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Pulse-wave velocity (PWV), a measure of arterial stiffness, is a known independent risk factor for cardiovascular events. Patients with single ventricle who undergo aortic to pulmonary anastomosis (recon) have noncompliant patch material inserted into the neoaorta, possibly increasing vessel stiffness and afterload. The purpose of this study is to determine if PWV in patients with single ventricle differed between those who did and those who did not undergo aortic reconstruction (nonrecon). We retrospectively reviewed cardiac magnetic resonance anatomic, cine, and phase contrast evaluations in the ascending aorta and descending aorta (DAo) at the level of the diaphragm data from 126 patients with single ventricle (8.6 ± 8.0 years) from January 2012 to May 2013. Significance = p0.05. Seventy-five patients underwent recon and 51 did not. PWV in recon was significantly higher than in nonrecon (3.9 ± 0.9 m/s vs 3.2 ± 1.0 m/s, p = 0.008); in recon, patients13 years old had a higher PWV than those7 years (4.5 ± 0.6 vs 3.5 ± 0.7 m/s, p = 0.004). Whether7 or13 years old, PWV of those with recon was higher than nonrecon DAo distensibility was similar between both groups. There was no difference in age, body surface area, or cardiac index between recon and nonrecon. No correlations between various hemodynamic and ventricular function parameters with PWV were noted. In conclusion, PWV in recon is higher than in nonrecon with similar DAo distensibility implicating the aortic reconstruction as a possible cause of increased afterload; older recon patients have stiffer aortas than younger ones, possibly imposing an additional cardiovascular risk in the future. Other biomaterials may potentially moderate PWV if clinical outcome is adversely affected.

Objectives This study investigated whether cardiac magnetic resonance (CMR) and echocardiography (echo) can replace catheterization (cath) for routine evaluation prior to Fontan and under what circumstances CMR and cath are used together. Background Routine cath prior to Fontan has been utilized for years; noninvasive methods, however, may be sufficient. Methods This study reviews clinical data in 119 consecutive patients investigating 3 groups: those who underwent CMR alone (MR; n = 41), cath alone (C; n = 41), or both cath and CMR (C+M; n = 37) prior to Fontan. Results No clinically significant differences were noted in patient characteristics, hemodynamics, or clinical status prior to or after surgery between the C and MR groups. CMR added information in 82%. There were no discrepant findings between CMR and cath data in the C+M group. Diagnostic success was ≥95% in all groups. Of those undergoing Fontan completion, the C+M group had similar outcomes to C and MR; C and CMR were utilized in combination to assess aortopulmonary collaterals or the need for an intervention or evaluate its success. Echo could not delineate pulmonary arterial anatomy in 46% to 53% of patients. The C+M and C groups were exposed to 6.8 ± 4.1 mSv of radiation. Conclusions Single ventricle patients not requiring an intervention can undergo successful Fontan completion with CMR and echo alone with similar short-term outcomes to C, which was used as a control, preventing an invasive test and exposure to radiation. CMR can add information in a significant number of patients. Cath and CMR are utilized together for interventions and assessment of aortopulmonary collaterals.

Background— Systemic-pulmonary collateral (SPC) flow occurs commonly in single ventricle patients after superior cavo-pulmonary connection, with unclear clinical significance. We sought to evaluate the association between SPC flow and acute post-Fontan clinical outcomes using a novel method of quantifying SPC flow by cardiac magnetic resonance (CMR) imaging. Methods and Results— All patients who had SPC flow quantified by CMR imaging before Fontan were retrospectively reviewed to assess for acute clinical outcomes after Fontan completion. Forty-four subjects were included who had Fontan completion between May 2008 and September 2010. SPC flow prior to Fontan measured 1.5±0.9 L/min/m 2 , accounting for 31±11% of total aortic flow and 44±15% of total pulmonary venous flow. There was a significant linear association between natural log-transformed duration of hospitalization and SPC flow as a proportion of total aortic (rho=0.31, P =0.04) and total pulmonary venous flow (rho=0.29, P =0.05). After adjustment for Fontan type and presence of a fenestration, absolute SPC flow was significantly associated with hospital duration ≥7 days (odds ratio [OR]=9.2, P =0.02) and chest tube duration ≥10 days (OR=22.7, P =0.009). Similar associations exist for SPC flow as a percentage of total aortic (OR=1.09, P =0.048 for hospitalization ≥7 days; OR=1.24, P =0.007 for chest tube duration ≥10 days) and total pulmonary venous flow (OR=1.07, P =0.048 for hospitalization ≥7 days; OR=1.18, P =0.006 for chest tube duration ≥10 days). Conclusions— Increasing SPC flow before Fontan, as measured by CMR imaging, is associated with increased duration of hospitalization and chest tube following Fontan completion.

Cardiac MRI can predict the likely tumor type in the majority of children with a cardiac mass. A comprehensive imaging protocol is essential for accurate diagnosis. However, histologic diagnosis remains the gold standard, and in some cases malignancy cannot be definitively excluded on the basis of cardiac MRI images alone.

Historically, congenital pulmonary lymphangiectasia (CPL) has had poor treatment outcomes despite aggressive therapy. There are recent reports of ethiodized oil (Lipiodol) lymphangiography successfully treating lymphatic leakage in adults. In this report, we describe two infants with CPL complicated by chylothoraces successfully treated by instillation of ethiodized oil into the lymphatic system. Congenital atresia of the thoracic duct was demonstrated on the lymphangiogram in both patients before treatment. Both patients have shown good short-term outcomes without supplemental oxygen or fat restricted diets at 9 months of age. Ethiodized oil lymphangiography represents a new treatment modality for some patients with CPL.

Background: Patients with a single ventricle experience a high rate of brain injury and adverse neurodevelopmental outcome; however, the incidence of brain abnormalities throughout surgical reconstruction and their relationship with cerebral blood flow, oxygen delivery, and carbon dioxide reactivity remain unknown. Methods: Patients with a single ventricle were studied with magnetic resonance imaging scans immediately prior to bidirectional Glenn (pre-BDG), before Fontan (BDG), and then 3 to 9 months after Fontan reconstruction. Results: One hundred sixty-eight consecutive subjects recruited into the project underwent 235 scans: 63 pre-BDG (mean age, 4.8±1.7 months), 118 BDG (2.9±1.4 years), and 54 after Fontan (2.4±1.0 years). Nonacute ischemic white matter changes on T2-weighted imaging, focal tissue loss, and ventriculomegaly were all more commonly detected in BDG and Fontan compared with pre-BDG patients ( P P Conclusions: Significant brain abnormalities are commonly present in patients with a single ventricle, and detection of these lesions increases as children progress through staged surgical reconstruction, with multiple coexisting lesions more common earlier than later. In addition, this study demonstrated that BDG patients had greater cerebral blood flow than did Fontan patients and that an inverse association exists of various indexes of cerebral blood flow with these brain lesions. However, CO 2 reactivity and oxygen delivery (with 1 exception) were not associated with brain lesion development. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02135081.

Background— Plastic bronchitis is a potentially fatal disorder occurring in children with single-ventricle physiology, and other diseases, as well, such as asthma. In this study, we report findings of abnormal pulmonary lymphatic flow, demonstrated by MRI lymphatic imaging, in patients with plastic bronchitis and percutaneous lymphatic intervention as a treatment for these patients. Methods and Results— This is a retrospective case series of 18 patients with surgically corrected congenital heart disease and plastic bronchitis who presented for lymphatic imaging and intervention. Lymphatic imaging included heavy T2-weighted MRI and dynamic contrast-enhanced magnetic resonance lymphangiogram. All patients underwent bilateral intranodal lymphangiogram, and most patients underwent percutaneous lymphatic intervention. In 16 of 18 patients, MRI or lymphangiogram or both demonstrated retrograde lymphatic flow from the thoracic duct toward lung parenchyma. Intranodal lymphangiogram and thoracic duct catheterization was successful in all patients. Seventeen of 18 patients underwent either lymphatic embolization procedures or thoracic duct stenting with covered stents to exclude retrograde flow into the lungs. One of the 2 patients who did not have retrograde lymphatic flow did not undergo a lymphatic interventional procedure. A total of 15 of 17(88%) patients who underwent an intervention had significant symptomatic improvement at a median follow-up of 315 days (range, 45–770 days). The most common complication observed was nonspecific transient abdominal pain and transient hypotension. Conclusions— In this study, we demonstrated abnormal pulmonary lymphatic perfusion in most patients with plastic bronchitis. Interruption of the lymphatic flow resulted in significant improvement of symptoms in these patients and, in some cases, at least temporary resolution of cast formation.

The investigators recently validated a method of quantifying systemic-to-pulmonary arterial collateral flow using phase-contrast magnetic resonance imaging velocity mapping. Cross-sectional data suggest decreased collateral flow in patients with total cavopulmonary connections (TCPCs) compared with those with superior cavopulmonary connections (SCPCs). However, no studies have examined serial changes in collateral flow from SCPCs to TCPCs in the same patients. The aim of this study was to examine differences in collateral flow between patients with SCPCs and those with TCPCs. Collateral flow was quantified by 2 independent measures from 250 single-ventricle studies in 219 different patients (115 SCPC and 135 TCPC studies, 31 patients with both) and 18 controls, during routine studies using through-plane phase-contrast magnetic resonance imaging. Collateral flow was indexed to body surface area, aortic flow, and pulmonary venous flow. Regardless of indexing method, SCPC patients had significantly higher collateral flow than TCPC patients (1.64 ± 0.8 vs 1.03 ± 0.8 L/min/m(2), p0.001). In 31 patients who underwent serial examinations, collateral flow as a fraction of aortic flow increased early after TCPC completion. In TCPC patients, indexed collateral flow demonstrated a significant negative correlation with time from TCPC. In conclusion, SCPC and TCPC patients demonstrate substantial collateral flow, with SCPC patients having higher collateral flow than TCPC patients overall. On the basis of the paired subset analysis, collateral flow does not decrease in the short term after TCPC completion and trends toward an increase. In the long term, however, collateral flow decreases over time after TCPC completion.

Background Diffuse fibrosis and strain are abnormal in adult cardiomyopathy patients and in children exposed to anthracyclines, but have not been well studied in pediatric hypertrophic (HCM) and dilated (DCM) cardiomyopathy. We hypothesized that HCM and DCM patients have different diffuse fibrosis and strain characteristics. Methods

Patients with single ventricle can develop aortic-to-pulmonary collaterals (APCs). Along with systemic-to-pulmonary artery shunts, these structures represent a direct pathway from systemic to pulmonary circulations, and may limit cerebral blood flow (CBF). This study investigated the relationship between CBF and APC flow on room air and in hypercarbia, which increases CBF in patients with single ventricle.106 consecutive patients with single ventricle underwent 118 cardiac magnetic resonance (CMR) scans in this cross-sectional study; 34 prior to bidirectional Glenn (BDG) (0.50±0.30 years old), 50 prior to Fontan (3.19±1.03 years old) and 34 3-9 months after Fontan (3.98±1.39 years old). Velocity mapping measured flows in the aorta, cavae and jugular veins. Analysis of variance (ANOVA) and multiple linear regression were used. Significance was p0.05.A strong inverse correlation was noted between CBF and APC/shunt both on room air and with hypercarbia whether CBF was indexed to aortic flow or body surface area, independent of age, cardiopulmonary bypass time, Po2 and Pco2 (R=-0.67--0.70 for all patients on room air, p0.01 and R=-0.49--0.90 in hypercarbia, p0.01). Correlations were not different between surgical stages. CBF was lower, and APCs/shunt flow was higher prior to BDG than in other stages.There is a strong inverse relationship between CBF and APC/shunt flow in patients with single ventricle throughout surgical reconstruction on room air and in hypercarbia independent of other factors. We speculate that APC/shunt flow may have a negative impact on cerebral development and neurodevelopmental outcome. Interventions on APC may modify CBF, holding out the prospect for improving neurodevelopmental trajectory.NCT02135081.

Anomalous origin of a coronary artery from the contralateral sinus of Valsalva is associated with exercise-induced ischemia and sudden death. That is thought to be due to aortic enlargement in patients with an elliptical ostium. We hypothesize that virtual angioscopy can identify abnormal coronary ostial morphology in these patients.We retrospectively analyzed 55 consecutive pediatric coronary artery magnetic resonance imaging studies from January 2006 to January 2010 with the diagnosis of anomalous right (n = 20), or left (n = 7) coronary artery, or normal coronary origins (n = 28). One postmortem heart specimen with anomalous left coronary artery was imaged and analyzed to validate our technique. Virtual angioscopy analysis was used for visualization and measurement of the coronary ostia.Distinct aortic origins of the right and left coronaries were seen in all 55 studies. An elliptical orifice with a longer superior-inferior dimension was seen in all anomalous ostia, in contrast to a circular ostium in all normal origins. That was quantified in anomalous ostia with a long-axis to short-axis ratio of 2.5 ± 0.5 (right) and 2.4 ± 0.5 (left) compared with 1.1 ± 0.2 (right) and 1.0 ± 0.3 (left) in controls (p0.001 for right and left ostia comparisons). Ostial morphology was confirmed in all 9 patients who underwent operative repair and in 1 patient at autopsy.Virtual angioscopy identifies abnormal ostial morphology in anomalous coronary artery patients, which is important for characterizing the diagnosis of patients who may be at risk for sudden death.

Background Single-ventricle patients undergoing surgical reconstruction experience a high rate of brain injury. Incidental findings on preoperative brain scans may result in safety considerations involving hemorrhage extension during cardiopulmonary bypass that result in surgical postponement. Methods Single-ventricle patients were studied with brain scans immediately preoperatively, as part of a National Institutes of Health study, and were reviewed by neuroradiology immediately before cardiopulmonary bypass. Results Of 144 consecutive patients recruited into the project, 33 were studied before stage I (3.7 ± 1.8 days), 34 before bidirectional Glenn (5.8 ± 0.5 months), and 67 before Fontan (3.3 ± 1.1 years) operations. Six operations (4.5%), 2 before stage I, 3 before bidirectional Glenn, and 1 before Fontan, were postponed because of concerning findings on brain magnetic resonance imaging. Five were due to unexpected incidental findings of acute intracranial hemorrhage, and 1 was due to diffuse cerebellar cytotoxic edema; none who proceeded to operation had these lesions. Prematurity and genetic syndromes were not present in any patients with a postponed operation. Four of 4 before bidirectional Glenn/Fontan with surgical delays had hypoplastic left heart syndrome compared with 44 of 97 who did not ( p = 0.048). After observation and follow-up, all eventually had successful operations with bypass. Conclusions Preoperative brain magnetic resonance imaging performed in children with single ventricles disclosed injuries in 4.5% leading to surgical delay; hemorrhagic lesions were most common and raised concerns for extension during the operation. The true risk of progression and need for delay of the operation due to heparinization associated with these lesions remains uncertain.

Therapy for X-linked hypophosphatemia (XLH) only partially corrects skeletal lesions and is often complicated by hyperparathyroidism. 24,25(OH)2 D3 improves skeletal lesions in a murine model of XLH and suppresses PTH secretion in animals. Therefore, we undertook a placebo-controlled trial of 24,25(OH)2 D3 supplementation to standard treatment in patients with XLH to improve bone disease and reduce hyperparathyroid complications. Fifteen subjects with XLH receiving standard treatment [1,25(OH)2 D3 or dihydrotachysterol plus phosphate] were evaluated, supplemented with placebo, and reevaluated one yr later. 24,25(OH)2 D3 supplementation was then begun and studies repeated after another year. Each patient underwent a detailed evaluation of calcium homeostasis over a 24-h period. Rachitic abnormalities were assessed radiographically in children. Adults underwent bone biopsies. 24,25(OH)2 D3 normalized PTH values in nine subjects (peak PTH was 46.5 +/- 6.6 pmol/L at entry, 42.3 +/- 5.9 pmol/L after placebo, and 23.3 +/- 5.4 pmol/L after 24,25(OH)2 D3). Nephrogenous cAMP decreased at night, coincident with the decrease in PTH, and serum phosphorus was slightly greater with 24,25(OH)2 D3. Radiographic features of rickets improved during 24,25(OH)2 D3 supplementation in children, and osteoid surface decreased in adults. 24,25(OH)2 D3 is a useful adjunct to standard therapy in XLH by effecting correction of hyperparathyroidism and improvement of rickets and osteomalacia.

Pts with transposition of the great arteries (TGA) may have varied coronary artery patterns; reimplantation during arterial switch operation (ASO) may necessitate acute angles of takeoff from the aortic root impacting left ventricular (LV) performance. Retrospective review of CMR scans from 2005–

Background— The significance and optimal treatment of systemic-to-pulmonary arterial collateral (SPC) vessels in single ventricle patients are poorly understood. The acute efficacy of SPC embolization has not been demonstrated in a quantifiable fashion. We sought to assess the acute efficacy of SPC embolization on blood flow as quantified by phase contrast magnetic resonance imaging and hypothesized that embolization acutely decreases SPC flow and increases systemic blood flow ( Q S ). Methods and Results— Six superior cavopulmonary connection patients underwent SPC flow quantification by phase contrast magnetic resonance imaging, including quantification of superior and inferior caval, total pulmonary artery, total pulmonary vein, ascending and descending aortic flows ( Q SVC , Q IVC , Q PA , Q PV , Q Ao , and Q Dao , respectively), both immediately before and after cardiac catheterization with coil and particle embolization of angiographically evident SPC vessels. All studies were performed under a single anesthetic. After embolization, we found a significant decrease in SPC flow of 0.9 (range, 0.6–1.3) L/(min·m 2 ) ( P =0.03); a median reduction of 47% (range, 32–60). There was a significant decrease in the median Q P : Q S from 1.3 before to 0.8 after embolization ( P =0.03), and an increase in Q S from a median of 3.4 to 4.4 L/(min·m 2 ) ( P Q SVC from a median of 1.7 to 2.3 L/(min·m 2 ) ( P =0.03). Conclusions— We report on the acute efficacy of SPC embolization, demonstrating a significant decrease in SPC flow and Q P : Q S and increase in Q SVC and Q S . Further studies are needed to assess the durability of the procedure and the effect on Fontan and longer-term outcomes.

Background Feature-tracking Strain (FT S) is a new technique that performs myocardial Strain evaluation on Steady State Free Precession (SSFP) cines without the need for myocardial tagging. As a pilot study to determine whether FT S may be useful in single ventricle patients, we applied this analysis to patients with hypoplastic left heart syndrome (HLHS) and tricuspid atresia (TA). Methods We retrospectively reviewed 22 patients with a history of Fontan palliation (median age 8.2, range 2 - 27.5 years) who had cardiac MRIs with a Siemens 1.5 Tesla Avanto (Siemens Medical Systems) scanner, 11 with TA, 11 with HLHS. All had steady-state free precession (SSFP) sequences of 4-chamber (4ch) cine and short axis (SAx) cine stacks from cardiac base to apex. Ejection fraction (EF) was calculated from the SAx stack on a Leonardo workstation (Siemens, Inc.). FT S analysis of the 4ch cine was performed off-line with TomTec 2D Cardiac Performance Analysis (version 1.0, TomTec Imaging Systems) following two tracking protocols: endocardial trace only (Endo), epicardial to endocardial trace (Endo-Epi) (Figure 1). Pearson correlation was used to test relationship between absolute global longitudinal Strain (GLSabs) and EF. Differences in GLS between tracking methods were tested with Bland Altman analysis. Results Mean EF was 60.2%, 95% CI 42.6% to 77.8%. Mean GLS was -15.7 (95% CI -6.8 to -24.7) by Endo., and -16.5 (95% CI -6.9 to -26.1) by Endo-Epi tracking methods. There was fair correlation (Figure 2) between GLSabs and EF using the Endo method (Pearson r = 0.67, p mean Endo GLS of 0.8, with a wide distribution in difference values, 95% CI 2.9 to -4.5. Morphologic ventricle type (single LV vs single RV) did not make a difference in GLS to EF correlations when compared to the mixed cohort. Mean GLS for single LVs was somewhat higher than single RVs, but this difference did not reach statistical significance. Conclusions There is fair correlation between GLS and EF in single ventricle patients with feature-tracking Strain analysis tracking the ventricular endocardium. Validation in a larger sample is warranted. Comparison of FT S with tagged harmonic phase MRI in single ventricle patients may further validate this promising technique in defining regional and global strain. Funding

2 important complications after tetralogy of Fallot (TOF) repair are left ventricular (LV) dysfunction and poor exercise performance. Cardiac magnetic resonance (CMR) can assess myocardial strain and determine diffuse myocardial fibrosis (DMF) using T1 mapping. Pts underwent CMR for ventricular

In multiple studies across disease states and age ranges, cerebral blood flow (CBF) has been linked to neurodevelopmental outcome (ND). The correlation between the two in patients with single ventricle has not been proven. 7 pts underwent cardiac magnetic resonance to determine CBF and CBF response

This study investigated whether cardiac magnetic resonance (CMR) and echocardiography (echo) can replace catheterization (cath) for routine evaluation prior to Fontan and under what circumstances CMR and cath are used together.Routine cath prior to Fontan has been utilized for years; noninvasive methods, however, may be sufficient.This study reviews clinical data in 119 consecutive patients investigating 3 groups: those who underwent CMR alone (MR; n = 41), cath alone (C; n = 41), or both cath and CMR (C+M; n = 37) prior to Fontan.No clinically significant differences were noted in patient characteristics, hemodynamics, or clinical status prior to or after surgery between the C and MR groups. CMR added information in 82%. There were no discrepant findings between CMR and cath data in the C+M group. Diagnostic success was ≥95% in all groups. Of those undergoing Fontan completion, the C+M group had similar outcomes to C and MR; C and CMR were utilized in combination to assess aortopulmonary collaterals or the need for an intervention or evaluate its success. Echo could not delineate pulmonary arterial anatomy in 46% to 53% of patients. The C+M and C groups were exposed to 6.8 ± 4.1 mSv of radiation.Single ventricle patients not requiring an intervention can undergo successful Fontan completion with CMR and echo alone with similar short-term outcomes to C, which was used as a control, preventing an invasive test and exposure to radiation. CMR can add information in a significant number of patients. Cath and CMR are utilized together for interventions and assessment of aortopulmonary collaterals.

The aim of this study was to report the results of an international multicenter experience of cardiac magnetic resonance imaging (MRI) evaluation of cardiac tumors in children, each with histology correlation or a diagnosis of tuberous sclerosis, and to determine which characteristics are predictive of tumor type.Individual centers have relatively little experience with diagnostic imaging of cardiac tumors in children, because of their low prevalence. The accuracy of cardiac MRI diagnosis on the basis of a pre-defined set of criteria has not been tested.An international group of pediatric cardiac imaging centers was solicited for case contribution. Inclusion criteria comprised: 1) age at diagnosis ≤18 years; 2) cardiac MRI evaluation of cardiac tumor; and 3) histologic diagnosis or diagnosis of tuberous sclerosis. Data from the cardiac MRI images were analyzed for mass characteristics. On the basis of pre-defined cardiac MRI criteria derived from published data, 3 blinded investigators determined tumor type, and their consensus diagnoses were compared with histologic diagnoses.Cases (n = 78) submitted from 15 centers in 4 countries had the following diagnoses: fibroma (n = 30), rhabdomyoma (n = 14), malignant tumor (n = 12), hemangioma (n = 9), thrombus (n = 4), myxoma (n = 3), teratoma (n = 2), and paraganglioma, pericardial cyst, Purkinje cell tumor, and papillary fibroelastoma (n = 1, each). Reviewers who were blinded to the histologic diagnoses correctly diagnosed 97% of the cases but included a differential diagnosis in 42%. Better image quality grade and more complete examination were associated with higher diagnostic accuracy.Cardiac MRI can predict the likely tumor type in the majority of children with a cardiac mass. A comprehensive imaging protocol is essential for accurate diagnosis. However, histologic diagnosis remains the gold standard, and in some cases malignancy cannot be definitively excluded on the basis of cardiac MRI images alone.

The importance of children’s involvement in athletics has been emphasized in recent years by The President’s Council on Physical Fitness and Sports through the United States Department of Health and Human Services, representing one of many countries seeking to improve the health of children through physical activity [1]. The benefits of organized sports for young people are well recognized, including increasing physical conditioning, improving skills, acquiring confidence, gaining a healthy attitude toward competition, winning and losing as well as learning to participate as a team member. Injuries do occur and are part of athletics. The minisymposium on sports imaging in children addresses a variety of events arising from the participation of youngsters in basketball, football, soccer and gymnastics. Understanding the patterns and mechanisms of injury in each sport is important in knowing when and how to use imaging in the young athlete’s care. Not every injury merits imaging, and learning this is also key. For the radiologists, we wish to emphasize that, as in other areas of pediatric imaging, the patterns of biomechanical susceptibility in response to stresses upon the immature musculoskeletal system may be quite different from those in adults. Each of the authors is also a parent who has had to consider allowing a child to participate in various sports. Part of our aim is to provide a resource, not only for healthcare personnel, but also for parents searching for information about injuries and risks in considering their own child’s athletic participation. Accordingly, some of the comments address entities that are not directly related to imaging but were thought by authors to be relevant to a complete discussion of the sport and the young people who participate. The authors have had the experience and pleasure during several years of working together as a team on this project, having been invited to present versions of this symposium as an organized course at a number of meetings. During the last few years, we have learned much from one another and have modified our material in response to comments from our audiences. We are very happy that Pediatric Radiology has chosen to preserve our efforts as a resource that others may find helpful for some years to come.

Purpose To describe the technical success and outcomes of a single incision technique for placement of internal jugular (IJV) tunneled vascular access devices in children. Materials and Methods A retrospective 4 year review was performed of 15 children (8 males, 7 females) who underwent placement of single incision IJV tunneled vascular access catheters. The single incision technique was defined as utilizing one incision with an ultrasound guided long needle tunneled venipuncture to create both the subcutaneous tunnel and the venous access. Radiologic and medical records were reviewed for technical success, early and delayed mechanical and infectious complications. The mean age of the children was 11.0 yrs (range 1.0 - 18.7) and the mean weight was 44.2 kg (range 9.6 - 99.0). Indications for the vascular access as per SIR criteria included; TPN and medications (8), antibiotic therapy (5), chemotherapy (2), immunotherapy (1), and dialysis (1). Results 17 primary insertions were performed in 15 patients. Technical success was 100%. Catheter types included non cuffed central line (14), cuffed hemodialysis catheter (1), cuffed central line (1), and a port (1). One catheter was placed in 14 patients and 3 catheters in 1 patient. There were no procedure related complications. The mean fluoroscopy time was 5.3 mins (0.7-14.7). The total catheter days for initial insertions was 1265 catheter days (mean 74.4 days, range 3 - 502 days). Mechanical and infectious complications occurred at a rate of 0.29 and 0.14 per 100 total catheter days respectively. The rate of removal for mechanical and infectious complications was 0 and 0.07 per 100 total catheter days respectively. Non-IR salvages (tPa) (75% of salvages), and IR salvages (25% of salvages) prolonged catheter days by an average of 28.5 days (range 10 - 81 days). Three catheters were still in use at the end of this study. Conclusion Radiologically guided single-incision technique is a safe and technically feasible method for insertion of central venous access devices in pediatric patients. Placing them in children has appeal when the conventional double-incision technique may be challenging, such as in those with a tracheostomy.

The in utero ultrasonographic diagnosis of a fetal subdural hematoma is presented. The value of percutaneous umbilical blood sampling, transvaginal ultrasonography, and magnetic resonance imaging for diagnosis and management is discussed.

Methods 28 Fontan subjects (median age 16.6 years, 14/28 morphologic left ventricle, 14/28 morphologic right ventricle) underwent a resting and exercise CMR. Standard high resolution, segmented balanced steady state free precession (SSFP) images were acquired with breath holds at rest. Cartesian real time (RT) cine images were acquired at rest then repeated at exercise, targeting the HR at anaerobic threshold on a recent metabolic exercise stress test (EST). Ventricular volumes and cardiac output were calculated offline. Off-line strain analysis was performed (TomTec 2D CPA, v. 1.0) on the “4-chamber” and shortaxis views at basal, mid, and apical levels.

Portal vein thrombosis has been associated with umbilical venous catheterization. We studied the incidence of portal vein thrombosis associated with umbilical venous catheterization with the catheter tip not in the portal venous system. Appropriate placement of an umbilical venous catheter in sick neonates is associated with a low risk of portal vein thrombosis (actual incidence, 1.3%).

Sir, We read with interest the recent letter of Drs. Daza and Osorio [1] concerning radiography in developmental dysplasia of the hip (DDH) and are pleased to note their comments and respond to them. We are in full agreement about their depiction of findings in DDH and their explanation of the correlation with normal and abnormal stresses upon the developing neonatal and infant acetabulum. When one examines the literature and history of medical care of DDH, one finds many methods over the years that have been developed radiographically to examine qualitatively and quantitatively the hip joints of infants and children. All are helpful, with some more than others. Our recent article was published in a supplement of Pediatric Radiology that summarized our contribution to the postgraduate course at the 2008 annual meeting of the Society for Pediatric Radiology where the theme was “Evidence-Based Imaging in Pediatrics.” Our task was to examine the last decade of literature on imaging in DDH and report upon the latest available information of whether outcomes in babies with DDH are improved by imaging. In doing so, we reviewed all modalities and comparisons with clinical examination that we could find. Admittedly, we searched only in English. The development and evolution of hip sonography in the last 20 years has been in response to the late emergence of DDH that previously had not been prevented by clinical examination alone or the accompanying use of radiography. In our opinion, the best evidence, as reported in our article, has come out of two Norwegian randomized controlled trials [2, 3]. In babies without risk factors, no statistical difference has been found between expert clinical hip examiners and expert hip sonologists in preventing the rare emergence of cases of late DDH. In babies with DDH risk factors, there has been a trend, not statistically significant, of hip sonography being slightly better diagnostically than clinical examination alone. Some evidence and opinion suggest that when clinical examiners are inexperienced or are unsure of their findings, the use of imaging is likely to be more sensitive in detecting DDH or confirming normal. We are not aware of any large-scale recent trials of infant AP pelvic radiography being compared to clinical hip examination and then checking long-term outcome and the late discovery of DDH. In our opinion, selective use of hip radiography remains a useful adjunct in the care of children beyond early infancy in the follow-up of DDH but has not been shown to improve outcomes when used in routine neonatal and early infant screening.

R enal medulla carcinoma is a recently described rare, aggressive tumor of the kidney occurring in patients younger than those in whom renal cell carcinoma occurs. To our knowledge, renal medulla carcinoma has been reported only in individuals of African descent carrying the sickle cell trait or afflicted by hemoglobin SC disease [1, 2]. We report what is, to our knowledge, the first case of renal medulla carcinoma occurring in a white child without a history of sickle cell disease or trait.

Plastic bronchitis (PB) is a potentially life-threatening disorder found in patients after total cavopulmonary connection (TCPC). Although lymphatic abnormalities have been postulated to play a role in the disease process, to date, the etiology and pathophysiology of this complication remains

Background Feature tracking strain (FTS) is a new technique to evaluate myocardial deformation from routinely acquired cardiac magnetic resonance (CMR) cine images, however, it has not been validated in single ventricle patients. The purpose of this study is to validate FTS against myocardial tagged harmonic phase (HARP) images, considered the reference standard in non-invasive deformation analysis.

Background Existing cardiac magnetic resonance sequences are frequently suboptimal in the measurement of the aortic arch, particularly in the case of arch obstruction. Navigated three-dimensional (3-D) sampling perfection with application optimized contrast using different flip angle evolution (SPACE) is a novel turbo spin echo dark blood cardiac magnetic resonance sequence that yields a robust 3-D dataset and gates in systole in order to demonstrate the maximal aortic caliber. Additionally, it utilizes susceptibility for optimal blood suppression by orienting blood flow in the readout direction, thereby enhancing imaging in the setting of turbulence. We report our experience measuring the aortic arch using this sequence.