Search

ObjectiveThe clinical and prognostic implications of a hypertensive response to exercise after repair of coarctation of the aorta (CoA) remain controversial. We aimed to determine the prevalence of a hypertensive response to exercise, identify factors associated with peak exercise systolic blood pressure (SBP) and explore the association of peak exercise SBP with resting blood pressure and cardiovascular events during follow-up.MethodsFrom the Dutch national CONgenital CORvitia (CONCOR) registry, adults with repaired CoA who underwent exercise stress testing were included. A hypertensive response to exercise was defined as a peak exercise SBP ≥210 mm Hg in men and ≥190 mm Hg in women. Cardiovascular events consisted of coronary artery disease, stroke, aortic complications and cardiovascular death.ResultsOf the original cohort of 920 adults with repaired CoA, 675 patients (median age 24 years (range 16–72 years)) underwent exercise stress testing. Of these, 299 patients (44%) had a hypertensive response to exercise. Mean follow-up duration was 10.1 years. Male sex, absence of a bicuspid aortic valve and elevated resting SBP were independently associated with increased peak exercise SBP. Peak exercise SBP was positively predictive of office SBP (β=0.11, pConclusionsA hypertensive response to exercise was present in nearly half of the patients in this large, prospective cohort of adults with repaired CoA. Risk factors for increased peak exercise SBP were male sex, absence of a bicuspid aortic valve and elevated resting SBP. Increased peak exercise SBP independently predicted hypertension at follow-up. These results support close follow-up of patients with a hypertensive response to exercise to ensure timely diagnosis and treatment of future hypertension.

Background After successful repair for coarctation of the aorta (CoA) abnormal blood flow patterns can be present, which may have a negative impact on left ventricular (LV) performance. The aim of this study is to investigate the relationship between aortic haemodynamics assessed by four-dimensional flow (4D flow) cardiac magnetic resonance imaging (CMR) and LV performance in CoA patients. Methods CoA patients with a clinical indication for CMR underwent additional 4D flow acquisition. Wall shear stress, oscillatory shear index, vorticity, viscous dissipation, energy loss, kinetic energy and velocity angle were assessed for several aortic segments at peak-systole. Global pulse wave velocity (PWV) was assessed for the entire aorta. Results In total, 17 CoA patients were included. Increased velocity angle in the ascending aorta was correlated with decreased LV mass (p=0.0445). Energy loss at the CoA site and increased degree of vorticity in the descending aorta were correlated with increased LV end-diastolic and end-systolic volume (p=0.0499, p=0.0461, respectively). Aortic PWV was correlated with LV mass and LV end-systolic volume (p=0.0385, p=0.0397, respectively). Conclusion Adverse aortic-ventricular interaction in CoA patients was demonstrated by abnormal aortic haemodynamics by 4D flow assessment which were associated impaired LV performance. 4D flow CMR may provide novel parameters to assess aortic-ventricular interaction.

Background Aortitis is a rare condition that can be caused by inflammatory or infectious aetiologies. The clinical presentation of aortitis includes a heterogeneous range of symptoms and clinical signs. Case summary We present a 53-year-old man whose medical history included presence of a ventricular septal defect, a bicuspid aortic valve, and coarctation of the aorta. The coarctation was treated with percutaneous stent implantation. One and a half years later, he presented to our hospital with complaints of fatigue, night sweats, and shivers. Physical examination revealed a fever, tachycardia, and hypertension. Imaging studies showed no signs of endocarditis. Positron emission tomography–computed tomography (PET–CT) showed an increase in 18F-fluorodeoxyglucose uptake at the distal end of the stent in the descending aorta. Blood cultures revealed a Streptococcus gordonii and antibiotic treatment was adjusted accordingly. The patients’ functional status improved quickly, the fever resolved, and the laboratory markers of inflammation returned to normal. Discussion Aortitis is extremely rare after stent implantation. Risk factors for aortitis include congenital vascular malformation and stent implantation. Computed tomography is currently the imaging study of choice for aortitis, while PET–CT seems ideal for identification of stent infection. Mortality associated with infectious aortitis ranges from 21% to 44%, with generally higher mortality if managed with antibiotics alone. The differential diagnosis of stent infection should be taken into account in patients presenting with fever and chills after previous stent procedures.

Congenital heart disease (CHD) is the most common form of congenital defects, with an incidence of 8 per 1000 births. Due to major advances in diagnostics, perioperative care and surgical techniques, the survival rate of patients with CHD has improved dramatically. Conversely, although 70%–95% of infants with CHD survive into adulthood, the rate of long-term morbidity, which often requires (repeat) intervention, has increased. Recently, the role of altered haemodynamics in cardiac development and CHD has become a subject of interest. Patients with CHD often have abnormal blood flow patterns, either due to the primary cardiac defect or as a consequence of the surgical intervention(s). Research suggests that these abnormal blood flow patterns may contribute to diminished cardiac and vascular function. Serial assessment of haemodynamic parameters in patients with CHD may allow for improved understanding of the often complex haemodynamics in these patients and thereby potentially guide the timing and nature of interventions with the aim of preventing progression of cardiovascular deterioration. In this article we will discuss two novel non-invasive four-dimensional (4D) techniques to evaluate cardiovascular haemodynamics: 4D-flow cardiac magnetic resonance and computational fluid dynamics. This review focuses on the additional value of these two modalities in the evaluation of patients with CHD with abnormal flow patterns, who could benefit from advanced haemodynamic evaluation: patients with coarctation of the aorta, bicuspid aortic valve, tetralogy of Fallot and patients after Fontan palliation.

Background The long‐term burden of cardiovascular disease after repair of coarctation of the aorta (CoA) has not been elucidated. We aimed to determine the incidence of and risk factors for cardiovascular events in adult patients with repaired CoA. Additionally, mortality rates were compared between adults with repaired CoA and the general population. Methods and Results Using the Dutch Congenital Corvitia (CONCOR) registry, patients aged ≥16 years with previous surgical or transcatheter CoA repair from 5 tertiary referral centers were included. Cardiovascular events were recorded, comprising coronary artery disease, stroke/transient ischemic attack, aortic complications, arrhythmias, heart failure hospitalizations, endocarditis, and cardiovascular death. In total, 920 patients (median age, 24 years [range 16–74 years]) were included. After a mean follow‐up of 9.3±5.1 years, 191 patients (21%) experienced at least 1 cardiovascular event. A total of 270 cardiovascular events occurred, of which aortic complications and arrhythmias were most frequent. Older age at initial CoA repair (hazard ratio [HR], 1.017; 95% CI, 1.000–1.033 [ P =0.048]) and elevated left ventricular mass index (HR, 1.009; 95% CI, 1.005–1.013 [ P P Conclusions This large, prospective cohort of adults with repaired CoA showed a high burden of cardiovascular events, particularly aortic complications and arrhythmias, during long‐term follow‐up. Older age at initial CoA repair and elevated left ventricular mass index were independent risk factors for the occurrence of cardiovascular events. Mortality was 3.3‐fold higher compared with the general population. These results advocate stringent follow‐up after CoA repair and emphasize the need for improved preventive strategies.

Three-dimensional rotational angiography (3DRA) is a suitable technique to detect the risk of left main bronchus (LMB) compression during left pulmonary artery (LPA) stenting in partial cavopulmonary connection and total cavopulmonary connection (TCPC). We report on a case of a 4-year-old boy with hypoplastic left heart syndrome and TCPC in which 3DRA and bronchoscopy gave conflicting information on airway patency during balloon interrogation. The balloon with high contrast concentration created a severe artifact impeding visibility of the LMB. Simultaneous flexible bronchoscopy revealed an unobstructed LMB. Repeated 3DRAs with lower contrast concentration had no artifact and showed a patent airway in accordance with the bronchoscopy. Conventional LPA stenting was performed without indication for stent ovalization. The benefit of low contrast concentration in the interrogation balloon was demonstrated in a second case of an 11-year-old boy with TCPC. The margins of the LPA and LMB were clearly visible without blank-out artifact. Oval stent procedure was necessary to prevent LMB compression. When 3DRA is used for vessel-airway interrogation, the balloon contrast concentration should be low in order to avoid artifacts. When in doubt, simultaneous flexible bronchoscopy can overcome the dilemma in airway judgment.

Background Stenosis of the total cavopulmonary connection (TCPC), in particular the pulmonary arteries, is common in children with single ventricle physiology. Stenting is an efficient interventional strategy to treat stenosis and optimize TCPC hemodynamics. Methods A retrospective single center study was performed to investigate the prevalence, causes and outcome of TCPC stenosis in children treated with stent implantation guided by three-dimensional rotational angiography (3DRA). Results From September 2011 to February 15th 2021 48 patients received 73 stents at 67 locations in 59 3DRA stent procedures. Median age and weight were 3.6 years (0.0–17.2) and 14.1 ​kg (3.4–70.0), respectively. Left pulmonary artery (LPA) stenosis accounted for 75% of the stenosis and is often caused by retroaortic compression. Adverse events occurred in 6 catheterizations (10.2%). Twenty-one patients (43.8%) underwent 27 reinterventions including planned serial redilation (N ​= ​17), extra stent placement (N ​= ​6), surgery (N ​= ​2), unplanned balloon dilation (N ​= ​1) and stent placement (N ​= ​1) for restenosis by intima proliferation. Conclusion TCPC stenoses, especially of the LPA, are common in children with single ventricle physiology and external compression is one of the main causes. 3DRA safely guides stent interventions as intraprocedural knowledge of possible interactions with surrounding structures are evaluated. Besides it is effective in both short and long term and can be performed in small children. Restenosis by intima proliferation is rare, though repeated redilations are necessary to match stent diameter with patient size.

Three-dimensional rotational angiography (3DRA) is an evolving technology that allows to acquire 3D volumetric data during heart catheterization based on a 180° scan of the frontal plane around the patient. 3DRA still is an underestimated tool and communication on a homogenous workflow is in progress. The angiographic principle of a rotational angiography differs from conventional angiography in terms of contrast injection timing, location, rapid pacing, and postprocessing options. The postprocessed 3D volume can be fusioned with CTA or MRI image data and used for 3D roadmapping to guide interventions like stent placement in complex pulmonary artery bifurcation stenosis or PPVI. Essential aspects in 3DRA are addressed as setting up a 3DRA system, radiation dose, contrast injection, understanding the role of Hounsfield units, postprocessing, image fusion, and 3D roadmapping. Furthermore, the approach of 3DRA in typical lesions as CoA, PPS, PPVI, and single ventricle morphology is explained in a step-by-step guide. Multiple figures demonstrated the entire workflow and give examples for vessel, airway, and device visualization with corresponding 3D roadmap illustrations.

Background Although pulmonary artery stenosis is common in congenital heart disease, not much is known about the hemodynamic impact. The effect of stenosis on flow, pressure and wall shear stress can be visualized with computational fluid dynamics. Objectives The aim of this study was to evaluate whether computational fluid dynamics is able to predict flow distribution and pressure gradients in normal and stenotic pulmonary arteries. Methods Three cases were selected. The cases included one normal anatomy and two geometries representing common patterns in pulmonary artery stenosis. The pulmonary bifurcation was reconstructed using 3D rotational angiography. On the inlet, a patient-specific transient mass flow curve was applied. Full patient-specific outlet boundary conditions were calculated and applied to the outlets of the models. Pressure and flow distribution outcomes were compared to cardiac catheterization and cardiovascular magnetic resonance imaging data respectively. Results In all three cases, the computationally calculated flow distribution was equal to the values measured by magnetic resonance imaging. In one case the pressure in the main pulmonary artery was slightly overestimated by computational fluid dynamics with 7 mmHg. All other pressure outcomes were in complete agreement with the invasive pressure measurements. Conclusions Pressure and flow distribution can be reliably predicted by computational fluid dynamics for normal and stenotic pulmonary arteries. The calculated values of pressure and flow distribution were in excellent agreement with the clinical values. This demonstrates the feasibility and reliability of this method for flow analysis in patients with stenotic pulmonary arteries.

Hybrid imaging (HI) during cardiovascular interventions enables the peri-procedural visualization of the organs and tissues by means of integrating different imaging modalities. HI can improve the procedural efficacy and safety. This review provides an overview of different systems, their possibilities and the current clinical use and benefits focused on structural and congenital heart diseases. We have performed a literature search and linked the software options to the clinical use in cardiology to gain insight into the clinical use of the systems. In this review, we focus on radiation and contrast exposure, complication rate and procedure time. We found that currently available studies are limited by small cohorts. Nevertheless, HI systems for valvular procedures result in a significant decrease of radiation and contrast exposure. The largest benefit hereof is observed when HI is used in combination with rotational angiography. Furthermore, automatically determined optimal implant angle for transcatheter aortic valve implantation decreases the complication rate significantly. Congenital heart disease interventions that require 2D/3D Transoesophageal echocardiography (TEE) such as septal defects show a significant decrease in radiation and contrast exposure and procedural time when using TEE-Mono- and bi-plane cine angiography and fluoroscopy (XRF) fusion software. MitraClip procedures using these HI systems, however, show only a trend in decrease of these effects. In conclusion, major interventional X-ray vendors offer HI software solutions which are safe and can aid the planning and image guidance of cardiovascular interventions. Even though current HI technologies have limitations, HI provides support in the increasingly complex cardiac interventional procedures to provide better patient care.

Background Despite a successful repair procedure for coarctation of the aorta (CoA), up to two-thirds of patients remain hypertensive. CoA is often seen in combination with abnormal aortic arch anatomy and morphology. This might be a substrate for persistent hypertension. Therefore, we performed endovascular aortic arch stent placement in patients with CoA and concomitant aortic arch hypoplasia or gothic arch morphology. The goal of this retrospective analysis was to investigate the safety and efficacy of aortic arch stenting. Methods A retrospective analysis was performed in patients who underwent stenting of the aortic arch at the University Medical Center Utrecht. Measurements collected included office blood pressure, use of antihypertensive medication, invasive peak-to-peak systolic pressure over the arch, and aortic diameters on three-dimensional angiography. Data on follow-up were obtained at the date of most recent outpatient visit. Results Twelve patients underwent stenting of the aortic arch. Mean follow-up duration was 14 ± 11 months. Mean peak-to-peak gradient across the arch decreased from 39 ± 13 mm Hg to 7 ± 8 mm Hg directly after stenting (p p = 0.014). Conclusion This retrospective study shows that stenting of the aortic arch is successful when carried out in a state-of-the-art manner. A direct optimal angiographic and haemodynamic result was shown. No major complications occurred during or after the procedure. At short- to medium-term follow-up a decrease in mean systolic blood pressure was observed.

Previously, median effective dose (ED) of 1.6 mSv per three-dimensional rotational angiography (3DRA) has been reported. This study evaluated ED and image quality in 3DRA after implementation of a simple dose reduction protocol in pediatric catheterizations. Simple conversion factors between 3DRA ED and readily available parameters at the cathlab were determined. The dose reduction protocol consisted of frame reduction (60–30 frames/s (f/s)), active collimation of the X-ray beam, usage of a readily available low dosage program, and a pre-3DRA run check. EDs were calculated with Monte Carlo PCXMC 2.0. Three observers blindly assessed 3DRA image quality of the dose reduction and normal-dose cohort. Between October 2014 and October 2015, 84 patients (median age 4.3 years) underwent 100 3DRAs with a median ED of 0.54 mSv (0.12–2.2) using the dose reduction protocol. Median ED in the normal-dose cohort (17 3DRAs) was 1.6 mSv (1.2–4.9). Image quality in the dose reduction cohort remained excellent. Correlations between ED and dose area product (DAP) and ED and skin dose were found with a ρ of 0.82 and 0.83, respectively. ED exposure of the entire catheterization was reduced to 2.64 mSv. Introduction of a simple protocol led to 66% dose reduction in 3DRA and 79% in the entire catheterization. 3DRA image quality in this group remained excellent. In 3DRA ED correlates well with DAP and skin dose, parameters readily available at the cathlab. Electronic supplementary material The online version of this article (10.1007/s00246-018-1943-3) contains supplementary material, which is available to authorized users.

AIMS Complex single ventricle topography, changes in vessel geometry after surgical steps and subsequent stenoses are difficult to visualise with biplane conventional angiography (CA). This study aimed to investigate the additional value of three-dimensional rotational angiography (3DRA) compared to CA for diagnostic and interventional purposes in children with univentricular hearts. METHODS AND RESULTS Demographic data, clinical data and catheterisation details of both imaging techniques were collected retrospectively. Image quality, interventional success and the additional value of 3DRA were reviewed and scored. Between January 2003 and March 2017, 140 patients underwent 183 CAs and 107 3DRAs. 3DRA image quality was superior to CA with fewer diagnostic angiographies performed (p

Objectives: To describe the use of fractional flow reserve (FFR) and intravascular ultrasound (IVUS) in the evaluation of patients with anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). Background: ACAOS of the right and left coronary are rare, but may lead to symptoms and impose a risk for sudden cardiac death, depending on several anatomical features. Assessment and risk estimation is challenging in (nonathlete) adults, especially if they present without symptoms or with atypical complaints. Methods: The team retrospectively studied 30 consecutive patients with ACAOS with interarterial course, who received IVUS- and FFR-guided treatment at our institution between October 2010 and September 2017. Results: FFR was abnormal in only seven patients. IVUS showed the typical slit-like anatomy of the orifice in 23 patients. Based on FFR and/or IVUS results, in conjunction with the clinical presentation, clinical decision was made. A decision for intervention was made if at least two out of three entities were abnormal. Intervention implied unroofing of the coronary artery (n = 10) or coronary artery bypass grafting (n = 1). In all other patients a conservative strategy was followed. No adverse events occurred in the total population after a median of 37 (0–62) months of follow-up. Conclusions: Conservative treatment may be justifiable in adult patients with ACAOS in the presence of normal FFR and nonsuspicious symptoms, despite the presence of an interarterial course and/or slitlike orifice on IVUS. We recommend the use of FFR and IVUS in the standard work-up for adult patients with ACAOS and propose the use of a flowchart to aid in decision-making.

Background The severity of aortic coarctation (CoA) may be underestimated during cardiac catheterization. We aimed to investigate whether epinephrine stress testing improves clinical decision making and outcome in CoA. Methods We retrospectively evaluated CoA patients >50 kg with a peak systolic gradient (PSG) ≤20 mm Hg during cardiac catheterization who underwent epinephrine stress testing. Subsequent interventional management (stenting or balloon dilatation), complications, and medium-term clinical outcome were assessed. Results Fifty CoA patients underwent cardiac catheterization with epinephrine stress testing. Patients with a high epinephrine PSG (>20 mm Hg; n = 24) were younger and more likely to have a hypertensive response to exercise compared to patients with a low epinephrine PSG (≤20 mm Hg; n = 26). In total, 21 patients (88%) with a high epinephrine PSG underwent intervention, and 20 patients (77%) with a low epinephrine PSG were treated conservatively. After a mean follow-up of 25 ± 18 months, there was a lower prevalence of hypertension in patients with a high epinephrine PSG who underwent intervention compared to patients with a low epinephrine PSG treated conservatively (19% vs. 76%; P = .001). In a multivariate model, intervention was independently associated with a 14.3–mm Hg reduction in systolic blood pressure (P = .001) and a decrease in the use of antihypertensive agents. Conclusions In CoA patients with a low baseline PSG but high epinephrine PSG, percutaneous intervention is associated with a substantial reduction in systemic blood pressure and the use of antihypertensive medication. Accordingly, epinephrine stress testing may be a useful addition in the evaluation of CoA.

Three-dimensional rotational angiography (3D-RA) enables volumetric imaging through rotation of the C-arm of an angiographic system and real-time 3D reconstruction during cardiac catheterization procedures. In the field of congenital heart disease (CHD), 3D-RA has gained considerable traction, owing to its capability for enhanced visualization of spatial relationships in complex cardiac morphologies and real time image guidance in an intricate interventional environment. This review provides an overview of the current applications, strengths, and limitations of 3D-RA acquisition in the management of CHD and potential future directions. In addition, issues of dosimetry, radiation exposure, and optimization strategies will be reviewed. Further implementation of 3D-RA will be driven by patient benefits relative to existing 3D imaging capabilities and fusion techniques balanced against radiation exposure.

ObjectiveLong-term prognosis of patients with coarctation of the aorta (CoA) is impaired due to the high prevalence of hypertension and consequent cardiovascular complications. Although stent implantation results in acute anatomical and haemodynamic benefit, limited evidence exists regarding the late clinical outcome. In this meta-analysis, we aimed to evaluate the medium-term effect of stent placement for CoA on systemic blood pressure (BP).MethodsPubMed, EMBASE and Cochrane databases were searched for non-randomised cohort studies addressing systemic BP ≥12 months following CoA stenting. Meta-analysis was performed on the change in BP from baseline to last follow-up using a random-effects model. Subgroup analyses and meta-regression were conducted to identify sources of heterogeneity between studies.ResultsTwenty-six studies with a total of 1157 patients and a median follow-up of 26 months were included for final analysis. Meta-analysis showed a 20.3 mm Hg (95% CI 16.4 to 24.1 mm Hg; pConclusionsStent implantation for CoA is associated with a significant decline in systolic and diastolic BP during medium-term follow-up. The degree of BP reduction appears to be dependent on baseline systolic BP, baseline peak systolic gradient, and whether stenting is performed for native or recurrent CoA.

Cardiac catheterization is a commonly used form of imaging and treatment in pediatric patients with congenital heart disease. Traditionally, two-dimensional conventional angiography was the method used, but since 2000 three-dimensional rotational angiography (3DRA) is increasingly used in the field of cardiology in both adult and pediatric patients. To investigate the use and applications of 3DRA in pediatric congenital cardiology, literature was systematically reviewed and 29 eligible articles were found. Those showed that 3DRA is already a greatly valued diagnostic and therapeutic technique in pediatric cardiology. However, the literature misses well-designed clinical, homogeneous, multicenter, prospective studies recording data in a standardized manner. These studies are necessary to ensure proper data analysis and to investigate the true advantages of 3DRA and how it exactly benefits the patients.

Background Children with aortic coarctations (CoA) are increasingly percutaneously treated. Good visualisation of the CoA is mandatory and can be obtained with three-dimensional rotational angiography (3DRA). This study aims to compare the diagnostic and therapeutic additional value of 3DRA with conventional biplane angiography (CA) in children with a CoA. Methods Patients undergoing percutaneous treatment of CoA with balloon angioplasty (BA) or stent between 2003 and 2015, were retrospectively reviewed on success rate, complications, radiation and technical settings. Diagnostic quality of CA and 3DRA and additional value of 3DRA were scored. Results In total, 134 patients underwent 183 catheterisations, 121 CA and 62 3DRA-guided. Median age was 0.52 years in the BA group and 11.19 years in the stent group. 3DRA was superior to CA in displaying the left ventricle (p = 0.008), ascending aorta (p < 0.001), aortic arch (p = 0.005) and coronary arteries (p < 0.001). In the BA group, 3DRA had a significantly higher success rate than CA (100.0 % versus 68.9 %, p = 0.016). All stent interventions were successful. Complication rates did not differ significantly. The median total dose area product did not significantly differ between CA and 3DRA in the BA (27.88 μGym2/kg versus 15.81 μGym2/kg, p = 0.275) or stent group (37.34 μGym2/kg versus 45.24 μGym2/kg, p = 0.090). 3DRA was of additional value in 96.8 % of the interventions. Conclusions 3DRA is superior to CA in diagnostic quality and not associated with increased radiation exposure. It provides high additional value in guiding CoA related interventions. Electronic supplementary material The online version of this article (doi: 10.1007/s12471-016-0899-2) contains supplementary material, which is available to authorized users.

Patients with congenital heart disease (CHD) with right ventricle outflow tract (RVOT) dysfunction need sequential pulmonary valve replacements throughout their life in the majority of cases. Since their introduction in 2000, the number of percutaneous pulmonary valve implantations (PPVI) has grown and reached over 10,000 procedures worldwide. Overall, PPVI has been proven safe and effective, but some anatomical variations can limit procedural success. This review discusses the current status and future perspectives of the procedure.

Background Surgical treatment of critical aortic coarctation (CoA) is difficult in very low birth weight (VLBW) infants ≤1500 g and preferably postponed until 3 kg with prostaglandins (PGE). Objectives To investigate the procedure and outcome of primary coronary stent implantation as bridging therapy to surgery in VLBW infants with CoA. Methods Retrospective evaluation of primary CoA stenting in VLBW infants from 2010 to 2015. Results Five VLBW infants with a median gestational age of 29 weeks (27–32) underwent primary CoA stenting. Indication was cardiac failure in 4 and severe hypertension in 1 patient. Age and weight at intervention were 14 days (range 12–16) and 1200 g (680–1380), respectively. Stent diameter ranged 3–5 mm. The femoral artery used for intervention was occluded in all infants without clinical compromise. Severe restenosis and aneurysm occurred in 1 VLBW infant and was successfully treated with covered coronary stents. Median age at surgical correction was 200 days (111–804) and weight 5500 g (4500–11,400). No reinterventions were required during a median postoperative follow-up of 2.8 years (0.1–5.0). Neurodevelopmental outcomes were normal and comparable between patients and siblings (4/5 gemelli). Conclusions Primary coronary stent implantation in VLBW infants with critical CoA is a feasible bridging therapy to surgery.

Introduction Transcatheter aortic valve implantation (TAVI) is a well-accepted alternative treatment for intermediate or high-risk patients with symptomatic severe native aortic valve stenosis. As the use of TAVI increases, there is a continuous growing insight into in the technical possibilities of the procedure and a parallel decrease in complications. A serious but rare complication of TAVI is a ventricular septal defect (VSD). Case presentation We report a case of a 90-year-old woman who underwent an uncomplicated TAVI procedure. She was readmitted within 2 weeks because of dyspnoea and oedema in the legs caused by acute left- and right-sided heart failure. Echocardiography showed a VSD of 1 cm, and mild to moderate paravalvular aortic regurgitation (PAR). Discussion This is the first report in which post-TAVI both a VSD and PAR are successfully repaired via a single percutaneous procedure.

Time-resolved tomographic cardiac imaging using an angiographic C-arm device may support clinicians during minimally invasive therapy by enabling a thorough analysis of the heart function directly in the catheter laboratory. However, clinically feasible acquisition protocols entail a highly challenging reconstruction problem which suffers from sparse angular sampling of the trajectory. Compressed sensing theory promises that useful images can be recovered despite massive undersampling by means of sparsity-based regularization. For a multitude of reasons-most notably the desired reduction of scan time, dose and contrast agent required-it is of great interest to know just how little data is actually sufficient for a certain task. In this work, we apply a convex optimization approach based on primal-dual splitting to 4D cardiac C-arm computed tomography. We examine how the quality of spatially and temporally total-variation-regularized reconstruction degrades when using as few as [Formula: see text] projection views per heart phase. First, feasible regularization weights are determined in a numerical phantom study, demonstrating the individual benefits of both regularizers. Secondly, a task-based evaluation is performed in eight clinical patients. Semi-automatic segmentation-based volume measurements of the left ventricular blood pool performed on strongly undersampled images show a correlation of close to 99% with measurements obtained from less sparsely sampled data.

AIMS: Three-dimensional rotational angiography (3DRA) is a relatively new but promising imaging technique in the paediatric catheterization laboratory. However, data on effective dose (ED) of this technique in children are lacking. The purpose of this study is to provide ED of 3DRA and to correlate this with parameters readily available in daily practice. Furthermore, the effect of dose-reducing techniques is evaluated. METHODS AND RESULTS: Effective doses were calculated with Monte Carlo PCXMC 2.0 in 14 patients who underwent a total of 17 3DRAs at our paediatric catheterization laboratory. Median age was 5.7 years (range 1 day-16.6 years). Median ED was 1.6 milliSievert (mSv) (range 0.7-4.9). Effective dose did not correlate with age and body surface area but did correlate with dose area product (DAP) and milliGray (mGy) with r(2) of 0.75 and 0.83, respectively. Reduction of the total amount of frames from 248 to 133 per rotation resulted in further dose reduction of over 50% with preserved image quality. CONCLUSION: The median ED of 3DRA in children is 1.6 mSv and correlates with DAP and mGy. This dose can be halved by applying frame reduction. A significant further dose reduction can be achieved by obtaining additional knowledge of the equipment used.

ACAOS of the right and left coronary are rare, but may give complaints and impose a risk for sudden cardiac death, depending on several anatomical features. Assessment and risk estimation is challenging in (non-athlete) adults, especially if they present with absent or atypical complaints.

Background: Three-dimensional rotational angiography (3DRA) is a relatively new but promising imaging technique in the pediatric catheterization laboratory. However, data on the effective dose (E) of this technique are lacking, since they are very time consuming to obtain. The purpose of our study is to provide E of 3DRA and to correlate Ed to parameters readily available in daily practice. Methods and Results: Effective doses were calculated in 14 patients who underwent a total of 17 3DRA's at our pediatric catheterization laboratory using Monte Carlo PCXMC 2.0. Median age was 5.7 years (range, 1 day-16.6 years). Median Ed was 1.6 mSv (range, 0.7 – 4.9). E did not correlate to age and BSA but did correlate to dose area product (DAP) and to milliGray (mGy) with a r-square of 0.8341. Conclusion: The median E of 3DRA in children is 1.6 mSv and seems to be age and BSA independent. Ed correlated to DAP and mGy in our population.

We report on a 37-year-old woman with essential systemic hypertension. An MRI was performed because of weak femoral pulses, depicting a severe almost atretic coarctation of the aorta (Fig. 1). Angiography of the proximal distal thoracic aorta was simultaneously performed (Fig. 2a). The transverse arch was narrow (16 mm), as was the diameter of the terminal aortic arch distal to the left subclavian artery (10 mm). Distal of the coarctation the diameter of the descending aorta was 11 mm. A trajectory of 2 mm in length seemed atretic. The atretic segment could be crossed in an antegrade fashion with a straight 0,014 in. coronary wire and balloon pre-dilatation was performed with a 5 mm coronary balloon. Thereafter, a multi-purpose catheter could be advanced retrogradely across the coarctation segment. A 9 French Mullins sheath (Cook) was advanced to the transverse aortic arch. A 41 mm long Advanta V12 premounted covered stent (Atrium, Hudson, USA) on a 12 mm high pressure balloon was implanted. Consecutive angiography revealed complete expansion of the stent up to 12 mm without residual stenosis, and no aneurysm formation (Fig. 2b). Fig. 1 MRI imaging of the left ventricle (LV), ascending aorta (AAo). The left subclavian artery (LSA) is dilated and the descending aorta (DAo) is hypoplastic. The coarctation imposes as atresia. There are numerous collaterals. RV: right ventricle Fig. 2 a Simultaneous angiography of the proximal and distal descending aorta; anterior projection. Atretic coarctation (CoA). Some small collaterals can be seen right of the coarctation. Abbreviations: Cath: catheter, DAo: descending aorta, LSA: left subclavian ... In conclusion, treatment with placement of a low-profile covered stent, using a simultaneous radial and femoral approach and pre-dilatation, delivered an excellent result without complications and a short hospital stay. The patient’s blood pressure returned to normal and her antihypertensive medication could be stopped within 3 weeks after stent implantation. We emphasise that in so-called ‘unexplained’ systemic hypertension, especially in young adults, coarctation of the aorta has to be excluded [1, 2]. When coarctation is confirmed primary stenting is the first choice therapeutic option [3–5].

A 13-year-old female patient with Turner syndrome and complex congenital heart disease including aortic coarctation presented to our hospital. Stenting of the coarctation was successfully performed with an open-cell-design non-covered stent (ev3 MaxLD). Due to the short distance between the left subclavian artery origin and the coarctation, partial overstenting of …