Follow-up Cardiac Catheterization Research Articles

Midterm fate of unifocalized major aortopulmonary collateral arteries in patients with retroesophageal major aortopulmonary collateral arteries.

Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (MAPCAs) is a relatively rare and complex form of congenital heart disease. Unifocalization of MAPCAs has been advocated by some groups for the treatment of this condition. The purpose of this study was to assess the midterm fate of unifocalized MAPCAs in a cohort of patients with retroesophageal MAPCAs. This was a retrospective review of 37 patients who underwent a unifocalization procedure. All patients in this study had 1 or more retroesophageal MAPCAs, and detailed mapping of the MAPCAs was made based on a combination of the cardiac catheterization and surgical findings. The 37 patients had a total of 166 MAPCAs, or 4.5 MAPCAs per patient. One hundred twenty-nine (78%) MAPCAs were unifocalized, whereas 37 (22%) were ligated because they were dual supply. Median follow-up was 69months. At follow-up cardiac catheterization, evaluation of the 129 unifocalized MAPCAs demonstrated that 123 (95%) had antegrade flow, whereas 6 were occluded. For the 123 MAPCAs with antegrade flow, 97 (80%) were widely patent, whereas 26 were stenotic. Thirteen of the 37 patients have subsequently undergone reintervention on MAPCAs that were determined to be stenotic following unifocalization. Seven of these patients had mild disease and had complete resolution with balloon (n=5) or surgical revision (n=2). Six patients with moderate or severe disease underwent surgical revision with confirmed resolution in 4 of 6. The data demonstrate that the majority of unifocalized MAPCAs remain widely patent following unifocalization. However, one-quarter of unifocalized MAPCAs develop stenoses or occlusion. These results suggest the fate for most unifocalized MAPCAs is favorable but highlight the need for close vigilance.

Visual liver assessment using Gd-EOB-DTPA\u2013enhanced magnetic resonance imaging of patients in the early post-Fontan period

No imaging modality can be used to evaluate Fontan-associated liver disease (FALD). We retrospectively reviewed hepatic gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) characteristics of patients within 1 year post-Fontan procedure, and we evaluated the association between hepatic imaging abnormalities and clinical parameters, including follow-up cardiac catheterization and laboratory test findings. The EOB-MR images were graded, based on the extent of the decreased enhancement, as “normal” (Grade 1), “segmental” (Grade 2), “regional” (Grade 3), and “diffuse” (Grade 4). We enrolled 37 patients (mean age, 3.5 ± 1.0 years): 9 patients had Grade 1 or 2; 14 patients, Grade 3; and 14 patients, Grade 4. EOB-MRI revealed characteristic reticular or mosaic patterns of diminished enhancement (i.e. “frog spawn” appearance). Ultrasonography did not detect diminished enhancement or “frog spawn” appearance. A trend existed toward increased grade severity in imaging with increased central venous pressure, pulmonary vascular resistance, and gamma-glutamyltransferase levels. Noninvasive EOB-MRI revealed the characteristic pattern of diminished enhancement, which was correlated with certain clinical parameters indicative of Fontan physiology and liver dysfunction. Early-stage FALD may occur soon after the Fontan procedure and is associated with increased pressure in the inferior vena cava and hepatic veins.

P4160Safety and efficacy of triple combination therapy with parenteral prostanoids in patients with Eisenmenger physiology

Abstract Aim While combination therapy is currently strongly advocated for idiopathic pulmonary arterial hypertension (PAH) patients, evidence to support its use in patients with PAH related to congenital heart disease (CHD), especially patients with Eisenmenger syndrome, is lacking. We evaluated the efficacy and safety of sequential triple combination therapy with parenteral prostanoids after failure of double oral therapy in patients with PAH-CHD and Eisenmenger physiology. Methods This is an international, multicentre, retrospective cohort study conducted in adult patients with Eisenmenger physiology on double oral PAH therapy in whom intravenous or subcutaneous prostanoid treatment was added due to clinical deterioration or failure to reach the treatment goals. Clinical status, 6-minute walk test distance (6MWD), biomarkers and haemodynamics were assessed at baseline and during the follow-up. Results A total 28 patients with Eisenmenger syndrome (6 [21%] male, age 37.6±14.3 years) were included. A post-tricuspid shunt was present in 16 (57%), 86% of whom had a ventricular septal defect. The majority (89%) were treated with subcutaneous treprostinil. At 27±14 months follow-up, WHO functional class improved in 18 (64%), remained unchanged in 8 (29%), and deteriorated in 2 (7%) patients. There was also an increase in 6MWD (mean 339±145 versus 233±140m, p=0.0001, fig 1A) and a reduction in NT-proBNP levels (median 1125 [123–5882] versus 3087 [234–7428] pg/mL, p<0.0001, fig 1B). On follow-up cardiac catheterization, an improvement in right atrial pressure (8±2 versus 11±5 mmHg, p=0.01), mean pulmonary artery pressure (68±12 versus 72±17 mmHg, p=0.005), cardiac index (2.3±0.3 versus 2.0±0.5 l/min/m2, p=0.005, fig 1C), and pulmonary vascular resistance (17±7 versus 21±10, p=0.008, fig 1D), was observed compared to baseline. No patients discontinued treatment. Five (18%) patients died during follow up. Figure 1 Conclusions Triple combination therapy with subcutaneous treprostinil or endovenous epoprostenol in patients with Eisenmenger syndrome is safe and well tolerated at 2 years follow-up, resulting in a significant improvement in clinical status, exercise tolerance and haemodynamics.

A successful treatment of tadalafil in incontinentia pigmenti with pulmonary hypertension

We describe a female infant with incontinentia pigmenti complicated by severe pulmonary arterial hypertension that was markedly improved by tadalafil administration. The infant was referred to our institution because of neonatal seizures and generalized skin rash at the age of 1 day. She was diagnosed with incontinentia pigmenti on skin biopsy findings. In addition to incontinentia pigmenti, she had pulmonary arterial hypertension without structural heart disease. The pulmonary hypertension rapidly worsened at the age of 2 months and was confirmed by cardiac catheterization. The pulmonary artery pressure was equal to systemic pressure but it decreased in response to nitric oxide inhalation. We, therefore, initiated treatment with tadalafil of 1 mg/kg/day. The follow-up cardiac catheterization performed at 9 months revealed dramatic improvement in the pulmonary artery pressure. An IKBKG mutation with deletion of exons 4–10 was detected in the blood of both the patient and her mother. Our experience indicates that tadalafil may be beneficial in treating pulmonary arterial hypertension associated with incontinentia pigmenti.

Device closure of atrial septal defect with severe pulmonary hypertension in adults: Patient selection with early and intermediate term results.

To describe a subset of atrial septal defect (ASD) with severe pulmonary hypertension (PHT) that is suitable for closure. As per American Heart Association/American College of Cardiology guidelines, ASD with elevated pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) >2/3rd systemic is considered as a contraindication for closure. Patients with anatomically large ASD measuring >25 mm and a high probability of reversible pulmonary vascular disease were subjected to fenestrated device closure, despite severe PHT and elevated PVR. They were discharged on pulmonary vasodilators and were followed for 39.5 ± 8.5 months. Four patients had repeat cardiac catheterization. Six patients underwent successful device closure of large ASD with severe PHT. Their basal Qp:Qs was 2.8 ± 0.3:1 while the systolic PAP and the PVR index (PVRI) were 102.6 ± 11.5 mm Hg and 9.6 ± 1.6 Wu m2 , respectively. Post 100% oxygen inhalation, the Qp:Qs increased to 3.5 ± 0.3:1, systolic PAP remained 103.5 ± 7.6 mm Hg while the PVRI dropped to 5.4 ± 1.1 Wu m2 . The postballoon occlusion systolic PAP decreased to 86.6 ± 8.8 mm Hg. At the last follow-up, their pulmonary artery systolic pressure by tricuspid regurgitation (TR) jet decreased from 105.6 ± 12.6 mm Hg to 45 ± 7.0 mm Hg. During follow-up cardiac catheterization (n = 4), the systolic PAP and PVRI were 55.7 ± 9.2 mm Hg and 3.2 ± 0.4, respectively. Patients with anatomically big defect and a large left to right shunt at baseline with a high probability of reversible PVR benefit with ASD closure and pulmonary vasodilators, despite significantly elevated PAP and PVRI.

Factors determining early outcomes after the bidirectional superior cavopulmonary anastomosis.

The bidirectional Glenn (BDG) procedure is a step in multistage palliation of univentricular heart (UVH). We aimed to report the factors determining the outcomes following BDG. Two hundred fifteen consecutive patients, 5.29±5years (range 1month to 38years, median 3years) of age, weighing 13±8.8kg (range 2.6 to 51kg, median 10kg) with variable forms of UVH underwent BDG from 2003 to 2013. Their clinical records were reviewed retrospectively. The most common anatomic diagnoses were tricuspid atresia (n=87, 40.5%) and double outlet right ventricle (n=78, 36%). Dextrocardia was present in 21 (9.86%) patients. Median left pulmonary (PA) and right PA diameters were 6 and 7mm, respectively. One hundred sixty-two (77%) patients received unilateral BDG, and 45 had bilateral BDG. The antegrade pulmonary blood flow was closed in 199 and was left open in 16 patients. Concomitant procedures were reconstruction of pulmonary arteries for non-confluent PA (n=28), atrial septectomy (n=15), atrioventricular valve repair (n=12) and repair of partial anomalous pulmonary venous connection (n=1). A total of 37% of patients (n=80) had a mean post-operative saturation of 90±3.2%. There were four (1.86%) early deaths. Mean Glenn pressure was 14.7±3.5 mmHg, and mean inotropic score and Vasoactive inotropic score (VIS) were 1.64±0.96 and 2.77±2.63, respectively. Mean intensive care unit stay was 24.1±26.4 (range 10-240)h, and mean duration of hospital stay was 7.15±3.2days. Mean saturation at the time of discharge was 92.4±2.2% and on follow-up was 82±2.16%. Follow-up cardiac catheterization data was available in 123 (60.3%). Sixty-nine (33.8%) patients underwent completion Fontan, and 135 patients were in follow-up or waiting for Fontan completion. BDG procedure can be performed safely with acceptable mortality. Age at presentation, pulmonary artery size and VIS were not related to mortality. Younger patients had similar outcomes but a longer hospital stay. Patients with preserved antegrade pulmonary blood flow had higher saturations. Those undergoing BDG without cardiopulmonary bypass had lower inotropic scores.

Cardiac catheterization in children with pulmonary hypertensive vascular disease.

The risks associated with cardiac catheterization in children with pulmonary hypertension (PH) are increased compared with adults. We reviewed retrospectively all clinical data in children with PH [mean pulmonary artery pressure (mean PAp) ≥25 mmHg and pulmonary vascular resistance index (PVRI) ≥3 Wood units m(2)] undergoing cardiac catheterization between 2009 and 2014. Our strategy included a team approach, minimal catheter manipulation and sildenafil administration prior to extubation. Adverse events occurring within 48 h were noted. Seventy-five patients (36 males), median age 4 years (0.3-17) and median weight 14.6 kg (2.6-77 kg), underwent 97 cardiac catheterizations. Diagnoses included idiopathic or heritable pulmonary arterial hypertension (PAH) (29 %), PAH associated with congenital heart disease (52 %), left heart disease (5 %) and lung disease (14 %). Mean PAp was 43 ± 19 mmHg; mean PVRI was 9.7 ± 6 Wood units m(2). There were no deaths or serious arrhythmias. No patient required cardiac massage. Three patients who suffered adverse events had suprasystemic PAp (3/3), heritable PAH (2/3), decreased right ventricular function (3/3), and pulmonary artery capacitance index <1 ml/mmHg/m(2) (3/3) and were treatment naïve (3/3). No patient undergoing follow-up cardiac catheterization suffered a complication. In 45 % of cases, the data acquired from the follow-up cardiac catheterization resulted in an alteration of therapy. Three percent of children with PH undergoing cardiac catheterization suffered adverse events. However, there were no intra or post procedural deaths and no one required cardiac massage or cardioversion. Follow-up cardiac catheterization in patients receiving pulmonary hypertensive targeted therapy is safe and provides useful information.

Unidirectional valved patch closure of ventricular septal defects with severe pulmonary arterial hypertension: Hemodynamic outcomes

The purpose of the present study was to study the midterm hemodynamic outcomes of unidirectional valved patch closure of ventricular septal defects (VSDs) in patients with VSD and pulmonary arterial hypertension (PAH). From January 2006 to January 2012, 20 patients with VSD with PAH and a pulmonary vascular resistance index >8 Wood units underwent VSD closure with a unidirectional valved patch using the technique previously described by us. Of these, 13 patients agreed to follow-up cardiac catheterization and were studied at a mean follow-up of 34.7 ± 18.6 months (range, 2-56). The mean age of these 13 patients was 8.5 ± 4.4 years (range, 2-19; median, 9), and the mean preoperative systemic saturation was 94.1% ± 3.4% (range, 87-99; median, 95.0) The mean preoperative pulmonary artery systolic pressure was 96.2 ± 13.6 mm Hg (range, 75-115; median, 103.0), and the mean preoperative pulmonary vascular resistance index was 10.0 ± 2.1 Wood units (range, 8.0-15.1; median, 9.3). At follow-up cardiac catheterization, the mean systemic saturation had increased to 98.92%. The pulmonary vascular resistance index had decreased significantly to 5.8 ± 2.1 Wood units (P = .02). A significant decrease was seen in the pulmonary artery systolic, diastolic, and mean pressures (P = .000), and none of the patients had severe PAH. No patients died, and all patients were in New York Heart Association class I. Unidirectional valved patch closure of VSD is a promising technique for patients with a large VSD and severe PAH. It had a favorable effect on the immediate, early, and midterm clinical outcomes and hemodynamic parameters.

First Report of Atretic Coronary Sinus Stenting in a 5-kg Infant Resulting in Dramatic Improvement of Ventricular Function in Functional Single Ventricle

The patient was a male infant with L-transposition of great arteries (L-TGA), Ebstein's anomaly of the tricuspid valve, subvalvar aortic stenosis, ventricular septal defect (VSD), hypoplastic right ventricle, arch hypoplasia, and congenital complete heart block. He underwent a Norwood procedure, aortic arch repair, permanent pacemaker implantation, and a 3.5-mm aortopulmonary shunt at 4 days of age. At the time of his surgery, left ventricular function was in the normal range (ejection fraction [EF] = 67%). However by 3 months of age, he was noted to have developed moderate-severe biventricular dysfunction (left ventricular ejection fraction [LVEF] = 34%). Atresia of the coronary sinus with a small left superior venacava (LSVC) and a bridging vein was discovered during cardiac catheterization at this time. The coronary sinus mean pressure was 17 mm Hg, and the common atrial mean pressure was 6 mmHg. We opened the atretic coronary sinus ostium using radiofrequency ablation and stent placement. There was dramatic improvement in ventricular function observed over a 2-month period. Follow-up cardiac catheterization 5 months later revealed the stent in the coronary sinus to be widely patent with no intimal buildup, and the ventricular function was normal (LVEF = 58%). The patient had a bidirectional Glenn procedure with an uncomplicated postoperative course and is currently awaiting Fontan completion.

Supraventricular Tachycardia in the Pediatric Trauma Patient: A Case Report

Any injured patient who is cool and tachycardic is considered to be in shock until proven otherwise.(1) We describe the diagnostic challenge when evaluating persistent tachycardia in the setting of multiple system trauma with hemorrhagic shock. This is a unique case of a 17-year-old patient with the secondary condition of cardiogenic shock due to supraventricular tachycardia (SVT) complicating ongoing hemorrhagic shock from a facial laceration. She had sustained tachycardia despite aggressive resuscitation and required medical cardioversion 30 minutes after arrival to the emergency department. After successful conversion, she maintained normal sinus rhythm for the rest of her hospitalization. During her follow-up cardiac catheterization, she was found to have a left-sided accessory pathway, consistent with atrioventricular reciprocating tachycardia. This is a unique and rare case of SVT in the traumatic patient. We review causes of tachycardia in the setting of pediatric multisystem trauma, as well as discuss acute SVT evaluation and management in the pediatric emergency department.

Advancing Cor Triatriatum in Fontan Circulation

A 14-year-old female with mitral atresia, double outlet right ventricle, l-malposition of the great arteries, pulmonary valvular stenosis, bilateral superior vena cavae, and juxtaposed right atrial appendage had undergone a staged Fontan completion at 22 months of age. Ten years later, transthoracic echocardiography detected blood flow acceleration in the left atrium and scheduled follow-up cardiac catheterization revealed a 3.3 mm Hg pressure gradient between the common pulmonary venous chamber and left atrium, confirming cor triatriatum. An abnormal septum in the left atrium was surgically resected through a left-side right atriotomy. Postoperative echocardiography showed no accelerated blood flow in the left atrium.

Regression of Pulmonary Vascular Disease After Therapy of Abernethy Malformation in Visceral Heterotaxy

A 1-year-old boy who had left isomerism and corrected transposition of the great arteries (c-TGA) with moderate-sized ventricular septal defect, severe pulmonary artery hypertension (PAH), and pulmonary vascular disease with significant right-to-left shunting received a diagnosis of type 2 Abernethy malformation, which was partly responsible for disproportionate PAH in the child. The malformation was treated by plugging of the portosystemic shunt. Follow-up cardiac catheterization on sildenafil demonstrated significant left-to-right shunting (2.16:1) and a fall in pulmonary vascular resistance, making surgical correction possible. This case highlights the importance of searching for additional rare causes of PAH in patients with congenital heart diseases when the degree of pulmonary hypertension is disproportional to the defect size.

Premenopausal woman with acute myocardial infarction caused by spontaneous coronary artery dissection and potential association with coronary vasospasm

A 45-year-old premenopausal woman presented with acute myocardial infarction (MI). An intravascular ultrasound (IVUS) revealed that her distal right coronary artery was occluded by spontaneous coronary artery dissection (SCAD). She did not have any specific condition related to SCAD. At follow-up cardiac catheterization, an acetylcholine provocation test was applied to examine the etiology of SCAD, and definitive coronary vasospasm was induced with chest symptoms and significant electrocardiographic change. A Ca-channel blocker was administered and since then chest pain has subsequently so far been relieved. The current case suggests the significance of the IVUS in detecting etiology of MI in younger patients and the potential association between SCAD and coronary vasospasm.

Arterial Switch Operation With Unidirectional Valved Patch Closure of Ventricular Septal Defect in Patients With Transposition of Great Arteries and Severe Pulmonary Hypertension

For patients with dextro-transposition of great arteries (d-TGAs), ventricular septal defect (VSD), and severe pulmonary arterial hypertension (PAH), the common surgical options are palliative arterial switch operation (ASO) or palliative atrial switch operation leaving the VSD open. We evaluated the role of ASO with VSD closure using a fenestrated unidirectional valved patch (UVP). Between July 2009 and February 2011, six patients with TGAs, VSD, and severe PAH (mean age 39.8 ± 47.4 months, median 21, range 8-132 months), weighing 10.7 ± 9.2 kg (median 8.6, range 4.3-29 kg), underwent ASO with VSD closure using our simple technique of UVP. Mean pulmonary artery systolic pressure before the operation was 106 ± 12.7 mm Hg (median 107.5, range 95-126 mm Hg) and pulmonary vascular resistance was 9.5 ± 4.22 units (median 9.5, range 6.6-17.1 Wood units). There were no deaths. All patients had a postoperative systemic arterial saturation of more than 95%, although there were frequent episodes of systemic desaturation due to right-to-left shunt across the valved VSD patch (as seen on transesophageal and transthoracic echocardiograms). Mean follow-up was 10 ± 7.6 months (median 7.5, range 1-22 months). At most recent follow-up, all patients had systemic arterial saturation of more than 95% and no right-to-left shunt through the VSD patch. In one patient, the follow-up cardiac catheterization showed a fall in pulmonary artery systolic pressure to 49 mm Hg. Arterial switch operation with UVP VSD closure is feasible with acceptable early results. It avoids complications of palliative atrial switch (arrhythmia and baffle obstruction) and partially or completely open VSD.

Kawasaki Disease with Giant Aneurysms: Long-term Outcome

Research Article| August 01 2011 Kawasaki Disease with Giant Aneurysms: Long-term Outcome AAP Grand Rounds (2011) 26 (2): 17. https://doi.org/10.1542/gr.26-2-17 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Kawasaki Disease with Giant Aneurysms: Long-term Outcome. AAP Grand Rounds August 2011; 26 (2): 17. https://doi.org/10.1542/gr.26-2-17 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: aneurysm, kawasaki's disease Source: Suda K, Iemura M, Nishiono H, et al. Long-term prognosis of patients with Kawasaki Disease complicated by giant coronary aneurysms: a single institution experience. Circulation. 2011; 123(17): 1836– 1842; doi: https://doi.org/10.1161/CIRCULATIONAHA.110.978213Google Scholar Investigators from Kurume and Fukuoka Universities in Japan studied the longterm prognosis of patients with Kawasaki Disease (KD) complicated by giant aneurysms (GA). A total of 76 children (57 boys) with GA (diameter ≥8mm) confirmed by cardiac catheterization treated at their institution from January 1972 through January 2011 were identified. The average age of onset was 2.9 years of age. Information was obtained from chart review and patient contacts with a median follow-up of 19 years. The patients with GA had a cardiac catheterization three months after the onset of symptoms and then were seen every one to three months with a clinic visit, electrocardiogram (ECG), and echocardiogram (ECHO). Pharmacological stress scintigraphy with dipyridamole infusion was performed every two to three years and treadmill ECG stress testing was performed between scintigraphy exams. Scintigraphy and ECG stress testing were also performed for symptoms of ischemia. A follow-up cardiac catheterization was obtained six months after the initial ECHO and every two to three years thereafter. Three indications for coronary interventions were noted: clinical ischemic symptoms, no clinical ischemia but ischemic findings provoked by stress testing, and no ischemic symptoms but at least 75% stenosis of the left anterior descending artery. Treatment changed over time with aspirin given only until 1990 and warfarin administered after 1990. Intracoronary thrombolysis and bypass grafting were used until 1994, and then replaced with percutaneous transluminal coronary rotational ablation. Over the observation period, seven patients died and one was rescued with a cardiac transplantation, leaving 95% surviving 10 years, 88% surviving 20 years and 88% surviving 30 years. Catheter and surgical procedures to treat ischemia were performed in 46 (61%) patients: a mean of 1.7 interventions (range 1–7) performed 1 month to 21 years after onset of KD. Intervention was most frequently needed one month after onset of symptoms. The authors conclude that although survival of patients with KD complicated by GA is moderately good, the majority of patients require multiple catheter and surgical interventions. Remodeling of the coronary arteries apparently continues long after the onset of this disease, presumably due to ongoing inflammation of the coronary wall. Close cardiac monitoring including stress testing is mandatory long after the initial diagnosis. Dr Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. KD most frequently affects infants and young children under 5 years of age. Diagnosis relies on a group of principal symptoms: 1) fever persisting five days or more; 2) bilateral conjunctival injection; 3) changes in lips and oral cavity; 4) polymorphous exanthema; 5) changes in peripheral extremities – (acute phase) reddening of palms and soles, indurative edema; (convalescent phase) membranous desquamation from fingertips; and 6)... You do not currently have access to this content.

Associations of positive T wave in lead aVR with hemodynamic, coronary, and left ventricular angiographic findings in anterior wall old myocardial infarction

No information is available on the clinical significance of a positive T wave in lead aVR in myocardial infarction (MI). Accordingly, in the present study, we sought to clarify the associations of the positive T wave in lead aVR with hemodynamic, coronary angiographic, and left ventriculographic findings in anterior wall old MI. We examined 122 patients with anterior wall old MI who underwent diagnostic or follow-up cardiac catheterization including coronary angiography and left ventriculography. The patients were classified into the following 2 groups: patients with a positive (≥ 1mm) T wave in lead aVR (n=20, group A) and those without (n=102, group B). Group A had higher pulmonary arterial, pulmonary capillary wedge, and left ventricular (LV) end-diastolic pressures and a lower cardiac index than group B. The prevalence of a long left anterior descending coronary artery (LAD) was higher in group A than in group B (60% vs 30.4%, p=0.01), and none of group A patients had an LAD that did not reach the apex. Group A had a lower LV ejection fraction than group B (36.4 ± 11.6% vs 48.4 ± 12.7%, p<0.001). The positive T wave in lead aVR is related to severely reduced cardiac function, with an LAD wrapping the apex, in anterior wall old MI. Further studies are needed to clarify whether the positive T wave in lead aVR is associated with an adverse outcome in patients with anterior wall old MI.

Ventricular Performance in Long-Term Survivors After Fontan Operation

Ventricular function and arrhythmia in patients with Fontan circulation in long-term follow-up are still unknown. We retrospectively reviewed 48 patients who survived and were followed up for more than 15 years, among 110 patients who underwent Fontan operation in our institute from 1979 to 1992. Atriopulmonary connection was performed in 26 patients and total cavopulmonary connection in 22. The patients were categorized into right ventricle, left ventricle, and biventricle groups. Follow-up cardiac catheterization and exercise test were performed routinely every 5 years post surgery. Median age at Fontan operation was 5 years. Mean follow-up was 18.5 years. Cardiac index in the total cavopulmonary connection group was higher than in the atriopulmonary connection group at 10 and 15 years post surgery (p<0.05). Ejection fraction in the left-ventricle group was higher than in the right-ventricle group. End-diastolic volume at 5, 10, and 15 years was significantly lower than at 1 year (p<0.05). End-diastolic pressure at 10 years was significantly higher than at 1 and 5 years (p<0.05). Beyond 15 years, 6 patients developed ventricular tachycardia. The only significant risk factors for the onset of ventricular tachycardia in a multivariate analysis were age at Fontan operation and absolute age (p<0.05). Long-term follow-up of patients demonstrated that postoperative ventricular systolic performance seemed to become steady. Ventricular tachycardia was detected 15 years post surgery, especially in older patients with older age at Fontan operation, possibly revealing a risk factor in the long-term postoperative period, thereby meriting further consideration.

The Role of Multiple Drug-Eluting Stents in the Treatment of Cardiac Transplant Vasculopathy

A 60-year-old male with cardiac transplantation six years prior was seen for easy fatigability and dyspnea on exertion. Electrocardiogram revealed new T-wave inversions in the anterolateral leads. Cardiac catheterization showed diffuse multivessel disease with significant stenosis consistent with cardiac transplant vasculopathy (CTV). Percutaneous intervention was performed with DES with improvement of symptoms. Follow-up cardiac catheterization revealed patent stents. CTV is the most common cause of death in heart transplant patients. Due to denervated heart, these patients rarely experience chest pain. Revascularization options are limited given the diffuse nature of the disease. Due to their very low restenosis rates, DES may represent a viable alternative to retransplantation.

Endovascular Stenting for Native Coarctation of the Aorta Is an Effective Alternative to Surgical Intervention in Older Children

Assess the early and intermediate results with respect to blood pressure control in older children undergoing endovascular stenting for native coarctation of the aorta. Eleven hypertensive patients (10 +/- 3 years of age) underwent endovascular stenting via standard techniques for native coarctation of the aorta as an alternative to surgical repair. Resting and exercise assessment of blood pressure control with Doppler echocardiography was performed pre- and poststenting. All 11 patients underwent successful stenting without complications and were able to be weaned off antihypertensive medications within a short period of time. At latest follow-up (34 +/- 26 months), all patients are normotensive at rest and during treadmill exercise stress testing. Two patients underwent uncomplicated additional stent dilation at follow-up cardiac catheterization. Endovascular stenting for native coarctation of the aorta in older children is a reasonable alternative to surgical correction. During early follow-up, stenting effectively alleviates the aortic arch obstruction with normalization of the systemic blood pressure both at rest and during maximal exercise.

Abstract 1550: Non-Doppler Two-Dimensional Strain Imaging for Early Detection of Heart Transplant Recipients with Coronary Stenoses

Background: Non-Doppler based two-dimensional (2D) strain imaging can reveal wall motion alterations not visible by conventional echocardiography (ECHO) and like tissue Doppler imaging (TDI) it can detect myocardial deformation (regional shortening and thickening) in the absence of visible ventricular wall displacement. Because TDI is dependent on the direction of Doppler angle of incidence in relation to myocardial motion, in our attempt to assess of the diagnostic value of strain and strain rate changes for early detection of transplant coronary arteriopathy (TCA), we focused our attention on the angle independent 2D strain imaging. Methods: In 68 heart recipients with normal LV wall motion and ejection fraction in conventional ECHO, 2D strain LV wall motion analysis were additionally performed before each follow-up cardiac catheterization. Circumferential, radial and longitudinal strain and strain rate were calculated from parasternal short axes and apical (3- and 4-chamber) views, respectively. 2D strain parameters were tested for relationships with angiographic findings. Results: In comparison with patients without TCA, those with angiographic TCA showed lower global systolic strain rate (radial, circumferential and longitudinal) values and longer systolic times measured from onset of contraction to the peak of systolic strain (p&lt;0.01). For radial peak systolic global strain rate values below 1.1/s we found a 93.3% likelihood of angiographic TCA in general, regardless of the presence or absence of focal stenoses on main coronaries. Regional strain and strain rate analyses showed differences in contraction asynchrony and dyssynergy indexes between patients with and without focal stenoses (p&lt;0.01). For longitudinal midsystolic dyssynchrony index values &gt;0.5 we found an 88.2% likelihood of relevant focal coronary stenoses (&gt;50% narrowing). Conclusions: In heart allografts with apparently normal LV kinetics in conventional ECHO, simple global strain rate measurements allow early TCA prediction, but without the ability to differentiate between diffuse TCA and predominantly focal coronary stenoses. Such differentiation is possible with more complex regional strain analyses using contraction asynchrony and dyssynergy indexes.