Defining capabilities in deployed UK military prehospital emergency care.

The UK military prehospital emergency care (PHEC) operational clinical capability framework must be updated in order that it retains its use as a valid operational planning tool. Specific requirements include accurately defining the PHEC levels and the 'Medical Emergency Response Team' (MERT), while reinforcing PHEC as a specialist area of clinical practice that requires an assured set of competencies at all levels and mandatory clinical currency for vocational providers.A military PHEC review panel was convened by the Defence Consultant Advisor (DCA) for PHEC. Each PHEC level was reviewed and all issues which had, or could have arisen from the existing framework were discussed until agreement between the six members of this panel was established.An updated military PHEC framework has been produced by DCA PHEC, which defines the minimum requirements for each operational PHEC level. These definitions cover all PHEC providers, irrespective of professional background. The mandatory requirement for appropriate clinical exposure for vocational and specialist providers is emphasised. An updated definition of MERT has been agreed.This update provides clarity to the continually evolving domain of UK military PHEC. It sets out the PHEC provider requirements in order to be considered operationally deployable in a PHEC role. There are implications for training, manning and recruitment to meet these requirements, but the processes required to address these are already underway and well described elsewhere.

Strategies and techniques for percutaneous Veno-Arterial ECMO cannulation and decannulation in children.

OBJECTIVES: To describe the techniques used for percutaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation and decannulation in children with the pediatric interventional cardiologist (PIC) as the primary operator, and present outcomes of this initial clinical experience. BACKGROUND: Percutaneous VA-ECMO during cardiopulmonary resuscitation (CPR) has been successfully performed in adults, but currently, not much data exists on children. METHODS: This is a single-center study including VA-ECMO cannulations performed by the PIC between 2019 and 2021. Efficacy was defined as the successful initiation of VA-ECMO without surgical cutdown. Safety was defined as the absence of additional procedures related to cannulation. RESULTS: Twenty-three percutaneous VA-ECMO cannulations were performed by PIC on 20 children with 100% success. Fourteen (61%) were performed during ongoing CPR, and nine for cardiogenic shock. The Median age was 15 (0.15-18) years, and the median weight was 65 (3.3-180) kg. All arterial cannulations were via the femoral artery except in one, 8-week-old infant who was cannulated in the carotid artery. A distal perfusion cannula was placed in the ipsilateral limb in 17 (78%). The median time from initiating cannulation to ECMO flow was 35 (13-112) minutes. Two patients required arterial graft placement at the time of decannulation and one needed below-knee amputation. ECMO support was maintained for a median of 4 (0.3-38) days. Thirty-day survival was 74%. CONCLUSION: Percutaneous VA-ECMO cannulations can be effectively performed, even during CPR with the Pediatric Interventional Cardiologist being the primary operator. This is an initial clinical experience. Future outcome studies compared with standard surgical cannulations are necessary to advocate routine percutaneous VA-ECMO in children.

Measurements on the external load acting on aquatic resistance fins during flexion/extension movements using a robotic joint.

Aquatic resistance training has been proven to be beneficial to many people, in particular those struggling with degenerative joint diseases or recovering from other musculoskeletal issues as the reaction forces acting on the joints become lower, but without compromising the cardiovascular and neuromuscular benefit of the movement. Little has been written on the load produced by or measurements of the devices used in aquatic resistance training. Therefore, uncertainties exist regarding details of how much load can be applied onto the foot when performing the movements and how to quantify progression. In this study, an instrumented robotic arm was designed, built, and used to measure the load acting on the three different types of fins during a simulated flexion/extension movement of a knee. The angular velocities of the knee ranged from 25°/s to 150°/s, which represent the physiological range of in vivo movements. The results demonstrated that the load followed a second-order polynomial with the angular velocities. The load is therefore a function of the angular velocity, the surface area of the fins, and the location of the fins away from the joint center rotation. We modeled the progression of speeds at maximal voluntary movements based on previous studies. The maximum loads measured between 11 kg and 13 kg in extension and 6 kg and 9 kg in flexion at 150°/s rotational velocity.

Feasibility and Safety of Percutaneous Cardiac Interventions for Congenital and Acquired Heart Defects in Infants ≤1000 g.

The transcatheter closure of patent ductus arteriosus (TCPC) has been demonstrated to be feasible even in infants weighing ≤1000 g. However, other percutaneous cardiac interventions (PCI) for such small infants born with congenital heart defects (CHD) or acquired heart defects (AHD) have not been well described. The purpose of this study was to describe the feasibility and safety of PCI in infants ≤1000 g. A retrospective review was conducted between June 2015 and May 2021, looking at 148 consecutive PCIs performed on infants weighing ≤1000 g at the time of the procedure. The procedural success rate was 100%. The major adverse event (AE) rate for TCPC was 3%, while there were no major AEs for other PCI. It is feasible to perform PCIs in infants weighing ≤1000 g with CHD and AHD using currently available technologies.

Echocardiographic versus Angiographic Measurement of the Patent Ductus Arteriosus in Extremely Low Birth Weight Infants and the Utility of Echo Guidance for Transcatheter Closure.

BACKGROUND: Transthoracic echocardiography (TTE) is increasingly utilized for guiding transcatheter closure of patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants. The objectives of this study were to compare PDA size measurements by TTE with angiographic measurements and to describe TTE techniques used in guiding transcatheter PDA closure (TCPC) in ELBW infants. METHODS: One hundred twenty-five consecutive ELBW infants (gestational age < 27 weeks, birth weight < 1 kg) who underwent TCPC before 8 weeks of age under TTE guidance were included. Patent ductus arteriosus sizes were measured from the procedural TTE and angiograms retrospectively by blinded observers. The TTE PDA diameters at the aortic (ED1) and pulmonary end (ED2) were compared with the corresponding angiographic diameters (CD1 and CD2). The TTE PDA lengths, obtained by two techniques (EL1, a straight line between ED1 and ED2; and EL2, a curvilinear line along the PDA), were compared with the PDA length by angiography (CL). Transthoracic echocardiography was used to guide accurate device positioning within the PDA. RESULTS: The procedure weight was 600-1,460 g. The TTE and angiographic PDA diameters were comparable (mean ED1 vs CD1 = 4.5 ± 0.68 vs 4.4 ± 0.85 mm, P = .26; and mean ED2 vs CD2 = 3.1 ± 0.72 vs 3.2 ± 0.94 mm, P = .14). The angiographic length was underestimated by EL1 by 2.6 ± 1.6 mm (P < .0001), while EL2 estimated it better (mean EL2 vs CL = 11.0 ± 1.83 vs 10.8 ± 2.15 mm; P = .40). Transcatheter PDA closure was successful in 100% of the cases using TTE guidance. There were no intraprocedural complications. CONCLUSIONS: Transthoracic echocardiography guidance during TCPC in ELBW infants eliminates the need for aortograms via femoral arterial access, preventing the complications associated with it. Transthoracic echocardiography PDA measurements are comparable to angiographic measurements, thereby assisting in appropriate device size selection.

Percutaneous Stage 1 Palliation for Hypoplastic Left Heart Syndrome.

Surgical palliation for hypoplastic left heart syndrome still carries significant morbidity and mortality in neonates. We previously described a percutaneous stage 1 palliation (PS1P) in a swine experiment. Here we report the human application of the PS1P for hypoplastic left heart syndrome in the United States. The procedure is performed through a 4F sheath in the femoral vein. Bilateral pulmonary flow restrictors are implanted in the proximal branch pulmonary arteries and a stent within the ductus arteriosus. PS1P could postpone surgical repair beyond the neonatal period. It offers a simple, less invasive alternative to currently available operations for newborns with HLHS.

Hemodynamic and clinical consequences of early versus delayed closure of patent ductus arteriosus in extremely low birth weight infants.

OBJECTIVES: To describe changes in hemodynamics, respiratory support, and growth associated with transcatheter PDA closure (TCPC) in ELBW infants, stratified by postnatal age at treatment. STUDY DESIGN: This is an observational study of ELBW infants who underwent TCPC at ≤4 weeks (Group-1; n = 34), 4-8 weeks (Group-2; n = 33), and >8 weeks of age (Group-3; n = 33). Hemodynamic assessment was performed during TCPC. Multivariate Cox-proportionate-hazard modeling was used to identify factors associated with respiratory severity score (RSS) > 2 for >30 days following TCPC. RESULTS: In comparison with Group-1, Group-3 infants had higher pulmonary vascular resistance (PVRi = 3.3 vs. 1.6 WU*m2; P = 0.01), less weight gain between 4 and 8 weeks of age (16 vs. 25 g/day) and took longer to achieve RSS < 2 (median 81 vs. 20 days; P = 0.001). RSS > 2 for >30 days was associated with TCPC > 8 weeks (OR = 3.2, 95% CI: 1.75-5.8; p = 0.03) and PVRi ≥ 3 (OR = 4.5, 95% CI: 2.7-8.9; p < 0.01). CONCLUSION: ELBW infants may benefit from PDA closure within the first 4 weeks of life in order to prevent early onset pulmonary vascular disease, promote faster growth, and for quicker weaning of ventilator and oxygen support.

Construction of Femoral Vessel Nomograms for Planning Cardiac Interventional Procedures in Children 0-4 Years Old.

The objectives of this study were to construct femoral artery (FA) and femoral vein (FV) nomograms in children aged 0-4 years and to construct probability curves for the occurrence of arterial access complications based on the size of the FA. The FV and FA are commonly accessed during cardiac catheterizations in children with congenital heart diseases (CHD). However, nomograms for vessel dimensions based on child's age or size are not available. This knowledge may be helpful for interventional planning. A prospective study was performed on 400 children (age 0-4 years) with CHD undergoing cardiac catheterizations over a 3-year period. Ultrasound evaluation of the right and left FA and FV was performed under anesthesia prior to vascular access. Regression modeling was applied to derive nomograms based on quantile polynomial regression, which yielded good fit to the data judged by R-squared. GAMLSS transformation method was used to formulate smoothed percentiles. A separate prospective evaluation of FA to determine the size below which loss of pulse (LOP) are likely to occur was performed. Nomograms for FA and FV diameter and cross-sectional area against age and body surface area and probability curves for FA LOP were constructed. It is now possible to examine ultrasound-based normal sizes of femoral vein and artery in children 0-4 years of age. Femoral vessel nomograms and LOP probability curves may help with interventional planning. Future studies with larger sample size, including children of other ages may be useful.

Accessing Femoral Arteries Less than 3 mm in Diameter is Associated with Increased Incidence of Loss of Pulse Following Cardiac Catheterization in Infants.

To evaluate whether avoidance of a risk factor associated with loss of pulse (LOP) following femoral artery (FA) catheterization in infants identified from previous study, was associated with decreased incidence of LOP during a prospective evaluation. Since initiation of routine ultrasound guided femoral arterial access (UGFAA) for infants undergoing catheterization in Jan 2003-Dec 2011 (Period-1), our incidence of LOP had stayed steady. Prospective evaluation between Jan 2012-Dec 2014 (Period-2), identified FA-diameter < 3 mm as risk factor for LOP. Between Jan 2015-Dec 2018 (Period-3), an initiative to avoid UGFAA for FA-diameter < 3 mm was implemented to determine whether that led to a decreased incidence of LOP. FA-diameter was measured prior to USGFAA and ratio of outer diameter of arterial sheath to luminal diameter of cannulated artery (OD/AD ratio) was calculated during Periods-2 and 3. The incidence and risk factors for LOP were assessed during the three periods. FA-access rates dropped significantly during Period-3 (56.7% vs. 93.8% and 90.4% during Periods-1 and 2, respectively, p < 0.001). Incidence of LOP in Period-3 decreased to 2.7% compared to 12.5% (Period-1) and 17.4% (Period-2) (p < 0.001). By multivariate analysis, FA size < 3 mm and an OD/AD ratio > 40% were the only significant independent predictors for LOP (OR 6.48, 95% CI 2.3-11.42, p < 0.001 and OR 4.16, 95% CI 1.79-8.65, p < 0.01, respectively). Access of femoral artery < 3 mm and OD/AD ratio > 50% are associated with increased incidence of LOP. Avoidance of these factors may help decrease complications in infants undergoing cardiac catheterizations.

Measuring the evolution of facial 'expression' using multi-species FACS.

Darwin observed that form, and in his view, meaning, of facial behaviour (observable changes in the appearance of the face, often termed facial 'expression') is similar between a wide range of species and concluded that this must be due to a shared ancestral origin. Yet, as with all social behaviours, exactly how to define similarity and determine homology is debated. Facial behaviour is linked to specific facial muscle movements, so one important factor in determining homology is the anatomical basis of facial behaviours that appear similar in both appearance and social function. The Facial Action Coding System (FACS) was developed for the scientific measurement of human facial behaviour and is based on individual facial muscle movements (Ekman and Friesen, 1978). FACS has since been modified for use with various non-human primate species (chimpanzees, macaques, hylobatids, orangutans) and domestic species (dogs, cats, horses). These FACS can be used to trace continuity of form in facial behaviour across species and build a better understanding of the evolution of facial communication in mammals.

Paediatric hearing loss: a community-based survey in peri-urban Kumasi, Ghana.

BACKGROUND: Paediatric hearing loss rates in Ghana are currently unknown. METHODS: A cross-sectional study was conducted in peri-urban Kumasi, Ghana; children (aged 3-15 years) were recruited from randomly selected households. Selected children underwent otoscopic examination prior to in-community pure tone screening using the portable ShoeBox audiometer. The LittlEars auditory questionnaire was also administered to caregivers and parents. RESULTS: Data were collected from 387 children. After conditioning, 362 children were screened using monaural pure tones presented at 25 dB. Twenty-five children could not be conditioned to behavioural audiometric screening. Eight children were referred based on audiometric screening results. Of those, four were identified as having hearing loss. Four children scored less than the maximum mark of 35 on the LittleEars questionnaire. Of those, three had hearing loss as identified through pure tone screening. The predominant physical finding on otoscopy was ear canal cerumen impaction. CONCLUSION: Paediatric hearing loss is prevalent in Ghana, and should be treated as a public health problem warranting further evaluation and epidemiology characterisation.

Diagnostic and Therapeutic Approach to Arrhythmias in Adult Congenital Heart Disease.

PURPOSE OF REVIEW: Adult survivors of congenital heart disease (CHD) are at increased risk of arrhythmia. The goal of this review is to outline diagnostic and therapeutic approaches to arrhythmia in adult CHD patients. RECENT FINDINGS: Macro-reentrant atrial tachyarrhythmia is the most common arrhythmia encountered in adults with CHD. Approximately 25% of hospitalizations associated with arrhythmia. The risk of ventricular arrhythmia is estimated as high as 25-100 times that for the general population and increased after two decades. Routine ambulatory monitoring is important for arrhythmia risk assessment in adults with CHD. There are limitations, potential adverse effects, and risk of recurrence with antiarrhythmic drugs, catheter ablation, and surgical approaches. Adults with CHD suffer various forms of arrhythmia, are at increased risk of sudden death, and require special consideration for medical and interventional therapy.

Utility of the Medtronic microvascular plug™ as a transcatheter implantable and explantable pulmonary artery flow restrictor in a swine model.

BACKGROUND: A surgical pulmonary artery band (PAB) is used to control excessive pulmonary blood flow for certain congenital heart diseases. Previous attempts have been made to develop a transcatheter, implantable pulmonary flow restrictor (PFR) without great success. We modified a microvascular plug (MVP) to be used as a PFR. The objectives of this study were to demonstrate feasibility of transcatheter implantation and retrieval of the modified MVP as a PFR, and compare PA growth while using the PFR versus PAB. METHODS AND RESULTS: The PFR was implanted in eight newborn piglets in bilateral branch pulmonary arteries (PAs). Immediately post-PFR implantation, the right ventricular systolic pressure increased from a median of 20-51 mmHg. Transcatheter retrieval of PFR was 100% successful at 3, 6, and 9 weeks and 50% at 12-weeks post-implant. A left PAB was placed via thoracotomy in four other newborn piglets. Debanding was performed 6-weeks later via balloon angioplasty. On follow-up, the proximal left PA diameters in the PFR and the PAB groups were similar (median 8 vs. 7.1 mm; p = 0.11); albeit the surgical band sites required repeat balloon angioplasty secondary to recurrent stenosis. By histopathology, there was grade II vessel injury in two pigs immediately post-retrieval of PFR that healed by 12 weeks. CONCLUSIONS: Transcatheter implantation and retrieval of the MVP as a PFR is feasible. PA growth is comparable to surgical PAB, which is likely to require reinterventions. The use of the MVP as a PFR in humans has to be trialed before recommending its routine use.

Can transcatheter PDA closure be performed in neonates ≤1000 grams? The Memphis experience.

OBJECTIVE: Advancements in transcatheter technology have now made it possible to safely close patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants. The objective of this article is to describe our technique for transcatheter PDA closure (TCPC) in ELBW infants. DESIGN: The techniques employed are very specific to this population and are drastically different when compared to the procedure performed in patients weighing >5 kg. SETTING: A multidisciplinary team approach should be taken to evaluate and manage ELBW infants in order to achieve success. It is important that specific techniques with venous-only approach outlined in this article be followed to achieve optimal results with low risk of complications. PATIENTS: To date, in Memphis, 55 ELBW infants have had successful TCPC at a weight of ≤1000 g with minimal procedure-related complications. INTERVENTIONS: It is important that specific techniques with venous-only approach outlined in this article be followed to achieve optimal results with low risk of complications. OUTCOME MEASURES: This procedure entails a steep learning curve and should be limited to specialized centers with expertise in these thanscatheter procedures. RESULTS: There has been 100% procedural success of performing TCPC in children ≤1000 g. There have been only two procedure-related complications which happened to the first two patients, ≤1000 g, that we performed TCPC on. CONCLUSIONS: It is feasible and probably safe to perform TCPC in children ≤1000 g. The techniques described in this article represent our institutional experience and have helped us improve clinical outcomes in ELBW infants.

Live broadcast of transcatheter PDA closure in a 700 grams ELBW infant during the International PDA Symposium.

OBJECTIVE: The objective of this article is to describe a live case transmission of transcatheter closure of a patent ductus arteriosus (PDA) in an extremely low birth weight (ELBW) infant during the first International PDA Symposium conducted in Memphis, Tennessee. SETTING: A multidisciplinary team approach including audiovisual specialists, information technology specialists, physicians, nurses, and other health care specialists was required to perform the transcatheter PDA closure (TCPC) in an ELBW infant at LeBonheur Children's Hospital and the procedure was broadcast live to the attendees at the International PDA Symposium allowing for a two-way audiovisual discussion during the procedure. PATIENT: The patient was a 14 days old 24-week premature ELBW infant, who weighed 700 g at the time of the procedure. The patient was requiring mechanical ventilation secondary to pulmonary hemorrhage. The PDA measured 4 mm in diameter and 12 mm in length. INTERVENTIONS: TCPC was performed safely without any procedural complications using a specialized minimally invasive technique. OUTCOME MEASURES: The patient was weaned off the ventilator in < 7 days after the procedure. The child was discharged 9 weeks after the procedure (35 weeks' corrected gestation) weighing 2.2 kg, on full oral feeds and no supplemental oxygen. RESULTS: The successful TCPC allowed for this child to have an uneventful hospital course. The case also highlights the technical nuances involved in setting up the live transmission. CONCLUSIONS: This case demonstrated to the audience in the International PDA Symposium the feasibility and safety of performing TCPC in an ELBW infant. Live cases are useful in exhibiting the nuances involved in any new technique and allows for best learning experience.

Practice variation in the management of patent ductus arteriosus in extremely low birth weight infants in the United States: Survey results among cardiologists and neonatologists.

BACKGROUND: Patent ductus arteriosus (PDA) is highly prevalent in extremely low birth weight (ELBW), preterm infants. There are diverse management approaches for the PDA in ELBW infants. The objectives of this research were to identify current PDA management practices among cardiologists and neonatologists in the United States, describe any significant differences in management, and describe areas where practices align. METHODS: A survey of 10 questions based on the management of PDA in ELBW infants was conducted among 100 prominent neonatologists from 74 centers and 103 prominent cardiologists from 75 centers. Among the cardiologists, approximately 50% were interventionists who perform transcatheter PDA closures (TCPC). Fisher's exact test was performed to compare practice variations among neonatologists and cardiologists. A potentially biased audience including a combination of health care providers belonging to cardiology, neonatology, and surgery were also surveyed during the International PDA Symposium. The results of this survey were not included for statistical comparison, due to this audience being potentially influenced by the Symposium. RESULTS: Statistically significant differences were identified between neonatologists and cardiologists regarding the impact of PDA closure on morbidity and mortality, with 80% cardiologists responding that it does vs 54% of neonatologists (P < 0.001), the need for PDA closure (P < .001), and the preferred method of PDA closure if indicated (P < .001). There was agreement between neonatologists and cardiologists on symptomatic therapy; however more neonatologists favored watchful waiting over intervention in contrast to more cardiologists favoring intervention over observation (77% vs 95%, P < .001). Survey responses also identified a need for further training and research on TCPC. CONCLUSION: Neonatologists and cardiologists have notable differences in managing PDA, and continued discussion across cardiology and neonatology has the potential to facilitate more of a consensus on best management practices. Further investigation is needed to identify outcomes in transcatheter PDA closure, particularly in ELBW infants.

Portable audiometric screening platforms used in low-resource settings: a review.

BACKGROUND: Millions of people across the world suffer from disabling hearing loss. Appropriate interventions lead to improved speech and language skills, educational advancement, and improved social integration. A major limitation to improving care is identifying those with disabling hearing loss in low-resource countries. OBJECTIVES: This review article summarises information on currently available hearing screening platforms and technology available from published reports and the authors' personal experiences of hearing loss identification in low-resource areas of the world. The paper reviews the scope and capabilities of portable hearing screening platforms, including the pros and cons of each technology and how they have been utilised in low-resource environments. CONCLUSION: Portable hearing screening tools are readily available to assess hearing loss in low-resource areas. Each technology has advantages and limitations that should be considered when identifying the optimal methods to assess needs in each country.

REBOA at Role 2 Afloat: resuscitative endovascular balloon occlusion of the aorta as a bridge to damage control surgery in the military maritime setting.

Role 2 Afloat provides a damage control resuscitation and surgery facility in support of maritime, littoral and aviation operations. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers a rapid, effective solution to exsanguinating haemorrhage from pelvic and non-compressible torso haemorrhage. It should be considered when the patient presents in a peri-arrest state, if surgery is likely to be delayed, or where the single operating table is occupied by another case. This paper will outline the data in support of endovascular haemorrhage control, describe the technique and explore how REBOA could be delivered using equipment currently available in the Royal Navy Role 2 Afloat equipment module. Also discussed are potential future directions in endovascular resuscitation.

Use of 3-D digital subtraction rotational angiography during cardiac catheterization of infants and adults with congenital heart diseases.

OBJECTIVE: To compare image quality, radiation and contrast doses required to obtain 3D-Digital subtraction rotational angiography (3D-DSRA) with 3D-Digital rotational angiography (3D-DRA) in infants (children ≤ 2 years of age) and adults with congenital heart diseases (ACHD). BACKGROUND: 3D-DRA can be performed with radiation doses comparable to bi-plane cine-angiography. However, 3D-DRA in infants requires a large contrast volume. The resolution of 3D-DRA performed in ACHD patients is limited by their soft tissue density. We hypothesized that the use of 3D-DSRA could help alleviate these concerns. METHODS: Radiation (DAP) and contrast doses required to obtain 3D-DSRA was compared with 3D-DRA in 15 age-, size-, and intervention-matched infants and 15 ACHD patients. The diagnostic quality and utility of these two modalities were scored by 4 qualified independent observers. RESULTS: Both in infants and adults, the median contrast volume for 3D-DSRA was lower than 3D-DRA (0.98 vs. 1.81 mL/kg; P < 0.001 and 0.92 vs. 1.4 mL/kg; P < 0.001, respectively) with an increased DAP (median: 188 vs. 128 cGy cm2 ; P = 0.068 and 659 vs. 427 cGy cm2 ; P = 0.045, respectively). The diagnostic quality and utility scores for rotational-angiography, and 3D-reconstruction were superior for 3D-DSRA (score = 94 vs. 80%, P = 0.03 and 90 vs.79%, P = 0.01, respectively) and equivalent for multi-planar-reformation and 3D-roadmapping in ACHD patients compared with 3D-DRA. All scores for both modalities were equivalent for infants. CONCLUSIONS: 3D-DSRA can be acquired using lower contrast volume with a mildly higher radiation dose than 3D-DRA in infants and ACHD patients. The diagnostic quality and utility scores for 3D-DSRA were higher in ACHD patients and equivalent for infants compared with 3D-DRA.