Shunt Volume Research Articles

Left Ventricular Diastolic Function in Children with Atrial Septal Defects Improves After Closure by Means of Increased Hydraulic Force

AbstractHydraulic force aids diastolic filling of the left ventricle (LV) by facilitating basal movement of the atrioventricular plane. The short-axis atrioventricular area difference (AVAD) determines direction and magnitude of this force. Patients with atrial septal defect (ASD) have reduced LV filling due to the left-to-right shunt across the atrial septum and thus potentially altered hydraulic force. The aims were therefore to use cardiac magnetic resonance images to assess whether AVAD and thus the hydraulic force differ in children with ASD compared to healthy children, and if it improves after ASD closure. Twenty-two children with ASD underwent cardiac magnetic resonance before ASD closure. Of these 22 children, 17 of them repeated their examination also after ASD closure. Twelve controls were included. Left atrial and ventricular areas were delineated in short-axis images, and AVAD was defined as the largest ventricular area minus the largest atrial area at each time frame and normalized to body height (AVADi). At end diastole AVADi was positive in all participants, suggesting a force acting towards the atrium assisting the diastolic movement of the atrioventricular plane; however, lower in children both before (6.3 cm2/m [5.2–8.0]; p < 0.0001) and after ASD closure (8.7 cm2/m [6.6–8.5]; p = 0.0003) compared to controls (12.2 cm2/m [11.3–13.9]). Left ventricular diastolic function improves after ASD closure in children by means of improved hydraulic force assessed by AVAD. Although AVADi improved after ASD closure, it was still lower than in controls, indicating diastolic abnormality even after ASD closure. In patients where AVADi is low, ASD closure may help avoid diastolic function deterioration and improve outcome. This could likely be important also in patients with small shunt volumes, especially if they are younger, who currently do not undergo ASD closure. Changes in clinical routine may be considered pending larger outcome studies.

Long-term impact of transcatheter closure interatrial shunts on disabling migraine

Backgrounds Effectiveness of patent foramen ovale (PFO) closure on relief of migraine, is still unclear. We sought to analyse the long-term (>10 years) effects of interatrial septal shunt repair on disabling migraine performing a retrospective non-randomised study. Methods Clinical records of patients with disabling, medication-refractory migraine and PFO or significant ASD referred to our centre for closure from 2006 to 2018, were analysed. Results Forty -six patients (38 female, mean age 40.0 ± 3.7 years) with PFO and 32 patients with significant ASD (28 female, mean age 38.0 ± 4.1 years) submitted to transcatheter closure had a pre-existing disabling migraine with mean Migraine Disability Assessment Score (MIDAS) of 35.8 ± 4.7. After a mean follow-up of 118.2 ± 19.1 months (range 96 to 144), 72 out of 78 patients were still followed-up: in all subjects, aura was abolished, and migraine improved also in patients without aura. The mean MIDAS significantly decreased from baseline value (p < 0.01). Complete migraine resolution was associated in PFO patients with a shorter history of migraine, a more severe thrombophilic profile, a more severe Right-to-Left Shunt (RLS) and larger left atrial diameter and volume, and in ASD patients with bidirectional shunt. Conclusions Device-based repair of PFO/ASD in patients with migraine was associated with abolition of aura and symptoms reduction in the long-term period.

Vein of Galen malformation with Obstructive Hydrocephalus- Endovascular Approach of Management : A Case Report

The vein of Galen malformation is a rare arteriovenous shunt that is estimated to represent 30% of all pediatric vascular malformations. Less than 1% of cerebral vascular malformations are aneurysmal abnormalities of the vein of Galen, making it a rare disorder. Despite being uncommon, VGM is of particular clinical importance since the large cerebral shunt volume causes a significant mortality rate when left untreated because to date, the treatment of patients with VGM remains challenging. Here we report a case of an 11-month-old baby who had VGM with obstructive hydrocephalus and was effectively treated by transarterial glue embolization of the fistula and the venous sac. Subsequently, the baby made a complete recovery. Bang. J Neurosurgery 2023; 13(1): 34-40

3D-Volumetric Shunt Measurement for Detection of High-Risk Esophageal Varices in Liver Cirrhosis.

Background and Objectives: Esophageal varices (EV) and variceal hemorrhages are major causes of mortality in liver cirrhosis patients. Detecting EVs early is crucial for effective management. Computed tomography (CT) scans, commonly performed for various liver-related indications, provide an opportunity for non-invasive EV assessment. However, previous CT studies focused on variceal diameter, neglecting the three-dimensional (3D) nature of varices and shunt vessels. This study aims to evaluate the potential of 3D volumetric shunt-vessel measurements from routine CT scans for detecting high-risk esophageal varices in portal hypertension. Methods: 3D volumetric measurements of esophageal varices were conducted using routine CT scans and compared to endoscopic variceal grading. Receiver operating characteristic (ROC) analyses were performed to determine the optimal cutoff value for identifying high-risk varices based on shunt volume. The study included 142 patients who underwent both esophagogastroduodenoscopy (EGD) and contrast-enhanced CT within six months. Results: The study established a cutoff value for identifying high-risk varices. The CT measurements exhibited a significant correlation with endoscopic EV grading (correlation coefficient r = 0.417, p < 0.001). A CT cutoff value of 2060 mm3 for variceal volume showed a sensitivity of 72.1% and a specificity of 65.5% for detecting high-risk varices during endoscopy. Conclusions: This study demonstrates the feasibility of opportunistically measuring variceal volumes from routine CT scans. CT volumetry for assessing EVs may have prognostic value, especially in cirrhosis patients who are not suitable candidates for endoscopy.

Accuracy of Shunt Volume Measured by Three-Dimensional Echocardiography and Cardiac Magnetic Resonance in Patients With an Atrial Septal Defect and a Dilated Right Ventricle

The accuracy of right ventricular (RV) quantification by three-dimensional echocardiography (3DE) has been reported mainly in patients with a normal right ventricle (RV). However, there are no data regarding the accuracy of 3DE in patients with a dilated RV, as in shunt diseases. In this study, we evaluated the accuracy of 3DE and that of volumetric (Vol) cardiac magnetic resonance (CMR) for assessment of RV and left ventricular (LV) stroke volume (SV) and the pulmonary (Qp)/systemic (Qs) blood flow ratio in patients with an atrial septal defect (ASD) using the two-dimensional phase contrast (2DPC) method as the gold standard. We retrospectively investigated 83 patients with ASD who underwent transcatheter closure and clinically indicated CMR and 3DE examinations. The ratio Qp/Qs was calculated using RV and LV SV measured by full-volume volumetric 3DE (Vol-3DE) and CMR (Vol-CMR) and by two-dimensional pulsed Doppler quantification (2D-Dop); the parameters were compared using 2DPC-CMR as the gold standard. There was no significant difference in the Qp/Qs value between 2DPC-CMR and Vol-3DE (2.29±0.70 vs 2.21±0.63, P=.79) and 2D-Dop (vs 2.21±0.65, P=1.00); however, a significant difference was found between 2DPC-CMR and Vol-CMR (P<.001). The Qp/Qs value obtained using Vol-3DE showed the best correlation with 2DPC-CMR (r=0.93, P<.001). The RV and LV SV values obtained by Vol-3DE showed the best correlation with 2DPC-CMR (RV SV, r=0.82, P<.001; LV SV, r=0.73, P<.001), although the absolute values were underestimated. Qp/Qs was more accurately evaluated by Vol-3DE than by Vol-CMR or 2D-Dop. Three-dimensional echocardiography assessment was feasible and reproducible even in a dilated RV.

PFO-spectrum disorder: two different cerebrovascular diseases in patients with PFO as detected by AI brain imaging software.

Patent foramen ovale (PFO) is a prevalent cardiac remnant of fetal anatomy that may pose a risk factor for stroke in some patients, while others can present with asymptomatic white matter (WM) lesions. The current study aimed to test the hypothesis that patients with a PFO who have a history of stroke or transient ischemic attack, compared to those without such a history, have a different burden and distribution of cerebral WM hyperintensities. Additionally, we tested the association between PFO morphological characteristics and severity of shunt, and their impact on the occurrence of ischemic cerebral vascular events and on the burden of cerebral WM lesions. Retrospective, case-control study that included patients with PFO confirmed by transesophageal echocardiography. Right-to-left shunt size was assessed using transcranial Doppler ultrasound. Cerebral MRIs were analyzed for all participants using the semi-automated Quantib NDTM software for the objective quantification of WM lesions. WM lesions volume was compared between patients with and without a history of stroke. Additionally, the anatomical characteristics of PFOs were assessed to explore their relation to stroke occurrence and WM lesions volume. Of the initial 264 patients diagnosed with PFO, 67 met the inclusion criteria and were included in the analysis. Of them, 62% had a history of PFO-related stroke/TIA. Overall burden of WM lesions, including stroke volume, was not significantly different (p = 0.103). However, after excluding stroke volume, WM lesions volume was significantly higher in patients without stroke (0.27 cm3, IQR 0.03-0.60) compared to those with stroke/TIA (0.08 cm3, IQR 0.02-0.18), p = 0.019. Patients with a history of PFO-related stroke/TIA had a tendency to larger PFO sizes by comparison to those without, in terms of length and height, and exhibited greater right-to-left shunt volumes. We suggest that PFO may be associated with the development of two distinct cerebrovascular conditions (stroke and "silent" WM lesions), each characterized by unique imaging patterns. Further studies are needed to identify better the "at-risk" PFOs and gain deeper insights into their clinical implications.

New method for quantification of atrial septum defect shunting by echocardiography

Abstract Background Atrial septum defect (ASD) is a common congenital heart disease. Echocardiography is the preferred method for detection and characterization of ASD. Accurate quantification of shunting is pivotal, but often requires right heart catheterization (RHC). In the present study, we introduce a new non-invasive method for accurate quantification of the ASD shunt by combined transesophageal- (TEE) and transthoracic (TTE) echocardiography. Shunt by RHC was used as a reference method. Method In 22 adults with secundum ASD, left ventricular (LV) stroke volume (SV) was measured by the pulsed Doppler method using 2D TTE. The shunt volume passing through the ASD was quantified as the ASD area measured by planimetry from 3D TEE, multiplied with the time velocity integral (TVI) of the PW Doppler obtained at the center of the ASD by TEE. Finally, the ratio of the pulmonary to systemic shunt (Qp:Qs) was calculated as (LVSV+ASDvolume)/LVSV. Shunt by RHC was assessed by the Fick’s principle. Results Mean shunt was 2.2±0.7 (±SD) by echocardiography and 2.1±0.7 by RHC, with a mean difference of -0.1±0.4 (Figure 1). The correlation between shunt measured by RHC and echocardiography was strong (r=0.86, p&amp;lt;0.0001; Figure 2). Conclusion The present study demonstrates that ASD shunting can be quantified accurately by combining TTE and TEE, suggesting a new non-invasive approach in settings where RHC is not feasible or available.Figures

Corrigendum: Rectal Acetaminophen Improves Shunt Volume and Reduces Patent Ductus Arteriosus Ligation in Extremely Preterm Infants.

Corrigendum: Rectal Acetaminophen Improves Shunt Volume and Reduces Patent Ductus Arteriosus Ligation in Extremely Preterm Infants.

Neurointerventional Treatment of Vein of Galen Malformation (VGM): A Structured Review with a Proposal for the Comparison of Outcome Quality

Background: Vein of Galen malformation (VGM) is a congenital intracranial vascular anomaly consisting of arteriovenous fistulas and/or malformations between various arterial feeders and the median prosencephalic vein of Markowski (MPV). Despite its rare occurrence, VGM is of particular clinical relevance, as the excessive intracranial shunt volume leads to high mortality without appropriate treatment. Methods: The objective of this article is to review the published data on neurointerventional treatment and compare outcome quality in the included studies. Eight studies were included and synthesized. One study was multicentric and the rest were retrospective monocentric (level 4 evidence studies according to the Oxford Centre for Evidence-based Medicine). Results: The total number of included patients was 480 and patient age ranged from 1 day to 18 years. Mild or severe heart failure, hydrocephalus, and other reasons led to the indication for neurointerventional treatment, which was performed in all studies in the form of embolization. Under consideration of the introduced semiquantitative multidimensional scoring system, the highest total score, i.e., the best outcome quality, was found for the study “Houston” 2002–2018 (19 points) and the study “Duisburg” 2001–2010 (19 points). Conclusions: Neurointerventional treatment represents the essential pillar in the interdisciplinary management of patients with VGM, although standardization is lacking—based on the results of the structured review. As complementary treatments, pediatric critical care is mandatory and includes medical hemodynamic stabilization.

Calf muscle pump tensing as a novel maneuver to improve the diagnostic performance of detecting patent foramen ovale during transesophageal echocardiography.

The Valsalva maneuver is the most sensitive provocative maneuver for patent foramen ovale detection. However, nearly half of patients are unable to perform the Valsalva maneuver well. The aim of this study was to investigate the mechanism of action of calf muscle pump tensing (TENSE) as a novel patent foramen ovale (PFO) provocative maneuver and to evaluate the diagnostic value for PFO and the effect on right-to-left shunt volume compared with the Valsalva maneuver. This study prospectively investigated 171 patients who were highly suspected to have PFO clinically. Five patients with atrial septal defects newly diagnosed on transesophageal echocardiography (TEE) were excluded. 166 patients were injected with agitated saline under three provocative maneuvers: Valsalva maneuver, TENSE, and Valsalva + TENSE combined maneuver. The patients were divided into the effective Valsalva group (n = 93) and ineffective Valsalva group (n = 73) according to whether they could perform an effective Valsalva maneuver. TENSE consisted of the straightening of both lower limbs, and when the right atrium was filled with microbubbles, the patient performed instantaneous ankle dorsiflexion movements while maintaining dorsiflexion for 3-5 s. Overall, the PFO detection rate of the Valsalva + TENSE combined maneuver (78 [50.1%]) was significantly higher than that of the Valsalva maneuver (51 [30.7%]) and TENSE maneuver (57 [34.3%]) (P < 0.001). In the patients who were able to perform an effective Valsalva maneuver, the PFO detection rate by TENSE was not significantly different from that by the Valsalva maneuver (Valsalva 37/93 [39.8%] vs. TENSE 31/93 [33.3%], P > 0.05), while for the patients who performed an ineffective Valsalva maneuver, the PFO detection rate by the TENSE maneuver was higher than that by the Valsalva maneuver (TENSE 26/73 [35.6%] vs. Valsalva14/73[19.2%], P = 0.017). TENSE is a simple and effective provocative maneuver in the diagnosis of PFO using TEE and can assist the Valsalva maneuver. For patients who cannot perform an effective Valsalva maneuver, TENSE can be an alternative to the Valsalva maneuver to some extent.

Comparison between Cardiac CTA and Echocardiography for Assessment of Ventricular Septal Rupture Diameter and Its Effect on Transcatheter Closure.

This study is aimed at comparing cardiac computed tomographic angiography (CTA) with echocardiography in the assessment of ventricular septal perforation diameter. A total of 44 ventricular septal rupture (VSR) patients undertaking transcatheter occlusion were included and randomly divided into the CTA group and echocardiography group with a 1 : 1 ratio. Clinical data, operation-related data, and 30 d follow-up data were collected and analyzed. Incidence of closure failure, occluder displacement, poor occluder molding, and occluder waist diameter shrinkage between the two groups were not statistically different. The mean residual shunt volume in the echocardiography group (4.2 (3.1, 5.9) mm) was significantly higher than that in the CTA group (2.1 (0, 4.0) mm) with a p value of 0.005. However, no significant differences were found in all-cause mortality and incidence of operative complications within 30 days after surgery. Within the CTA group, the correlation was strongest between postoperative occluder diameter and long diameter measured by CTA with a correlation coefficient of 0.799 and p < 0.001, followed by the correlation between postoperative occluder diameter and mean diameter measured by CTA with a correlation coefficient of 0.740 and p < 0.001. The diameter measured by echocardiography was not correlated to postoperative occlude diameter. Assessment of VSR diameter by cardiac CTA is more accurate than by echocardiography.

Vein of Galen aneurysmal malformation

The vein of Galen aneurysmal malformation (VGAM) is arare aneurysmatic cerebrovascular malformation in newborns and children. The VGAM results from an arteriovenous fistula between the persistent vein of Markowski (embryonic precursor of the vein of Galen) and deep choroidal arteries. The VGAM is the most common noncardiac cause of high-output cardiac failure in newborns. It may also cause hemorrhage, seizures, and liquor malabsorption resulting in hydrocephalus. Preferred treatment of VGAM is transarterial embolization (TAE) to reduce the arteriovenous shunt volume and allow normal brain development.

White matter changes should not exclude patients with idiopathic normal pressure hydrocephalus from shunt surgery

IntroductionWhite matter changes (WMC) on brain imaging can be classified as deep white matter hyperintensities (DWMH) or periventricular hyperintensities (PVH) and are frequently seen in patients with idiopathic normal pressure hydrocephalus (iNPH). Contradictory results have been reported on whether preoperative WMC are associated with outcome after shunt surgery in iNPH patients. The aim of this study was to investigate any association between DWMH and PVH and shunt outcome in patients with iNPH, using magnetic resonance volumetry.MethodsA total of 253 iNPH patients operated with shunt surgery and clinically assessed before and 12 months after surgery were included. All patients were investigated preoperatively with magnetic resonance imaging of the brain. The volumes of DWMH and PVH were quantified on fluid-attenuated inversion recovery images using an in-house semi-automatic volumetric segmentation software (SmartPaint). Shunt outcome was defined as the difference in symptom score between post- and preoperative investigations, measured on the iNPH scale, and shunt response was defined as improvement with ≥ 5 points.ResultsOne year after shunt surgery, 51% of the patients were improved on the iNPH scale. When defining improvement as ≥ 5 points on the iNPH scale, there was no significant difference in preoperative volume of WMC between shunt responders and non-responders. If outcome was determined by a continuous variable, a larger volume of PVH was negatively associated with postoperative change in the total iNPH scale (p < 0.05) and negatively associated with improvement in gait (p < 0.01) after adjusting for age, sex, waiting time for surgery, preoperative level of symptoms, Evans’ index, and disproportionately enlarged subarachnoid space hydrocephalus. The volume of DWMH was not associated with shunt outcome.ConclusionsAn association between outcome after shunt surgery and volume of PVH was seen, but there was no difference between shunt responders and non-responders in the volumes of DWMH and PVH. We conclude that preoperative assessment of WMC should not be used to exclude patients with iNPH from shunt surgery.

A rare pediatric case report: Salvage transcatheter closure of atrial septal defect before parent‐to‐offspring living‐donor liver transplantation

1. Case presentationA 4‐month‐old female infant was admitted to our clinical ward in May 2021 due to her skin manifestation of the jaundice since birth. Her symptoms aggravated progressively despite various medications (e.g. Ursodeoxycholic Acid, Stronger Neo‐Minophagen C Tablets) were prescribed. Initial Work‐up. The admission abdominal ultrasound demonstrated contracted gallbladder, with no sign of common bile duct. Two weeks ago, she was admitted into Pediatric ICU, where her conditions worsened to coagulation dysfunction, digestive tract hemorrhage and hypotension. Diagnosis and Management. With initial work‐ups, the patient was diagnosed with congenital biliary atresia, liver cirrhosis, respiratory failure secondary to severe pneumonia (aspergillus and mycoplasma infections), secundum atrial septal defect (ASDII, 9.7mm) and hypoalbuminemia. Accordingly, CPAP‐assisted ventilation, injections of meropenem, vancomycin, and carprofen, as well as IVIG (2g/kg) and vitamin K1 were admitted. Echocardiogram confirmed pulmonary artery hypertension (PAH), right atrial enlargement, and portal hypertension. Further, she exhibited right heart failure (HF) symptoms, such as abdominal effusion, lower extremity edema. An urgent percutaneous ASD closure was scheduled prior to the parent‐to‐offspring liver transplantation, thereby reducing the high risk of right HF and PAH during the surgery.2. Surgical proceduresBriefly, a venous access was probed in groin area under local anesthesia (1% lidocaine). Upon bleeding, a 6F venous sheath tube (FAST‐CATHTM, ST.JUDE Medical) was gently inserted into the right femoral vein, followed by a Cordis MPA catheter (Cordis 6F, Johnson &amp; Johnson Inc), which was further threaded through the vessel into heart. Once MPA catheter reached the left superior pulmonary vein through ASD, we released the guidewire and retracted the venous sheath tube simultaneously. (Fig. 1) Next, we inserted a 9F delivery sheath tube to transport the 10mm MemoPart™ ASD Occluder (FQFDQ‐I 10, SHSMA Corp) into anatomical left atrium through the interatrial hole. Once the umbrella at both atrial sides was released consecutively forming a sandwich‐like skeleton, the closure was successfully completed along with retraction of the occluder. (Fig.2)3. Follow‐upOne week after ASD closure, she received a living‐donor liver transplantation, and her liver function returned to normal shortly, with no further cirrhosis‐associated complications. Before discharge, echocardiogram demonstrated no shunt exist. (Fig.3)4. DiscussionStatistically, 15.8% of liver‐transplant recipients are having cardiovascular diseases, among whom 30% are diagnosed with ASD.Most children with ASD remain asymptomatic and their physical activities are typically unaffected till adolescence. Congestive HF and PAH will occur in patients with medium‐to‐large ASD around the age of 20‐30 years. In our case, the child was very young, yet with an extremely complicated condition requiring multiple resuscitation procedures. The large left‐to‐right shunt volume in the 9.7mm ASD was further exacerbated by heavy fluid loads formed during the rescues. Thus, transcatheter ASD occlusion was performed before liver transplantation to effectively manage the hemodynamic stability in perioperative period.

Management of the patent ductus arteriosus in preterm infants.

Management of the patent ductus arteriosus (PDA) is one of the most contentious topics in the care of preterm infants. PDA management can be broadly divided into prophylactic and symptomatic therapy. Prophylaxis with intravenous indomethacin in extremely low birth weight infants may reduce severe intraventricular hemorrhage. Echocardiography should be routinely used to confirm the presence of a PDA before considering symptomatic therapy. A symptomatic PDA can be managed conservatively, using pharmacotherapy or with procedural closure. Ibuprofen should be considered as the pharmacotherapy of choice for a symptomatic PDA. High-dose ibuprofen may be preferable, especially for preterm infants beyond the first 3 to 5 days of age. If pharmacotherapy fails (after two courses) or is contraindicated, procedural closure may be considered for infants with a persistent PDA with significant clinical symptoms in addition to echocardiographic signs of a large PDA shunt volume and pulmonary over-circulation.

Trends in United States pediatric neurosurgical practice during the COVID-19 pandemic

There is minimal information on COVID-19 pandemic’s national impact on pediatric neurosurgical operative volumes. In this study, using a national database, TriNetX, we compared the overall and seasonal trends of pediatric neurosurgical procedure volumes in the United States during the pandemic to pre-pandemic periods. In the United States, the incidence of COVID-19 began to rise in September 2020 and reached its maximum peak between December 2020 and January 2021. During this time, there was an inverse relationship between pediatric neurosurgical operative volumes and the incidence of COVID-19 cases. From March 2020 to May 2021, there was a significant decrease in the number of pediatric shunt (−11.7% mean change, p = 0.006), epilepsy (−16.6%, p < 0.001), and neurosurgical trauma (−13.8%, p < 0.001) surgeries compared to pre-pandemic years. The seasonal analysis also yielded a broad decrease in most subcategories in spring 2020 with significant decreases in pediatric spine, epilepsy, and trauma cases. To the best of our knowledge, this is the first study to report a national decline in pediatric shunt, epilepsy, and neurosurgical trauma operative volumes during the pandemic. This could be due to fear-related changes in health-seeking behavior as well as underdiagnosis during the COVID-19 pandemic.

Prevalence of Venovenous Shunting and High-Output State Quantified with 4D Flow MRI in Patients with Fontan Circulation.

To assess the ability of four-dimensional (4D) flow MRI to quantify flow volume of the Fontan circuit, including the frequency and hemodynamic contribution of systemic-to-pulmonary venovenous collateral vessels. In this retrospective study, patients with Fontan circulation were included from three institutions (2017-2021). Flow measurements were performed at several locations along the circuit by two readers, and collateral shunt volumes were quantified. The frequency of venovenous collaterals and structural defects were tabulated from concurrent MR angiography, contemporaneous CT, or catheter angiography and related to Fontan clinical status. Statistical analysis included Pearson and Spearman correlation and Bland-Altman analysis. Seventy-five patients (mean age, 20 years; range, 5-58 years; 46 female and 29 male patients) were included. Interobserver agreement was high for aortic output, pulmonary arteries, pulmonary veins, superior vena cava (Glenn shunt), and inferior vena cava (Fontan conduit) (range, ρ = 0.913-0.975). Calculated shunt volume also showed strong agreement, on the basis of the difference between aortic and pulmonary flow (ρ = 0.935). A total of 37 of 75 (49%) of the patients exhibited shunts exceeding 1.00 L/min, 81% (30 of 37) of whom had pulmonary venous or atrial flow volume step-ups and corresponding venovenous collaterals. A total of 12% of patients (nine of 75) exhibited a high-output state (>4 L/min/m2), most of whom had venovenous shunts exceeding 30% of cardiac output. Fontan flow and venovenous shunting can be reliably quantified at 4D flow MRI; high-output states were found in a higher proportion of patients than expected, among whom venovenous collaterals were common and constituted a substantial proportion of cardiac output.Keywords: Pediatrics, MR Angiography, Cardiac, Technology Assessment, Hemodynamics/Flow Dynamics, Congenital Supplemental material is available for this article. © RSNA, 2021.

Acute Rupture of Sinus of Valsalva into Right Atrium: An Echocardiographic Halftone

AbstractA ruptured sinus of Valsalva is a rare and emergent cardiac abnormality, which can be acute and rapidly expanding to cause hemodynamic deterioration. Rupturing into right-sided heart chambers causes severe left-to-right shunt and sudden volume overload. Echocardiography especially transesophageal echocardiography (TEE) is the gold standard facility for early perioperative diagnosis and also to guide surgical technique. Medical stabilization followed by prompt surgical intervention is the treatment of choice.We hereby report a case of sinus of Valsalva rupturing into right atrium leading to severe left-to-right shunt and the role of TEE in its perioperative management.

Rectal Acetaminophen Improves Shunt Volume and Reduces Patent Ductus Arteriosus Ligation in Extremely Preterm Infants.

An alternative therapy for preterm infants with a hemodynamically significant patent ductus arteriosus (hsPDA) is needed when cyclooxygenase inhibitors fail or where treatment is contraindicated due to coexisting renal failure, necrotizing enterocolitis, and/or intestinal perforation. No studies have evaluated the efficacy of per rectum (PR) acetaminophen. The study aimed to evaluate the efficacy of PR acetaminophen in modulating the risk of PDA ligation. A retrospective matched case-control study was conducted to compare neonates born <29 weeks' gestation with evidence of hsDA, in an era when rescue rectal acetaminophen was used (January 2014-March 2018) as a treatment strategy, versus historical controls (July 2006-August 2012). All patients underwent comprehensive echocardiography assessment of ductal shunt volume according to a standardized protocol. Acetaminophen treated neonates were matched according to demographics, gestation, preintervention echocardiography features, and comorbidities. Control patients were selected when an echocardiography was performed at an equivalent postnatal age. Infants with a genetic syndrome, severe congenital malformation, or major forms of congenital heart disease excluding small atrial septal defect or ventricular septal defect, PDA, or patent formale ovale were excluded. The primary outcome was surgical ligation of the PDA. Secondary outcomes included echocardiography indices of hemodynamic significance, the composite of death, or severe BPD (defined by ventilator dependence at 36 weeks postmenstrual age). Descriptive statistics and univariate (t-tests, Fisher's exact test, and Mann-Whitney U test) analyses were used to evaluate clinical and echocardiography characteristics of the groups and compare outcomes. Forty infants (20 cases and 20 controls), with similar demographic and echocardiography features, were compared. Cases received 6.8 ± 0.7 days (60 mg/kg/day) of PR acetaminophen. Responders (n = 12, 60%) had echocardiography evidence of reduced ductal diameter (2.2 mm [1.9-2.6] to 1.1 mm [0-1.7], p = 0.002), left ventricular output (363 ± 108-249 ± 61 mL/min/kg; p = 0.002) and left atrium to aortic root ratio (1.7 ± 0.3-1.3 ± 0.2; p = 0.002) following treatment. The rate of PDA ligation was 50% lower (p = 0.02) and composite outcome of death or severe bronchopulmonary dysplasia was reduced (p = 0.04) in the acetaminophen group. Rectal acetaminophen was associated with improvement in echocardiography indices of PDA shunt volume, a 50% reduction in PDA ligation rates and a reduction in the composite outcome of death or severe BPD. Pharmacologic and further prospective clinical studies are needed. · Many preterm infants encounter the clinical consequences of a hemodynamically significant PDA.. · The merits and optimal timing of PDA ligation remains an area of controversy amongst neonatologists.. · Cyclooxygenase inhibitors are associated with adverse events or are often contraindicated..

Anesthetic management of a parturient with Eisenmenger’s syndrome: A case report

Eisenmenger’s syndrome results from certain uncorrected congenital abnormalities of the heart facilitating left to right shunt and chronic volume overload of the pulmonary vasculature, leading to irreversible changes in the pulmonary vasculature. Pregnancy in the patients of this syndrome is associated with a high risk of cardiovascular decompensation, thromboembolic complications, and sudden cardiac death. We present the case of a 25-year-old pregnant woman with Eisenmenger’s syndrome who delivered through the vaginal route at 37 weeks of gestation, under labor epidural anesthesia. A healthy male baby was delivered within 40 min of drug deposition in the epidural space. The postpartum period was essentially uneventful with successful maternal and neonatal outcomes.