Search

Background—Fetal echocardiography is widely established in the United Kingdom for prenatal diagnosis of congenital heart disease. This may result in a substantial reduction in incidence at birth because of selected termination of pregnancy. The objective of this population-based study was to determine the incidence of pulmonary atresia with intact ventricular septum (PAIVS) at birth, the impact of fetal echocardiography on this incidence, and to compare the outcome of cases with and those without prenatal diagnosis. Methods and Results—From 1991 to 1995, all infants born with PAIVS and all fetal diagnoses in the United Kingdom and Eire were studied. There were 183 live births (incidence 4.5/100 000 live births). The incidence was 4.1 cases per 100 000 live births in England and Wales, 4.7 in Scotland, 6.8 in Eire, and 9.6 in Northern Ireland (P=0.01). There were 86 fetal diagnoses made at a mean of 22.0 weeks of gestation leading to 53 terminations of pregnancy (61%), 4 intrauterine deaths (5%), and 29 li...

We describe the morphologic variability in pulmonary atresia with intact ventricular septum (PAIVS) within a population-based study.An uncommon disease, PAIVS shows considerable morphologic heterogeneity. Clinical reports, based mostly on small samples of patients, may not reflect the true spectrum of pathology of this condition. We have studied the entire range of morphology in a prospective population-based study of patients over a five-year period (1991 to 1995). METHODS; As part of the United Kingdom and Ireland Collaborative Study of PAIVS, all 18 pediatric cardiac centers were visited by a single investigator. Morphologic features of each case were determined by direct review of the echocardiograms and angiocardiograms, from surgical and autopsy reports, and by review of pathology specimens where available.Among 183 live-born infants, atresia was valvar (membranous) in 74.7% and muscular in 25.3%. Muscular obliteration of the apical trabecular cavity, and in some cases its infundibulum, resulted in "bipartite" right ventricle (RV) in 33.6%, and a "unipartite" chamber in 7.7%. The remaining 58.7% had "tripartite" morphology. Coronary arterial abnormalities were identified in 45.8%, including arterial stenoses, interruptions and ectasia in 7.6%. Ebstein's malformation coexisted in 18 patients. Median tricuspid valvar size and RV inlet Z-scores were -5.2 and -5.1, respectively.This study provides unique data on the diverse pathology of PAIVS in an unselected population. This will help determine if published reports reflect the true spectrum of pathology of the condition.

This represents the first case of an Askin's tumor demonstrated on MRI. It showed a large pleural-based mass which trapped pleural fluid in large pseudotumors. The disease was unilateral and involved the mediastinum as well. Magnetic resonance imaging was helpful in demonstrating extrathoracic disease in the area of the right brachial plexus.

Background. Complete repair of infants with interrupted arch and ventricular septal defect through a midline incision has been the preferred method for more than 20 years. End-to-end anastomosis can result in restenosis if there is excess tension. Two methods of reducing this tension have been described, and the subsequent growth of the new aortic arch is demonstrated. Methods. In 2 infants (5 and 9 months old) and duct was used to create a new aortic arch. In 3 other younger infants the left carotid artery was divided, turned down, and anastomosed to the descending aorta to form the new arch. These operations were performed through the midline at the same time as the ventricular septal defect was closed. Results. All 5 patients are well now 8 to 19 years postoperatively. One patient required reoperation for stenosis at the anastomotic site, but all have subsequently shown good growth on follow-up angiographic and magnetic resonance imaging studies. Conclusions. Although end-to-end repair is best, these alternative methods have shown very satisfactory aortic growth into adult life.

New medical image display devices or processes are commonly evaluated by anecdotal reports or subjective evaluations which are informative and relatively easy to acquire but do not provide quantitative nieasures. On the other hand, experinients eniploying ROC analysis, yield quantitative measurements but are very laborious and demand pathological proof of outcome. We have designed and are employing a new approach, which we have termed "agreement experiments," to quantitatively test the equivalence of observer performance on two systems. This was specifically developed to test whether a radiologist using a new display technique, which has some clear advantages over the standard technique, will detect and interpret diagnostic signs as he would with the standard display technique. Agreement experiments use checklists and confidence ratings to measure how well two radiologists agree on the presence of diagnostic signs when both view images on the standard display. This yields a baseline measure of agreement. Agreement measurements are then obtained when the two radiologists view cases using the new display, or display method, compared to the standard technique. If the levels of agreement when one reads from the new and one reads from the standard display are not statistically different from the baseline measures of agreement, we conclude the two systems are equivalent in conveying diagnostic signs. We will report on an experiment using this test. The experiment compares the agreement of radiological findings for chest CT studies viewed on the conventional multiformat film/lightbox to agreement of radiological findings from chest CT images presented on a multiple screen video system. The study consists of 80 chest CT studies. The results were an 86% to 81% agreement between the two viewing modalities which fell within our criteria of showing agreement.© (1990) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

A case is reported of a patient with the subclavian steal syndrome in whom the reversed blood flow of the vertebral artery was shown by phase encoded magnetic resonance angiography.

For patients with pyogenic lung abscesses who do not respond to medical therapy, thoracotomy with pulmonary resection is the widely-accepted treatment of choice. Six patients with lung abscess who failed to respond to conservative medical management were treated by percutaneous catheter drainage using small catheters (10 Fr or smaller). Five patients showed prompt clinical improvement and the sixth improved after a modification in antibiotic therapy. All patients recovered with radiographic resolution of the abscess and were well at followup periods from two months to two years. In such patients, percutaneous drainage with small catheters provides an excellent clinical result with minimal risk and trauma.

Digital subtracted images of iodinated rods, incorporating accurately measured areas of eccentric stenosis were obtained. The average subjective estimations of fractional area reduction (211 readings each) by three experienced angiographers were compared with values obtained using an interactive computer algorithm using the densitometric data. Results were analyzed to identify major influences on accuracy, including iodine concentration, vessel width, absolute severity of the stenosis, and vessel orientation. While no single factor appeared to seriously affect human accuracy, computer readings were significantly influenced by the tilt of the vessel in relation to the x-ray beam. Various potential sources of error including beam hardening, stenosis geometry, and scattering are discussed and appropriate algorithm corrections suggested. The importance of the availability of a reliable and accurate method to quantify vascular stenosis and volume of stenotic material is stressed.

A 50-yr-old man with a history of 19 yr of work in the aluminum smelting industry, including 14 years in the potrooms, was found to have diffuse interstitial fibrosis, slightly more severe in the upper zones. He died of respiratory insufficiency 5 yr after initial presentation. Analysis of lung by electron optical techniques revealed 15,000,000,000 nonfibrous particles and 1,300,000,000 fibrous particles of aluminum oxide/g dry lung, values representing approximately a 1,000-fold increase over background exposure. The nonfibrous particles had a geometric mean diameter of 0.4 mu, and the fibers had a geometric mean length of 1.0 mu, a width of 0.06 mu, and an aspect ratio of 16. X-ray diffraction demonstrated alpha but not gamma aluminum oxide. These studies indicate that previous suggestions relating aluminum-induced fibrosis to the presence of gamma aluminum oxide are not correct. Although pulmonary fibrosis in this case may be a response to a very high total aluminum particle burden, the presence of large numbers of fibers raises the possibility that fibers play a role in aluminum fibrosis.

Thexs accumulation of large amounts of fluid in the pleural space is a common sequela of disseminated carcinomatosis. Traditional management has included therapeutic thoracentesis or the placement of a large bore chest tube for drainage with the subsequent installation of a sclerosing agent in an attempt to achieve pleural symphysis. An evaluation of all patients treated in this manner during a 4-year period was undertaken to assess the degree of success obtained with a large bore standard chest tube versus a small pigtail catheter. A study group consisting of 20 patients with a total of 24 pleural effusions was treated with drainage and sclerotherapy. In this group, eight of 13 effusions were adequately treated with pigtail catheter drainage and sclerotherapy, compared with four of 11 effusions adequately treated with standard chest tube drainage and sclerotherapy. Although the numbers are small, it appears that pigtail catheter drainage and sclerosis is at least as successful as the more traditional drainage with the standard chest tube.

A fatal case of massive hemoptysis in a patient with isolated peripheral pulmonary artery stenosis is described. Such patients are predisposed to developing pulmonary artery aneurysms. When hemoptysis develops, erosion of an aneurysm into an adjacent bronchus should be considered and aggressive diagnostic evaluation undertaken.

Acute and subacute infection in the mediastinum, though rare, is associated with a substantial mortality which increases with delay in diagnosis. The conventional radiographic and computed tomographic studies of 14 patients with proven infective mediastinitis were reviewed in an attempt to identify their relative roles in its diagnosis. Signs of infection demonstrated by computed tomography (CT) included abscess formation, mediastinal masses, soft tissue collections contiguous with other infected compartments and areas of diffuse mediastinal infiltration with fat plane loss without prominent lymphadenopathy. The anatomy and extent of the infection was well delineated by CT in all patients. In nine cases this information affected clinical management, facilitating percutaneous drainage of the abscess in three. In five patients, information from CT did not alter clinical management.

Forty consecutive patients underwent flexible fiberoptic transbronchial lung biopsy for diagnosis of diffuse nodular or infiltrative lung disease. Biplane fluoroscopic examination with image intensification greatly facilitated accurate placement of the biopsy forceps near the pleura. Specimens of lung parenchyma were obtained for culture and histological study in every case. A pathological diagnosis was correctly established in 34 of 40 patients. Transbronchial biopsy was helpful in the clinical management of an additional 4 patients. Biopsy results were not accurate in 2 patients. No significant morbidity was associated with the procedure. Fiberoptic transbronchial lung biopsy is a safe and useful adjunct to the diagnosis of parenchymal lung disease.

A case is reported of cardio-respiratory failure in a neonate due to the pressure effect of a posterior mediastinal cyst. The plain film and angiographic findings of this lesion are discussed.

child at 4 days of age. A diagnosis of tricuspid atresia was made, and she remained well. Cardiac catheterization, performed at 8 months of age, confirmed the diagnosis of tricuspid atresia with a moderate-sized RV and limiting ventricular septal defect. There was a left-to-right shunt of 2:1. She remained well but became cyanotic and short of breath on exertion at the age of 4 years. A Fontan procedure was then performed (on July 9, 1980), and the RA was connected to the RV with a size 19 mm antibiotic-sterilized homograft. At the same time, the atrial and ventricular septal defects were closed. She made good progress attending a normal school and undertaking sporting activities, but 7 years later, her physical status deteriorated, and further echocardiography and angiography demonstrated moderate homograft regurgitation and stenosis with a gradient of 7 mm Hg. The RV had grown and was producing satisfactory flow. She had a reoperation, at which the RA-RV conduit was replaced with an 18-mm antibiotic-sterilized homograft. She initially did well, but 9 years later, she had reduced exercise tolerance and palpitations. Hemodynamic investigations on this occasion showed a high-velocity diastolic flow through the homograft, an RA “a” wave of 16 mm, and an “a” wave gradient of 10 mm Hg. At the time of the second reoperation, 16 years after her original modified Fontan procedure, the calcified aortic antibiotic-sterilized homograft was removed. The RA and RV orifices were widened, and the resulting defects were closed with two valved conduits. The upper one was a Homografts used to establish a right atrioventricular connection in patients having tricuspid atresia with a good-sized right ventricle (RV) tend to calcify and become obstructive and nonfunctional. Compression of the homograft by the overlying sternum contributes to this process. We present a technique whereby an incompressible heterograft and a homograft are inserted side by side between the right atrium (RA) and the RV in a double-barreled fashion. The heterograft protects itself and the homograft, which is inferior to it, from collapsing because of sternal compression. Improved RA-RV blood flow is possible because the much larger combined orifice area offers much lower resistance. Longer patency may be anticipated because of the lack of sternal compression and the improved hemodynamics. Clinical summary. A murmur was heard in this female DOUBLE-BARRELED CONDUIT FOR RIGHT ATRIOVENTRICULAR CONNECTION IN TRICUSPID ATRESIA: A NEW TECHNIQUE

We studied 243 patients in whom 248 pulmonary angiograms were performed because of suspected pulmonary embolism. Ventilation and perfusion lung scanning in 140 of them revealed 38 to be in low and high probability groups. Of 19 patients with subsegmental and nonsegmental perfusion defects that were matched with ventilation defects, none had pulmonary embolism. Conversely, angiography was positive in 17 of 19 patients with multiple segmental or lobar perfusion defects in areas of normal ventilation. Doppler flow examinations of the veins of the legs showed normal flow in 61 of 79 (77 percent) patients with pulmonary emboli and, therefore, were insensitive indicators of embolism. There was no mortality from angiography, and serious complications occurred in 2 percent of the patients. Anticoagulation in 83 patients was associated with bleeding in 25, two of whom died. The data indicate that ventilation-perfusion lung scanning can be used to separate many of the patients suspected of having pulmonary embolism who need anticoagulant treatment from those who do not. However, there is a considerable number of patients with nonspecific abnormalities on lung scan. For this group of patients with nonspecific abnormalities, the risk of complications from empiric treatment with anticoagulant drugs is probably greater than the risk of complications from pulmonary angiography. Further, our data show that patients with negative angiography have a very low risk of subsequent pulmonary embolism. In this group of patients, therefore, pulmonary embolism should be demonstrated by angiography before long-term anticoagulant therapy is prescribed.

A case of successful correction of type IB tricuspid atresia is described in which the patient's own normal pulmonary valve was used in its natural location. Morphological features of tricuspid atresia suggest that use of the in situ pulmonary valve is possible in most patients with normally related great arteries. Elimination of the requirement for valved conduits and bioprosthetic valves may eventually permit corrective operation in the very young child.

Computed tomography was used to evaluate three patients with complicated pulmonary vascular patterns. The physiologic and anatomic changes seen on chest radiography were well defined by CT and in each case CT suggested the correct diagnosis.

The revolution in data handling associated with digital systems has excited the medical world into considering replacing existing methods. The integration of digital with analogue video systems into a complete electronic communications network holds tremendous promise. One area where these changes will have significant impact is in medical imaging. The potential of more and better information being,obtained from current studies, more rapid access to studies, intercomparison of images from different modalities, savings in space and equipment, reduced procedure time, improved communication in a distributed department, remote image consultation, and timely data base for management are only some of the advantages that can accrue from proper use of electronic systems. In the hospital, the traditional radiology department is becoming a medical imaging de-partment. To effect a change from the ubiquitous silver halide film base system into a more electronic department will necessitate much experimentation. At the University of North Carolina we are attempting to involve the entire department in these endeavors as well as others such as biomedical engineering, computer science and traditional clinical areas. To facilitate this, a management system has been developed and is being used. The system, our architectural draft of a future department and the initial problems and questions which have arisen from implementing a prototype system will be the subject of this report.© (1982) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Small-bore percutaneous drainage catheters have been used extensively in the management of abdominal disorders and are gaining acceptance in thoracic problems. The records have been reviewed in 44 consecutive patients in whom 53 small-bore catheters were placed for thoracic disease, including empyema, 20; effusion, 9; pneumothorax, 10; lung abscess, 4; and mediastinal cyst, 1. Insertion was performed under fluoroscopy in 88%, computed tomography in 6%, and ultrasonography in 6%. Catheters ranged in size from 6.5F to 12F, but catheter size did not seem to influence outcome (p = 0.6). There was complete resolution of the problem in 75% (33 of 44) of the patients, although 20% of them required more than one catheter. Treatment was successful in all cases of lung abscess. These patients had been previously treated with standard medical therapy for 12 to 53 days without significant improvement in their clinical condition. Patients with empyema composed the largest group treated. Eighty percent (16 of 20) of them had a loculated (LOC) process. The LOC group appeared to have a slightly better success rate than did the non-LOC group (75 versus 50%, p = 0.33). When the catheters failed to resolve the problem (empyema, 6; chylous effusion, 1; malignant effusion, 3; and spontaneous pneumothorax, 1, either operation (9.1%) or a standard thoracostomy tube (13.6%) was required. The complications rate was 20%, but most of these were minor problems including pneumothorax, 5; catheter occlusion 3; fractured catheter, 1; infection, 1; and significant subcutaneous emphysema, 1.(ABSTRACT TRUNCATED AT 250 WORDS)

Three patients presenting with gastrointestinal bleeding and characteristic radiologic findings of hereditary hemorrhagic telangiectasia are described. Emphasis is placed not only on the angiodysplasia evident from abdominal angiography, but also on the demonstration by the chest radiograph of a chronic mild hyperdynamic state.

A prototype electronic picture information and communication system (PACS) should provide a means to gain practical experience in the use of video communications within a medical center, as well as provide a mechanism to accommodate sophisticated video applications in conjunction with clinical procedures. Such a system under current development at The University of North Carolina, will be described. Installation of the system will initially be within the confines of the radiology area; however it will be expanded to include other medical center locations once an appropriate system has been fully developed and verified.Dr. Edward Staab, presented an overview, describing radiology departmental PACS philosophy and program development. This report will expound upon the development of the prototype PACS to include conceptual approaches for a departmental design technique, communications network development, and test programs and project progress to-date.IntroductionThe University of North Carolina, prototype PACS project has as its initial objective the evaluation of PACS system configurations and components in a clinical environment. This system is being implemented within the North Carolina Memorial Hospital, Radiology Department. Individual PACS modules, including reading stations, picture storage devices, and picture processors are being established and are to be evaluated within a clinical environment. PACS operational parameters are to be evaluated as to their acceptability in 'supporting each individual medical imaging modality. While this approach will provide immediate clinical benefits, initially the main thrust is on evaluation and flexible modification. The system will provide objective operational data as a basis for planning system improvements. Expansion of the prototype PACS can be accomplished by the addition of PACS modules within each department section, as well as providing remote displays within appropriate areas.Over the next decade, we hope to create a PACS, which will provide the following operational capabilities:rapid access to imagesrapid access to data from non-imaging studiesrapid intercomparison of images from different modalitiesdecreased radiation dosage to patients and personnelsavings in space, equipment and personnelreduced procedure timeimproved communications in a distributed departmentremote image consultationThe following will discuss three major issues in the design of a system that can achieve these capabilities by successive evaluation and modification: "(1) Radiology physical plant design, (2) a broad band picture information communications network, and (3) implementation of PACS test programs."Radiology physical plant designPACS systems will change the physical constraints on a radiology department. Presently these constraints include:Radiology examination rooms and support areas must be nearby to enable handling, processing and examination of patients (patient throughput).X-ray film reading areas should be arranged for direct access to examination rooms, yet should provide for physical access to other reading areas for communications among radiologists and with outside clinical housestaff.

A multimodality projection console for the radiology conference room is described. The configuration of the TV camera, view boxes, switches, and adjacent lectern allows better transmission and easier manipulation of images during consultation and lecture sessions with the faculty, and house officers.

We report the presence of an unusual systolic murmur associated with a traumatic left ventricular pseudoaneurysm. Echophonocardiographic studies showed the murmur to begin at the first heart sound, but end well before the second heart sound. It seems likely that the murmur is caused by the systolic flow of blood from the left ventricle into the relatively noncompliant pseudoaneurysm. The echocardiographic scan of the left ventricle demonstrated a relatively echo-free space posterior to the left ventricular wall, supporting the diagnosis of pseudoaneurysm, which was confirmed with angiographic studies and at surgery. These findings indicate that a combination of noninvasive techniques is useful in establishing this diagnosis.

In serial experiments on cats, intravenous digital subtraction angiography (DSA) was utilized to observe orbital and ocular circulation. Images of the orbital arterial system as well as normal ocular vasculature were obtained, utilizing dosage of contrast material acceptable for human study. Images obtained after intra-arterial DSA had no advantage over those obtained with intravenous DSA. After retrobulbar injection of 3 ml of saline, intravenous DSA demonstrated straightening of the external ophthalmic arteries showing the potential of this method for identifying orbital vascular pathology.

ObjectivesPulmonary atresia with intact ventricular septum is a form of congenital heart disease usually associated with right-heart hypoplasia, with considerable morphologic heterogeneity and often poor outlook. Ascertainment of risk factors for poor outcome is an important step if an improvement in outcome is to be achieved.MethodsThe UK and Ireland Collaborative study of Pulmonary Atresia with Intact Ventricular Septum is an ongoing population-based study of all patients born with this disease from 1991 through 1995. All available clinical, morphologic, and investigative variables were directly reviewed, and risk factor analysis was performed for poor outcome.ResultsOne hundred eighty-three patients presented with pulmonary atresia with intact ventricular septum. Fifteen underwent no procedure, and all died. Of the remainder, 67 underwent a right ventricular outflow tract procedure (catheter or surgical), 18 underwent an outflow tract procedure with shunt, and 81 underwent a systemic-to-pulmonary shunt alone. One- and 5-year survival was 70.8% and 63.8%, respectively. Results from Cox proportional hazards model analysis showed that low birth weight (P = .024), unipartite right ventricular morphology (P = .001), and the presence of a dilated right ventricle (P < .001) were independent risk factors for death. The presence of coronary artery fistulae, right ventricular dependence, or the tricuspid valvar z score did not prove to be risk factors for death. After up to 9 years of follow-up, 29% have achieved a biventricular repair, 3% a so-called one-and-a-half ventricular repair, and 10.5% a univentricular repair, with 16.5% still having a mixed circulation (41% died).ConclusionsThis population-based study has shown which features at presentation place an infant in a high-risk group. This is important information for counseling in fetal life and for surgical strategy after birth.