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Byline: N.R. Lundstrom (1), H. Berggren (2), G. Bjorkhem (1), P. Jogi (3), J. Sunnegardh (4) Keywords: Key words: Congenital heart surgery -- Centralization Abstract: In Sweden, which has a population of 8.9 million people, pediatric heart surgery was previously performed in four cities. After a long, difficult process, centralization of pediatric heart surgery to two centers was achieved in 1993. The overall 30-day mortality for open-heart surgery on infants and children of 9.5% before the centralization (1988--1991) was reduced to 1.9% in 1995--1997. A causal relationship between the mortality rates before and after the centralization is impossible to prove. Heart surgery was concentrated to the two centers with the lowest surgical mortality, and the reduction in surgical mortality was observed over a short period of time which makes it likely that the centralization of the surgical activity promoted the improved results. During the later time period the amount of more complex surgery was clearly increased compared to that performed previously. Author Affiliation: (1) Department of Pediatrics, University Hospital, SE-221 85 Lund, Sweden, SE (2) Department of Thoracic and Cardiovascular Surgery, Sahlgrenska University Hospital, Goteborg, Sweden, SE (3) Department of Thoracic Surgery, University Hospital, SE-221 85 Lund, Sweden, SE (4) Department of Pediatrics, Sahlgrenska University Hospital, Goteborg, Sweden, SE

Byline: D. Holmgren (1), L. Solymar (1), B.O. Eriksson (1), J. Sunnegardh (1) Keywords: Key words: Endomyocardial -- Biopsy -- Perforation -- Children Abstract: The risk of perforation during 65 endomyocardial biopsies (380 specimens) was investigated using two different sheaths to guide the biopsy forceps in five heart-transplanted children aged 1.6--12.9 years. One of the sheaths guided the biopsy forceps simply into the right ventricle (prefabricated 110deg curved tip) the other (specially curved sheath) had two curves, the distal one of which guided the forceps posteriorly toward the interventricular septum. The position of the sheath was evaluated by biplane fluoroscopy and, in children a$?4 years of age, also by transesophageal echocardiography (TEE). Perforation was defined as clinical perforation (chest pain and pericardial effusion as judged by transthoracic echocardiography or TEE) and ``near perforation'' (epicardial fat in specimens). The prefabricated sheath was associated with 10 incidents of perforation (one clinical and nine near perforations) after 16 biopsies and 96 specimens (10.4%) compared with 2 near perforations after 49 biopsies and 284 specimens (0.7%) after using the specially curved sheath (p &lt 0.001). We conclude that the risk of perforation during endomyocardial biopsy can be reduced by using a specially curved sheath to guide the biopsy forceps toward the interventricular septum. Author Affiliation: (1) Department of Pediatric Cardiology, University of Goteborg, East Hospital, S-416 85 Goteborg, Sweden, SE

A study was carried out to assess significant short-term postoperative complications in children undergoing valved homograft surgery for congenital heart defects. Clinical and laboratory parameters of 50 patients undergoing this type of surgery were compared with those of 50 randomly selected but age-matched controls in whom open-heart surgery was performed without a homograft. Extracorporeal circulation, aortic clamping and intensive care times and the duration of febrile response were significantly longer in the study patients than in the controls (each p < 0.0001). In laboratory data the only significant difference between the two groups was in the C-reactive protein response, which was high in the study group (p < 0.0004) and did not correlate with extracorporeal circulation time or with positive blood cultures. The prolonged febrile and acute-phase reactant response following valved homograft surgery is an inflammatory reaction to the foreign antigen. [ABSTRACT FROM AUTHOR]

Background: The present study presents a diagnostic course for the characterization of a congenital left ventricular outpouching (LVO) in a 4-year-old boy with severe neonatal heart failure, evaluating the added value of cardiac magnetic resonance (CMR) 4Dflow., Case Presentation: A boy, born at full term, presented with heart failure immediately after birth. Echocardiography showed dilated left ventricle with poor function and LVO was initially interpreted as an aneurysm. No infection, inflammation, or other cause for heart failure was found. With intensive medical treatment, the heart function returned to normal, and eventually, all medication was terminated. At follow-up, surgical treatment of the LVO was discussed but after CMR 4Dflow, a thorough evaluation of the function of the left ventricle as well as the LVO was possible and the LVO was determined a double-chambered left ventricle with a good prognosis., Conclusions: The present case demonstrates the clinical usability of CMR 4Dflow for improved decision-making and risk assessment, revealing advanced hemodynamic flow patterns with no need for operation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2022 Lagerstrand, Svensson, Andersson, Synnergren, Öhman, Petersson, Sunnegardh and Dangardt.)

Purpose: To assess the z-axis resolution improvement and dose reduction potential achieved using a z-axis deconvolution technique with iterative reconstruction (IR) relative to filtered backprojection (FBP) images created with the use of a z-axis comb filter., Methods: Each of three phantoms were scanned with two different acquisition modes: (1) an ultrahigh resolution (UHR) scan mode that uses a comb filter in the fan angle direction to increase in-plane spatial resolution and (2) a z-axis ultrahigh spatial resolution (zUHR) scan mode that uses comb filters in both the fan and cone angle directions to improve both in-plane and z-axis spatial resolution. All other scanning parameters were identical. First, the ACR CT Accreditation phantom, rotated by 90° so that the high-contrast spatial resolution targets were parallel to the coronal plane, was scanned to assess limiting spatial resolution and image noise. Second, section sensitivity profiles (SSPs) were measured using a copper foil embedded in an acrylic cylinder and the full-width-at-half-maximum (FWHM) and full-width-at-tenth-maximum (FWTM) of the SSPs were calculated. Third, an anthropomorphic head phantom containing a human skull was scanned to assess clinical acceptability for imaging of the temporal bone. For each scan, FBP images were reconstructed for the zUHR scan using the narrowest image thickness available. For the CT accreditation phantom, zUHR images were also reconstructed using an IR algorithm (SAFIRE, Siemens Healthcare, Forchheim, Germany) to assess the influence of the IR algorithm on image noise. A z-axis deconvolution technique combined with the IR algorithm was used to reconstruct images at the narrowest image thickness possible from the UHR scan data. Images of the ACR and head phantoms were reformatted into the coronal plane. The head phantom images were evaluated by a neuroradiologist to assess acceptability for use in patients undergoing clinically indicated CT imaging of the temporal bone., Results: The limiting spatial resolution was 12 lp/cm for the FBP-zUHR images and the IR-UHR images, although visual assessment indicated a slight improvement for the IR-UHR images. Image noise was 213.0, 181.8, and 153.5 for the FBP-zUHR, IR-zUHR, and IR-UHR images, respectively. While the FWHM was essentially the same for the FBP-zUHR and IR-UHR images, the FWTM of the IR-UHR images was almost 50% smaller compared to the FBP-zUHR images (0.83 vs 1.25 mm, respectively). Images of the anthropomorphic head phantom were judged to be of higher quality for the IR-UHR images compared to the FBP-zUHR images., Conclusions: With use of a z-axis deconvolution technique, z-axis spatial resolution was improved for scans acquired using a comb filter only in the fan angle direction relative to FBP images acquired with a comb filter in both the fan and cone angle directions. By avoiding use of the comb filter in the cone angle direction and use of an IR algorithm, image noise was substantially reduced for the same scanner output (CTDIvol). Thus, overall image quality (spatial resolution and image noise) can be maintained relative to the FBP-zUHR technique at a lower radiation dose.

Objective: Pulmonary venous obstruction (PVO) is an important cause of late mortality in total anomalous pulmonary venous connection (TAPVC). We aimed to describe current practices for the management of postoperative PVO and the efficacy of the different interventional procedures., Methods: We conducted a retrospective international collaborative population-based study involving 19 pediatric cardiac centers in the United Kingdom, Ireland, and Sweden. Patients with TAPVC born between January 1, 1998, and December 31, 2004, were identified. Patients with functionally univentricular circulation or atrial isomerism were excluded. All available data and images were reviewed., Results: Of 406 patients undergoing repair of TAPVC, 71 (17.5%) had postoperative PVO. The diagnosis was made within 6 months of surgery in 59 (83%) of the 71 patients. In 12, serial imaging documented change in appearance of the pulmonary veins. Good-sized pulmonary veins can progress to diffusely small veins and rarely atresia. Patients presenting after 6 months had less severe disease; all are alive at most recent follow-up. Fifty-six (13.8%) of 406 patients underwent intervention for postoperative PVO: 44 had surgical treatment and 12 had an initial catheter intervention. One half underwent 1 or more reinterventions. Three-year survival for patients with postoperative PVO was 58.7% (95% confidence intervals, 46.2%-69.2%) with a trend that those having a surgical strategy did better (P = .083). Risk factors for death included earlier presentation after TAPVC repair, diffusely small pulmonary veins at presentation of postoperative PVO, and an increased number of lung segments affected by obstruction., Conclusions: Postoperative PVO tends to appear in the first 6 months after TAPVC repair and can be progressive. Early intervention for PVO may be indicated before irreversible secondary changes occur., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: This study was undertaken to investigate the long-term outcome of balloon angioplasty for recurrent coarctation of the aorta in a large series of patients., Background: Balloon angioplasty has become the standard treatment for residual or recurrent aortic coarctation. Despite the widespread use of this treatment modality, there are few data outlining the long-term outcome of a large patient cohort., Methods: Clinical, echocardiographic, hemodynamic and angiographic data on 90 consecutive patients who underwent balloon angioplasty between January 1984 and January 1996 were reviewed., Results: Mean systolic pressure gradients were reduced from 31 +/- 21 to 8 +/- 9 mm Hg after dilation (p = 0.0001). The mean diameter of the stenotic site, measured in the frontal and lateral views, increased by 38% and 35%, respectively (p = 0.001). Neurologic events occurred in two patients, with one death. An aortic tear occurred in one patient, requiring surgical intervention. Optimal results were defined as a postprocedure gradient < 20 mm Hg and were obtained acutely in 88% of patients. At long-term follow-up (12 years), 53 (72%) of 74 patients with an early optimal result remained free from reintervention. Transverse arch hypoplasia, defined as an arch dimension < 2 SD below the mean for age, was the primary predictor of the need for reintervention., Conclusions: Although the majority of patients undergoing percutaneous balloon angioplasty for recoarctation of the aorta will achieve long-term benefit, the need for further surgical intervention in those with transverse arch hypoplasia remains high.