >/=50% and >/=70% with a confidence level of 1 to 10. MR image quality was judged as insufficient in 6 grafts and these were excluded. Receiver-operator characteristic analysis revealed an area under the curve of 0.89 and 0.89 for identifying graft occlusion, 0.81 and 0.87 for stenosis >/=50%, and 0.82 and 0.79 for stenosis >/=70% for the 2 observers, respectively. Interobserver agreement in assessing graft occlusion and stenosis >/=50% and >/=70% was 94% (kappa=0.74, r=0.81), 72% (kappa=0.40, r=0.66), and 82% (kappa=0.53, r=0.72), respectively., Conclusions: High-resolution navigator-gated 3-D MR angiography allows not only good differentiation between patent and occluded vein grafts but also the assessment of vein graft disease with a fair diagnostic accuracy. This approach offers perspective as a noninvasive diagnostic tool for patients who present with recurrent chest pain after vein graft surgery.

Purpose: To validate fast magnetic resonance (MR) flow mapping with intravascular Doppler flow measurements in vitro and in patients with nonstenotic and stenotic coronary artery bypass grafts., Materials and Methods: MR and Doppler flow measurements were performed in a small-diameter flow phantom with physiologic flow conditions and at baseline and during adenosine stress in 27 grafts in 23 patients, who were scheduled for cardiac catheterization. At invasive analysis, the grafts were divided into those with stenosis of less than 50% (nonstenotic) and those with stenosis greater than or equal to 50% (stenotic). In vitro velocity values and velocity values in nonstenotic and stenotic grafts were compared with linear regression analysis, and the in vitro interstudy variability was determined., Results: Excellent correlations in average peak velocity (r = 0.99, P <.001) and diastolic peak velocity (r = 0.99, P <.001) were demonstrated in vitro between MR and Doppler flow measurements, with less than 5% interstudy variability. MR and Doppler flow measurements revealed good correlations in peak velocity and velocity reserve both in nonstenotic (n = 20) (average peak velocity: r = 0.81, P <.001; diastolic peak velocity: r = 0.83, P <.001; velocity reserve: r = 0.56, P =.010) and stenotic (n = 7) (average peak velocity: r = 0.83, P <.001; diastolic peak velocity: r = 0.78, P =.001; velocity reserve: r = 0.70, P =.078) grafts., Conclusion: Fast MR flow mapping provides noninvasive measures of peak velocity and velocity reserve, which closely correlate with Doppler values both in vitro and in nonstenotic and stenotic grafts.