M-mode sonography of diaphragmatic motion: description of technique and experience in 278 pediatric patients

BACKGROUND: The use of M-mode sonography for evaluation of diaphragmatic motion has only been previously reported in small series of children, and its use is not widespread among pediatric radiologists. OBJECTIVES: To present our experience with M-mode sonography in the evaluation of diaphragmatic motion in a large number of children with suspected diaphragmatic paralysis, to describe the technique used and to correlate sonographic findings with chest radiographs and clinical outcome. MATERIALS AND METHODS: Retrospective analysis of all M-mode sonograms performed in children from September 1999 to December 2003. The available chest radiographs and the clinical findings were reviewed and correlated with the sonographic findings. RESULTS: A total of 742 hemidiaphragms were evaluated in 278 children. There was no visualization of the left hemidiaphragm in 2 children (0.71%). Movement of the right hemidiaphragm was normal in 238 and abnormal in 131. Movement of the left hemidiaphragm was normal in 232 and abnormal in 135. Abnormal diaphragmatic movement was present in 118 (63%) of 187 children in whom chest radiographs had shown normal position of the hemidiaphragms. Follow-up examinations were obtained in 56 children, revealing improvement in diaphragmatic motion in 26, no change in 23 and deterioration of motion in seven. SUMMARY: M-mode sonography should be the modality of choice to assess diaphragmatic motion, as it can easily depict diaphragmatic dysfunction and allows comparison of changes in follow-up studies. Normal chest radiographs are poor predictors of normal diaphragmatic motion.     

Can portable bedside fluoroscopy replace standard, postreduction radiographs in the management of pediatric fractures?

OBJECTIVE: To determine the accuracy of portable bedside fluoroscopy in documenting postreduction fracture alignment in the pediatric emergency department (ED). DESIGN/SETTING: Prospective trial in an urban pediatric ED. PARTICIPANTS: Convenience sample of 80 pediatric patients requiring ED reduction of isolated long bone fractures. METHODS: Patients who underwent closed fracture reduction using portable fluoroscopic guidance (FluoroScan) in the ED were enrolled in the study. Postreduction images were obtained using both bedside fluoroscopy and conventional radiographs. A pediatric orthopedic subspecialist, blinded to clinical outcome, reviewed the fluoroscopic and radiographic images for adequacy of alignment and rated the utility of conventional radiography for fracture management. RESULTS: The patients were 2.5 to 16 years of age (mean 8.3). Distal radial and radioulnar fractures comprised 96% (76/80) of cases. Sixty-three percent of the fractures were displaced, and the mean angulation of the primary fracture site was 24 degrees . Fluoroscopy was found to be 100% sensitive (75/75 cases) and 100% specific (5/5 cases) in predicting postreduction fracture position when compared to conventional radiographs. Intra-rater observer agreement on the necessity of conventional postreduction radiographs was 0.92 (95% CI 0.82-1.00) using the kappa coefficient. In no case did postreduction radiographs alter acute fracture management. CONCLUSIONS: Bedside fluoroscopy with printed fluoroscopic images are highly reliable in evaluating fracture reduction and can replace conventional radiography in documenting adequate distal forearm fracture reduction when there is no intraarticular involvement.     

Comparison of echo-enhanced ultrasound with fluoroscopic MCU for the detection of vesicoureteral reflux in neonates

BACKGROUND: Fluoroscopic micturating cystourethrography (MCU) is used for screening and grading of vesicoureteral reflux (VUR). It involves ionizing radiation. This study was designed to assess the efficacy of contrast-enhanced sonography in predicting the presence or absence of VUR. OBJECTIVE: To compare an ultrasound contrast agent for detection of VUR in at-risk infants, and to compare these findings with fluoroscopic MCU with the aim of determining whether echo-enhanced sonography could be used instead of fluoroscopic MCU to identify neonates who do not have VUR, thus avoiding the use of radiation in this group. MATERIALS AND METHODS: From August 1999 to August 2000, 97 neonates (69 male, 31 female), aged 28-90 days (mean 48 days), referred for MCU and renal ultrasonography for investigation of VUR were recruited consecutively. Echo-enhanced sonography using stabilized microbubbles was followed immediately by fluoroscopic MCU. VUR was diagnosed if transient hyperechogenicity appeared within the pelvicalyceal system or ureter. The mean number of micturitions was 2.7 (range 1-6). RESULTS: Reflux was detected in 19 kidneys (14 babies) by one or other technique. The findings were concordant in 181 kidneys (94.2%). Echo-enhanced sonography had a sensitivity of 64% (95% CI 35-87%), a specificity of 100% (95-100%), a positive predictive value of 100% (66-100%), and a negative predictive value of 94% (87-98%). CONCLUSIONS: The role of echo-enhanced sonography is limited at present in our neonatal population as a screening examination. Its ability to detect cases of high-grade reflux may make it an attractive alternative in follow-up of known cases of VUR, and may help to reduce radiation exposure in this group.     

Transcarotid Balloon Valvuloplasty with Continuous Transesophageal Echocardiographic Guidance for Neonatal Critical Aortic Valve Stenosis: An Alternative to Surgical Palliation

Neonatal critical aortic valve stenosis is a life-threatening malformation if untreated. Before the late 1980s, the preferred treatment was surgical valvotomy; however, operative mortality was high. Early reports of transcatheter balloon dilation were encouraging, although femoral artery damage and aortic valve insufficiency were procedural limitations. With new balloon catheter technology, transumbilical, transvenous, and transcarotid approaches have been advocated, although a comparison with recent surgical results has not been performed. We compared all neonates who presented to our institution since 1985 with the diagnosis of critical aortic stenosis. Ten patients underwent surgical transventricular valvotomy and 13 patients underwent balloon valvuloplasty via a right carotid cutdown with continuous transesophageal echocardiographic guidance. Prior to intervention, all patients had either left ventricular dysfunction, an aortic valve gradient >100 mmHg, significant mitral valve insufficiency, and/or ductal dependent systemic blood flow. All patients had successful relief of aortic valve obstruction with normalization of left ventricular function and successful discontinuation of prostaglandin E₁. Use of continuous transesophageal echocardiographic guidance resulted in fluoroscopic exposure of only 12 ± 8 minutes. At the latest follow-up, a similar proportion of patients has required additional aortic valve procedures (38% vs 25%) and overall mortality (20% vs 15%) is similar. In the transcarotid group, 9 of 13 patients (69%) have a normal appearing right carotid artery by Duplex imaging, and no neurologic events have been reported. Balloon aortic valvuloplasty via a right transcarotid approach is safe, simplifies crossing the valve, and is effective for the initial palliation of neonatal critical aortic stenosis. The use of transesophageal echocardiographic guidance reduces fluoroscopy exposure, enables accurate assessment of hemodynamics without catheter manipulation or angiography, and avoids femoral artery injury.     

Paediatric fluoroscopy – a survey of children's hospitals in Europe

Background. Fluoroscopy is an important, sometimes vital radiological procedure in paediatric patients with high variability in frequency and technique. Objective. To obtain data on paediatric fluoroscopy practice in Europe using a simple questionnaire mailed to 191 children's hospitals. Results. Eighty-eight radiology departments in 21 European countries participated in the survey. There was great variation in the size of paediatric hospitals in Europe and, consequently, the numbers of staff members (radiographers and radiologists). The total number of fluoroscopy procedures varied widely; the mean value was 1,073 examinations per year. The most frequent fluoroscopic examination was the micturating cystourethrogram, comprising 40 % of total fluoroscopies. For all types of investigations there were enormous differences in the number of spot film images routinely obtained. Only a few departments have prepared protocols for junior doctors or radiographers. Conclusions. Although the number of fluoroscopic investigations per radiologist does not reflect real workload (the difficulty of the investigation was not requested), it can be stated that a considerable percentage of children's hospitals are understaffed. These results also clearly demonstrate that fluoroscopy guidelines for the most common investigations in paediatric patients are needed to improve the quality of examinations and limit radiation exposure to the patients. Received: 16 August 1999 Accepted: 13 March 2000     

Echocardiographic evaluation of patients cured of childhood cancer: a single center study of 117 subjects who received anthracyclines

BACKGROUND: The risk of cardiomyopathy following exposure to anthracycline in asymptomatic long-term survivors of childhood cancer is still hard to predict and precisely quantify. To identify the impact of different cumulative doses, even within a non-high dose range, and the echocardiographic parameters suitable for evaluating cardiac function, we studied diastolic and systolic echocardiographic parameters in a cohort of patients followed in a single center. PROCEDURE: A total of 117 subjects were studied at a median time of 7 years after treatment completion. A complete M-mode, two-dimensional and Doppler echocardiographic study was obtained at rest in all patients according to the standard recommendations of the American Society of Echocardiography. RESULTS: Ninety-nine patients (85%) had completely normal cardiac function, while 18 had abnormal echocardiographic findings: 12 had one abnormal value, 5 had two, and 1 had three abnormal values. All the changes were in left ventricular dimensions, wall thickness or indices of systolic function; no alterations in left ventricular diastolic function parameters were found. None of the echocardiographic parameters correlated significantly with the cumulative dose of anthracyclines administered either at univariate analysis or after adjusting for sex, body surface area or considered risk factors. CONCLUSIONS: Subjects exposed to a median cumulative dose of 214 mg/m(2) had no echographic abnormalities a median of 7 years later. We did not find any correlation between cumulative anthracycline dose and the echocardiographic parameters tested. We now offer echocardiographic follow-up to patients with mildly reduced fractional shortening and/or ejection fraction to rule out late onset dysfunction.     

Hypercontractile heart failure caused by catecholamine therapy in premature neonates

Catecholamine treatment for hypotension is common practice in neonatal intensive care units. In the presence of left ventricular hypertrophy, the positive inotropic action of catecholamines with mainly β-receptor specificity can lead to excessive hypercontractility and paradoxical hypotension. This reports presents two cases of hypercontractile heart failure during β-agonist treatment in very low birthweight (VLBW) infants. Both patients (27 wk, 5 d; and 26 wk, 6 d of gestation) underwent surgical arterial duct ligation and coarctation repair. After operation they developed arterial hypotension that failed to respond to epinephrine (adrenaline) or dobutamine treatment. Echocardiography demonstrated a complete systolic obliteration of the left ventricular cavity. Epinephrine and dobutamine were stopped, and norepinephrine (noradrenaline) was successfully used to control the hypotension.

Conclusion: Treatment of hypotension with β-agonists in VLBW infants with left ventricular hypertrophy can lead to hypercontractility and left ventricular obliteration with paradoxical hypotension. Careful echocardiographic monitoring is indicated in such cases.     

A comparison between digital fluoroscopic hard copies and 105-mm spot films in evaluating vesicoureteric reflux in children

Objective. To compare fluoroscopic freeze-frame digital images with conventional 105-mm spot films during voiding cystourethrography (VCUG) with regard to diagnostic quality and radiation dose. Materials and methods. VCUG was performed on 57 consecutive children by a commercially available fluoroscopic digital system. Both freeze-frame digital images and conventional 105-mm spot films were obtained during 90 s of fluoroscopy. Skin radiation dose was assessed separately for spot films and for both fluoroscopy and spot films, employing thermoluminescent crystals on the anterior surface of the body. Patients were classified into three age groups: group A younger than 12 months, group B 1–5 years old and group C 5–12 years of age. Results. Digital and conventional images provided diagnostically identical results in 108 out of 114 ureters examined (94.7 %). Percentage reductions in skin radiation dose due to the fluoroscopic hard copies compared with the four 105-mm radiographs were 53.8 %, 50.5 % and 57.1 % for groups A, B and C, respectively. Conclusion. Substitution of conventional 105-mm spot films during VCUG with digital fluoroscopic hard copies resulted in a substantial reduction in radiation dose. Digital images were as accurate as the conventional films in excluding vesicoureteric reflux (VUR). The two methods correlated well in diagnosing and grading VUR. Received: 20 March 1997 Accepted: 15 September 1997     

Spontaneous breathing trial predicts successful extubation in infants and children.

OBJECTIVE: To assess the value of a spontaneous breathing trial (SBT) using a flow-inflating bag in predicting extubation success. Secondary goals were to evaluate the positive and negative predictive accuracy of a 15-min SBT. DESIGN: Prospective, blinded, clinical study. SETTING: Pediatric intensive care unit (ICU) of a university hospital PATIENTS: Infants and children intubated for >or=24 hrs. INTERVENTIONS: Patients who met defined criteria for extubation underwent a 15-min SBT connected to a flow-inflating bag set to provide 5 cm H2O continuous positive airway pressure. MEASUREMENTS AND MAIN RESULTS: Seventy patients underwent the SBT. Respiratory rate, heart rate, blood pressure, and pulse oxygen saturations were recorded at baseline and at 5 and 15 mins into the SBT. The ICU physicians were blinded to the results of the SBT, and all patients were extubated at the end of the trial. Patients were observed for the next 24 hrs, and the need for noninvasive ventilation or reintubation (i.e., extubation failure) was recorded.Sixty-four patients (91%) passed the SBT with a subsequent extubation failure rate of 7.8% (only 1.6% required reintubation). Six of the 70 (9%) patients enrolled failed the trial, but half were extubated successfully. Successful completion of the SBT has a 95% sensitivity for predicting successful extubation with a positive predictive value of 92% and an odds ratio of 12 (95% confidence interval, 1.3, 53.7). The specificity of the SBT was 37% with a negative predictive value of 50%. Logistic regression analysis revealed a significant association between passing the SBT and extubation success (p = .017). CONCLUSIONS: A 15-min flow-inflating bag SBT represents a practical, reliable bedside test that has 95% sensitivity for predicting extubation success in pediatric ICU patients. A trial failure is associated with but does not accurately predict extubation failure.     

Pediatric patient surface doses in neuroangiography

Background: Neuroangiographic techniques (diagnostic and interventional) can be lengthy and complex and can be associated with high radiation entrance skin doses from fluoroscopy and digital subtraction angiography (DSA). Objective: To measure entrance surface doses received by pediatric patients undergoing neuroangiographic procedures and to (1) compare these doses with thresholds for deterministic effects, (2) compare these doses with those reported in adults, and (3) to understand the dose relationships among diagnostic and interventional procedures, DSA and fluoroscopy. Materials and methods: A neurobiplane unit with fluoroscopic and DSA capabilities was used for all neuroangiographic procedures. An automated patient dosimeter, installed on both planes of the unit, calculated maximum surface dose. The dosimeter also recorded the number of angiographic frames and the length of fluoroscopy time for each procedure. Results: This retrospective study analyzed entrance surface doses to 100 pediatric patients, 76 of whom underwent neuroangiographic diagnostic procedures and 24 of whom underwent neuroangiographic interventional procedures. The DSA acquisitions ranged from 44 frames to 1,428 frames per procedure and fluoroscopy times ranged from 1.1 to 85.6 min per procedure. The mean surface dose from fluoroscopy was 68.1 mGy (max: 397.1 mGy) in the frontal (PA) plane; in the lateral (LAT) plane, the mean surface dose was 40.9 mGy (max: 418.5 mGy). The mean surface doses from DSA were 263.1 and 126.9 mGy in the frontal and lateral planes, with maximum doses of 924.4 and 410.1 mGy, respectively. Mean fluoroscopy dose rates were 5.4 mGy/min in the PA plane and 4.7 mGy/min in the LAT plane. The DSA largely contributed to the overall procedural surface dose, accounting for 82% of the combined surface dose in the each of the imaging planes. Conclusion: The surface dose for each procedure measured in this study was found to be below thresholds for deterministic effects. Interventional procedures consistently yield the highest doses.     

Preliminary Data on the Diagnostic Accuracy of Rubidium-82 Cardiac PET Perfusion Imaging for the Evaluation of Ischemia in a Pediatric Population

Evaluation of myocardial perfusion is sometimes necessary in children with congenital heart disease or acquired coronary artery abnormalities. Limited information is available regarding the clinical utility of myocardial perfusion imaging in children. PET imaging with rubidium-82 may provide a convenient clinical means of assessing regional circulatory compromise in pediatric patients with small hearts, due to its improved spatial resolution. Clinically indicated cardiac PET studies obtained in 22 pediatric patients were reviewed by two blinded observers and assigned myocardial perfusion scores using a standard 17-segment model. PET results were correlated with coronary angiography, available in 15 cases, to determine the accuracy of PET scanning for evaluating compromise of the myocardial circulation. Reversible defects consistent with myocardial ischemia were present in 6 of 15 (40%) PET cases. The sensitivity and specificity of cardiac PET for the detection of significant coronary artery disease were 100% and 82%, respectively. The positive predictive value of cardiac PET was 67%, while the negative predictive value was 100%. Cardiac PET imaging with rubidium-82 appears promising for the noninvasive assessment of myocardial perfusion in the pediatric population. The findings from this small series suggest that prospective study in a larger patient cohort merits consideration.     

Kawasaki disease in south India: a prospective, case-control study

AIM: To describe the clinical and laboratory profile of Kawasaki disease in south India and compare patients with normal and abnormal cardiac status. METHODS: This was a nested case-control study. All patients admitted to Kanchi Kamakoti CHILDS Trust Hospital, Chennai with Kawasaki disease between January 2002 and March 2006 were included. They were stratified into two groups: cases, who had abnormal echocardiography (ECHO), and controls, who had normal ECHO. All clinical and laboratory investigations, results of echocardiography and management were recorded and follow-up was organised. RESULTS: Of 56 patients, 36 (64.3%) were boys and 58.9% were under 3 years of age. Only 17.9% had an atypical presentation. Oral cavity changes and cervical lymphadenopathy were the most common clinical parameters and were detected in 85.7%. Thrombocytosis and elevated CRP on admission were seen in 41% and 100%, respectively. Echocardiography was abnormal in 27 (48.2%). Apart from raised CRP, which was higher in those with cardiac abnormality, the clinical and laboratory profiles were similar in the two groups. CONCLUSION: Kawasaki disease is not uncommon in south India. The clinical and laboratory profiles were similar between those with and without cardiac echocardiographic abnormality.     

A randomized, blinded comparison of chloral hydrate and midazolam sedation in children undergoing echocardiography

The objective of this prospective, randomized, and blinded study was to compare the use of chloral hydrate versus oral midazolam sedation in children undergoing echocardiography. No adverse effects (nausea, vomiting, paradoxical agitation, or significant deviations from baseline vital signs) were noted with either medication. No differences were noted in onset of sedation between the 2 groups, however, the time to complete recovery was significantly shorter with midazolam than with chloral hydrate. The children in the chloral hydrate group had a significantly deeper level of sedation and were more likely to receive a more nearly comprehensive echocardiographic evalation.     

Latex agglutination for the rapid diagnosis of streptococcal pharyngitis: use by house staff in a pediatric emergency service

A rapid latex agglutination (LA) method was evaluated in 2401 consecutive pediatric patients presenting to an emergency service with suspected group A beta-hemolytic streptococcal pharyngitis. LA tests were performed by the treating physicians, who were not blinded to the clinical condition of the children and who made therapeutic decisions based on the results of the tests. When compared with anaerobic culture, the LA method had a sensitivity of 91%, a specificity of 82%, and a positive predictive value of 43%. There was a marked seasonal variation in the positive predictive value: 62% in winter and 16% in summer. However, even in peak streptococcal pharyngitis season (January to March), basing therapy on a positive LA test leads to the unnecessary treatment of a large number of patients. Therefore, we cannot recommend the routine performance of this test by all practitioners in all clinical settings.     

Diaphragmatic paralysis in children: Diagnosis by TM-mode ultrasound

Diaphragmatic paralysis, a difficult diagnosis in the pediatric age group, has classically been made by fluoroscopy or B-mode ultrasound. We report our experience with TM-mode exploration. Twenty-seven patients suspected to have diaphragmatic paralysis were examined by means of inspiratory and expiratory chest radiography, fluoroscopy and B-mode ultrasound. The diaphragmatic echo was recorded on TM-tracing during spontaneous breathing using coronal oblique scans. Direction, excursion and the pattern of the transition between inspiration and expiration were analysed. In 7 patients examination was normal and TM mode demonstrated movement of normal direction and excursion with a sharp aspect of the transition zone. Diaphragmatic paralysis was present in 11 patients: unilateral in 9 and bilateral in 2 cases. TM mode demonstrated paradoxical movement, reduced excursion and a smooth transition zone. In 9 patients with diaphragmatic dysfunction TM mode demonstrated movement in the normal direction but with reduced excursion and a smooth transition zone. Compared to other imaging modalities, TM-mode records diaphragmatic movements more objectively. It can identify direction of the movement even if they are fast and of weak amplitude and in the case of bilateral paralysis. TM can differentiate paralysis from dysfunction. Moreover, this low-cost, non-irradiating made of imaging can be performed at the bedside and is available on all basic devices.Presented at the 31st Congress of the European Society of Pediatric Radiology, June 1–3, 1994, Brussels, Belgium and selected for publication by an International Group of the ESPR     

Clinical prediction of post-extubation radiological changes of the chest in newborn infants

Objective: Whether a chest radiograph should be performed routinely in all infants after extubation, or selectively only in those with clinical deterioration, is a controversy in neonatal unit practice. This study tested the hypothesis that most cases of post-extubation radiological deterioration in the lungs could be detected by clinical assessment. Methods: A chest radiograph was performed at 8 h post-extubation in 100 episodes of extubation in 85 newborn infants ventilated for a variety of lung diseases. Each infant was assessed at the same time by a neonatologist blinded to the radiological findings, to determine whether a chest radiograph would have been requested based on clinical judgement. The infants were continuously monitored for their respiratory and oxygenation status before and after extubation. Results: Compared to the pre-extubation chest radiographs, 23 of the 100 post-extubation chest radiographs showed either deterioration of the pre-existing lung pathologies or appearance of significant new pathologies. The clinicians' assessment failed to detect most of the deterioration, with a sensitivity of only 21.7%. Systematic analysis of the infants' clinical parameters showed that the development of significant intercostal/subcostal retraction, and an increase in inspired oxygen concentration by ≥ 7% after extubation, were the best predictors of post-extubation radiological deterioration (sensitivity 82.6%, specificity 62.3%, positive predictive value 39.6%, and negative predictive value 92.3%). Serial blood gas in contrast had little predictive value. Conclusion: We conclude that most cases of radiological deterioration of the lungs after extubation are clinically predictable, provided the correct clinical criteria are used.     

Early NT-proBNP Is Able to Predict Spontaneous Closure of Patent Ductus Arteriosus in Preterm Neonates, But Not the Need of Its Treatment

The objective of this study was to establish the potential utility of N-terminal pro-brain natriuretic peptide (NT-proBNP) in the management of patent ductus arteriosus (PDA). This was a monocentric prospective blind study that was conducted in a referral neonatal intensive care unit. The patients were very low-birth-weight/gestational-age neonates. Babies with cardiac congenital anomaly other than PDA, life-threatening congenital malformation, severe asphyxia at birth, persistent pulmonary hypertension, and death within the first week of life were excluded. Plasma NT-proBNP concentrations were determined on days 2, 4, and 7 of life. Echocardiography was performed on days 4 and 7. Results were blinded to clinicians. Only echographic results were available upon request. Thirty-one infants were included. NT-proBNP levels were significantly correlated to ductal size and to left atrial-to-aortic diameter ratio. The median NT-proBNP on both days 2 and 4 was significantly higher in neonates with later treated or persistent PDA. A level above 10.000 pg/mL at 48 h of age yielded a 100% positive and a 87% negative predictive value to exclude spontaneous ductal closure. However, no NT-proBNP threshold could predict which PDA would be judged necessary to treat. It was concluded that early low NT-proBNP values can be used as a reliable independent marker to predict spontaneous ductal closure in preterm neonates. Yet, high NT-proBNP levels should not be used to guide the decision to treat PDA, the risk being of treating many bystanding PDAs.     

Contrast-enhanced MR angiography of pulmonary venous abnormalities in children

BACKGROUND: Echocardiography and X-ray angiography have been considered as gold standards for evaluation of pulmonary venous abnormalities. However, each technique has its own limitations, such as limitation in visualization of the pulmonary veins within the lungs by echocardiography, and the invasive nature of and use of ionizing radiation in X-ray angiography. Contrast-enhanced MR angiography (MRA) is a fast noninvasive method of visualization of the vessels including the pulmonary arteries and veins. OBJECTIVES: To evaluate the utility of contrast-enhanced MRA in the evaluation of pulmonary venous abnormalities in pediatric patients and to compare its diagnostic accuracy with that of transthoracic echocardiography. MATERIALS AND METHODS: In 30 pediatric patients 31 contrast-enhanced MRA studies were performed for evaluation of pulmonary venous abnormalities. Each of 124 pulmonary veins was evaluated for site of connection, course within the lung, presence of obstruction, and topographic relationship with the adjacent structures. The findings of MRA were compared with echocardiographic findings for 116 veins in 29 studies in 28 patients. RESULTS: Contrast-enhanced MRA visualized 99% (123 of 124) of the pulmonary veins investigated, while echocardiography visualized 89% (103 of 116). Exact agreement was found between the two methods in 72% of the veins with a weighted kappa of 0.60 (0.47-0.73, 95% CI). Echocardiography failed to diagnose an abnormal connection in 2 of 15 pulmonary veins, a discrete stenosis in 2 of 19 veins, and diffuse hypoplasia in 10 of 14 veins. In 29% of patients, MRA made the uncertain echocardiographic findings clear. In another 29%, MRA provided a new diagnosis. CONCLUSIONS: Contrast-enhanced MRA is a powerful, safe, and accurate fast-imaging technique for the anatomical evaluation of pulmonary venous abnormalities. MRA may obviate the need for conventional X-ray angiography. Cardiac catheterization may be reserved for those patients in whom pulmonary vascular resistance needs to be determined.     

Cryoablation of Anteroseptal Accessory Pathways in Children With Limited Fluoroscopy Exposure

Due to its safety profile, cryoablation is used increasingly in pediatric patients, especially for septal arrhythmia substrates. Recent advances in electroanatomical-mapping technologies have resulted in a decrease or complete elimination of fluoroscopy exposure during catheter ablation procedures. The aim of this study was to assess the efficacy and safety of cryoablation of anteroseptal accessory pathways (APs) using electroanatomical-mapping system guidance with limited fluoroscopy exposure. A total of 24 patients underwent cryoablation of anteroseptal APs between July 2010 and April 2012. Cryomapping was performed with a 6 mm–tip catheter at ?30 °C before the lesions were delivered. An 8 mm–tip catheter was used in one patient. The EnSite system (St. Jude Medical, St Paul, MN) was used in all procedures. The mean age was 11.9 ± 4.3 years. Acute success rate was 95.8 % (23 of 24). The mean procedure and cryoablation durations were 168 ± 58 min and 1,463 ± 525 s, respectively. Limited fluoroscopy was used only in 7 patients, and the mean fluoroscopy time was 1.7 ± 1.8 min (range 0.1–4 min) in these patients. Recurrence was noted in 2 patients (8.7 %) who underwent a second successful cryoablation procedure. The patient who underwent a failed attempt during the first procedure was successfully treated with a repeat procedure. The resultant long-term success rate was 100 % at a mean follow-up period of 14.2 ± 7.7 months. There were no complications except for transient atrioventricular block in one patient. Cryoablation of anteroseptal APs can be performed effectively and safely in children using a limited fluoroscopic approach with the help of electroanatomical-mapping systems.