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Background— Improvement in outcome of infants born with congenital heart defects has been accompanied by an increasing frequency of late arrhythmias. Ablation is difficult because of multiple tachycardias in the presence of complex anatomy with limited accessibility. We report on remote-controlled ablation using magnetic navigation in conjunction with 3D image integration in patients with previous intra-atrial baffle procedures. Methods and Results— Thirteen patients (8 male; age, 30.5±8 years) with supraventricular tachycardia (SVT) underwent catheter ablation. Group A had a medical history of a Mustard or Senning operation, whereas group B had undergone total cavopulmonary connection. A total of 26 tachycardias were treated in 17 procedures (median cycle length of 280 ms). Group A patients had more inducible SVTs than group B, and all index SVTs were located in the remainder of the morphological right atrium in all but 1 patient. Retrograde access through the aorta was performed and led to successful ablation, using magnetic navigation with a very low total radiation exposure (median of 3.8 minutes in group A versus 5.9 minutes in group B). Only 1 of 13 patients continued to have short-lasting SVTs despite 3 ablation procedures during a median follow-up time of >200 days. Conclusions— Remote-controlled catheter ablation by magnetic navigation in combination with accurate 3D image integration allowed safe and successful elimination of SVTs, using an exclusively retrograde approach, resulting in low radiation exposure for patients after intra-atrial baffle procedures (Mustard, Senning, or total cavopulmonary connection).

Background— Late mortality after repair of total anomalous pulmonary venous connection is frequently associated with pulmonary venous obstruction (PVO). We aimed to describe the morphological spectrum of total anomalous pulmonary venous connection and identify risk factors for death and postoperative PVO. Methods and Results— We conducted a retrospective, international, collaborative, population-based study involving all 19 pediatric cardiac centers in the United Kingdom, Ireland, and Sweden. All infants with total anomalous pulmonary venous connection born between 1998 and 2004 were identified. Cases with functionally univentricular circulations or atrial isomerism were excluded. All available data and imaging were reviewed. Of 422 live-born cases, 205 (48.6%) had supracardiac, 110 (26.1%) had infracardiac, 67 (15.9%) had cardiac, and 37 (8.8%) had mixed connections. There were 2 cases (0.5%) of common pulmonary vein atresia. Some patients had extremely hypoplastic veins or, rarely, discrete stenosis of the individual veins. Sixty (14.2%) had associated cardiac anomalies. Sixteen died before intervention. Three-year survival for surgically treated patients was 85.2% (95% confidence interval 81.3% to 88.4%). Risk factors for death in multivariable analysis comprised earlier age at surgery, hypoplastic/stenotic pulmonary veins, associated complex cardiac lesions, postoperative pulmonary hypertension, and postoperative PVO. Sixty (14.8%) of the 406 patients undergoing total anomalous pulmonary venous connection repair had postoperative PVO that required reintervention. Three-year survival after initial surgery for patients with postoperative PVO was 58.7% (95% confidence interval 46.2% to 69.2%). Risk factors for postoperative PVO comprised preoperative hypoplastic/stenotic pulmonary veins and absence of a common confluence. Conclusions— Preoperative clinical and morphological features are important risk factors for postoperative PVO and survival.

Background —The increase in pulmonary vascular resistance (PVR) seen in children after cardiopulmonary bypass has been attributed to transient pulmonary endothelial dysfunction (PED). We therefore examined PED in children with congenital heart disease by assessing the l -arginine–nitric oxide (NO) pathway in terms of substrate supplementation ( l -arginine [L-Arg]), stimulation of endogenous NO release (substance P [Sub-P]), and end-product provision (inhaled NO) before and after open heart surgery. Methods and Results —Ten patients (aged 0.62±0.27 years) with pulmonary hypertension undergoing cardiac catheterization who had not had surgery and 10 patients (aged 0.65±0.73 years) who had recently undergone cardiopulmonary bypass were examined. All were sedated and paralyzed and received positive-pressure ventilation. Blood samples and pressure measurements were taken from catheters in the pulmonary artery and the pulmonary vein or left atrium. Respiratory mass spectrometry was used to measure oxygen uptake, and cardiac output was determined by the direct Fick method. PVR was calculated during steady state at ventilation with room air, during F io 2 of 0.65, then during additional intravenous infusion of L-Arg (15 mg · kg −1 · min −1 ) and Sub-P (1 pmol · kg −1 · min −1 ), and finally during inhalation of NO (20 ppm). In preoperative patients, the lack of an additional significant change of PVR with L-Arg, Sub-P, and inhaled NO suggests little preexisting PED. Postoperative PVR was higher, with an additional pulmonary endothelial contribution that was restorable with L-Arg and Sub-P. Conclusions —Postoperatively, the rise in PVR suggested PED, which was restorable by L-Arg and Sub-P, with no additional effect of inhaled NO. These results may indicate important new treatment strategies for these patients.

Older-adults are a priority within policy designed to facilitate healthy lifestyles through physical activity. Golden Goal is a pilot programme of physical activity-led health improvement for older-adults 55 years and older. Activities were delivered at Burton Albion Football Club. Sessions involved weekly moderate-intensity exercise sessions including exer-gaming (exercise orientated video-games), indoor bowls, cricket, new age curling, walking football, and traditional board games and skittles. Secondary analysis of data collected through the original programme evaluation of Golden Goal investigated the impact of the intervention on participants. Older-adults completed self-reports for demographics, health-screening/complications and quality of life. Attendees, n=23 males (42.6%) and n=31 females (57.4%) with a mean age of 69.38 (±5.87) (n=40), ranging from 55-85 years took part. The mean attendance was 7.73 (±3.12) sessions for all participants, (n=51). Older-adults with two or more health complications (n=22, 42.3%) attended fewer sessions on average (6.91 ±3.322) compared to those reporting less than two health complications (8.65 ±2.694). Self-rated health was higher for women (87.32 ±9.573) versus men (80.16 ±18.557), although this was not statistically significant (U= 223.500, p=0.350). Results support the potential of football-led health interventions for recruiting older-adults, including those reporting health problems.

A full-term neonate presented with systemic arterial hypoxia at 12 hours of age. Examination revealed a single second heart sound preceded by a holosystolic murmur. The ECG and chest X-ray demonstrated right atrial enlargement. Cross-sectional echocardiography demonstrated severe right ventricular hypertrophy and mild high-velocity tricuspid regurgitation. The pulmonary valve was normally formed and mobile, with a membrane connecting the leaflet tips, creating functional atresia (Figure 1 and Figure 2⇓). At cardiac catheterization, the diagnosis was …

OBJECTIVE--To examine left ventricular function after surgical resection of subaortic stenosis during childhood. DESIGN--Left ventricular performance was measured non-invasively in all patients who responded to an invitation for formal assessment. SETTING--Outpatient study, tertiary referral centre. PATIENTS--Twenty three (12 male and 11 female) patients (age range 3 to 31 years) of 43 consecutive patients with fixed subaortic stenosis undergoing surgical resection between 1975 and 1989 reattended for formal assessment 16 months to 15 years (median 4 years 4 months) after operation. MAIN OUTCOME MEASURES--Left ventricular dimension, left ventricular wall thickness, left ventricular Doppler inflow velocities, and left ventricular diastolic pressure (measured from apexcardiograms). Results were compared with those in controls individually matched for age and sex. RESULTS--All patients were symptom free. Left ventricular cavity dimensions were normal, as was the mean fractional shortening. Posterior wall thickness tended to be greater in the patients and there was a significant increase in septal thickness. Normalised peak rate of posterior wall thinning was significantly lower in the patients and the isovolumic relaxation time was significantly shorter. Doppler inflow velocity measurements showed that early diastolic mitral flow acceleration time was normal but deceleration time was significantly shorter in the patients. The ratio of mitral flow in early diastole (E) to E plus mitral flow in late diastole (A) was significantly higher in the patients and in two patients there was complete absence of A wave flow despite large A waves on the apexcardiogram. CONCLUSIONS--Systolic function was well preserved in patients after operation for subaortic stenosis. A restrictive pattern of left ventricular filling was common, however, and presumably reflected a response to the chronic pressure load and to surgery in the paediatric heart.