[3 tesla magnetic resonance imaging in children and adults with congenital heart disease]. / 3-Tesla-Magnetresonanztomographie zur Untersuchung von Kindern und Erwachsenen mit angeborenen Herzfehlern.

Cardiovascular magnetic resonance imaging (CMR) has become a routinely used imaging modality for congenital heart disease. A CMR examination allows the assessment of thoracic anatomy, global and regional cardiac function, blood flow in the great vessels and myocardial viability and perfusion. In the clinical routine cardiovascular MRI is mostly performed at field strengths of 1.5 Tesla (T). Recently, magnetic resonance systems operating at a field strengths of 3 T became clinically available and can also be used for cardiovascular MRI. The main advantage of CMR at 3 T is the gain in the signal-to-noise ratio resulting in improved image quality and/or allowing higher acquisition speed. Several further differences compared to MRI systems with lower field strengths have to be considered for practical applications. This article describes the impact of CMR at 3 T in patients with congenital heart disease by meanings of methodical considerations and case studies.

Deposition and spectral performance of an inhomogeneous broadband wide-angular antireflective coating.

Gradient index coatings and optical filters are a challenge for fabrication. In a round-robin experiment, basically the same hybrid antireflection coating for the visible spectral region, combining homogeneous refractive index layers of pure materials and linear gradient refractive index layers of material mixtures, has been deposited. The experiment involved three different deposition techniques: electron-beam evaporation, ion-beam sputtering, and radio frequency magnetron sputtering. The material combinations used by these techniques were Nb(2)O(5)/SiO(2), TiO(2)/SiO(2), and Ta(2)O(5)/SiO(2), respectively. The spectral performances of samples coated on one side and on both sides have been compared to the corresponding theoretical spectra of the designed profile. Also, the reproducibility of results for each process is verified. Finally, it is shown that ion-beam sputtering gave the best results in terms of deviation from the theoretical performance and reproducibility.

Myocardial viability assessed by positron emission tomography in infants and children after the arterial switch operation and suspected infarction.

OBJECTIVES: The aim of the study was to assess regional glucose metabolism and contractile function by gated positron emission tomography using fluoro-18-deoxyglucose (FDG-PET) in pediatric patients after the arterial switch operation and suspected myocardial infarction. BACKGROUND: Morbidity and mortality after the arterial switch operation for transposition of the great arteries are often related to impaired coronary function. Justification of high-risk revascularization procedure in infancy requires thorough evaluation of myocardial viability. Although PET is state-of-the-art for evaluation of myocardial viability in adults there are no reports on its impact and feasibility in infants and children. METHODS: We applied electrocardiogram-triggered FDG-PET for assessment of metabolic and functional status of the myocardium in seven infants and seven children. Glucose metabolism, wall motion and wall thickening were evaluated visually and quantitatively on the basis of parametric 3-D images. Additionally, single-photon emission computed tomography perfusion scan was performed in six children. RESULTS: In two of seven infants, FDG-PET demonstrated viable myocardium in akinetic or hypokinetic regions corresponding to a coronary artery stenosis or occlusion. Therefore, indication for revascularization was derived from this finding. In six of the seven children, impaired glucose uptake reflecting myocardial scarring was present. Two patients had pathological findings on coronary angiography and signs of ischemia but were not suitable for revascularization. CONCLUSIONS: Myocardial viability and contractile function can be assessed simultaneously by gated FDG-PET even in infant hearts. This method contributes pertinent information to guide further therapy after the arterial switch operation and suspected myocardial infarction.

Transcatheter closure of membranous ventricular septal defects with a new nitinol prosthesis in a natural swine model.

Transcatheter closure of a membranous ventricular septal defect (MVSD) is much more difficult than closure of other intracardiac defects because of the proximity to the aortic and tricuspid valves and their relatively large size in small children. In this report, transcatheter closure of naturally occurring membranous VSDs was attempted in 12 Yucatan minipigs. The prosthesis is constructed from fine Nitinol wires in the shape of two buttons and a connecting waist filled with polyester fiber. Two kinds of prosthesis were used in this study: concentric and eccentric left-sided retention disks. A 6 or 7 Fr delivery sheath was advanced across the membranous VSD over a wire from femoral vein. The prosthesis was inserted through the sheath by pushing the delivery cable to deploy a button into left ventricle and the second button was then deployed into right ventricle by withdrawing the sheath. Successful implantation of the device was achieved in all animals except one. Complete closure rate was 58.3% immediately after placement, 100% at 1 week, 90.9% at 1 month and 3 months, and 100% at 6 months. An associated aneurysm of the membranous septum increased significantly in size in two of three animals using the concentric device, and in none of the animals using the eccentric device. A trace to mild aortic regurgitation was present in two of the three animals using the concentric device, and only in one of the eight animals using the eccentric device. Five animals developed a trace to mild tricuspid regurgitation. Pathologic examination showed all devices to be covered by smooth neoendothelium at 3 months. This report presents the first experimental study where closure of membranous ventricular septal defects in a swine model was attempted by specially constructed devices. Procedural success and occlusion rates are very encouraging but overall results cannot equal surgery. Further experimentation is needed with devices that are redesigned according to the experience gained from this study.

New self-expanding patent foramen ovale occlusion device.

Our purpose was to evaluate a new self-expanding device for closure of the patent foramen ovale (PFO). A transeptal catheter passage through the flap of the fossa ovalis was performed with a transeptal needle inside a catheter, creating a PFO in two minipigs. In an additional five animals, a naturally occurring PFO was found. The device is made from 0.005 inch nitinol wire mesh with polyester fabric inside, similar in construction to the Amplatzer atrial septal occluder. However, the left atrial disc is smaller (18 mm) than the right atrial disc (26 mm). Both discs are connected by a very short flexible waist (3 mm) that allows free movement of both retention discs. Pulmonary and right atrial angiography were performed after placement, at 1 month, and at 3 months follow-up. Placement of the device was technically successful in six animals. One animal died from ventricular fibrillation during placement. Pulmonary angiography and echocardiography showed complete occlusion of the PFO in six animals. Two animals were sacrificed after 1 month and four animals after 3 months. In the animals sacrificed at 1 month, histopathological examination showed partial (n = 2) endothelialization, and in the 3 months follow-up group (n = 4) endothelialization was complete. The device appears to be highly effective for occlusion of PFOs. This procedure may be performed as an outpatient procedure due to the small 7 Fr delivery system sheath. Cathet. Cardiovasc. Intervent. 47:370-376, 1999.

Percutaneous closure of secundum atrial septal defect with a new self centering device ("angel wings").

OBJECTIVE: To investigate the safety, efficacy, and clinical application of a new self centering device ("angel wings") for closure of secundum atrial septal defects (ASD II) and persistent foramen ovale in all age groups. DESIGN: Multicentre, prospective, nonrandomised study. INCLUSION CRITERIA: defects with an occlusive diameter of < or = 20 mm and a surrounding rim of > 4 mm; body weight > 10 kg; and an indication for surgical closure of secundum atrial septal defect. Additionally, there were compassionate indications for closure in patients with persistent foramen ovale. INTERVENTIONS: Defects were closed by a transcatheter device consisting of two square frames made of superelastic nitinol wire. The frames are covered by elastic polyester fabric, which is sewn together at a central circle. All procedures, except for three interventions that were carried out under sedation, were performed under general anaesthesia using transoesophageal echocardiography and fluoroscopy to monitor intervention. RESULTS: Closure was attempted in 75 (71%) of 105 patients. An ASD II was present in 35 children and 15 adults. A persistent foramen ovale was present in 25 adults with suspected paradoxical embolism. Transcatheter closure was unsuccessful in three children and crossover to surgery was required. Residual shunts were found in 20 patients (27%) immediately after the procedure. A transient atrioventricular third degree block occurred in three patients (4%) and the right atrial disk was not fully deployed in three. A minor shunt (< 3 mm) was present in only three (4%) of 72 patients during follow up of 1-17 months. Blood clots on the right atrial disks in two patients (one required lysis) were seen during follow up transoesophageal echocardiography. Serious complications demanding surgical removal of the device occurred in three patients. One patient had haemopericardial tamponade because of an aortic lesion. Left atrial thrombus formation due to an unfolded right atrial disk was found in a second patient and dislodgement of the left atrial disk resulted in a large residual shunt in a third. CONCLUSIONS: Percutaneous closure of a central ASD with a diameter < or = 20 mm in paediatric and adult patients is feasible and effective with this new device. It is a promising alternative to surgical closure. Modifications of the design, however, seem to be mandatory as 4% of patients developed serious complications.

[Resuscitation in ventricular fibrillation as the first manifestation of Bland-White-Garland syndrome in adulthood]. / Reanimation bei Kammerflimmern als Erstmanifestation eines Bland-White-Garland-Syndroms im Erwachsenenalter.

CASE REPORT: This case presents a 31-year-old male patient with anomalous origin of the left coronary artery from the pulmonary trunc. First symptom of the disease was a survived sudden cardiac death. Subsequent angiographic and echocardiographic studies demonstrated the anomalous origin of the left coronary artery from the pulmonary artery. There were no signs of prior myocardial infarction. After reimplantation of the anomalous originating left coronary artery no myocardial ischemia could be detected in the thallium-201 myocardial imaging, which was present before surgical correction. In this case myocardial ischemia was the only potential triggering mechanism responsible for the sudden cardiac death, which was no longer detectable after surgical correction. Therefore no additional pharmacological and nonpharmacological antiarrhythmic treatment was initiated. CONCLUSION: In rare cases the first manifestation of Bland White Garland syndrome in the adult patient could be sudden cardiac death due to ventricular fibrillation.

Subthreshold stimulation in the region of the slow pathway during atrioventricular node reentrant tachycardia: correlation with effect of radiofrequency catheter ablation.

OBJECTIVES: The present study sought to investigate the role of subthreshold stimulation in patients with atrioventricular node reentrant tachycardia (AVNRT) undergoing catheter ablation of the slow pathway. BACKGROUND: Subthreshold stimulation applied to right atrial sites has been demonstrated to terminate AVNRT but has not been correlated with the effects of radiofrequency current delivery to the area of the slow pathway. METHODS: Eighteen patients with common AVNRT were prospectively included in the study. Sustained AVNRT was reproducibly inducible in all patients (cycle length 334 +/- 58 ms). Anatomic and electrogram guided mapping of the slow pathway was started posteroseptally and continued to more midseptal sites if required. Subthreshold stimulation (3 s, up to 5 mA) during induced AVNRT was performed at each site eligible for slow pathway ablation until termination of AVNRT or capture was observed. Irrespective of the effect of subthreshold stimulation, radiofrequency current was delivered at each site after exclusion of catheter dislocation. RESULTS: Termination of AVNRT due to block of the anterograde slow pathway induced by subthreshold stimulation occurred without apparent capture in 15 of 18 patients. This phenomenon was exclusively observed at successful posteroseptal to midseptal ablation sites. Subthreshold stimulation was not successful at any of 30 target sites with ineffective radiofrequency current delivery. Thus, subthreshold stimulation identified successful target sites with 83% sensitivity and 100% specificity. Atrioventricular node reentrant tachycardia was abolished in all patients after a median of two (range one to nine) radiofrequency current applications. CONCLUSIONS: Subthreshold stimulation delivered to the region of the slow pathway terminates AVNRT with high safety and efficacy. High sensitivity and specificity for prediction of the effect of radiofrequency current application suggest that subthreshold stimulation may become a new tool for identifying target sites for slow pathway ablation.

[Pseudodefects in myocardial SPECT after implantation of defibrillator patches: phantom measurement with SPECT and PET]. / Pseudodefekte bei der Myokard-SPECT durch implantierte Defibrillator-Patches: Phantommessungen mit SPECT und PET.

AIM AND METHODS: In order to estimate the effect of an epicardial or subcutan defibrillator patch electrode on the imaging of myocardium with SPET and PET we performed measurements with a body phantom and two different patch electrodes. RESULTS: We found that in 201TI-SPET with epicardial placing one electrode causes significant pseudodefects, which might lead to the impression of an infarction ("pseudoinfarction"), particularly in the case of reduced myocardial wall thickness. Measurements with 99nTc show the same pseudodefects. In case of subcutaneous placing the electrodes are much less likely to cause relevant absorption effects. With PET even epicardially placed both patch electrodes do not produce pseudodefects. Therefore the risk of false-positive findings is very small with PET. CONCLUSION: In order to avoid false positive findings in cardiovascular nuclear medicine caused by defibrillator patch electrodes, patients with patch electrodes should be referred to PET, if available.

[Pseudoinfarct after placing an epicardial ICD patch electrode: differentiation with SPECT and PET technique]. / Pseudoinfarkt nach Plazierung einer epikardialen ICD-Patch-Elektrode: Differenzierung mit SPECT und PET-Technik.

A 64-year-old male who received an implantable cardioverter defibrillator with epicardial patch electrodes in 1990 was admitted to the emergency room because of recurrent defibrillator shocks. During the following diagnostic work-up a remarkable discrepancy between coronary angiography (no significant stenosis), 201Thallium-SPECT imaging (antero-septal persistent defect) and PET imaging (no 18FDG defect) was noticed. In order to assess the impact of the epicardial defibrillator patch electrodes on the imaging, we performed SPECT and PET measurements using a thorax phantom. We found that in 201Tl-SPECT an epicardial patch caused a significant (up to 20%) photon attenuation, which may lead to the phenomenon of "pseudoinfarction". On PET images epicardial patch electrodes failed to produce any significant attenuation artifacts suggestive of infarction.